December 7, 2010

Lessons Learned: Reducing Vulnerability to Post-payment Audits, Takebacks with Clinical Documentation Improvement

By

kbasak100

 

This month we are highlighting case studies from two organizations that were able to develop and successfully implement Clinical Documentation Improvement Programs (CDIP) as part of their revenue integrity and compliance strategies.

CDIPs typically consist of nurse specialists who review patient charts for completeness and accuracy; the programs are designed to ensure that providers receive appropriate reimbursement for patient care via the proactive identification and addressing of documentation shortfalls.


Nearly all CDI programs involve concurrent chart reviews, the identification of documentation improvement opportunities and the querying of physicians with greater specificity to be able to capture appropriate CC/MCC indicators. The best-practice programs are characterized by close working relationships with finance departments, adequate staffing levels and an explicit focus on driving accurate DRG assignments. These attributes, coupled with strong tracking and accountability mechanisms, ensure that CDI staff make the strongest possible revenue contribution to the hospital. The payoff between average and best-in-class performance is significant, potentially reaching seven figures for a medium-sized hospital.

Best-in-class Institution I:  First year of a CDI Program

The first organization I’d like to highlight is a 170-bed, multi-specialty hospital in the Midwest. This organization’s revenue integrity technology flagged individual claims at high risk of documentation error, and revenue cycle leaders identified a persistent problem with coding and clinical documentation across many categories of claims, resulting in hundreds of thousands of dollars in lost revenue. 

In order to mitigate this problem and ensure improved revenue integrity, hospital leadership decided to implement a formal CDIP. In the first year of the program, they assigned two dedicated CDI specialists who concurrently reviewed about 26 charts per day (according to the Advisory Board Financial Leadership Council’s 2010 CDI Benchmarking Survey, high-performing CDI Specialists can review an average of 33 charts a day, including 10–15 initial charts and about 20 follow-up chart reviews).

Finance leadership generated monthly reports highlighting the areas of greatest opportunity for improvement, guiding the CDI specialists on which departments and clinicians to focus on during a particular month. These specialists then worked with physicians on each designated floor, driving appropriate documentation, ensuring the assignment of working MS-DRGs and monitoring concurrent coding. The CDI specialists also kept an ongoing list of issues they identified to utilize as case studies for the coding and documentation training sessions they hold on a continuing basis.

This hospital now has hardwired a process through which it proactively reviews a major subset of charts every day on various floors, capturing documentation needed for appropriate severity assignments. As a result, the institution enjoyed an additional $550,000 in reimbursement and a higher CMI after the first year of the CDIP implementation.

Best-in-class Institution II: Engaging Physicians Directly to Drive Improvement

A data-driven approach to clinical documentation improvement was the key to success at the second organization I’ll profile, a 150-bed hospital in the South. As part of its preemptive, post-payment audit work, the hospital’s compliance officer, director of case management and HIM Director used a proprietary business intelligence tool to quantify potential revenue risk tied to each of their attending physicians. They did this by pulling claims billed during a three-month period and identifying ones that fell below or rose above the LOS and charge thresholds, per DRG relative to their peers (please note that this approach is consistent with the methodology I highlighted in my article last month). The results revealed the claims that had potential for documentation errors.

They then drilled down into the data to segment physicians by relative potential revenue risk tied to their claims. Specifically, they used the data to identify physicians who had:

 

1.  high volume and high risk of documentation error;
2.  low volume, but high risk of documentation error; and
3.  high volume, but low risk of documentation error.


For clinicians in each of those three categories, they identified key opportunities for additional education and documentation improvement efforts, reporting their recommendations to the chief medical officer (CMO) during weekly meetings. The CMO used these reports to guide physician discussions and to design special one-on-one education sessions. The documentation areas exhibiting the greatest opportunities for improvement were related to respiratory failure, congestive heart failure, renal failure, pneumonia and sepsis.

The process of continual physician performance monitoring has resulted in reduced risk for the organization going forward, and the discipline of sharing data and strategies directly with physicians has resulted in measurable improvement during a relatively short period of time.   The organization has seen a significant reduction in outlying claims in several key areas, including one-day stays and sepsis. Annualizing the impact to date, hospital executives quantified the CMI increase and risk mitigation impact at approximately $450,000.


 

What should you expect from a successful CDIP?

 

Many hospitals that successfully have implemented CDIPs reported an appreciable increase in Case Mix Index (CMI) after implementing the program. Most hospitals also found the education components of these programs to be very effective, resulting in increased physician responsiveness to queries and increased compliance with documentation guidelines.

The good news is that all of these efforts also are expected to reduce the institutional vulnerability to post-payment audit and takebacks.

About the Author


Basak Kaya is an Associate Director at The Advisory Board Company, assisting member institutions in improving their revenue capture through business intelligence and best practices in coding, documentation and charge capture. Over the years, Basak supported over 60 hospitals, ranging from 100 bed community hospitals to multi-hospital systems, as a Revenue Cycle consultant. Prior to joining forces with providers, Basak worked as a strategy analyst for pharmaceutical companies such as Pfizer and GlaxoSmithKline. Basak received her MBA in Health Services Administration from The George Washington University and holds a Bachelor of Science degree in Economics from University of Virginia. 

Contact the Author


kayab@advisory.com

This email address is being protected from spambots. You need JavaScript enabled to view it.