There have been many articles over the years published about the importance of physician specialties communicating and coordinating patient care. The result is a shared knowledge of care plans, timely discharges of patients, and improved clinical outcomes. Various models were implemented as facilities adopted the use of intensivists or hospitalists acting as “captains of the ship.” There is an opportunity to duplicate this model between coding, CDI, and the medical staff. Such a collaboration can reduce documentation issues and improve revenue flow by reducing denials.
Three areas where there is potential for a large impact by utilizing a combined collaborative model are:
Documentation requirements for accurate reflection and code assignment have become much more complex with the initiation of the ICD-10-CM and ICD-10-PCS code sets. These code sets are based on high levels of specificity which, if not initially documented by the physician correctly, result in numerous concurrent and post-discharge queries. These queries not only delay final billing and reimbursement, they can be a source of frustration for the physicians.
Many facilities have a program where the coder and CDI work together on documentation and DRG reconciliation. CDI’s are often tasked with monitoring for concurrent documentation needs and querying the physician if further specificity is needed. Likewise, retrospective queries are performed either by coding or CDI. Because the physicians also play the most important role in documentation, facilities should consider enlisting the help of physician champions – those physicians who understand the importance of detailed documentation and are willing to work with coders and CDI staff along with medical staff to make improvements.
Healthcare organizations across the country have been experiencing clinical denials from payers resulting in a lower MS-DRG reimbursement. Some of the most common denials are for acute kidney injury and acute respiratory failure as principle or secondary diagnosis. Although the ICD-10-CM/PCS Official Guidelines for Coding and Reporting state that clinical indicators should not be used in determining if a diagnosis should be reported, payers still compare the clinical picture to the indicators as the basis for their denials. Enlisting the assistance of a physician in the denial/appeal process can be extremely beneficial because of the level of clinical knowledge and ability to detect nuances in the treatment in support of the denied diagnosis. Having a physician champion is also helpful in the appeal process if dealing with a physician reviewer on the payer side.
Focus areas of improvement can be developed from various sources. Coding and CDI can rank problematic diagnoses based on denials from outside payers and the top five or 10 reasons for concurrent and retrospective queries. Using this data, coding and CDI professionals can work with the physician champion to develop education and documentation guidelines for the medical staff to ensure clear, concise representation of the diagnoses in question. The diagnosis of AKI not meeting RIFLE*criteria, type and acuity of heart failure (systolic, diastolic, combined, acute, chronic), presence of acute respiratory therapy, depth and type of wound debridement are just a few of the high risk/high volume areas where facilities see the most external denials or internal queries.
The last area of impact that is extremely important for a successful collaboration is education. All of the work done to this point is important but will not promote change unless all of this information is shared with the entire medical staff (including residents and medical students) and their associated allied health professionals. This can be done within specialty meetings, grand rounds, or by working with Medical Staff Education to develop small educational seminars.
Successful collaboration of the three main stakeholders and promotion of the information to medical staff will result in a better understanding of the documentation requirements for correcting coding and reporting and will also have a mitigating impact on retrospective denials.
*RIFLE criteria – Risk, Injury, Failure, Loss, End-stage – grades of severity for classification of acute kidney injury with specific parameters in determining the presence of the injury based on acute rise and duration of a patient’s serum creatinine.
Robyn McCoart, RHIT, Managing Auditor Excite Health Partners
Reference: Hughes, Piper Julie, MD. Updated 8/7/2018. What Are The RIFLE Criteria for Acute Kidney Injury (AKI)? Retrieved 6/30/2020