Unlocking the PotentialCDI

We Have the KeyWe Have the KeyGlenn Krauss, BBA, RHIA, CCS,

CCS-P, CPUR, C-CDIS, CCDS

Present CDI Focus

Clarification of Principal Diagnosis CC/MCC Capture Revenue Generation

– Case Mix Increase– Return on Enhancement

Measurement– Number of generated queries– Physician response rate– Impact upon revenue

Office of CDI

Present Limitations

Limited scope General lack of consistency & continuity in

documentation Discharge Summary completeness History & Physical clinical accuracy

– Medical Necessity– Patient acuity and severity– Assessment & Plan

The Big Question

CDI- Asset or Liability?

Gross vs. Net Revenue RAC Exposure Financial Liability Data applications & constituents

– Outcome studies– Risk of in-house and 30 day mortality– Resource Measurement (Efficiency,

Effectiveness, Value=Quality/Costs, VBP, PFP)

Thoughts to Consider

Underlying premise of medical record documentation– Service is reasonable and necessary– Supporting documentation of the same

Medical Necessity– Role of documentation– Role of CDI– Collaboration with case manager & utilization

review/utilization management

Medical Necessity-The Skinny

The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.

Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis.

Medical Necessity-More Skinny

However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting

The Point! Factors to be considered when making the decision

to admit include such things as:– The severity of the signs and symptoms exhibited by the

patient;– The medical predictability of something adverse

happening to the patient;– The need for diagnostic studies that appropriately are

outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and

– The availability of diagnostic procedures at the time when and at the location where the patient presents.

CDI Review Process

CDI Review Process– Emergency Room Notes– History & Physical– Progress Notes – Results Diagnostic Tests

Generation of Query if clinically appropriate and warranted

Chief Complaint- “I Have Chest Pain”

DRG 392DRG 392 DRG 313DRG 313

Mitigating Factors

Medical Necessity – Conclusory statements– Facts of the Case-informational content– Severity of recorded patient signs and

symptoms– Assessment and Plan

Medicare Part B Review

First Coast Service Option– Medicare Part A Inpatient Widespread Probe Review

– MS-DRG 392- Esophagitis, gastroenteritis & misc. digestive disorders w/o major complications and comorbidities (MCC)

– Data from this review will assist us in determining our providers' educational needs. Once completed, results of these probes will be posted to the FCSO Medicare provider website

Focal Point

Clinical Documentation Improvement

Clinical Documentation Effectiveness