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Critical components: CDI moves into CAH

Association of Clinical Documentation Improvement Specialists, May 1, 2015

In many ways, CDI efforts in the critical access hospital (CAH) setting mirror the typical duties of those working in the short-term acute care world. Just ask specialists to identify their top documentation trouble spots.

“Congestive heart failure [CHF] is our number one, hands down,” says Rebecca Lenz, RN, CDI specialist at Tomah (Wisconsin) Memorial Hospital.

Chronic obstructive pulmonary disease, pneumonia, and respiratory distress top the list for Sara Filas, RN, CDI specialist at Aspirus Medford Hospital and Clinics in Wisconsin.

Janelle Cisneros, CDI specialist at Vernon Memorial Healthcare in Viroqua, Wisconsin, runs down her list: Pneumonia, CHF, COPD, and urinary tract infections round out the top 10. Since the facility has a strong orthopedic program, the list also includes knees and hips, but it generally reflects her CAH CDI peers. (See the related article on p. 12 in the full issue for additional target areas.)

Although those working in CAH need not worry about a shift from standard clinical definitions for the patient population they serve (like those working with pediatric populations might), the rules governing Medicare reimbursement for the setting differ, and the workload itself presents interesting CDI challenges and opportunities.

Size matters

Legislation enacted as part of the Balanced Budget Act of 1997 authorized states to establish a Medicare Rural Hospital Flexibility Program, under which certain facilities participating in Medicare can become CAHs. CAHs represent a separate provider type with their own Medicare Conditions of Participation (CoP) as well as a separate payment method.

In general, a CAH must:

  • Be located in a rural area, or be treated as rural under specific designation rules.
  • Furnish 24-hour emergency care services seven days a week.
  • Maintain no more than 25 inpatient beds that may also be used for swing bed services, if certified by Medicare to do so. It may also operate a distinct part rehabilitation and/ or psychiatric unit, each with up to 10 beds.
  • Have an annual average length of stay of 96 hours or less per patient for acute care.

Tomah Memorial Hospital has 25 inpatient beds. Aspirus Medford Hospital and Clinics has 25. Vernon Memorial Healthcare also has 25. The small census size in facilities like these makes it difficult to justify the return on investment in CDI—it doesn’t take all day to review less than 25 records, typically. So, those facilities that do hire often add additional duties and specialty projects to specialists’ task lists.

Last February, Vernon Memorial hired Cisneros essentially to prepare for ICD-10-CM/PCS implementation. Then the delay happened, and Cisneros scrambled to obtain a better awareness of the CDI role and prove her worth.

She spends mornings looking through the history and physical reports to ensure physicians include the necessary elements. She examines admission orders and makes sure physicians appropriately sign and date them. She confirms that the patient’s problem list is up to date.

Now that ICD-10-CM/PCS implementation date seems set for this fall, Cisneros re-started educating providers about the new code set’s documentation requirements.

“Every month I go to the clinic providers’ meetings and offer a little ICD-10 education,” she says. “I feel they would rather have a computer program to walk them through it all, but once you explain it to the physicians, they seem to listen.”

In the afternoons, she works with quality and compliance and helps enter information for data abstractions. As needed, she does audits on clinic charts and takes on additional projects. “I definitely wear multiple hats,” Cisneros says.

“I like the variety. I took the job to step outside of my comfort zone, but CDI is really just so vast that it can be hard to wrap your head around it.”

Lenz tells a similar story. She started in October 2014, coming to the role from a nursing career in cardiac and emergency.

“As a nurse, I had no idea that my documentation mattered so much,” she says.

She reports to the quality director and performs quality abstraction and utilization reviews, in addition to some case management work. In the morning, she focuses on concurrent review of all inpatient charts, and then in the afternoon concentrates on quality-related efforts.

“Everyone wanted something different from the [CDI] position,” says Lenz. “So, in the beginning, my biggest role was really understanding what CDI was all about and bridging that gap.”

Now she creates weekly CDI “fun facts” for the facility, works with the coders to develop physician education, performs all concurrent queries, and helps the HIM team when physicians don’t respond to their retrospective query efforts.

And Lenz constantly hunts for additional ways her efforts can help the facility.

For Filas, tasks differ from day to day. “It all depends on what the day holds,” she says, although she too reports to quality and focuses on inpatient admission reviews, looking at the daily census every morning and following up on any opportunities for improvement.

“CDI programs in the rural healthcare area is really about finding a facility’s documentation weak points and adapting that focus,” says Sheila Goethel, RHIT, CCS, CDIP, AHIMA-Approved ICD-10-CM/ PCS Trainer, coding consultant for the Rural Wisconsin Health Cooperative (RWHC) in Sauk City.

As more CAHs look to implement CDI efforts, RWHC decided to host special CDI roundtable discussions on a quarterly basis to develop best practices and identify common roles and responsibilities for staff members.

Many facilities, Goethel says, “simply weren’t aware of the full responsibility of CDI. They’re learning the process and seeing the benefits.”

Return on investment

Facility size isn’t the only difficulty facing CAH CDI staff. CAHs are not subject to the inpatient prospective payment system or outpatient prospective payment system, as short-term acute care hospitals are. CMS reimburses CAHs at 101% of actual reasonable costs for most inpatient and outpatient services, says Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro in Danvers, Massachusetts.

Traditional acute care programs start CDI efforts by identifying principal and secondary diagnoses. Doing so allows coders to capture more specific codes, which often equates to a higher reimbursement based on CMS’ Medicare severity diagnosis-related group (MS-DRG) payment method. For traditional hospital settings, this improvement in CC/MCC capture rate means an almost immediate return on investment for CDI efforts.

CAH CDI staff cannot turn to monetary gains to prove their worth, which may actually be a blessing in disguise in terms of obtaining physician support, Cisneros says.

“We are not a very wealthy community. The physicians work hard to keep the costs down for the patients. So, when they hear that the hospital could get more money if the physician would only document X instead of Y, they worry that it will end up adversely affecting their patient, that their patient could end up bearing that additional cost and having to pay more out of their own pockets,” she says.

Nevertheless, CAHs can (and often do) track their case-mix index and look to the annual Program for Evaluating Payment Patterns Electronic Report, specifically for CAH to identify outlier diagnoses. CAH CDI staff can also look to parse data from Intellimed or MedPAR, Goethel says, or look to state and national CAH associations for data sharing within those cooperatives.

CDI staff in CAH also need to look for public quality reporting and delve into such data to identify potential documentation opportunities there. For example, if a particular physician scores low on treatment of heart failure on Physician Compare, the CDI specialist can audit a sampling of the facility’s heart failure patients and compare the documentation and final coding and billing, bringing any identified opportunities and research back to the provider in the end.

“There really isn’t a money component here,” says Goethel. “For us, it’s really about quality documentation.”

Assessing the 96-hour rule

Although CAHs receive the 101% reimbursement rate, “that doesn’t mean the CAH can keep the patient forever,” says Melinda Battaile, MD, PA, FHM, MMCI, CDI reviewer for Vidant Medical Center in Greenville, North Carolina.

Enter the so-called 96-hour rule.

Part of CAH CoP states that patients should have an annual average length of stay of 96 hours (roughly four days) or less. The thinking goes that a patient in a rural setting who requires critical care can  anifestation and the etiology, clearly documenting the relationship between the diabetes and any relevant additional diagnoses. go to a CAH for it and be stabilized and discharged. For ongoing critical care, the patient would be transferred to a typical hospital.

The rule has two parts. The first says that the provider must certify the patient will be there 96 hours or less.

For the second part, in order for the hospital to get paid for the patient’s stay, the treating CAH physician needs to assess the patient’s needs and certify that he or she expects that particular patient can be effectively treated within that time period, says Goethel.

The second part takes away the ability to use the average patient length of stay (LOS) over a year’s time and says each patient must be 96 hours or less, Battaile says. The second part was never previously enforced, so CAHs could have an average yearly LOS of less than 96 hours.

Medicare notified facilities last fall that they will begin to enforce the rule for each patient, and that “has people really scrambling,” says Battaile.

“For rural facilities, sometimes the nearest hospitals can be 35 miles away or more,” she notes. So, transferring a patient on the fourth day of care, when he or she may only need another 12 to 24 hours to stabilize, is “a hardship for the patient and the facility” and a potentially pointless additional expense.

Although the American Hospital Association is lobbying CMS to change the rule, CDI specialists in CAHs can help ameliorate the situation in the interim.

For example, a 40-year-old heart failure patient typically requires an average LOS of two to three days, Battaile says, but if the patient has additional complications, the expected LOS becomes six days. Goethel similarly points to a patient with a gastrointestinal bleed that becomes obstructed. Now that the patient has passed the 96-hour threshold, the CAH needs to decide whether to transfer the patient or keep him or her for another 12 hours to get the condition under control.

In facilities where no CDI program exists, the utilization review staff member might investigate the situation. Where CDI programs do exist, staff can return to the medical record and examine the information to determine what additional data might be needed to illustrate the complexity of the patient’s condition, Goethel says.

“Really, we’re talking about the same thing that CDI does everywhere—getting good documentation in the medical record. Helping you [the physician] document everything that you do and treat so we can justify that patient’s continued stay,” she says.

Additional opportunities

Just as in the typical hospital setting, CAH CDI professionals continue to look for opportunities to expand their programs’ horizons.

Lenz is working to help develop sepsis protocols and has taken over reviews for present on admission conditions.

Goethel points to efforts focused on capturing the medical necessity of the inpatient admission, and documentation adjustments needed to meet requirements associated with CMS’ 2-midnight rule.

Filas looks to expand reviews into outpatient records.

“I am very new, only one year, so I am still trying to grow and explore, still looking for processes and ideas to improve our program,” Filas says. “CDI is definitely a collaborative effort.”

The small, community nature of the CAH at Tomah Memorial Hospital was one of the main reasons Lenz decided to work there.

“You can really make a difference here,” she says. “It’s like an episode of Cheers, where everyone knows your name. We all know each other and we all care about each other. We take care of these patients. For CDI, it’s like a big puzzle. My job is to see what I can find out and how I can improve the documentation for these patients and for my facility. It’s a challenge, but it’s a rewarding one.”