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CDI Insights

Clinical Documentation Is Critical for CMS Bundles

Avoiding those dreaded CDI 'gotcha' moments with bundled payments.

On July 25, 2016, Centers for Medicare and Medicaid Services (CMS) announced that cardiac bundles would be added to their existing value-based bundled payment programs for sepsis and joint replacements, the Comprehensive Care for Joint Replacement Model (CJR). These bundles are meant to support the experience of overall care through better coordination, and ultimately better outcomes across an entire episode of care - from before admission through up to 90 days post-discharge as is the case with the CJR model.

Since CMS is directing this bundle initiative toward improved quality of care and reduced costs, we can expect more bundles ahead, including an expanded roster of cardiac bundles. (Click here to see the CMS fact sheet on the proposed bundle rule.)

With more bundles comes the need to capture more comprehensive clinical documentation across the entire enterprise to support coding, billing, quality reporting, cost management and reimbursement distribution spanning the time period of the bundled payment. Certainly, administrative costs are a concern as well. All this begs the question: Considering the new bundled payment options, where are the CDI "gotchas" with CMS bundled payments and how can we avoid them?

More Chart Reviews Ahead

In terms of simple productivity, most organizations have a finite number of CDI specialist (CDIS) resources. If a CDIS must review 15 new admissions per day, say for the cardiac bundle, but there are 100 new patients admitted that meet the CMS criteria, there simply aren't enough hours in a day. As organizations expand their participation in bundled payment programs, it's critical for CDI teams to prioritize cases, focusing only on those admissions that fit both the CMS criteria for the cardiac bundle and have suspected documentation issues within the chart.

SEE ALSO: Data Quality Drives Data Integrity

Are you avoiding pitfalls when it comes to bundled payments?It will be critical to focus on trends for specific documentation gaps as we shift from case mix monitoring to watching quality outcomes for bundled-payment patients. For example, CDI teams must know which cases and physicians are most notorious for documentation insufficiencies. Continually evaluating the query process and associated query rules is another critical step within the CDI process to stay ahead when participating in bundled-payment programs.

Finally, most EHRs have analytics and alerts to recommend documentation queries. Be sure to take full advantage of EHR documentation triggers to steer you in the right direction. One key to minimizing administrative costs associated with burgeoning charts reviews will be maximizing technology.

There are three important steps to consider for effectively managing CMS bundles.

Step One - Know Ahead of Time

Within a specific patient subset, in this case the cardiac bundle, the first step is to analyze cardiac and thoracic surgeon documentation by physician, ahead of time, before participation in the bundle begins. Know which physicians have the most complex procedures and identify specific trends in their documentation for education and monitoring. Also, take a look at the typical codes used in their respective procedures post discharge, and compare coding to CMS guidelines for each bundle to identify any additional documentation or codes that might be included.

Doing all this ahead of time is preparation for the queries and documentation requirements for future patients participating in the CMS bundles. Think of it as laying out the roadmap before you depart on the journey!

Step Two - Put Proactivity in the CDI Process

Equipped with information on the procedure and physician trends, you are ready to move to step two. Use technology to help identify encounters where patients meet CMS bundle criteria and there's a strong propensity for documentation gaps - before the case is documented and coded. Technology tools could include EHR alerts as mentioned above or natural language processing (NLP) text mining.

These applications flag patients at the front end, before documentation becomes an issue. You can gather what you need at each step of the process, rather than backtracking to fill gaps after the fact.

To do this, be keenly aware of where your technology falls short. Work closely with your vendor and IT team to strengthen the tool and make it more proactive. Provide specific recommendations with regard to strengthening the queries and setting documentation alerts.

Here are three specific tactics to consider:

1. Get clarification on the chart early, to alert the entire care team and so the bundle is not miscoded.

2. Locate clinical indicators and buzzwords that indicate the potential for the case to move into the bundle and be earmarked with issues at final coding (particularly helpful for participation in the sepsis bundle).

3. Inform the attending physician of participation in the bundle and offer your expertise proactively and from a consultative position.

This step is an opportunity for the CDIS to collaborate with the physician, rather than do things to them. In this way, CDI teams become physician advocates, rather than adversaries. There is an opportunity for CDI specialists to become a source of information and education for physicians, and a critical part of the care team.

Here's an example involving sepsis. The sepsis bundle criteria states lactic acid levels of 2.0 or greater potentially meet the severe sepsis criteria. A level over 4.0 meets septic shock criteria. By seeing an elevated lactic acid level in the EHR alerts, the CDI specialist could review the case, look at other clinical indicators, flag the patient to watch, and clarify with the doctor - is this patient in septic shock? Subjective assessments by the RN can also trigger an alert. It's one more way to be proactive, rather than reactive.

Step Three - Conduct Targeted Physician Education

As the bundle process sets in, you'll start to see clumps of queries by both topic and physician. What are the queries for the cardiac bundle? What cases had documentation gaps? Where are the opportunities for improvements? In establishing a continuous feedback loop to the medical staff, specialty by specialty, you can begin to shift patterns.
 
Reporting to both executives and physicians is essential. Let them know where they successfully met criteria and metrics, and where they need to improve. Remind physicians that documentation drives quality reporting and national score cards, while also preventing denials for the hospital and potential OIG audits for their practices. Empower physicians with information so they see how their documentation is driving value-based care.

Move Toward Greater Collaboration

With the new bundle models, coordination of care across departments and functions must become more collaborative and less bureaucratic. We already see silos breaking down between departments such as patient access, CDI, coding and billing within organizations participating in the CJR model. Transparency and teamwork become the norm - rather than the exception - under bundled payment models. Clinical documentation drives this ship, and plays a starring role in the success of CMS bundles.

Amy Czahor, RHIT, CCS, CDIP is vice president of optimization and analytics services at Records One She was the former regional CDI program director for Sutter Health in Sacramento, California and has over 13 years of HIM experience.

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4 Physician Education Tips

1. Physicians are subject matter experts on providing care. CDI specialists are subject matter experts on translating that care into clinical documentation and codes. We are partners (not adversaries) in providing patient care - our combined expertise necessary for a favorable outcome.

2. Highlight what physicians are doing well. Show them examples of a good report, and a positive score card, based on solid clinical documentation.

3. Explain key query metrics at a staff meeting to show CDI trends, and then provide recommendations for improvements. Having a strong example of the right way to document is always helpful.

4. Relate the CDI process to a topic physicians are passionate about, like mortality rates. If you can show a link to something that gets their attention, it will create a greater sense of urgency to ensure correct documentation.

- Amy Czahor

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