The Importance of Baseline Metrics
Feb 10, 2015
by Dr. Jon Elion

This above all: to thine own self be true,

And it must follow, as the night the day,

Thou canst not then be false to any man

     – William Shakespeare

Clinical documentation should include a thorough record of all of the diagnoses for the patient (past and present), symptoms experienced, treatments and procedures planned and executed, all of the care provided, and the outcome of the treatments. This documentation naturally evolves and develops during a hospital stay, thereby presenting a challenge when trying to measure the impact of a Clinical Documentation Improvement (CDI) program.

A useful concept that helps in this measurement is the Baseline DRG, defined is the DRG that would have been coded and billed without the intervention of the CDI staff. The impact that CDI has on a patient’s chart is then measured as the difference between the Baseline DRG and the Billed DRG (either the weights or the reimbursement).

Selection of the Baseline DRG should be done carefully, honestly, and precisely. It is important that you have control over the designation of the Baseline DRG, and not leave this to automation or to non-medical staff (such as the clerk at the admissions desk).

The problem in determining the Baseline DRG and the impact of the CDI program is illustrated by the following example:

  • The patient presents with abdominal pain. While it is not desirable to code from just symptoms, if you did it would result in DRG 392, “Esophagitis, Gastrointestinal and Miscellaneous Digestive Disorders without MCC”, with a representative reimbursement of $5,008.
  • Further testing reveals cholecystitis, which would be DRG 446, “Disorders of the Biliary Tract without CC/MCC, and a reimbursement of $5,175.
  • Due to a low eGFR (20), you query for the stage of Chronic Kidney Disease (which would be Stage IV CKD, a CC). If the physician agrees and documents this, the DRG would be 445 “Disorders of the Biliary Tract with CC” with a reimbursement of $7,464
  • Patient requires surgery on the gallbladder, and undergoes a laparoscopic Cholecystectomy. This results in DRG 418 (“Laparoscopic Cholecystectomy without common duct exploration with CC”) and a reimbursement of $11,868
  • 48 hours post-operatively, the patient has a severe episode of shortness of breath, diagnosed and documented by the consulting Cardiologist a acute-on-chronic systolic Congestive Heart Failure. This corresponds to DRG 417 “Laparoscopic Cholecystectomy without common duct exploration with MCC”and a reimbursement of $17,478.

So, what is the impact of the CDI program for this patient? It is tempting to say that the impact is $12,470, which is the difference between the initial diagnosis and DRG ($5,008) and the final billed DRG ($17,478). And, this is what would be reported by software that picks up the initial diagnosis for its analysis. But in reality, the surgeon did not operate because a query was sent, so CDI can’t take credit for that. And, the documentation for the MCC designation came unprompted from the Cardiology consult. So, the impact that the CDI process had on this particular patient is $0!

Of course, responses from queries like the CDK stage query may impact Severity of Illness or Risk of Mortality. Such queries are vital to fulfill our role in producing the complete and high-quality medical record, as was discussed in a previous blog entry.

Concept of the “Baseline CMI”

  • The Baseline DRG is that DRG that would have been coded and billed without our intervention
  • While not traditionally done, the Baseline DRG can be used to compute a Case Mix Index
  • The Baseline CMI gives us a direct measure of how the physicians are doing on their own
  • A rise in the Baseline CMI reflects the “training effect” as a side-effect of having a CDI program

Training Effect Shown by Initial CMI



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