To support a growing focus on quality measures in healthcare, there is a need for improving the precision and completeness of the data used in the analyses.
Complete and accurately coded data is essential, and clinical documentation is the cornerstone of accurate coding. All aspects of the patients’ conditions, treatments and outcomes have to be fully documented, and accurately and completely coded.
The easiest place to see the importance of clinical documentation in quality measures is when looking at “Observed-to-Expected” rates, sometimes referred to as an “O/E” ratio. These are commonly calculated and reported for complications and for mortality. A ratio greater than 1.0 means that the observed events are occurring more often than expected. Failure to completely and accurately document comorbidities will result in a higher ratio implying a lower quality outcome than what may truly be happening. By fully documenting the comorbidities, the quality scores will be more accurate.
The coding department is tasked with ensuring that high-quality data drive the calculations of quality measures. This means creating a complete and accurate set of codes that correspond to the information in the clinical documentation. True, this is generally outside the purview of CDI programs, but CDI managers need to be aware of the impact that the quality of coding has on apparent CDI program performance and on quality measures. In addition to looking at the documentation side, healthcare providers should also spend time auditing and reviewing their coding practices and performance. If it’s not documented, it can’t be coded. But if it’s not coded, it cannot be reimbursed or measured.
So, the most obvious role of a Clinical Documentation Improvement program is to fully document all comorbidities, thereby assuring that the “Expected” part of quality calculations properly reflects the condition of the patient. When CDI programs emphasize the pursuit of increased reimbursement, this important function can be overlooked or missed. There are many diagnoses that will impact the Risk of Mortality (ROM) without changing the DRG or reimbursement; failure to pursue the full documentation of these will have an adverse impact on quality measures that rely on O/E ratios.
Solidifying Quality Measures
So, do you query a physician even if the answer would only impact a quality measure, and not reimbursement? It is disquieting to know that in a recent survey by the Association of Clinical Documentation Improvement Specialists (ACDIS), only 75 percent of the 248 respondents report that they queried this way. This should be 100 percent. It would be interesting in future surveys to find out the reasons underlying this result, as this may reflect an opportunity to education hospital executives on the importance of full and complete documentation and a comprehensive CDI program.
It is also interesting (albeit unsettling) that nearly 38 percent of 237 the ACDIS respondents report that reviewing for quality measures hinders their traditional CDI chart review productivity. This too suggests some opportunities for further clarifications in future surveys. How is productivity being measured, as there are many potential metrics that have been suggested (such as the number of reviews, number of queries, improved reimbursements, increase in Severity of Illness, etc.). This survey response also suggests that many programs consider that working on behalf of solidifying quality measures is not part of “traditional CDI chart review”, when in fact it should be.
Improving the Environment
The following list summarizes some of the activities related to providing the best environment and data for quality measures:
Implement periodic code reviews and audits to ensure accurate and complete coding of the information on the chart.
Ensure that there is adequate documentation (not just orders) regarding do-not-resuscitate (“DNR”) and palliative care status. These are not yet fully incorporated into all quality measures, but are being studied and will start to show up soon, so we might as well get in the habit of doing it now. There are specific codes for DNR (V49.86 for ICD-9 and Z66 for ICD-10) and for palliative (“comfort”) care (V66.7 for ICD-9 and Z51.5 for ICD-10).
Better Data, Better Outcomes
The CDI field has seen a gradual change from reviews and queries done only after discharge to where they are now done concurrently during the hospital stay. Quality measures are also poised to make a similar transition, as we strive to know not only how we were doing six months ago, but how we were doing six minutes ago. This will in turn allow a hospital to focus on improving the quality of care while the patient is still in the hospital, resulting in better outcomes.
All of this is driven by a high-quality CDI program that is concerned about more than reimbursements, and is motivated to develop a complete medical record. And at the end of the day, isn’t better quality and better patient outcomes the goal?
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