With a shift toward risk-based payments and the transition to ICD-10, hospitals across the country are evaluating their clinical documentation improvement programs. When I meet with CFOs on this topic, there’s never a shortage of questions. I thought I’d share some of the most common questions I heard during the Q&A session at the recent CFO Forum:
Q: Who should own managing CDI?
Robin Brand: There are some organizations where it resides in case management or HIM. However, we really do feel that CDI is a key component of the mid-cycle, so it’s something that should be in the CFO’s world. That’s not to say there’s no dotted line reporting to HIM, or a dotted line reporting perhaps to case management, but we can’t forget that this is a financial initiative.
Q: How do you resolve the tension between the push to manage utilization and increasing documentation to make sure you’re getting accurate reimbursement?
Brand: What we’re trying to do with documentation is not to manage utilization—or increase it. The goal is to accurately capture patient acuity. As we think about the move to population health management, this will be critical. While we don’t want to do extra things on the inpatient side, we want to capture everything that accurately reflects the patient’s care. Beyond the reimbursement aspect, it’s essential to have a more accurate picture of patient acuity and be able to treat them appropriately moving forward.
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Q: Does improved CDI impact payment for Medicare Advantage patients?
Brand: This is a great question. And the answer is yes – absolutely! This is really where the outpatient sphere comes in. Medicare Advantage payments are predicated on HCCs (hierarchical categorical conditions). So, we want to make sure that we’re capturing that and assigning patients to the right HCC. That’s what the risk adjustment factor is based upon—a direct input into Medicare Advantage payments. And it’s naturally the case for a lot of capitated models on the commercial side as well. Payment is going to be based upon patient acuity, so this goes beyond just Medicare. The ability to capture a holistic picture of patients’ conditions is key to reimbursement across capitated models.
Q: How does this set us up for the eventual ICD-10 conversion?
Brand: ICD-10 was the impetus for a lot of organizations to revisit CDI these last two years, and we really do think of it as an opportunity to continue to engage physicians. But it becomes more complex as we’re talking about an increased number of codes. This is where that initial and ongoing training really does come in as a key piece of success.
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