Queries that result in negative financial impact

bmurphy@hcpro.com

Posted on behalf of an ACDIS member... thanks for weighing in, CDI managers!

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I am hoping you can all weigh in on this.  When your program calculates CDI financial impact - and if a query causes a lower weighted DRG - do you subtract money from the CDI impact?

I think it is good to report negative impacts to demonstrate a compliant practice (clarifying to get to the true integrity of the record)- however I have always calculated negative dollars in a neutral/no impact way.  Can any of you share with me what you are doing?

cmclose@saintfrancis.com

 Hi Brian~

I do track negative financial impacts and include them in my CDI financial impact reports for my boss. I believe it is good to show that even though it (CDI intervention: query, discussion with coding, etc.) may have resulted in a negative $ impact, the goal is having a correct account of that pt visit, including appropriate Pdx and MS-DRG assignment.

Also, I am not a manager but I did set up the Peds CDI program and am the sole CDIS for Pediatrics where I work.

Claudine

bmurphy@hcpro.com

Thanks Claudine! I should add that your opinion is welcomed as is any non-CDI manager's.

evanspx@sutterhealth.org

Agree and same workflow as per Claudine.  I compute metric to reflect net impact of clarifications, and feel this is an important element of compliance given some CDI workflow (validations as one example) will result in lower, but proper payments.

Paul Evans, RHIA, CCDS

cynthia.mead@nahealth.com

We don’t track every query for financial impact. We tried this at our smaller facility but ran into the issues of: if we query away an MCC but the patient has another MCC how would you gauge the impact? Or if the query adds a CC to a record with a MCC?

 

We track some financial changes through our reconciliation process, which frequently means we placed a query that resulted in the removal or an addition of a CC/MCC. But it can also mean that after discussion with the coder we agree that a diagnosis did not meet criteria to be coded. This process does not capture where we added or removed a CC/MCC with a query on other records as we are only looking at mismatches.

 

Another way to look at this is that we prevented a denial by ensuring the coding accurately reflects the patient’s admission.

theresadiane

Cynthia, 
Since there is so much more to clinical documentation that just the financial gains, it is good to track the positive and negative impacts your queries make. Also as Claudine said, and Paul agreed with, this can also show your hospital's compliance in accurately coding the patient chart. While it would be fabulous to only show how much your team makes for the hospital monetarily, you can not accurately report that number if you don't track all queries that create either a positive or negative impact.

What to do if you have queried for an MCC and later another MCC pops up which is naturally occuring?  We change our MCC type query to a severity query, because now the CDS is not responsible for maximizing that shift to the highest DRG. The coders would be able to code to the highest DRG without the CDS having touched that chart.  While it is frustrating to do all of the extra work to query the MD and not get credit, it is the compliant thing to do. 

Theresa Diane RN, BSN, CDS Lead

bmurphy@hcpro.com

Great commentary on this thread, thank you very much!

Jane.Brown@ensemblehp.com

We do track negative financial impact but I would note that typically a move to a more accurate DRG that does result in negative impact typically causes relatively small shifts financially and this is more than made up for by ensuring that we are sending out an accurate record. 

stegmanj@ellismedicine.org

We keep track of our "negative impacts" on a separate graph and call them "Good Catches".  We do not subtract this from the financial gains of the other queries that result in a DRG increase. 

CDI is about quality of documentation, so it is to be expected that while we catch mistakes that result in higher DRG's we will also catch mistakes that result in lower DRG's.  But in the end if the documentation is accurate then your organization will get reimbursed for the appropriate services provided to the patient and insurance disputes/RAC audits should have less findings of inaccurate billing. 

It is important to show the "Good Catches" independent from the other queries because it lends to the accuracy of the CDI program and the quality of the medical record.  Hope this helps!

kerryseekircher

We created a focus study in Midas to track and store information regarding all CDI work that results in a decreased relative weight. This includes queries to the provider and any changes made following discussion with the coding department. This helps to demonstrate the impact of a well rounded CDI program as if the  goal is accuracy and quality documentation there should be revenue fluctuations both up and down.  

For compliance purposes, I think it is very important to be able to readily produce this information.

Hope this helps!

lostwater

When we setup our new tech here at CNMC, I am pushing to create a bucket for the "negative impacts" and report them two ways - the "compliance catch", and also the "denial averted".  I will attach the entire DRG payment amount to the "denial averted" metric.  Reports to higher leadership will not include the "denial averted" financial metric, but it will be available on our Sharepoint Intranet webpage as part of our tracked metrics.

kelly.harney

Great comments by all!!  I LOVE the 'denial averter' and 'compliance catch' metric's.

That is a fantastic idea!

I also agree that the negative as well as positive all need to be captured in the overall impact of the program.  Our primary goal is always to capture the most accurate picture of the patient.  From a compliance perspective, if you ever needed to demonstrate the integrity of your program, it will be evident when all impact is combined.