Payment reform is here to stay. Although reimbursement will continue to evolve over the next several years, it’s unlikely that payers—commercial or government—are going to abandon risk-based models and value-based purchasing and turn the clock back to fee-for-service and volume over value. Hospitals must realign key departments to thrive under these new models and improve coordination and communication from the top down. And with so much uncertainty surrounding the future of healthcare, improving the quality and value of care will keep hospitals in shape to meet the changes and challenges to come.
Value, quality, and the medical record
In the new world of pay-for-performance, quality must come first. Organizations that focus primarily on finance and expect the rest to follow need to rethink their strategy. The value and quality of services provided must be supported by the medical record, says Jonathan Elion, MD, FACC, president and CEO of ChartWise Medical Systems in Wakefield, Rhode Island. Documentation and correct coding have never been more important, so organizations should evaluate current priorities and standards to see how they measure up. “Don’t just go after the almighty dollar; go after the quality medical record,” Elion says. “If you go after the reimbursement, you’re going to miss the high-quality record. Just go after the high-quality record; the proper reimbursement will follow.” Organizations can’t overestimate the importance of quality medical records. It’s not uncommon for CMS to base payments for a given year on a previous year’s data, but many hospitals aren’t preparing for the big shift to pay-for-performance. Chief financial officers (CFO) often still focus on areas such as
“Don’t just go after the almighty dollar; go after the quality medical record,” Elion says. “If you go after the reimbursement, you’re going to miss the high-quality record. Just go after the high-quality record; the proper reimbursement will follow.” Organizations can’t overestimate the importance of quality medical records. It’s not uncommon for CMS to base payments for a given year on a previous year’s data, but many hospitals aren’t preparing for the big shift to pay-for-performance. Chief financial officers (CFO) often still focus on areas such as
Organizations can’t overestimate the importance of quality medical records. It’s not uncommon for CMS to base payments for a given year on a previous year’s data, but many hospitals aren’t preparing for the big shift to pay-for-performance. Chief financial officers (CFO) often still focus on areas such as case-mix index that are important to traditional reimbursement methodologies, Elion says. That affects the goals and targets set for other departments, such as coding, that are instrumental in creating data.
Getting hospital CFOs to lead the shift may be difficult, and the factors influencing the decision to focus on traditional reimbursement methodologies should be considered. CFOs typically take a per-quarter look at the organization, and longer-term initiatives will have a tough time competing with actions that keep the hospital on budget today, says Amy Czahor, RHIT, CDIP, CCS, vice president of optimization and analytics services at RecordsOne in Naples, Florida. It can be difficult for CFOs to agree to fund a project that won’t see a return on investment for several years.
“I think that’s the hard part,” Czahor says. “You’re trying to keep the doors open today, and so you have to be able to balance short term and long term.”
Realigning an organization to focus on creating high-quality medical records can be a huge task with many moving parts and requires buy-in from everyone involved. “These are complex issues, and this is not the only thing worrying a CFO,” Elion says.
Everyone who touches the medical record must understand how risk-based and pay-for-performance methodologies impact their role, but some departments will be more affected than others. Coding, CDI, and clinical staff are key players in creating data, and they need solid training and ongoing education, says Steve Robinson, MS-HSM, PA-O, RN, SSBB, CDIP, vice president of clinical revenue integrity at RecordsOne. Staff must keep up with regulatory changes and best practices. This is especially important for CDI, who must know how to phrase queries to ensure the physician understands exactly what information is needed. Only the right questions will lead to the right answers, he says.
“I’m a big proponent for coaching and educating CDI folks in those regulatory environments so they’ll know how to ask the questions,” Robinson says.
Some CDI departments still train staff to target complications or comorbidities and major complications or comorbidities, Elion says, adding that valuebased information may simply not be on their radar.
Although coding, CDI, and physicians all play major roles in creating a quality medical record, cooperation and collaboration between the departments isn’t always easy. Competing reporting structures and departmental targets, plus a frequent lack of communication, can create and exacerbate conflicts.
Coding and CDI must work together to translate physician documentation. Unfortunately, at some organizations, coders and CDI specialists work in departmental silos, and communication may be strained, Elion says. The departments may feel they must compete for credit, but this attitude can foster an adversarial relationship that hurts each department’s performance and the organization as a whole.
But change is in the cards as the roles of coders and CDI specialists evolve. In traditional models, the record is coded after the patient is discharged, but concurrent coding is becoming more common, Elion says.
“When you have a coder involved concurrently, now you can have those two sides communicating and helping each other out,” he says. “That collaboration is essential.”
Coders and CDI specialists may also come from very different backgrounds, and the cultures of the two departments may not easily fit together, Robinson says. The number of remote coders is increasing, and even coders who work on-site are unlikely to have face-toface interactions with clinical staff. CDI specialists, however, regularly interact with clinical staff and may have made the professional jump to CDI from a clinical position such as nursing. Managers and department leaders must set the example for staff to follow, he says.
“It takes leadership to pull them out of that silo,” says Robinson. “It takes good relationships between the leaders of those departments to be able to come together and make it happen.”
Departmental leaders may report up to different executive teams at some organizations, making it even more vital that they forge direct connections, he says. Otherwise, each department may find itself targeting different revenue goals and metrics. “There has to be some harmony,” says Robinson.
A disconnect in reporting structures can throw a wrench into an otherwise well-operating system, Czahor says. She recalls an organization she worked at where CDI reported to quality while coding was part of revenue cycle. “You had 85 inpatient coders, and they were held to productivity metrics and DNFB and getting that down,” she says. “Then you had CDI that reported to quality, and we were supposed to be ensuring that the severity of illness and risk of mortality was maximized on every single patient, while the coders were judged on MS-DRG accuracy.”
CDI specialists at the organization often asked for rebills to ensure the severity of illness and risk of mortality matched, but coding resisted because holding the bills would mean they wouldn’t meet their goals. That kind of conflict undermines an organization’s revenue and leaves both departments at odds.
“The problems is—because of the shift from volume to value—if you let those bills go out the door and those metrics aren’t maximized, then at the end of the year when you start to look at your risk adjustment factors and contracts, it does financially bite you,” Czahor says. “I think both departments feel like they’re caught in the middle.”
Staff work hard to meet their metrics, but when they’re at odds, it takes alignment at an enterprise level to ensure everyone is working toward the same common goal, she says. Value-based purchasing and risk-based payment models inherently tie revenue to quality, and hospitals should begin to look at realigning their coding and CDI departments. Czahor’s former organization developed an initiative to bring quality and revenue cycle in alignment and eliminate competing goals and metrics. The initiative pulled in leaders from beyond coding and CDI to create an enterprisewide approach.
“To continue the status quo is not going to work,” Czahor says. “I think there is an incentive to assure that it’s aligned because, ultimately, if you’re not aligned with the quality metrics, it will impact your revenue cycle.”
One way to bring coding and CDI together takes a page from the clinical world, Elion says. In hospitals, physicians are sometimes paired with nurses in dyads: When the physician makes rounds, he or she knows that specific nurses will be assigned to that physician’s patients. This allows the physician to coordinate the timing of rounds with the nurse, improving communication and quality of care. As concurrent coding becomes more common, some organizations are applying this model to coders and CDI specialists, allowing them to work a case together from start to finish, he says.
Success due to change
Physicians are as essential as coders and CDI specialists to success. They should be included in education, and organizations should evaluate and align standards applied to physicians. A hospital should not enforce one standard of documentation for inpatient documentation and another for outpatient, Elion says, or one standard for commercial payers and another for Medicare. It makes documentation needlessly complex for physicians, undermines education, and can lead to a poor-quality medical record.
“Good documentation is good documentation,” Elion says. “You just need to be careful and complete at every step along the way.”
Sometimes all a physician needs to step up the quality of his or her documentation is a nudge—or even two words, Elion says. “Two words changed my documentation. Those two words are ‘due to.’ ” Using those two words draws a clear connection between the diagnosis and any underlying condition that may be causing it.
Physicians can use another pair of words, “manifested by,” to indicate conditions related to a diagnosis, he adds. For example, a physician could write that a patient has complex diabetes manifested by retinopathy. Making the connections clear boosts the quality of the record for everyone—the coder, the physician, the patient, and other clinicians who may need to refer to the record later.
“In the old days, I could say my patient has a GI bleed and they have anemia,” Elion says. “And today that would drive a coder crazy because I need to say the patient has anemia due to a GI bleed.”
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