Clinical Documentation Integrity Specialists Play a Major Role

The Office of Inspector General recently released a report titled CMS Could Strengthen ?Program Safeguards to Prevent and Detect Improper Medicare Payments for Short Inpatient Stays. Prior Office of Inspector General (OIG) audits identified millions of dollars in Medicare overpayments for inpatient claims with short lengths of stay. Instead of being billed as inpatient, the claims should have been billed as outpatient, which usually results in a lower Medicare payment. After the two-midnight rule was implemented, OIG issued a report about the effect of this rule on short inpatient stays (i.e., stays that lasted less than two midnights) for FY 2014. The report concluded that although short inpatient stays decreased overall, vulnerabilities to improper payments remained. According to the previous OIG report, hospitals were still billing for many short inpatient stays that were potentially inappropriate under the two-midnight rule, and Medicare paid almost $2.9 billion for these stays.

Some of the highlights and findings from the most recently released report include the following:

·???????? The most recent audit covered $19.7 billion in Medicare Part A claims with dates of service during our audit period for 2.5 million short inpatient stays at 3,340 acute-care hospitals

·???????? Short inpatient stays for calendar years 2016 through 2020 were the focus of the audit

·???????? OIG defined a short inpatient stay as one in which the claim showed that the enrollee was an inpatient for 1 or 2 days (i.e., a stay that lasted less than two midnights) based on the date of admission and date of discharge on the claim

·???????? Prior OIG reports, CMS, and the BFCC-QIO we interviewed identified short inpatient stays with the following four risk factors for noncompliance with the two-midnight rule: (1) stays for care generally spanning 1 week or longer, (2) stays with canceled procedures, (3) stays billed with MS-DRGs that CMS identified as at risk for noncompliance, and (4) stays billed with MS-DRGs identified by a BFCC-QIO as at risk for noncompliance

·???????? Of the $19.7 billion that Medicare paid for short inpatient stays during the OIG audit period, up to $11 billion was paid for claims with one or more of these risk factors. However, there were no prepayment edits for claims for short inpatient stays with these risk factors. Instead, CMS relied on post-payment edits and claim reviews to ensure compliance with the two-midnight rule

Short-stay inpatient admissions continue to be problematic with hospitals continuing to admit and discharge patients with relatively short stays. Commercial payers and Medicare Advantage plans require authorization and as such short stay inpatient visits are tightly managed and denied for medical necessity. Straight Medicare is where the bulk of improper payments continue to be seen and with the PEPPER Program on hold, hospitals are not receiving their quarterly reports from the CMS contractor to help hospitals analyze and compare their short-stay admissions to other hospitals in their state or region.

Clinical Documentation Integrity Specialists Can Play a Major Role

CDI (Clinical Documentation Integrity Programs) can be crucial in managing short stays in healthcare facilities, especially in the context of CMS (Centers for Medicare and Medicaid Services) regulations. Here’s how CDI can help:

1. Accurate Documentation: CDI specialists ensure that all clinical documentation accurately reflects the severity of illness and intensity of care provided during a short stay. This is crucial because CMS reimbursement often depends on the documented severity of the patient's condition.
2. Compliance: CDI specialists help ensure compliance with CMS guidelines and regulations regarding documentation standards. They can assist in capturing all necessary elements required for appropriate reimbursement and compliance with regulatory requirements.
3. Optimized Reimbursement: By improving the accuracy and completeness of clinical documentation, CDI can help optimize reimbursement for short stays. This ensures that healthcare facilities receive appropriate reimbursement for the services provided to patients during their brief hospitalization.
4. Quality Metrics: CDI can also contribute to improved quality metrics by ensuring that documentation accurately reflects the care provided, which in turn contributes to better quality scores and outcomes reporting.
5. Clinical Decision Making: Clear and comprehensive documentation supports better clinical decision-making processes. CDI specialists can help clinicians by ensuring that all relevant details about the patient's condition and treatment are documented, which facilitates continuity of care and reduces the risk of errors.
6. Educational Support: CDI programs often include educational components for healthcare providers to improve their documentation practices. This ongoing education helps providers understand the importance of accurate documentation for both patient care and compliance purposes.

In summary, CDI is instrumental in enhancing documentation accuracy, ensuring compliance with CMS regulations, optimizing reimbursement, improving quality metrics, supporting clinical decision-making, and providing educational support—all of which are essential in managing short stays effectively within healthcare settings. A strong recommendation from a proactive preemptive denials avoidance approach to effectively manage inpatient short-stays is for CDI to focus their reviews on low-severity diagnoses such as chest pain, syncope, abdominal pain, dehydration, cellulitis, gastroenteritis, etc., as these are generally outpatient observation level of care. The Agency for Healthcare Research and Quality has published A Guide to Prevention Quality Indicators- Hospital Admission for Ambulatory Care Sensitive Conditions (AHRQ Report) This report contains a complete list of diagnoses CDI should also use in prioritizing daily admission chart reviews as an approach to denials avoidance versus inefficient costly denials management.

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