Health Information Management

Column: Offer insight in addition to education when training physicians

CDI Strategies, September 30, 2010

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By Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

I recently received a fortune cookie from a colleague. After reading the fortune several times, I realized the hidden message certainly has direct relevance to CDI efforts toward affecting overall change in patterns of physician documentation. It read:
"Anyone can memorize things, but the important thing is to understand it."
Most people remember reading college textbooks, listening to professorial lectures, taking notes, and regurgitating the information we supposedly "learned" on tests and final exams, as part of our endeavors of higher learning. We always seemed to ask ourselves why we were "learning" the majority of that rote information anyway. It was difficult to appreciate and understand its practicality and usefulness.
Now, let's look at CDI training and education. The majority of training, education, and execution of CDI programs center around:
  • understanding the MS-DRG system
  • learning what a MCC/CC is
  • gaining a practical sense and understanding of coding rules and policies governing principal and secondary condition selection/assignment
  • learning how to review the record
  • learning how to identify opportunities to improve clinical documentation and financial reimbursement
Finally we learn how to enter the data into the tracking software for reporting purposes. If we're lucky we learn to track
  • how many queries were left
  • how many were responded to
  • how many contained a positive response
  • how often records were reviewed
  • how much of a financial impact CDI has on hospital's bottom line
The entire process is similar to the college experience in the sense we "memorize" the steps of CDI, apply its principles consistently, and ensure we review the standard number of records each day. While I am not fundamentally against established "quotas" for record review, I do advocate for quality of chart reviews which work in tandem with CDI efforts to educate of physicians, particularly to the extent that we are not repeatedly leaving the same queries day in and day out for the likes of acute blood loss anemia or the type of congestive heart failure.
A broader picture of CDI
The need to understand the role of clinical documentation in a form or fashion beyond immediate, measurable reimbursement comes into play under the auspices of healthcare reform provisions introduced as part of the Patient Protection and Affordable Care Act.
This greater understanding also stems from other healthcare reform demonstration projects under way. These projects aim to identify novel and potentially effective approaches to "bending the healthcare cost curve" as we know it today. 
Take the Acute Care Episode Project, or ACE Project. The ACE Project which began January 1, 2009 is stark proof of Medicare's efforts to become a value based purchaser of healthcare. ACE is designed to align incentives and provide flexibility to hospitals and physicians by bundling all related services into an "episode of care" and paying a single global payment that can be used as most appropriate. (Read a related article in Becker's Hospital Review.)
The goals appear noble—to improve quality of care and outcomes for Medicare beneficiaries while providing a savings for Medicare beneficiaries, providers, and the Medicare program, and to improve decision making for beneficiaries and increased cooperation among providers.
Savings in this instance will be shared with Medicare beneficiaries, based upon quality and costs, to the extent the beneficiary chooses to receive care from participating demonstration providers. Medicare will share 50% of the savings it gains under the demonstration with the Medicare beneficiary up to the maximum of the annual Part B premium, currently $1,157. The exact amount of the shared savings payment will vary by site and procedure, with Medicare sending the shared saving payment directly to qualified beneficiaries within 90 days after discharge from the hospital.
Five hospitals were selected to participate in the ACE Project:
  • Baptist Health System - San Antonio, Texas.
  • Oklahoma Heart Hospital, LLC - Oklahoma City, Oklahoma.
  • Exempla Saint Joseph Hospital - Denver, Colorado.
  • Hillcrest Medical Center - Tulsa, Oklahoma.
  • Lovelace Health System - Albuquerque, New Mexico
 The procedures targeted by the project include:
  • Hip replacement
  • Knee replacement
  • Other lower extremity joint replacement
  • Coronary artery bypass graft surgery
  • Cardiac valve replacement surgery
  • Cardiac pacemaker implantation and replacement
  • Cardiac defibrillator implantation
  • Coronary artery angioplasty
The global payment
Payment rates for each of the above procedures were negotiated with CMS to be facility specific. The global payment is made to the hospital, the physician still submits his professional bill to the carrier or MAC as a no pay claim, and receives his/her payment from the hospital.
Global payment to the hospital includes:
  • All claims for professional services from date of admission through date of discharge.
  • All claims for services under arrangement.
  • All claims for preadmission services, which would normally be included on the inpatient claim.
  • Any professional or technical fees for services provided by laboratories or other diagnostic facilities that are not billed by the demo hospital but which provide services to the patient during the inpatient stay.
Under the global payment arrangement, the physician and hospital collaboratively agree upon achieved quality outcome milestones as well as costs in determining physician bonus arrangements in the performance of above mentioned procedures for eligible Medicare beneficiaries.
Eligible Medicare beneficiaries include the following patient types:
  • Entitled to both Part A and Part B
  • Not enrolled in Medicare Advantage or other Medicare health plan
  • Not receiving Medicare due to Railroad Retirement or United Mine Workers of America
  • With at least one lifetime reserve day at the time of admission
  • With Medicare as his or her primary insurance
The message for physicians
The specificity, accuracy, and detail of physician clinical documentation assumes a new role for surgeons as the movement towards bundled payment, shared savings, gain sharing, and accountable care organizations takes hold and moves from demonstration to reality. The transformation of the current financial reimbursement methodologies based strictly on Relative Value Units and volume of services provided is moving more quickly than physicians anticipate as Medicare struggles with development and implementation of physician reimbursement alternative to the ill conceived sustainable growth rate formula in setting and determining levels of physician reimbursement on an annual basis.
Physicians will control their own financial destiny and fate through delivery and demonstration of efficient, quality outcome oriented, cost effective patient care, whether it be global payment for surgery or management of chronic care as part of the primary care model. While physicians strive to provide clinical, evidenced-based medicine, it is their reporting of this care that physicians struggle with, particularly given their lack of formalized training in clinical documentation. 
Physicians will need to attain efficiency, value, and costs measures in order to be financially successful under the pay-for-performance and other bundled payment provisions coming down the pike. 
When inquiring about blood loss anemia post surgery, try referencing the ACE Project and educating the physician as to the merits of documentation of blood loss anemia when clinically appropriate. Acute blood loss anemia resulting from a clinical disease process and the performance of surgery is not strictly considered a "complication" and the required blood transfusion should be explicitly documented to reflect the added expense and cost of the case.
Accurate, concise, and succinct clinical documentation is something the physician will need to adapt to and consistently strive for, given the physician's goal of accurately representing and reporting clinical outcomes and justifying the cost of achieving the recorded quality of care. In part the physician’s financial success will depend upon it.
In closing, concerted effort to continually learn and maintain relevancy in the constantly changing provisions of healthcare payment and other reforms will go a long way in achieving success in our true role of facilitating CDI.
Knowledge is important. Wisdom comes from application of that knowledge. Over and out.
Editor’s note: Krauss is manager of clinical documentation improvement services at YPRO Corporation in Corydon, IN.A fact sheet on the ACE Project is available online.

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