CDI-There is A Far Better Way

Rising inpatient acuity may not mean patients are sicker, Mass. commission finds

The Massachusetts Health Policy Commission's findings that despite a nearly 14% decline in commercial inpatient utilization from 2013 to 2018, inpatient spending grew about 11% and inpatient acuity grew more than 10% over that span while length of stay only inched up 1.5% and intensive and critical care days fell almost 10%, raises several interesting points highlighted in the Modern Healthcare article. 

Final Reporting Findings

1) Higher coding severity for chronic obstructive pulmonary disease.  

2) 180% increase from 2010 to 2018 in inpatient discharges associated with septicemia, or blood poisoning. But the number of inpatient discharges associated with conditions that often lead to septicemia—pneumonia, fever, respiratory and gastrointestinal infections, cellulitis and urinary tract infections—decreased 14% to 19% over that span.

3) Coders have latched onto this," said Laura Nasuti, an associate director at the commission. "There are coding blogs and groups that help promote the coding of septicemia, which if it is true septicemia and it is early detection that is great, but unfortunately we see here that there is financial incentive to be aggressively coding septicemia."

The latter point is quite troubling and concerning for me as a long tenured coding and CDI professional. My take is the word “coders” should be substituted for Clinical Documentation Improvement Specialists; coders cannot assign a code for sepsis without the physician documenting the condition in the record. A quick review of the 2019 CMS Fee-For-Service Improper Payment Supplemental Data Report Table D4 highlighting the Top 20 MS-DRGs with the highest improper payment reveals that Sepsis (DRG 872-871) carried the dubious distinction of being number 3 on the list with $275,840,946 in improper payment, 3.1% overall improper payment rate, and 100% of the improper payments identified for sepsis cases attributable to incorrect coding, Given the other two categories of improper payment errors are insufficient documentation and medical necessity, my interpretation is these coding errors are vetted in the physician documentation of the clinical facts, clinical information and context not supporting the clinical diagnosis of sepsis. Perhaps the clinical indicators as evident in the record may suggest sepsis, yet the clinical picture as described and depicted in the record may not support the diagnosis. Along with my CDI colleague who drafts clinical validation denials for several hospital clients, I am observing questionable queries initiated for sepsis in an effort to “optimize” the record and case-mix index. This is in many ways reflective of what transpires when CDI performance is measured by Key Performance Indicators associated with task-based activities such as the query process that drive reimbursement-based outcomes. The old adage of “Tell me how I am going to be measured and I will perform” accordingly certainly applies in this instance.

Let’s not lose sight of the Code of Ethics promulgated and endorsed by AHIMA and CDI governing the CDI profession. I do not and will not subscribe to the philosophy of aggressive queries in the name of optimal reimbursement. Our unwavering approach to CDI must incorporate and embrace the vision and mission of truly imparting and achieving real improvement in the completeness and accuracy of the physician’s communication of patient care. To this end, I am a Co-Founder of Top Gun Audit School with Ernie de los Santos as the Founder, our goal is to further and advance the CDI profession by promoting and advocating for CDI transformation that includes CDI redesign and repositioning, facilitating effective communication of patient care. There is a better way to CDI-CDI professional’s mindset and commitment should embrace the notion of “Facilitators in Communication of Patient Care.”

I highly encourage all CDI professionals to check out the TopGunAuditSchool.com website and sign up for emails. I promise you will not be spammed with emails to buy this and buy that. In the near future I will be setting up a list-serve for those interested in becoming part of community of CDI professionals who wish to go beyond the traditional CDI approach of queries and CC/MCC capture. This will not be a list-serve for discussion of CC/MCC, CMI, queries, etc. Instead my goal is to engage CDI discussion on thought provocative topics supportive of the true mission and vision of CDI in enhancing communication of patient care. I hope you will decide to participate!

Good luck in all your CDI efforts, remain committed to the CDI profession and support of solid effective physician documentation that best communicates patient care.

https://www.modernhealthcare.com/hospitals/rising-inpatient-acuity-may-not-mean-patients-are-sicker-mass-commission-finds