CDI Monitored in IRF, Mental Health and Emergency Departments

2019 AHIMA Clinical Documentation Improvement (CDI) Summit Summary

At the American Health Information Management Association’s (AHIMA’s) recent Clinical Documentation Improvement (CDI) Summit, CDI industry experts shared insights on the most pressing issues affecting the CDI industry. Real-world examples and best practices on compliance, documentation across the healthcare continuum, clinical validation, mobile query technology, data-driven CDI and much more were discussed.

CDI Compliance and Ethics
The CDI Summit kicked off with a presentation delivered by Gloryanne Bryant, RHIA, CDIP, CCS, and Dr. William Haik, FACCP, CDIP, regarding CDI compliance and ethics. The presentation covered how to structure CDI functions from a compliance perspective using AHIMA’s practice brief, Guidelines for Achieving a Compliant Query Practice. Dr. Rae Godsey, DO, MBA, CPC, addressed a physician’s perspective on documentation initiatives. Godsey emphasized that physicians are paid for outcomes and quality, and recommended that medical schools expand education to include information on value-based purchasing and quality documentation.

Preventing Denials, Clinical Validation, and Quality

During a presentation by Denise Wilson, MS, RN, attendees learned about managing and preventing denials through clinical validation. Clinical validation is a process in which a determination is made regarding whether a patient truly possesses the conditions that were documented in the health record. This is different from DRG validation, which follows coding guidelines, coding, and conventions. The diagnostic chasm can cause a disconnect between clinical indicators used by payors versus what is used by the provider. Wilson noted the importance of teamwork in denials management, and suggested reviewing provider documentation first, but also reviewing nursing documentation, which can be used support appeals.

Dr. Beth Wolf, CPC, CCDS, also spoke on the topic of clinical validation and described this process as a system-wide effort. She outlined how to approach clinical validation by identifying stakeholders and subject matter experts (SMEs) to help establish minimum threshold criteria. This then can be used to create a physician education plan, standardize the CDI team practice, and address barriers to efficient documentation, and it can be incorporated into denials management. Wolf explained that the process should include the assessment of quality metrics to identify vulnerable diagnoses and determine which should be assessed. Dr Wolf concluded her presentation with a review of three clinical validation case scenarios to help the audience apply what they had just learned.

Ashley Vahey’s presentation focused on quality and defined patient safety indicators (PSIs), a set of indicators developed by the Agency for Healthcare Research Quality (AHRQ) to provide information on potentially preventable complications and adverse events following surgeries, procedures, and childbirth. She explained that her organization has a committee that reviews all PSIs. A letter is sent to providers with a determination from the committee if a PSI was or was not recognized as preventable. When a PSI is deemed preventable, a meeting is scheduled with the provider to discuss the situation. She also provided information on observed-expected (O-E) mortality rates and how CDI and physician education regarding accurate and complete documentation can impact the O-E ratio. She concluded by describing the vital need for quality officer engagement and explained that this is vital in the role of risk stratification.

Physician Query Technology
Tracey Davidson, MSN, discussed the impact of mobile physician query technology at Western Maryland Health System. This technology has helped improve workflow and compliance with the use of AHIMA-compliant templates, according to Davidson. This technology allows signed queries to flow seamlessly into the electronic health record (EHR) and allows real-time dashboard tracking of queries. It also has the ability to send a notice of a provider’s response to CDI professionals and compares response times to the rest of the organization’s medical staff. The utilization of this technology has resulted in a  query response rate of 100 percent and a response time of less than one day. They also saw a decrease in their discharged not final filled (DNFB) list of 27 percent in the first six months of implementation. 

CDI Opportunities in Care Areas
Experts also shared insights on CDI opportunities in specific care areas, including inpatient rehabilitation facilities (IRFs), mental health, and emergency departments. Nirmala Sivakumar, CCS, CDIP, assessed CDI strategies for IRFs. This session shared information on IRF prospective payment systems (PPSs), which use case-mix groups (CMGs), which are similar to DRGs. An IRF Patient Assessment Instrument (PAI) is completed on all Medicare patients, and they use impairment group codes (IGCs) to identify the primary reason for the admission. IRFs cannot code diagnoses from a pre-admission screen, as it’s done prior to admission even though it is signed by the provider. Comorbid conditions are separated by tiers, and coding guidelines for IRFs vary from acute care.

Heather Greene, MBA, RHIA, CDIP, CPC, CPMA,  dove into CDI needs within mental health. She explained that specific conditions should be specified in the documentation, providing examples of major depressive disorder and anxiety as being inherent to certain conditions, and noting that they would not be coded separately. Another example she gave was the need for providers to specify types of withdrawal. Prior authorizations are needed in mental health if a specific diagnosis is approved but then the provider documents another condition; there could be an issue at discharge when billing is done.

Bobbie Starkey, RHIT, CCS-P, focused on data integrity and quality reporting in the emergency department. She explained that professionals in this area may need to start thinking about a query process for nursing documentation in the ED. The evaluation and management (E&M) level is determined by much of the documentation provided by nursing. Bobbie provided some examples of when some services are not coded, as they were missed or the documentation was not complete. Frequent denials are often found to be due to medical necessity and lack of proper modifier assignment. The presentation concluded with the advice that organizations should perform both internal and external audits to identify errors early.

For additional insights from the CDI Summit, click here.