Note from the Advisory Board: Create a CDI/coding reconciliation process

Association of Clinical Documentation Improvement Specialists, November 1, 2015

by Judy Schade, RN, MSN, CCM, CCDS

Reconciliation is the process of reviewing medical record documentation and comparing this information to the coding summary: principal diagnosis, secondary diagnoses, present on admission indicators, procedure(s), and discharge disposition. Documentation and coding inpatient reconciliation practices exist as a second look at both the CDI specialist and coding reviews after the patient is discharged and the record is complete.During concurrent record review, all the information needed for accurate code assignment (discharge summary, lab and diagnostic results, pathology findings) may not be available, which could lead to documentation opportunities and significantly affect coding and follow-up care.

During the 2015 ACDIS Conference, I had the opportunity to discuss many aspects of CDI programs. Some programs had reconciliation processes in place and others did not. Generally speaking, however, there was a consensus that reconciliation encouraged open dialogue and collaboration between CDI and coding, presenting learning opportunities for both.

Two of the more common types of reconciliation processes are:

  • Reviewing concurrent cases after coding, prior to billing, to ensure CDI/coder agreement
  • Specific MS-DRG edits identified as high audit risk or other facility-specific focus area

I developed the CDI program at Mayo Clinic Hospital in Arizona and have continued working there in the inpatient setting. Both of the above-mentioned reconciliation processes have been practiced at Mayo since our CDI program began. The specific MS-DRG edits were initiated because of limited time for concurrent reviews. The current staff consists of five CDI specialists, and reconciliation remains a valuable method to ensure complete and accurate documentation and coding.

Develop an effective process
At Mayo, our reconciliation process includes comparison of the final MS-DRG assignment as determined by the CDI specialist with that of the coder and identification of any documentation or coding opportunities for a complete and accurate clinical picture.

During the concurrent record review, the CDI specialist enters a principal diagnosis, secondary diagnoses, procedure(s), and an initial DRG based on provider documentation. All of the information, including queries/clarifications, is entered in a data collection system. As the hospital stay is reviewed and additional information is added, the CDI specialist adjusts the initial DRG to a working DRG and then to a final DRG.

Mayo Clinic Hospital uses a data collection system that generates specific work lists for each CDI specialist. One of these work lists is “DRG present,” which notifies the CDI specialist when a case has been coded and is ready for reconciliation. These cases are considered a priority in order not to hold the claim any longer than necessary. The holds and edits are closely monitored by the billing staff.

The CDI specialist uses the documented information in the concurrent review process to identify any missed documentation and/or coding opportunities by comparison of data with the coding summary.

In the case of MS-DRG edits, if the stay had not been previously reviewed, a complete review of the record is done and a comparison is made between CDI specialist’s findings and the coding summary.

When documentation opportunities are identified, the CDI specialist clarifies the issue retrospectively with the provider and obtains documentation in the record. When a potential coding opportunity is identified, the CDI specialist notifies a coding staff lead to review the case and discuss it with the coder. This communication is usually done via email or verbally.

It is important to note that really, the first step in the reconciliation process is to have a method of holding the accounts after they have been reviewed and coded, prior to billing. This involves the revenue department as any account holds can affect filing the claim.

All diagnoses that meet the Uniform Hospital Discharge Data Set definitions need to be coded for a complete and accurate clinical picture. If the CDI specialist and coder agree, the case is re-coded. For those instances when the CDI specialist and coder do not agree, a quality review coding team member or a physician advisor reviews the record.

In some cases, chosen codes may appear inaccurate to the clinical CDI specialist; however, upon review, coding conventions and other requirements take precedence. All clarifications and coding changes are recorded, so statistical data is available for educational purposes.

Reconciliation involves CDI and coding colleagues working closely together and having opportunities to discuss cases. This procedure requires time and effort, but it gives participants an opportunity to gain insight and understanding of cases’ clinical and coding aspects, as well as to learn from each other.

Reconciliation outcomes
Coding and revenue cycle administrators often resist the idea of reconciliation, as these accounts are held until reviewed and in some cases sent back to the coder for revisions to resolve the situation and drop the bill. However, the data collected from this process and resulting discussions often proves beneficial as it reveals statistical outcomes and higher MS-DRG assignments; improves severity of illness and risk of mortality scores; supports resource consumption, risk adjustments, and quality care; and can even help substantiate medical necessity. In addition, data can be compared between service lines, individual providers, and coders for feedback and education.

The goal of reconciliation is complete and accurate documentation and coding. Collaboration and partnership between CDI and coding are essential to have a successful CDI program. Accurate coded data is critical to an organization’s quality and outcome measurements.

If your current CDI program does not include reconciliation, my recommendation is to start the process with one MS-DRG edit, which may be a Recovery Auditor target or a DRG outlier in your organization. Another option is to have an edit in place to review all expiration records, focusing on severity of illness and risk of mortality scores. Remember, however, to involve coding and revenue cycle administrators in the process as reconciliation is a team effort and could impact coder productivity and claim submission.

In light of the changing landscape of risk adjustments and varying methodologies, secondary diagnoses are vital factors in the equation. Accurate and complete documentation and coding has a profound impact on reimbursement and quality—possibly saving an organization millions of dollars.

Editor’s note: Schade is a CDI specialist at Mayo Clinic Hospital in Phoenix. A nurse with more than 30 years’ experience, she has been an ACDIS member since 2008 and was recently elected as co-leader of the Arizona ACDIS chapter. In 2013 she received the CDI Professional Achievement award, and in 2015 she was elected to the ACDIS Advisory Board. Contact her at Schade.judy@mayo.edu.