Negative impacts on queries
There are instances where if the initial primary diagnosis for a case goes to a signs and symptoms DRG and CDI queries for a more definitive primary diagnosis for admission, the result goes to a lower weighted DRG thus resulting in a negative financial impact. My team has questions on whether we should take these negative financial impact on our cases. I would like to know how other facilities are dealing with these situations. should we take the negative impact?
Comments
Our program never claims a negative variance for obtaining clarification and accuracy in the chart. We usually create the coding options exactly alike with the correct documentation (physician response) captured in both options so that our CDI tool will calculate this as what we call a "washout". DRG is the same in both coding options, with no financial variance. I hope this makes sense.
Hillary Guidry RN, BSN, CDIP
Ochsner Lafayette General
Good Morning, this is a great question. Making the record accurate correct is our goal. We know that often sign and symptom diagnoses may have a higher relative weight than the true medical diagnosis. Also, we see this issue when overdocumentation occurs. For instance, when a provider has documented sepsis but there are not strong clinical indicators to support sepsis, the clinical documentation specialist (CDS) often sends a clinical validation query. If the provider rules sepsis out, it will look like a negative shift. In fact, what really occurred is, the query helped to substantiate the record and prevent a future DRG downgrade. We do not subtract these dollars from our overall reimbursement but use this data to track where we may have compliance issues for documentation. This data is great at helping the CDS know where to educate providers.
Jeanne Johnson
In cases like sepsis being ruled out, we can tag the impact as clinical validity because in essence that is what we are doing and avoid the negative shift in our impacts. but in the case of signs and symptoms that we query for etiology and get a lower weighted DRG for the diagnosis, how should we reflect our impact?
Hello, here at Banner Health our opinion is yes, we do show and report out on negative impacts. We report these under denials prevention and compliance. We have three areas of impact that we report out on, listed below:
- Financial
PDX, Proc, MCC, CC, APR-SOI
-Quality
ROM, MS-SOI, POA, HCC, PSI, HAC
-Denials Prevention and Compliance
Validation and Record Clarity
By showing the negative impacts you are telling a better story of how CDI impacts the entire Revenue Cycle and up holds the integrity of the chart. (We also have a process to review all negative impacts prior to reporting, just to be safe)
Hope that helps.
-Jessica Risner
CDI Director for Banner Health
This is very helpful @j.risner...thanks for sharing!
Thank you all very much. your comments are very helpful