Clinical Documentation

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

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 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

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 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.

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 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
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 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
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 Servant Leadership

Coder
Physician

CDI
Team
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Why This is Important to
Physicians

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 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

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Provider Profiling
Episode Groupers
Case Mix Index 0.82 High Cost Index is
Cost Index 1.17 Less Efficient

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 Physician Profiling
United Healthcare - 2010

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 Impact on Physicians
Directions for Healthcare Reform

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 Impact on Physicians
Direction 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

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Source: Medicare Payment Advisory Commission 13
 Pneumonia
MS-DRG Options
• HCAP Pneumonia requiring Zosyn & • DRG 194: With CC – 1.0152
Vancomycin
(*LTC –0.6138)
•DRG 195 w/o cc/mcc– Simple
• DRG 193: With MCC – 1.4796
Pneumonia & Inflammation – 0.7096
(LTC .4864) (*LTC 0.7620)
• Pneumonia prob. 2° pseudomonas &
MRSA requiring Zosyn & Vancomycin – • DRG 178 With CC – 1.4887
Not HCAP (*LTC 1.7176)
DRG 179 w/o cc/mcc – Respiratory • DRG 177 With MCC – 2.0667
Infections & Inflammations - 0.9861 (*LTC.8886)
(LTC 0.5980)

• Sepsis due to Pneumonia

•DRG 871
•DRG 871 – Septicemia or Severe
Sepsis with MCC – 1.9074 •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

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 Cardiac Surgery
Acute Care Episode (ACE) Project

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 CCs & MCCs in ICD-9/ICD-10
CC/MCC Code Description
MS-DRG CC I5020 Unspecified systolic (congestive) heart failure
MS-DRG MCC I5021 Acute systolic (congestive) heart failure
MS-DRG CC I5022 Chronic systolic (congestive) heart failure
MS-DRG MCC I5023 Acute on chronic systolic (congestive) heart failure
MS-DRG CC I5030 Unspecified diastolic (congestive) heart failure
MS-DRG MCC I5031 Acute diastolic (congestive) heart failure
MS-DRG CC I5032 Chronic diastolic (congestive) heart failure
MS-DRG MCC I5033 Acute on chronic diastolic (congestive) heart failure
Unspecified combined systolic (congestive) and diastolic
MS-DRG CC I5040
(congestive) HF
Acute combined systolic (congestive) and diastolic (congestive)
MS-DRG MCC I5041
HF
Chronic combined systolic (congestive) and diastolic
MS-DRG CC I5042
(congestive) HF
Acute on chronic combined systolic (congestive) and diastolic
MS-DRG MCC I5043
(congestive) heart failure
I509 Heart failure, unspecified
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 Medical Homes
HCC 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.
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 Medicare Advantage
HCC methodology — Example
No Chronic
Conditions Metastatic
Protein Calorie Pressure Ulcer,
RISK FACTOR Cancer Lung Bone
Base Malnutrition Hip
Cancer
Payment (PCM)
65 yo Male 0.328 0.328 0.328 0.328 0.328
1.053
Cancer Lung (No Credit for
“Hx of Cancer”)
Metastasis to
2.276 2.276 2.276
Bone
Protein Calorie
Malnutrition
(PCM) 0.856 0.856

Pressure Ulcer,
1.153
Hip
TOTAL HCC
SCORE
0.328 1.381 2.604 3.560 4.713

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 HCC Methodology
HCC
HCC Category Title
Coefficient
Diabetes with Renal or Peripheral
HCC15 0.508
Circulatory Manifestation
Diabetes with Neurologic or
HCC16 0.408
Other Specified Manifestation
Diabetes with Acute
HCC17 0.339
Complications
Diabetes with Ophthalmologic or
HCC18 0.259
Unspecified Manifestation
HCC19 Diabetes without Complication 0.162

Imperative that physicians document diabetic

complications impacting HCC score.

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 2010 IPPS Final Rule:
Quality Measures
● PSI 04: Death among surgical patients with treatable serious
complications
● PSI 06: Iatrogenic pneumothorax, adult
AHRQ ● PSI 14: Postoperative wound dehiscence
Patient ● PSI 15: Accidental puncture or laceration
Safety ● IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or
without volume)
Indicators
● IQI 19: Hip fracture mortality rate
● Mortality for selected surgical procedures (composite)
● Complication/patient safety for selected indicators (composite)
● Mortality for selected medical conditions (composite)
Hospital performance in these
will affect reimbursement after October 1, 2013 20

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 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
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Thank you!

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