CDI doing only retrospective reviews?
Good Morning
We have been doing CDI for a few years at our hospital and have always done concurrent reviews and mostly concurrent queries. Recently we have had some changes in upper management and one of the managers wants the program to change so that we do only retrospective reviews. Nothing concurrent. So, after the coders coded the chart, and before the bill drops, CDI would look at the chart to see if there could be any changes in documentation to 'improve' the DRG. If there is, we would then query the physician. She states the previous hospital she work at did this and it worked great. I have never heard of a CDI program that works this way so I am very interested in hearing from people who do it this way, or input/opinions about a program set up this way. To me it seems like a lot of red flags. Would it not be frowned upon if we keep changing DRG's after discharge to get a higher DRG. I know it is okay to query after discharge if there was a descrepency that wasn't addressed concurrentlty, I'm just not sure it is okay to do it on the majority of cases. I'm not sure, so again, any input would be apreciated.
Thank You
Renee, RN, CCDS
We have been doing CDI for a few years at our hospital and have always done concurrent reviews and mostly concurrent queries. Recently we have had some changes in upper management and one of the managers wants the program to change so that we do only retrospective reviews. Nothing concurrent. So, after the coders coded the chart, and before the bill drops, CDI would look at the chart to see if there could be any changes in documentation to 'improve' the DRG. If there is, we would then query the physician. She states the previous hospital she work at did this and it worked great. I have never heard of a CDI program that works this way so I am very interested in hearing from people who do it this way, or input/opinions about a program set up this way. To me it seems like a lot of red flags. Would it not be frowned upon if we keep changing DRG's after discharge to get a higher DRG. I know it is okay to query after discharge if there was a descrepency that wasn't addressed concurrentlty, I'm just not sure it is okay to do it on the majority of cases. I'm not sure, so again, any input would be apreciated.
Thank You
Renee, RN, CCDS
Comments
We have one person whose title is "pre-bill reviewer."
She reviews all Medicare charts above a certain financial threshold prior to the bills being dropped. Mostly to ensure coding has captured all the secondary diagnoses as well as the correct DRG assignment.
However, it seems somewhat counterproductive to me to have a CDI program for retrospective review. The purpose of a CDI program is to enhance and capture documentation concurrently. IT seems to me she is trying to make you coders instead of CDIs .
My two cents.
Lisa
Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
Office phone: 804-228-6527
Cell phone: 804-629-0396
AHIMA Approved ICD-10 CM/PCS Trainer
Angelisa.Romanello@HCAHealthcare.com
I am curious is someone from HIM can speak to any ethical issues. I also would be curious how this impacts AR days/DNFB, etc. To me, one of the huge values to a concurrent review process is that ideally the chart is optimized by the time the coder gets it. A retro process would definitely extend out the time between coding and billing.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Our program focuses on concurrent reviews; but, we also will perform 'some' retrospective reviews on select cases, for the purpose of quality - VBP, ROM, and so forth.
It can be compliant to rebill a case after the initial MS-DRG is billed, but please be aware that the 3rd party will then request a copy of the chart in order to verify documentation matches the coding.
Some feel this can raise a red flag if volumes of rebills rise significantly compared to peers. I concur w/ other statements that the prime purpose of a CDI team is to perform concurrent reviews rather than retrospective.
If the person making this suggestion wishes to offer advice regarding how you may increase your impact, perhaps try to prioritize reviews where you believe concurrent reviews may be most needed - ICU, Telemetry, CV Surgery, etc.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Yes, Katy, coded but not billed yet.
We only do Medicare. When there is an audit, would it not raise a red flag if there is a significant amount of charts with addendums to documentation after patients was discharged? Or does that not matter to them?
Renee
Sharon Cooper, RN-BC, CCS, CCDS, CDIP, CHTS-CP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation/Appeals
sharon.cooper@owensborohealth.org
(270) 417-4612 Office
(270) 316-9088 Cell
(270) 417-4609 Fax
Owensboro Health Regional Hospital
P.O. Box 20007
Owensboro, KY 42304-0007
One of the many good reasons for doing concurrent CDI is to promote consistency and continuity throughout the medical record, and you won't get that if you do nothing but retro queries. You'll get a lot of one-offs that may be harder to defend than a query response that's carried through the progress notes into the discharge summary. And as Katy mentioned, would the small changes you could effect be worth the increase in A/R and extension of the DNFB? Because of that, I'd be concerned that you might be incentivized only to query for diagnoses and procedures that impact the DRG and increase relative weight, thereby losing focus on severity and quality issues that are just as much a valuable outcome of CDI as revenue.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
The MD's appreciate the concurrent reviews and have recently mentioned that they have requested their "other" facilities to begin to do the same and not retrospective. (as they have a difficult time recalling the information.)
Recent denials from insurance companies, have reflected that if it isn't in the record, especially the discharge summary, they are denying. So, now if and when we do leave a retrospective query - especially if it is for a MCC/CC we are asking the docs to do an addendum to their discharge.
I would ask if your current program is working. If "yes" - then I wouldn't want to change it. But, as with anything, if you're doing it well, could it be done better? - Are you working with the coders? - do you occasionally retrospectively review a chart, i.e. a patient that was in for an extended stay? - High dollar charges and little return charts reviewed before a bill is dropped? - any other complicated chart/patient stay.
My 2 cents. I'd be curious to know why retrospectively it would be "better". Seems like it would be a little more labor intensive...more time elapses before billing can go out, follow up with doctors - (and then they need to re-review the whole chart) and, we utilize hospitalists, so they are on a week/off a week with vacations/day offs in between - sometimes long periods of time may go by before they could review the chart again. So, docs, coders, CDI, docs, coders, billers....as concurrently - docs, cdi, coders, billers! -- and, all of it is captured in the record - like a book!!
Lona McNamara, RN, BSN, CCM
Clinical Documentation Integrity Specialist
Cortland Regional Medical Center
How will your finance people feel about increased AR days while you pend accounts for query responses? You may want to do a quick tally of the number of queries you do while patients are in-house and extrapolate that to delayed bill drops. With ICD-10 looming, whose cashflow can afford that?
One of the key benefits of concurrent CDI is the "luxury" of asking for better documentation EVEN IF it doesn't impact reimbursement. CDI isn't just about better DRG's, it's about better clinical documentation, period. How long is your rev cycle director willing to hold up a claim while you query for a "nice to know" piece of documentation that has no DRG ramifications? Not long I'll wager. That will reduce your CDI efforts to nothing more than DRG optimization, which consciencious coders have done ad infinitum. Maybe your solution is to involve your inpatient coders in the process so that you can bring your CDI efforts full circle and keep the concurrent component. I believe it is invaluable.
Judy
Judy Riley,RHIT, CCS, CPC, AHIMA-Approved ICD-10 Trainer
Manager, Coding and CDI
LRGHealthcare
524-3211 x 3315
My understanding is that she feels if we do only retro reviews we only have to focus on what would increase the DRG and therefore not 'waste time' doing all the other stuff (missing cc's/mcc's, improved SOI/ROM, better documentation which is what we currently do) because that does not influence the CMI.
Renee
IMO, that's just sad, and reflects a complete lack of understanding by your manager of the role of CDI. I hope you are able to educate her as to the true value of a clinical documentation program, but if she really thinks that about what you do, she may be beyond hope.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
I see a strong red flag with the perspective of "not waste time doing all the other stuff" -- as CMS and others continue to modify payment models, the value of a complete and accurate picture of the patient both for a single encounter as well as over many encounters will continue to have increasing financial importance.
**The readmission program is already risk adjusted , so it is all of the other stuff coded that will play into that.
**Physician payments THIS YEAR for groups of 100 providers (physicians as well as other licensed providers -- OT, Speech, etc.) are swung +2% to -1% based both on quality as well as HCC risk adjusted complexity.
CMS:
• Tying 30%of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models by the end of 2016 (ACOs or bundled payment arrangements)
• Tying 50% of payments to these models by the end of 2018
• Tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs
http://www.hhs.gov/news/press/2015pres/01/20150126a.html
As an additional point for much more information, I've attached the poster presentation from last year on Pre-bill reviews. There is definite value (both in increased coding accuracy as well as financial return) with a pre-bill review program, however I feel that this is best as an additional element for reasons many have already raised.
Donald A. Butler, RN, BSN
Manager, Clinical Documentation Advisor Program
Vidant Health, Greenville NC
252-847-6855
Judy
Judy Riley, RHIT, CCS, CPC
Coding/CDI Manager
LRGHealthcare
Lakes x 3315
Lona
A post discharge query for chf type is straightforward and hard to argue if chf exacerbation is already documented. In contrast (and playing devils advocate), one mention of severe protein malnutrition in an addendum and at the end of a long stay can look a bit strange-how was this clinically significant to the stay if there was no mention previously?
Last point, the amount of $$$'s on hold can be substantial if you wait until after d/c to query. Make sure your CFO is going to be okay with that!
Good luck and keep us posted: )
Kerry
Kerry Seekircher, RN, BSN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
Vickie Smith RN, BSN, CCM, CCDS | Clinical Documentation Specialist-Manager | 740-779-7548 | vsmith@adena.org
Adena Health System | Clinical Documentation Integrity Program
272 Hospital Rd. | Chillicothe, OH 45601
Phone: 740-779-7548