Clinical documentation improvement (CDI) initiatives are underway in healthcare organizations across the country, with the aims of improving care and reducing costs. Are they working? At least one such initiative, at Baptist Health South Florida, is providing solid return on investment.
"Like all health systems, we are trying to do things better, and the better we document and code, the better we may be reimbursed, but what we learned over the years is, the best way to protect ourselves is to have the most accurate documentation," says Ralph Lawson, executive vice president and corporate CFO of Baptist Health South Florida, which has 13,000 employees working in six hospital campuses and satellite locations. "We don't want up-coding or down-coding. We want the best clinical documentation."
Baptist's CDI initiative consists of two elements: the use of tools that facilitate documentation in realtime, and the employment of physicians as clinical documentation specialists who ensure documentation is being done correctly and help train caregivers in documentation.
Baptist launched its CDI program in October 2011. The first step was selecting a clinical documentation improvement vendor who could provide the tools needed to create more accurate documentation and ultimately improve reimbursement. The vendor it chose contractually guaranteed a 4-8 percent increase in case mix index (CMI).
"When we started the CDI program, quality improvement wasn't new for us, but it became a formalized program in October 2011," says Eric Shatanof, Baptist's corporate vice president of managed care and network development. "Ten to 15 years prior to that, we had physicians do queries after care delivery. The benefit of having the CDI program on the front end of care delivery is that we can educate in a more real-time way to improve clinical documentation."
The tools the vendor provided were interfaced with the system's electronic health record and allow the clinical documentation specialists to work in realtime and fine-tune their training where it is most needed, Shatanof explains. The tools help documentation specialists determine if the documentation specificity is sufficient to support the diagnosis and procedure codes. Accuracy in these areas is important to mitigate some of the risks associated with outcomes-based payment systems (see the exhibit below).
Risks of Outcome-Based Reimbursement
Those tools paid off quickly: "We saw our return on investment in just six months," says Lorena Chicoye, MD, corporate medical director of managed care, who oversees Baptist's CDI initiative.
Another element of Baptist's CDI program is the employment of CDI specialists and clinical care providers who collaborate with senior management to ensure the right information is available at the right time. This includes accurate documentation of patient condition and diagnosis, and documentation of the medically necessary procedures recommended and provided.
"We use international physicians as clinical documentation specialists because doctor-to-doctor communication works best when making suggestions about what they should do differently," Chicoye says. "We recruit physicians who are medical graduates, ready and waiting to get into residency programs-some are working as secretaries or Uber drivers."
Chicoye says that using the physicians as clinical documentation specialists has reduced physician resistance to CDI, because they use the same clinical terminology and can speak with authority.
"Also, when we use physicians from a country that adopted ICD-10 before the U.S., we gain from their knowledge," Chicoye says. "For example, a physician from South Africa who has experience with ICD-10 can be of more help, though we know that there are differences [between] the U.S. and South African ICD-10 implementation."
The results of Baptist's CDI initiative have included improvements in several key measures, showing a solid ROI.
"Once the clinical documentation programs were up and running in the hospitals in Miami, it was amazing how much more documentation Baptist was able to capture and how much more specificity was realized," Chicoye says. "The severity of the problem, and quite frankly the recoupment of monies not being billed properly because the documentation was not there before the CDI program, was notable. You cannot bill what is not there."
Accurate and specific documentation is essential in value-based care measures such as merit-based incentive payment systems, Shatanof notes (see the exhibit below).
Clinical Documentation Improvement Opportunities
"In value-based care and population health initiatives such as Medicare Advantage as well as Accountable Care under the Affordable Care Act, accurate documentation in the physician office is critical to enable correct risk adjustment of the patient using HCC groupings," Chicoye says. "We don't up-code. We train them to document care in the right way, with the right level of severity. For example, I tell the docs at our health system that the symptoms for urosepsis could look like a UTI [urinary tract infection]. However, clearly sepsis is a higher-severity illness than a UTI.
According to Chicoye, "Why that matters to physicians is that if a female senior patient from the nursing home comes in and you treat her in the ICU and she dies, you look like you killed her when she had a bladder infection. No one goes to the hospital or the ICU with a UTI."
Baptist improved its severity-of-illness reporting measure from 8 percent to a 17.1 percent capture rate, and its risk-of-mortality measure from 7.7 percent to 14.5 percent. "Both increases are over double, all in just a four-year period from 2011 to 2015, showcasing the strength of growth and improvement in quality and reimbursement," Chicoye says.
Baptist's CMI also substantially improved.
"At Baptist Hospital of Miami, specifically, the baseline Medicare case mix index for the first year of the program was 1.66, a 6 percent increase from initial implementation. By 2015, the case mix index reached 1.74," Chicoye says. "The initial 6 percent uptick in case mix index translates into $15 million to $20 million in revenue per year."
The bottom line for the program was an ROI of greater than 5 times, Lawson says, broken down this way:
Not all improvements that resulted from the CDI initiative are measured in dollars. For example, physician engagement in documentation has improved because of the program, Lawson says.
"Today, physician responses that confirm the accuracy of documentation from all of our hospitals to our CDI queries is more than 90 percent, and our CDI review rate is just about 80 percent, which reflects the buy-in we have from our physicians," Lawson says. "In addition, our response to CDI queries is about 98 percent year to date as of 2015, which far exceeded our benchmark of 80 percent."
Here are four key takeaways on CDI from Baptist Health South executives:
Ensure that both financial ROI and patient benefits are part of the justification for the program. A focus on quality patient care encourages strong engagement leading to improved performance and financial results.
Use clinicians to engage clinicians. Physicians and nurses feel most comfortable in peer-to-peer sharing and education.
Position CDI as a quality and accuracy program. Quality-focused CDI is about integrity and accuracy of the progress note. Make sure providers understand CDI is not about increasing revenue for the hospital, even though it may be an indirect by-product of quality enhancement.
Break down the silos. CDI, coding, and quality are often in different departments. Organizations should strive to break down any silos that exist to encourage collaboration. Use business road maps including all relevant stakeholders to prioritize the work and ensure communication.
"The most important thing about our CDI program is that we are coding accurately," Lawson says. "I sleep better at night knowing Baptist is executing well on CDI."
Interviewed for this article: Lorena Chicoye, MD, is corporate medical director of managed care, Baptist Health South Florida, Coral Cables, Fla.
Ralph Lawson is executive vice president and corporate CFO, Baptist Health South Florida, Coral Gables, Fla., and a member of HFMA's Florida Chapter.
Eric Shatanof is corporate vice president, managed care and network development, Baptist Health South Florida, Coral Gables, Fla.
Michael F. Arrigo is the managing partner for No World Borders. He has served as an expert along with a team of PhDs in economics and computer science, clinical professionals, a premier litigation firm in New York, and a large publicly traded healthcare IT firm in a matter before the U.S. Federal Trade Commission and several State Attorneys General. He is retained by the U.S. Department of Justice involving a False Claims Act investigation. He has presented before the FBI, U.S. HHS Office of Inspector General (OIG) and Assistant U.S. Attorney while retained by counsel for a defendant.
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