OIG Report: Query Aggressive CDI Practices?

Aggressive CDI practices may account for at least some of their findings

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) wrapped up its investigation into hospital upcoding in February. My first thought when I read the associated proposed plan turned to aggressive clinical documentation integrity (CDI) practices taking place in some hospitals. Was this investigation (and, presumably, others to follow) in some way going to target such programs? After all, clinical documentation integrity key performance indicators (KPIs) often involve complications and comorbidities (CCs) and major CCs (MCCs) capture.

Out of sheer morbid curiosity, I waited with bated breath for the outcome of OIG’s investigation to see if my suspicions were founded. Although CDI was not mentioned in the OIG report, there is a likelihood that aggressive CDI practices may account for at least some of their findings. For example, the report noted the following (bold emphasis my own):

“The number of stays at the highest severity level increased almost 20 percent from FY 2014 through FY 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays. The number of stays billed at each of the other severity levels decreased. At the same time, the average length of stay decreased for stays at the highest severity level, while the average length of all stays remained largely the same.” 

You can read the full report online here https://oig.hhs.gov/oei/reports/OEI-02-18-00380.pdf.

Clinical documentation initiatives are a must in today’s healthcare landscape. The implementation of quality improvement initiatives by the Centers for Medicare & Medicaid Services (CMS), such as value-based incentive payments (Hospital Value-Based Payment Program, or HVBP), the readmission reduction program (Hospital Readmission Reduction Program, or HRRP), and the HAC Reduction Program (HACRP) make such programs absolutely necessary to ensure quality of care.

However, at some point, MCC and CC capture became a metric for which the CDI industry is most prominently known. I vividly recall consulting with a healthcare system where the CDI professionals said MCC and CC capture was “job security.” And let’s be honest: most physicians believe that queries for such capture are all about reimbursement, having nothing to do with patient care. I have had multiple discussions with providers who have said “just tell me what I need to document.”

This cookie-cutter approach to CDI, with an assembly line of MCC and CC capture, surely ripens the field for investigations such as the recently concluded OIG audit, and as evidenced by payer denials.

How did we get here? Whether it was consulting firms advising “best practices” or PEPPER (Program for Evaluating Payment Patterns Electronic Report) and other benchmark data demonstrating what peers are doing (or a combination of both and other factors), we, as a profession, are sitting in the crosshairs of further targets. For example, we are all very well aware of the OIG audit of severe malnutrition, whereby multiple incidences of upcoding (or overcoding) were implicated.

The commercial payers and Medicare Advantage (MA) payers agree, and make no bones about it (no pun intended). Severe malnutrition is an MCC commonly queried for in the medical record, and just as commonly denied by payers.

I remember with horror one such query for malnutrition, wherein the patient’s clinical description was that of a very tall and thin individual with bony prominences. The provider specifically documented that he did not believe that the patient was malnourished; the physical characteristics were due to Marfan syndrome. The CDI professional queried anyway, and managed to get the provider to document “severe malnutrition!” Likewise, I have seen charts where the provider documents “not clinically septic” on every progress note, but the CDI process successfully got sepsis added to the discharge summary!

What has benchmarking done for the industry, such as statistics provided by PEPPER reporting or other data providers? I have to wonder: in this backdrop of payer denials and OIG investigations, is it wise to benchmark against what your peers are doing? I am reminded of the old proverb, “everyone is doing it.” That never went over well with the wise. My parents would say, “if everyone jumped off a cliff, would you?” How apropos is that question to the state of affairs related to MCC/CC capture.

Benchmarking is an unfair comparison, flawed in many respects. There is no exact science the industry uses for benchmarking; however, it is safe to say that multiple assumptions are made in the process. Add to that, the cohort may be over-reporting or under-reporting, with no way to know. Throw in the mix outliers like a pandemic and you are really flying blind! Benchmarking presents a moving target, with no known baseline of the health of the clinical documentation process. Imagine trying to obtain a baseline creatinine level of a patient while looking at all of the other patient’s creatinine levels.

I concur with Terrance Govender, MD when it comes to benchmarking. Even if you are benchmarking against a carefully chosen cohort, you will never be able to do an apples-to-apples comparison of your unique and ever-changing patient population. Benchmarking of capture rates for specific DRGs presents additional challenges, since due to sample size limitations, you are mostly looking at statistical “noise.”

One approach to evaluating the effectiveness of a CDI program is to track and trend payer denials and CDI metrics that granularly report actionable data. That is not to say that the payer is always correct, but it gives a baseline for the provider to identify trouble spots and areas to refocus CDI efforts.

A shift in CDI focus has long been advocated for by my colleague, Glenn Kraus, as well as many others in the industry who encourage severity reporting as reflected by the true clinical picture of the patient – and not by MCC/CC capture alone. This is not to say that all CDI professionals and programs are lacking, but there is increasing indication, in the face of avalanches of clinical validation and audit investigations, that something is amiss.

The future state of CDI remains to be seen, but all evidence suggests we need change. What that change looks like is up to us.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Robin Sewell, CDIP, CCS, CPC, CIC

Robin Sewell, CDIP, CCS, CPC, CIC, is a 25-year healthcare consultant with a background that includes outpatient and inpatient revenue cycle as well as RAC and clinical validation audits on the payer side of healthcare. Robin is the founder and creator of Cleopatra "Queen of Denial" revenue cycle denial management application on behalf of hospitals.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Inpatient Admission Order: Master the Who, When, and How

The Inpatient Admission Order: Master the Who, When, and How

During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.

June 20, 2024
Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

May 21, 2024
Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

June 26, 2024
Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.

July 11, 2024
Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.

June 26, 2024
Mastering E/M Coding: Navigating the Evolving Landscape

Mastering E/M Coding: Navigating the Evolving Landscape

Join industry expert, Kathy Pride, RHIT, CPC, CPMA, CCS-P, for an in-depth exploration of Evaluation and Management (E/M) coding, tailored for healthcare professionals navigating recent guideline changes. Dive into advanced topics beyond mere code selection, including shared visits, criteria for selecting E/M levels, and documentation best practices. Gain clarity on complex guideline terminology and ensure compliance with regulatory standards. This comprehensive session is essential for coders, auditors, educators, and practitioners seeking to enhance their proficiency in E/M coding and maximize revenue capture.

June 19, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Honor Memorial Day with Savings! Get 20% off all items using code MEMORIAL24 at checkout. Shop today and save! Offer valid until May 31. Exclusions apply.

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.