The Role of CDIS’ in Denials Avoidance

Clinical Documentation Improvement (CDI) took on an entirely new meaning as the operational and financial landscape of business of healthcare changed over the course of the last several years.

The introduction of the Recovery Auditor, formally known as the Recovery Auditor Contractors (RAC), began as a demonstration project under the Medicare Prescription, Drug, Improvement, and Modernization Act of 2003 (MMA) from 2006-2008. This demonstration project evolved into a permanent program due to its overwhelming success in recouping alleged overpayments from providers – primarily hospital inpatient services – under the guise of medical necessity and improper payments.

CMS announced that RACs collected $2.29 billion in overpayments from providers in fiscal year 2012, a record level that is almost three times more than what was recorded in 2011: $797.4 million. Just in the fourth quarter 2012 alone, RACs collected $648 million in overpayments. The bulk of these are improper payments categorized as medical necessity short stays, which are defined as inpatient stays of two days or less.

CDI Programs Today
CDI programs began in the late 1990s, serving as a means of solidifying principal and secondary diagnoses, particularly secondary diagnoses consisting of CCs and MCCs. An ultimate goal of these programs, still true to heart today, is to increase the hospital’s monthly case mix and resulting financial reimbursement under the MS-DRG prospective payment system.

A major shortfall of CDI programs as they exist is their relentless focus upon reimbursement to the extent that they have not adapted to meet the healthcare regulatory environment’s current requirements pertaining to compliance with Medicare and other third-party guidelines and regulations that govern medical necessity for inpatient admission and continued stay in the hospital.

Compounding this lack of CDI evolution to meet hospitals’ business needs is the self-sustaining silo approach to CDI that exists throughout the industry. CDI narrowly focuses upon a miniscule piece of the clinical documentation in the record, and review of medical necessity and utilization functions with typical health record documentation deficiencies. This approach cannot effectively address and circumvent the continual barrage of medical necessity denials from the RACs and other third-party payer schemes in the name of reducing hospital provider payment outlays.

Seizing the Opportunity: The True Value of CDI
CDI specialists (CDIS) are capable of complementing the role of case managers and utilization review/utilization management professionals by becoming familiar with and practically applying Medicare’s guidelines, policies, and procedures that outline clinical documentation requirements governing the inarguably subjective moving target of medical necessity. RACs capitalize upon the subjective nature of medical necessity establishment by second guessing physician clinical judgment and medical decision-making in the admission versus observation process.

Let’s take a moment to discuss Medicare’s guidelines, policies, and procedures governing medical necessity that the RACs often refer to in making the determination of medical necessity or lack thereof.

First and foremost is reference to section 1862(a)(1)(a) of the Social Security Act, Title XVIII that states:

No payment can be made under Part A or Part B for any expenses incurred for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

This definition of medical necessity is more a “textbook” definition that is utilized as a basis for medical necessity denials in conjunction with the following guidelines outlined in respective chapters of the CMS Internet Only Manual.

Medicare Benefit Policy Manual Chapter 1, Section 10
This section states that 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.

However, the decision to admit a patient is a complex medical judgment that 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. 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

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

Of note is the statement included in this chapter that admissions are not covered or non-covered solely on the basis of length of time the patient actually spends in the hospital. More on this later in the discussion.

Medicare Program Integrity Manual, Chapter 6, Section 6.5
This section states that the reviewer shall consider, in his/her review of the medical record, any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary. Factors that may result in an inconvenience to a beneficiary or family do not, by themselves, justify inpatient admission. When such factors affect the beneficiary’s health, consider them in determining whether inpatient hospitalization was appropriate.

Inpatient care rather than outpatient care is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician’s office, or that may cause the beneficiary to worry, do not justify a continued hospital stay.

Where Does the CDIS Go From Here?
Indisputably, third-party payer scrutiny of inpatient admissions and ensuing rapid-fire increase in medical necessity denials from a volume and dollar perspective will infinitely continue. CDIS are in a unique position to integrate medical necessity into their clinical thought processes and analytical skills as part of the regular medical record chart review. Complementing identification of clinical documentation specificity opportunities, the CDIS can and must identify like opportunities for clinical specificity in patient acuity reporting within the emergency room documentation as well as the attending physician’s history and physical.

In particular, the History of the Present Illness (HPI) is critical in describing and showing the severity of the patient’s signs and symptoms as the physician observes and elicits clinical information from the patient. The HPI consists of eight specific elements that include:

1. location
2. quality
3. severity
4. modifying factors
5. duration
6. associated signs and symptoms
7. context
8. timing.

Well laid out and executed HPI sets the tone for establishment of medical necessity for admission, serving as a clear prism closely approximating the physician’s clinical judgment and thought processes associated with the decision to admit the patient as an inpatient versus observation.

The detailed picture of patient severity of illness painted in the H&P documentation beginning with the HPI and physical exam and then culminating with an assessment outlining provisional diagnoses in support of plan for patient workup, serves as the foundational backbone for establishment of medical necessity. While this process beckons complexity, the reality is the process can be simplified through CDI interventional application of continuous quality improvement.

Key to improvement is the promotion of a back-to-basic physician clinical thought process and succinct documentation of the same as part of the CDI review process. This six-step thought process is taught to and ingrained in residency school as part of formal physician training; unfortunately, it quickly fades as graduates enter the reality of the competing forces of medicine in the real world. The six step process entails:

• Identify abnormal findings.

• Localize findings anatomically.

• Interpret findings in terms of probable processes.

• Make hypotheses about the nature of the patient’s problem.

• Test the hypotheses, and establish a working diagnosis.

• Develop a plan agreeable to the patient.

Consider the following actual case study where the physician does an excellent job of capturing his thought processes, clinical judgment, and medical decision-making.

Case Study
Assessment and Plan: Abdominal pain, concern for severe constipation, bowel obstruction, pancreatitis, ischemic bowel, C-diff, abdominal distention with tympany, hyperactive bowel sounds, pain at rest, right upper epigastric region. WBC 6.5 and heme stool is negative. Order CBC and CMP, abdominal series. Will consult Dr. Help. Stool panel for C-diff.

Notice the clinically plausible diagnoses listed as part of the physician’s assessment and plan, clearly outlining the physician’s thought processes in fulfilling his/her responsibility in addressing the complexities of appropriate hospital admissions determinations. Bear in mind that per Medicare guidelines, when RACs carry out their medical necessity reviews, they can only use medical evidence that was available to the physician at the time an admission decision had to be made. Other information (e.g., test results) that became available only after admission, except in cases where considering the post-admission information would support a finding that an admission was medically necessary, cannot be used in judging the appropriateness of inpatient admission.

Final Thoughts
CDI in its current state fails to address the real nature and degree of documentation improvement necessary to offset the onslaught of unfavorable medical necessity determinations initiated by the RACs and other Medicare contractors. The time is ripe for CDIS to step up to the plate, acknowledge the inherent ability of our profession to focus upon true CDI, and make a signification contribution to an effective hospital revenue cycle process that embraces denials avoidance.

Take the first step by committing to this endeavor, acquire the requisite skill sets, and begin the journey in CDI progression and advancement of your career.

Glenn Krauss is an independent revenue cycle consultant in Madison, Wisc., and author of The Documentation Improvement Guide to Physican E/M.

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