The Documentation and Coding Adjustment (DCA): A CDI Specialist's View
This
week, I am pleased to present Donna Wright, MSN, RN, CCDS, currently a medical
coding data analyst at M*Modal, formerly a Clinical Documentation Improvement Specialist for a health system here in Pittsburgh. Donna has a 28-year-long
nursing career and has worked in a variety of fields including critical care,
OR, clinical research, and supervisory/management in long term care. She is a graduate
of Lehigh University, St. Luke's School of Nursing, with a BSN from Slippery Rock
University and MSN in Informatics from Walden University. Donna is married to a structural engineer and
has two grown children.
Donna
brings up some interesting points in her post about clinical documentation
improvement and the stance CMS has taken with respect to changes in reimbursement levels resulting from documentation improvement. I
visited a provider two weeks ago who told me, “we are only asking to be paid for what
we are actually doing - no more and no less." What does everyone think? Do
you have a story to tell about CDI in your organization?
Please allow me to introduce Donna Wright, MSN, RN, CCDS. Thank
you Donna for your insights!
I
am a certified clinical documentation improvement specialist, one of a group of pioneers hired into the new CDI program in October of 2005 at one of the West
Penn Allegheny Health System (WPAHS) hospitals where I spent four-and-a-half
very successful years. I am a member of AHIMA (American Health Information Management
Association) and ACDIS (Association
of Clinical Documentation Improvement Specialists). Both organizations do a
great job of keeping their members informed of updates and I rely on their
publications and emails to stay current in health information and documentation
improvement. On August 3rd, members received a “flash” email with the FY 2012 Inpatient Prospective
Payment System (IPPS) final rule, which updates yearly changes in Medicare
payments to short-term and long-term acute care hospitals. This email contained
the very surprising news that the Documentation and Coding Adjustment (DCA)
would be reduced to 2%, instead of making the expected increase to 3.15%. The
DCA, as you will see later, was enacted in 2008 by the Centers for Medicare and
Medicaid Services (CMS).
Before
I discuss the DCA, let me explain what a Clinical Documentation Improvement
Specialist (CDIS) is and what we do. We are clinicians, mostly nurses, with a
minimum of 5 years of nursing experience and a bachelor’s degree. Hospitals, in
an effort to improve physician documentation and more accurately reflect the
severity of illness and use of resources, have turned to documentation
improvement programs. Hospitals can create their own programs or use consulting
services to train CDIS’ and coding professionals. CDIS’ are taught about
diagnosis related groups (DRGs), coding principles and practices, Medicare
rules, and documentation improvement strategies. Our program was very
successful, recouping thousands of dollars in payments that would have been
otherwise missed. Coding professionals know all the coding rules but they do
not see the chart until after discharge; also, coding professionals are highly
trained but do not have clinical expertise. CDI specialists are clinicians
(usually nurses) who “speak” the same language as physicians and understand
their documentation nuances. Combining our medical knowledge with our CDI
training allowed us to review charts and find opportunities to improve
documentation while the patient was still in the hospital. Coding professionals
often find clarification issues, but not until after discharge, and physicians
may not want to update their documentation after “Elvis has left the building.”
CDI specialists can catch the physician in person, by phone, or by email, query
about ambiguous or incorrect documentation, and improve the quality and clarity
of the documentation while “Elvis” is still in the bed.
For
example, “hyponatremia” is a low sodium count in the blood. Hyponatremia can
complicate the patient’s recovery and it requires some additional treatment and
monitoring. A physician may write in his progress note “Na 119” or Na with a
“down arrow” drawn next to it. He orders an IV of normal saline and a repeat
serum sodium in the morning. When this chart gets to the coding professional,
he or she cannot code the hyponatremia because it is not stated explicitly. The
CDI specialist, however, can review the chart and leave a query for the
physician, asking what the implication of “Na 119” or “Na down arrow” is, based
on his documentation and orders for IV normal saline and lab tests (doctors
would occasionally look at me with “duh” clearly written across their faces,
but if the word “hyponatremia” is not in the chart, it cannot be coded).
That’s
a simple example. There are other conditions that are implied in physician
notes but not stated explicitly. There are conditions and situations that are
gleaned from other clinician’s notes (nurses, therapists, nutritionists) and
that can change the patient’s DRG and increase the reimbursement as well as
make the documentation more correct. Coding professionals can only code from
physician documentation, and unless a physician reads all the notes in the
chart and then comments on them, he or she may miss something that, if coded,
could increase the reimbursement or spare the hospital from loss of
reimbursement. As an example, a physician’s H & P might not mention that
the patient was admitted with a Stage 3 pressure ulcer of the left heel;
however, the nurse’s admission assessment contains the information. The CDI
specialist discusses this with the physician, who then writes it in the
progress note. The hospital is now “off the hook” for that pressure ulcer,
because it was documented and verified as being present on admission. The
presence of that pressure ulcer increases the severity of the patient’s
condition and requires the use of additional resources, and since hospitals are
not paid per resource but by a lump sum for a diagnosis, the increased severity
rating will increase the reimbursement and cover the cost of the additional
treatment. The CDI specialist helps the coding professional be more productive
because the coder no longer has to put the chart on hold for clarification, or
spend time searching the chart to find Present on Admission criteria. The CDI
specialist has also helped clarify the principal diagnosis, saving the coding
professional time and increasing their productivity.
The DCA
In
FY 2007, the DRG system was expanded from 538 to 745 MS-DRGs (Medicare Severity
Diagnosis Related Groups), to better reflect severity of illness and expected
risk of mortality. MS-DRGs depend on accurate identification of the principal
diagnosis and co-morbid conditions.
Present on Admission indicators were implemented in October of 2008,
making accurate documentation even more important for coding and for reporting
severity of illness in an in-patient population. In the FY 2008 IPPS final rule,
the CMS indicated:
“For
purposes of the impact analysis, we also assume a 1.2 percent increase in
case-mix growth, as determined by the
Office of the Actuary, because we believe the adoption of the MS–DRGs will result in case-mix growth due to
documentation and coding changes that do not reflect real changes in patient severity of
illness.” (Federal Register, vol. 72, no. 162, August 22, 2007, pg. 66923.)
CMS
instituted the DCA to adjust for improved documentation.
The
DCA, the Documentation and Coding Adjustment, is an across-the-board percentage
decrease in payments to all hospitals. The DCA increases incrementally each
financial year. In FY 2008, the DCA was 0.6%; in 2011 it was 2.9% and in 2012
it was to be 3.15%.
When
CMS proposed the 2008 IPPS rule, they reiterated that improved documentation
practices were legitimate and to be encouraged:
“We
do not believe there is anything inappropriate, unethical or otherwise wrong
with hospitals taking full
advantage of coding opportunities to maximize Medicare payment that is
supported by documentation in the
medical record…We encourage hospitals to engage in complete and accurate coding.” (Federal Register, vol.
72, no. 162, August 22, 2007, pgs. 47180-47181).
Prior
to the release of the 2012 IPPS final rule, the ACDIS (Association for Clinical
Documentation Improvement Specialists) advisory board submitted their comments
regarding the DCA to the CMS, protesting the implementation of the DCA. The
board noted that “the current methodology of a uniform, across-the-board
reduction unfairly penalizes hospitals with true rises in patient severity and
actual case mix.” The board also noted that the DCA, coupled with RAC audits,
forces hospitals to pay back monies twice to CMS. (ACDIS Journal, July 2010,
ACDIS comments to CMS on FY 2011 IPPS proposed rule, pgs. 9-11).
CMS
announced in its final rule release of IPPS for 2012 that it was cutting the
DCA to 2.0%. However, the IPPS final rule also states that “the CMS understands
the burden the DCA places on facilities, but still considers the adjustments
necessary to correct past overpayments due solely to documentation and coding
improvements.” The final rule notes in
comments and responses that MedPAC (Medicare Payment Advisory Commission) may
have used faulty assumptions to conclude that changing the DRG system resulted
in overpayments of as much as 5.9%. You can read these comments and responses
in the Final Rule, pages 77-101, http://www.ofr.gov/OFRUpload/OFRData/2011-19719_PI.pdf.
As
a CDIS, I find this CMS statement to be at odds with their stamp of approval of
documentation improvement as outlined in the FY 2008 IPPS final rule. Every
financial year, the CMS has been decreasing the amount of reimbursement by
decreasing the relative weights of DRGs and cutting back on the co-morbid
conditions that note increased severity. CDIS’ have had to work harder to find
co-morbid conditions and documentation opportunities to offset these decreases.
Even modest gains in severity of illness and the case mix index are demolished
by application of the DCA. Decreased payments to hospitals means cuts in
services to patients.
There’s
an element of unfair punishment in the statement “..necessary to correct past
overpayments due solely to documentation and coding improvements.” There is an
implication of wrong-doing that is confusing, given CMS’ assertions that coding
and documentation improvements are ethical and legitimate. . It is puzzling;
improved documentation and increased Case Mix Index….oh, no, sorry, we are
going to cut back on that co-morbidities list. Improved physician education and
compliance leads to improved documentation…oh, no, sorry, we are going to cut
payments by a certain percentage because your CDI program is doing exactly what
we encouraged it to do. I’m the RAC
auditor and despite your clear and compliant query, after which the infectious
disease specialist noted that the patient had sepsis due to a UTI, I am going
to go with the admitting diagnosis of simple UTI.
Most
of the CDIS’ that I know are nurses, and it was a difficult transition to go
from patient care to an indirect role in health care. We learned to gain our
satisfaction by knowing that an improved case mix index and improved
reimbursement would help the hospital and and improve patient care in the
future. It was very satisfying to watch our case mix index rise as we worked to
improve physician documentation and take credit for the severity of illness.
But instead of being rewarded for accuracy, hospitals, coders and by extension
CDIS’ are being punished for doing their jobs, and doing them correctly. There
are hospitals that behave unethically; we heard about them at the ACDIS
conference in April. Punish those hospitals, not every hospital in the system!
And if there are CDI programs that encourage physicians to change documentation
based solely on improved reimbursement, then shame on them and their policy
makers. We must never forget that the purpose behind anything we do, whether we
do it at the bedside or by clinical documentation improvement, is SAFE, COMPREHENSIVE
PATIENT CARE.
Donna Wright, MSN, RN, CCDS