CDI and Compliance: Achieving a Balance
Sep 7, 2016
by Dr. Jon Elion

I have discussed the benefits of pursuing the complete medical record, as opposed to simply trying to improve reimbursement, in previous blog entries. I am fond of saying (and usually put this into every presentation I do): If you pursue reimbursement, you will miss the High Quality Medical Record … but … If you pursue the High Quality Medical Record, the proper reimbursement will follow.

If you do a little digging you can find many examples of Medicare and other agencies supporting our efforts to do the best job possible in documenting and coding, for example:

“We highly encourage physicians and hospitals to work together to use the most specific codes that describe their patients’ conditions. Such an effort will not only result in more accurate payment by Medicare but will provide better information on the incidence of this disease in the Medicare patient population.” [Federal Register, Vol. 72, No.  162, Wed. Aug. 22, 2007, Rules and Regulations, pp. 47180—47181]

Medicare is also comfortable with efforts such as Clinical Documentation Improvement (CDI) that can have a positive impact on reimbursement, saying:

“We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record. We encourage hospitals to engage in complete and accurate coding.” [Federal Register, Vol. 72, No. 162, Wed. Aug. 22, 2007, Rules and Regulations, pp. 47180–47181]

Unfortunately, some hospitals have been a bit too creative with their documentation and coding, and have ended up making news headlines at the national level. You may find your hospital on the front page of the newspaper if:

  • an analysis of your coding shows you claim to have a 20 percent incidence of Kwashiorkor (protein malnutrition), encephalopathy malnutrition or sepsis.
  • your CDI consultant promises in writing to increase revenues.
  • the first hour of your first day of CDI training is all about encephalopathy.
  • you are told – “Find one major complication or comorbidity then move on,” or “just query for reimbursement.”

A good hospital Compliance Officer can be a valued ally in keep a balance: getting justified reimbursements on one side of the scale, while avoiding fraudulent billing practices on the other side. Here are three simple steps that CDI programs can take to support their Compliance Officer:

  1. Provide timely concurrent data with information such as lists of patients currently in the hospital who have a diagnosis that has been identified as a potential problem area—before their charts go to the coding and billing department.
  2. Implement “best practices” in CDI queries, and use a library of multiple choice queries that have been fully reviewed and vetted. Be sure that possible responses adhere to AHIMA guidelines, and include all medically reasonable responses, not just those that are associated with the highest reimbursement.
  3. Create a process, preferably automated, for report generation and distribution to support internal auditing and review processes.

When we see your hospital making front page headlines, let’s be sure that it is for the right reason (like bragging about your quality), and not for creativity in documenting and coding.

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