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Enjoin, a physician-directed clinical documentation improvement (CDI) services provider, is an official exhibitor at the AHIMA20 Virtual Conference. To learn more about Enjoin, its physician-directed CDI services, or arrange a meeting with representatives during AHIMA20, please contact Mary McNerney, RHIA, Chief Brand Officer.

By James P. Fee, MD, CCS, CCDS, and Jennifer Eaton, RN, MSN, CCDS

In terms of first impressions, COVID-19 has left a lasting one. Many hospitals continue to struggle with revenue recovery even despite increased outpatient visits, elective procedures, and inpatient admissions. A recent report published by the American Hospital Association found that hospitals and health systems lost an average of more than $50 billion per month between March 1 and June 30 alone. Although Medicare advanced payments helped offset some of this loss, organizations will soon need to pay back these loans if they haven’t done so already. It’s hard to imagine rebuilding revenue when you’re already in the negative.

In addition, payers that “pressed pause” on audits during the first few months of the pandemic have now resumed audit activity. The Office of Inspector General (OIG) also recently announced it would begin auditing Medicare payments for inpatient admissions for beneficiaries with a diagnosis of COVID-19.

What’s one thing all auditors have in common?

The advantage of unprecedented regulatory change. In the last six months, organizations have had to operationalize a lot of changes: New CPT and ICD-10 codes related to COVID-19, telehealth waivers and expansion, new coding guidelines, and more. In addition, Medicare now requires a positive COVID-19 lab test documented in the patient’s medical record as a prerequisite for a 20 percent increase in the MS-DRG weighting factor. When organizations don’t comply with these changes, they automatically put themselves at risk for costly denials and recoupments—or they miss out on payment increases.

The most successful organizations in 2021 will be those that:

  • Make data-driven decisions to ensure the financial health of the organization
  • Prioritize proactive—not reactive—CDI, documentation, and coding compliance
  • Reimagine the role of clinical documentation integrity (CDI) in a new age of COVID-19

Following are five steps every organization can take in the months ahead to set the stage for financial success in 2021:

1. Align CDI resources with strategic goals.

Traditionally, CDI specialists haven’t strayed from the well-worn path of MS-DRG assurance. However, times have changed, and old strategies don’t fit with the new normal of value-based payment arrangements. To complicate matters, CDI departments are being asked to do more with less as specialists are furloughed, laid off, or even pulled into direct patient care roles.

What does this mean? It means aligning the CDI function with payer contracts and other strategic goals. When CDI specialists understand payer contracts—specifically at-risk populations—and target those cases, they’re better able to prove a return on investment.

Healthcare organizations must also realign their CDI strategy with shifts in payor mix. At the start of this year, 156 million Americans participated in employer-sponsored health plans. However, since the pandemic, there has been an estimated 17 percent shift in payer mix towards government-sponsored plans. With a 35 percent margin with commercial insurance compared to Medicare, a 17 percent shift in payer mix on a trillion dollar spend would result in a significant reduction in financial resources. That’s in addition to lost revenue due to decreased patient volumes. Organizations must understand this vulnerability at the contract level and deploy CDI resources appropriately. In addition to the payer, CDI should align its efforts with shifts in care access as well. Emergency department volume (a large source of hospital revenue and admissions) is still down by 25 percent while outpatient volumes are down by only 1.5 percent. This means organizations need to consider shifting resources to support ambulatory programs. A strategy for financial solvency must incorporate CDI.

Alignment is also about prioritizing resources with organizational goals in mind. Consider the following: Organization A incurs readmission penalties totaling $1 million. Organization B incurs no penalties; however, several payer contracts have shifted from volume to value. Both scenarios require completely different success metrics and CDI priorities.

With that said, collaboration is critical as organizations move toward pay-for-performance while continuing to success in fee-for-service arrangements. CDI specialists, coders, and others need to collaborate to identify goals and initiatives that will ensure the financial health of the organization. All voices must be heard so they can be a part of the solution.

2. Establish new key performance indicators (KPI).

Long gone are the days in which CC and MCC capture rates denoted the success and value of a CDI program. Instead, organizations need to also look at the following:

  • Cost to collect
  • Denial overturn rates
  • Denials as a percentage of net patient revenue
  • Net patient revenue
  • Risk adjustment capture tied to Center for Medicare and Medicaid Services quality-related payment incentives and penalties
  • Type of denials and the impact of those denials (note: all denials are not equal in a resource-limited world)
  • Volume of denials

These are among the new KPIs that will offer insight as payment models shift and evolve. In addition, organizations must align CDI KPIs with clinical care variation and outcome analysis.

3. Perform pre-bill reviews.

With pre-bill reviews, physicians and clinical coding analysts staff review and discuss the medical record to ensure compliance and accurate clinical documentation and coding prior to final billing. The pre-bill process drives revenue integrity and mitigates financial risk because it often uncovers documentation, coding, and query opportunities. This is true for all MS-DRGs—not just high-impact ones. As organizations seek to recover revenue post-COVID-19, all revenue matters.

A pre-bill audit also supports efficiency (e.g., reduction in potential rework and rebilling), and it protects revenue. With that said, collaboration between coding, CDI, and providers is also imperative because it enables a quick turnaround time for accurate claim submission that is necessary to maintain control of discharged not final bill (DNFB). Additionally, pulling representatives from all cooperating disciplines into the planning process early on will increase the likelihood of short- and long-term sustainable success.

Some questions to consider: Do coders and CDI specialists strive to capture orthopedic, oncologic, and gastrointestinal procedures that will drive the recovery of lost revenue? Do they correctly capture the costs of COVID-19 testing? Do they strive to capture the chronic disease burden of patients with chronic heart, lung, kidney, and liver disease who also have COVID-19? What about mental health? The anxiety and isolation brought on by social distancing may intensify mental problems and associated mental illnesses, all of which must be accurately depicted through documentation and coding.

4. Re-evaluate CDI messaging to providers.

Often referred to as an epidemic itself, physician burnout has been a challenge long before COVID-19 came onto the scene. According to a recent Medscape survey, 42 percent of physicians say they’re burned out. Sixty-four percent say their burnout has become more intense since COVID-19. The last thing most physicians want is additional tasks on their to-do list.

What does this mean for CDI? It’s all about the messaging. Providers will be more willing to collaborate when they understand the overarching purpose of CDI. Promoting consistent and accurate documentation in the medical record benefits all: the patient, provider, and facility. CDI specialists need to reiterate this message: We all have the same goal—to tell the patient’s story accurately. Tying CDI efforts to better patient care and outcomes is imperative.

5. Assess data reporting capabilities.

In some organizations, the CDI reporting is often insufficient to meet today’s needs, or it’s inaccurate due to lack of integration with payer contracts. However, organizations need to make sure they have access to accurate and timely data regarding financial impact.

Can organizations identify their biggest vulnerabilities by payer? What about their most high-risk patients—and related interventions that improve outcomes? Can they predict how their current coding might affect future rate setting and benchmarks in value-based payment arrangements? Can they easily monitor documentation and coding compliance related to new methods of care delivery such as telehealth, remote patient monitoring, and more?

Being able to dive deeply into the data—and tie that data to specific payer contracts—helps hospital executives make data-informed decisions that optimize efficiency and impact. An investment in a robust CDI reporting tool is an investment in patient care, revenue integrity, and financial security.

Conclusion

COVID-19 has taught us that flexibility and the ability to pivot is critical. Now is the time to re-evaluate existing processes, roles, and responsibilities to ensure that organizations can continue to provide—and be paid for—high-quality patient care. The road to recovery may be challenging, but it’s ripe with opportunities to improve and be stronger for it in the end.

Register for AHIMA20

The AHIMA20 Virtual Conference is the premier educational, exhibition, and networking event for health information professionals. Whether you are seeking cutting-edge education, evaluating the latest market innovations, or are seeking new professional connections, the AHIMA20 Virtual Conference is the place to be. Register today.

James P. Fee, MD, CCS, CCDS, CEO of Enjoin (james.fee@enjoincdi.com) and Jennifer Eaton, RN, MSN, CCDS, (jennifer.eaton@enjoincdi.com) is executive director, CDI and education, for Enjoin.

With thirty years of direct physician leadership, Enjoin delivers complete solutions for clinical documentation integrity across the continuum and ensures evidenced-based care is accurately reflected through precise documentation and coding. Enjoin clients achieve a demonstrable improvement in CMI, coding accuracy, quality metrics, risk adjustment and physician alignment. For more information, visit enjoincdi.com.

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