The Cherry-Pickers Are Back
Sep 23, 2015
by Dr. Jon Elion

Up to now, we have been under the impression that the field of Clinical Documentation Improvement has been moving away from the outdated practice of just trying to improve reimbursement. The unfortunate practice of “Find an MCC and Move On” that was so prevalent several years ago had seemed to have faded away.

Newspaper headlines have been replete with stories of hospitals being investigated for inexplicably high rates of sepsis, malnutrition, malignant hypertension or encephalopathy. While this bad press represents a small minority of institutions, the notoriety stains the entire field, and keeps our compliance officers up at night. But I thought these episodes had started to recede in number.

But now a new disturbing trend seems to gaining momentum. Namely, the practice of cherry-picking admissions for review to maximize results. A recent trade journal article proudly announced that a hospital system added $20 million in revenue by tightening clinical documentation. The article goes on to describe that “they developed a prioritization tool that helps CDI reviewers triage daily case assignment to determine which patient cases would most benefit from documentation review”.

Another organization proudly presented their approach at a recent conference, describing how they use Natural Language Processing (“NLP”) to read over all the charts and to derive a priority score for each potential review. Those scores are then sorted in numerical order show those cases having the highest likelihood of needing a query or queries.

If you wanted to devise a scheme for waving the red cape in front of outside auditors, this seems like a good way to do it. CDI programs should strive to review all targeted admissions, and be prepared to show that the queries sent represent a broad range of DRGs and diagnoses, not simply those associated with the highest increase in reimbursement.

As we move into the world of risk adjustment, cherry picking is going to be less and less effective. For example, if you cherry pick your most “acute” patients based on admission codes, patients with chronic conditions are likely to to be missed or overlooked. A DRG with a high weight does not necessarily equate to a high level Risk Adjustment Factor (“RAF”) score. Remember, most “acute conditions” don’t map to a Hierarchical Condition Code (used to derive the RAFs); it’s those “chronic” conditions that make a major contribution to moving the RAF score.

The Association for Clinical Documentation Improvement Specialists has a Code of Ethics that is “based on core values and broad ethical principles that professionals can aspire to and use when making a decision or choosing a course of action”. The practice of cherry-picking runs contrary to the guidance provided in that document which states that “CDI policies should be designed to promote complete documentation”. Cherry-Picking puts you on the Highway to the Danger Zone, not the road to enhancing your CDI program.

 

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