Urology Coding Alert

CDI:

Establish an Effective CDI Program With Expert Knowledge

Published on Wed Nov 10, 2021

Remember: Involve providers from beginning to end.

At the 2021 RISKCON session, “Establishing an Effective CDI Program,” instructor Amy C. Pritchett, AAPC Fellow, BSHA, CCS, CPC, CPC-I, CANPC, CPMA, CASCC, CDEO, CRC, CMPM, CMRS, CEDC, C-AHI, shared helpful information about how to build a robust clinical documentation improvement (CDI) program in your practice. For example, she taught how to measure the effectiveness of your CDI program, as well as how to properly query your physicians.

Apply this expert knowledge to create a successful CDI program today.

Certain Factors Drive Effective CDI Program

The golden rule of coding is that if it is not documented by the physician or provider, it didn’t happen, Pritchett said. Documentation has never been as important as it is in today’s facilities and physician’s offices. Documentation is critical for painting a picture for insurance and CDI alike about the patient during an encounter.

Certain factors will drive an effective CDI program, according to Pritchett. They are as follows:

Documentation specificity to support medical necessity
Coding accuracy
The assignment of hierarchical condition categories (HCC)
Satisfaction of the patient
Quality incentives
Benchmarking goals

Use These Measurements and Metrics

You can measure different aspects of your CDI program, Pritchett said. Measurements and metrics include the following:

1. The rate of review: This takes into consideration how many patients were discharged and how many of those charts were actually reviewed. Also, in a CDI program, you should ask: What are some of your largest risk areas?

2. Rate of physician query: For example, if you had 200 discharges last week and queried 191 of those, what are you doing wrong? Pritchett asked.

3: Agreement rate: How often does the CDI agree with a query?

4. HCC capture rate

5. Denial rate

6. Provider and patient satisfaction

Follow Essential Rules for Your CDI Program

You should keep several rules in mind when it comes to your CDI program, Pritchett said.

First, providers should always be involved in your CDI program from beginning to end.

Also, you should have skills on your team that range from clinical expertise to coding expertise.

Next, you should always follow the Association of Clinical Documentation Integrity Specialists (ACDIS), American Health Information Management (AHIMA), and Practice Brief updates.

You should also maintain regular reviews by nonbiased experts such as physicians, clinical staff, coders, billers, and admin staff who are not part of your CDI team. “This does two things,” Pritchett said. “It gives you a fresh perspective on your CDI team and makes sure that peer review is going on and those queries are actually being legitimately posed to the physician.”

Finally, you should have written policies and procedures, which is a really important step, according to Pritchett.

“Policies and procedures indicate when and why to query a physician,” Pritchett said. “For example, I have seen in my career all sepsis encounters on hold for the physician’s query. All sepsis claims. This is not proactive.”

As a coder you should not have to code the chart then place it on hold for CDI review retrospectively, Pritchett added. Instead, for effective CDI, you should be working with the physician during the patient encounter for clarity, concise documentation, and the underlying condition documentation.

“I’ve also seen cases where the physician was non-specific on sepsis, the laboratory results were positive while the patient was in-house, and it’s still not documented,” Pritchett said. “This is really important because not only is sepsis categorized by the type of infection or ‘due to a bacterium,’ but also unspecified codes are bad and frowned upon by Medicare, Medicaid, and most commercial payers.”

Learn How to Query a Physician the Right Way

Pritchett also discussed when you should query your physicians and how to query the right way.

Reasons you should query your physician include the following:

There is a disconnect between physicians and coders.
Many definitions in the CPT^® and ICD-10 are different from the way physicians learn to document.
There is no documentation or lack thereof to support the billing and or claim charges.
The documentation does not meet medical necessity.
Documentation by the physician is conflicting, contrasting and/or ambiguous.
Office of Inspector General (OIG) audit findings of Diagnosis Related Group (DRG) reporting
Recovery Audit Contractor (RAC) findings
American Health Association (AHA) Coding Clinic guidance and quarterly updates

When to query your physician: Querying usually occurs during the health information management (HIM) coding process, according to Pritchett.

Different types of queries include the following:

1. Concurrent: This type of query is initiated while the patient is still on the floor of the hospital and encourages timely, accurate, and reliable responses from the physician.

2. Retrospective: Additional info is available in the medical record. A short stay where the concurrent review could not or was not performed.

3. Post-bill: This happens after the claim is submitted or the claim is paid. A post-bill query occurs as a result of an audit or internal monitoring

When it comes to querying, you must make sure that you are not leading your provider, Pritchett cautioned. Leading is defined as implying there is an expected answer to your question or providing the expected answer to your question.

Pritchett provided an example of a leading query you should avoid: “Hi, Dr. X. If the diagnosis for Mr. Smith is sepsis, then document sepsis due to a urinary tract infection (UTI). This would ‘up’ the DRG to 678 from 677, and the reimbursement difference would be greater by $2,818.00. As it stands right now, the reimbursement is only $5,798.10.” This is an example of what not to do because you are breaking the cardinal rules of querying a physician: talking about DRG and money, Pritchett said.

Questions to ask when querying your provider: When you query your provider you should ask yourself the following questions, Pritchett said:

1. Was the physician to whom the query posed involved in the direct patient care?

2. Are there policies and procedures that guide the diagnosis suggestion process?

3. Can my facility, ambulatory surgical center (ASC), or physician’s office defend the query process? Remember that your queries become part of the medical record. You need to be able to defend why you asked for additional information from your physician, Pritchett added.

Editor’s note: Want more great coding info like this? You can register for the upcoming educational events here: https://www.aapc.com/resources/events.aspx.