Clinical Documentation Improvement (CDI) What Is It? Why Does It Matter?

1. Clinical Documentation Improvement (CDI) What Is It? Why Does It Matter?

2. Speaker Information • James S. Kennedy MD CCS Managing Director, FTI Healthcare Engaged in Clinical Documentation and Coding Integrity (CDCI) physician/CDS/coder education, training, and process development • Education and Certifications Medical School – University of Tennessee - Memphis, 1979 Board Certified – Internal Medicine, 1983 AHIMA CCS Certification – 2001 • Publications • 2007 – AHIMA – Severity Adjusted DRGs, an MS-DRG Primer • 2009 – ACDIS – Physician Query Handbook • Ongoing – “Minute for the Medical Staff” in HcPRO’s Medical Records Briefings • Ongoing – “Coding Clinic Update” – HcPRO’s CDI Journal (ACDIS) • Contact 5310 Maryland Way, Suite 250 Brentwood, TN 37027-5370 (615) 324-8500 – Nashville Office or (404) 460-6250 – Atlanta Office (615) 479-7021 – Cellular James.Kennedy@fticonsulting.com

3. What is CDI? Clinical Documentation Improvement (CDI) is the process of preventing and reconciling inconsistent, incomplete, imprecise, conflicting, or illegible provider documentation prior to the final assignment of clinically congruent HIPAA-associated transaction set codes and their submission to fiscal intermediaries or other entities for adjudication.

4. Questions: • Why on Levo(Phed)? • Why on Clinda/Vanc? • Why on Primaquine? • Why unresponsive? • Why is AST/LDH/CPK so high? • Significance of +HIV w/CD4 of 98? • Significance of Sputum w/Candida? • Cause of thrombocytopenia? Courtesy of C. Trey LaCharité, M.D., University of Tennessee Medical Center, Knoxville

5. Foundation of CDIs • Physician/Provider • Definition of terms • Diagnosis of patient condition • Documentation in the medical record • Clinical Documentation, Ancillary, and Coding Staff • Delineation of documented diagnoses or treatments in the context of the patient’s treatment and the limitations of HIPAA-associated transaction set nosologies. • Deciphering inconsistent, incomplete, imprecise, conflicting, or illegible documentation and clarifying it prior to claim submission. • Everyone • Defense when held accountable by outside entities

6. Servant Leadership

7. Why This is Important to Physicians

9. Provider Profiling of Quality and Efficiency Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs: Ensuring Transparency, Fairness and Independent Review http://healthcaredisclosure.org/docs/files/PatientCharter040108.pdf

10. Provider ProfilingEpisode Groupers Case Mix Index 0.82 Cost Index 1.17 High Cost Index is Less Efficient

11. Physician ProfilingUnited Healthcare - 2010

12. Impact on PhysiciansDirections for Healthcare Reform

13. Impact on PhysiciansDirection for Healthcare Reform • Increasing Use of Bundled Payments • Hospitals and Physicians paid out of the same payment for current admissions and all care within 30 days of discharge • Addresses “Preventable” Readmissions • 18% of Medicare’s inpatient expenditures is for readmissions within 30 days • $12 billion spent annually spent on “preventable” readmissions • Places physicians at risk for efficient hospital resource utilization. • Requires physicians to understand and document completely consistent with MS-DRG methodologies 13 Source: Medicare Payment Advisory Commission

14. PneumoniaMS-DRG Options • HCAP Pneumonia requiring Zosyn & Vancomycin • DRG 195 w/o cc/mcc– Simple Pneumonia & Inflammation – 0.7096 (LTC .4864) • Pneumonia prob. 2° pseudomonas & MRSA requiring Zosyn & Vancomycin – Not HCAP DRG 179 w/o cc/mcc – Respiratory Infections & Inflammations - 0.9861 (LTC 0.5980) • Sepsis due to Pneumonia • DRG 871 – Septicemia or Severe Sepsis with MCC – 1.9074 • DRG 194: With CC – 1.0152 (*LTC –0.6138) • DRG 193: With MCC – 1.4796 (*LTC 0.7620) • DRG 178 With CC – 1.4887 (*LTC 1.7176) • DRG 177 With MCC – 2.0667 (*LTC.8886) • DRG 871 • With MCC – 1.9074 • (*LTC .8713) *(LTC) Long-Term Acute Care are reimbursed by CMS at a higher level (per 1.0 severity weight for resources needed for >/= LTC 25 day complex patients

15. Cardiac SurgeryAcute Care Episode (ACE) Project

16. CCs & MCCs in ICD-9/ICD-10

17. Medical HomesHCC Methodology • Hierarchical Condition Coefficients (HCCs) depend upon diagnoses assigned in both physician and hospital inpatient and outpatient venues. • Used in other demonstration projects integral to the PPACA • Unless physicians report appropriate severity and specificity in their notes, their patients’ illness severity are artificially underrepresented.

18. Medicare Advantage HCC methodology — Example

19. HCC Methodology Imperative that physicians document diabetic complications impacting HCC score.

20. 2010 IPPS Final Rule: Quality Measures Hospital performance in these will affect reimbursement after October 1, 2013

21. Define – Diagnose – Document “Think with Ink” • Physicians are essential to CDI • Unless the provider defines, diagnoses, and documents conditions and treatments using ICD-9-CM (and ICD-10 after October, 2013), administrative databases will not know that these existed • Physician integration strategies are tied to CDI • For physicians to perform well in healthcare reform, the data has to be correct • Facilities have a shared interest in data integrity • Increasing accountability for clinical congruence of ICD-9-CM codes • We are the solution

22. Thank you!