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Employ a business-savvy CDI specialist to tackle chemotherapy services

Association of Clinical Documentation Improvement Specialists, May 1, 2009

By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS
Editor’s note: This article in a part of a series taken from ACDIS sister publication JustCoding.com, part of which can be read online at the ACDIS Blog. The following article explores how a dedicated chemotherapy CDI specialist can clarify difficult documentation quandries. Part one discussed the mounting documentation challenges surrounding the chemotherapy services. 
In the current economic climate, hospitals face decreased reimbursement from third-party payers as well as Medicare and Medicaid. They also face heightened scrutiny from Medicare contractors, including fiscal intermediaries, Program Zone Integrity Contractors, the Office of Inspector General, and recovery audit contractors.
 
The MS-DRG behavioral offset of 1.9% slated to take effect in fiscal year 2010 in combination with the Medicare market basket adjustment for 2010 estimated to be 2.1% will contribute to a negative overall Medicare reimbursement adjustment of 0.2% for 2010.
 
Hospitals can take steps to mitigate some of these challenges by implementing a dual-approach CDI program that focuses on both the clinical and business sides of medicine. Taking this unique approach can be particularly beneficial when the CDI specialist focuses primarily on the high-dollar chemotherapy service line.

Create a CDI program that focuses on the following:

  • Prospective analysis
  • Clinician education about the business aspects of medicine
  • Denials prevention
  • Root cause analysis with process improvement when denials occur

All of these elements play a fundamental role in achieving buy-in from hospital administration and clinicians in developing this type of program that has a dual approach.

Understand inherent challenges that come with chemotherapy service line
The most prevalent challenge associated with operating a chemotherapy department is the increasing costs of drugs associated with the following:
  • Clinical breakthroughs
  • Limited coverage of these targeted chemotherapy drugs
  • Narrow diagnosis-specific limitations of Medicare coverage
  • Clinical documentation required to meet CPT and other third-party payer guidelines and regulations
  • Official HCPCS code billing units that are incongruent with how the facility acquires, stores, and administers drug regimens
 Implementing a dual-approach CDI program can help address these challenges and get to the root causes of continuous self-inflicted denials that occur for a variety of reasons (e.g., insufficient documentation). These denials contribute to costly business office rework, foregone revenue opportunity, and potential write-offs with third-party health insurance companies.
 
Look at these common process deficiencies
Common process deficiencies that often contribute to chemotherapy service denials include the following:
  • Incomplete and ineffective clinical documentation patterns (e.g., lack of documentation for start and stop times for intravenous [IV] chemotherapy and other time-based IV services)
  • Unfamiliarity with official CPT and Medicare coding rules that govern charging, coding, and billing for IV therapy and hydration services
  • Failure to adhere to National Correct Coding Initiatives (NCCI), Medicare Unlikely Edits, and National and Local Coverage Determinations
  • Failure to adequately establish medical necessity for rendered services
  • Incongruence of pharmacy billing units reported on the claim form with patient dosage administration as documented in the medical record
  • Failure to monitor updates to fiscal intermediary, carrier, and other third-party payer requirements
  • Lack of follow up with third-party payer denials of chemotherapy services
 
Keep in mind that this list represents just a portion of potential process inadequacies.
 
Employ the right candidate for the job
The first step in implementing a dual-approach CDI program is to make a case for the selection and training of a qualified applicant. Now that so many facilities are struggling with tight budgets, it’s important to convey to hospital administration that this could be a part-time position.
 
Educate clinicians about the importance of balancing patient healthcare delivery needs and the needs of the department to maintain a positive financial margin. Although  physicians strive to provide quality evidence-based medicine, the integration of medical necessity, NCCI edits, and clinical documentation into the chemotherapy practice is imperative to promote sound, fiscally prudent operations within the department. A dedicated CDI specialist could be instrumental in achieving this balance.
 
Review with your administration any financials related to denials for chemotherapy services over the last year to demonstrate lost revenue that could have been avoided.
 
Select a CDI specialist who is a clinically astute coding professional with a strong business background. Ideally, this individual would also be an experienced business graduate who possesses the following core competencies:
  • Written and oral communication skills
  • Ability to influence others using novel approaches
  • Willingness and ability to continually improve his or her own clinical knowledgebase
  • Commitment to staying up-to-date regarding third party-payer business and financial regulatory changes in chemotherapy administration
  • Ability to stay abreast of CPT changes that affect chemotherapy charging, coding, and billing and educate other staff members regarding those changes
Consider hospital coders with a business background as likely candidates for the position because they not only posses business experience, but they also have a clinical knowledge and competency in IV infusion and other related coding areas.
 
Once the hospital chooses and hires the CDI specialist, establish parameters of the program with measureable objectives and achievable outcomes so this individual has a roadmap for program development and implementation.
 
Tailor the CDI program to fit your needs
Tailor the program to the needs of the chemotherapy department so it improves identified process deficiencies. Ensure that the basic structure of the program includes the following:
  • Regular meetings between the revenue cycle, business office, and department staff members to identify process deficiencies that affect financial outcomes.
  • Recognition of key points and clinical staff knowledge barriers that contribute to process deficiencies, denials, and rework on the back end. Execute this step through staff interviews, chart and bill reviews, and root cause analysis of past denials.
  • Training sessions for chemotherapy clinician staff members to improve upon current knowledge bases and demonstrate core competencies in clinical documentation, charge capture, medical necessity concepts, and knowledge of third-party payer coverage limitations.
  • A training manual that includes clinical scenarios to help form the basis for ongoing educational training.
  • Monitoring of training effectiveness though ongoing record review.
  • Regular feedback to staff members based on record review.
  • Collaboration with other revenue cycle initiatives as part of a synergistic strategy to meet and exceed hospital financial goals, plans, and objectives.
  • Dissemination of coding, billing, and coding regulatory updates to clinical and billing staff members.
  • Measurement of achieved financial improvements to demonstrate the hospital’s return on investment for this program.
  • Training for new clinical staff members in the department as well as current staff members who are having a difficult time assimilating to the initiative.
  • Facilitation of best practices in departmental chargemaster operations through structured policies and procedures. This will help to ensure accurate charge capture, which transcends into the department’s billing functions.
Consider potential benefits of a dual-approach CDI program
The advent of the permanent Recovery Audit Contractor program along with this grim economic forecast provides an impetus for making the case for a business financial and CDI program, especially for a high-dollar service line such as chemotherapy.
 
The chemotherapy department can serve as a template for the development and implementation of a larger initiative to improve overall financial business operations of the hospital. Success with this kind of program can help pave the way for the expansion of similar initiatives to improve business operations and revenue integrity of other departments.
 
The old adage, “Easier said than done” certainly applies when trying to launch this kind of initiative. Capitalize on the opportunity to exchange ideas and learn best practices for CDI with the hospital’s current CDI program specialists if your hospital is fortunate to have invested in such a program.
 
Begin efforts to convey the value and potential return on investment for this program to hospital administration, seek approval and support, develop a reasonable business plan, and begin the implementation.
 
Seize the opportunity and good luck in your efforts.
 
Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, is an independent coding consultant in Milton, WI. E-mail him at glennkrauss@earthlink.net.

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