In speaking to clinical documentation improvement (CDI) professionals on a daily basis, I have seen many trends develop over the past 10 years regarding where this job market has been and where it is going. Professionals I talk to give me their trust to discuss their current job situation and they put faith in me to give them the best advice when it comes to finding a new opportunity in the CDI field. With that thought in mind, I offer my two cents.
It seems as though the CDI job market is on an uptick. Last year, we seemed to be bogged down in a bit of a post-ICD-10 lull when it came to hiring and a lot of organizations were working with much smaller budgets than in years prior. Legislative uncertainly also played a key role in planning and spending for most organizations.
We have started to see the CDI contract/interim solution taper a bit and hospitals are hiring more full-time equivalents now than before. Despite a slower 2017, the one fact that has always been an issue is the shortage of good qualified CDI professionals. The demand for highly skilled and experienced CDI staff remains at an all-time high and the supply of these individuals still falls short.
Most CDI hiring managers are looking for a technical skill set, to be sure, but more times than not, the personality of the individual matters equally if not more so. The CDI profession is not for the faint of heart; one must possess the clinical and coding acumen to be relevant and converse on a collegial level with physicians, nursing staff, coders, and the C-suite.
Successful CDI professionals understand they need to stand and hold their ground when trying to get clarification on the cases they review. They need to be articulate and understand the nuances of communication—to challenge when necessary and calm when appropriate. One needs the investigative insight to identify opportunities and the fortitude to present them. And now more than ever, the ability to continually learn and educate oneself on the many changes that affect documentation almost daily is a must.
Recent changes in traditional CDI programs within hospitals are a big reason that programs across the country are expanding. The traditional CDI program that was more focused on reimbursement and information capture has given way to programs much larger in scope.
Hospital administrators are starting to truly understand the value that an effective and successful CDI program can have on multiple departments. CDI programs are working much more closely with quality personnel; CDI professionals are spending more time in each chart to truly get the most accurate and complete picture for each patient.
CDI is also expanding to the outpatient arena. This is a relatively new and undefined area for the CDI profession, but one that is evolving quickly; the demand for these professionals today is proof of that. Also contributing to the addition of CDI staff is the fact that many programs are now expanding to cover all units and all payers when possible. The need to standardize and streamline programs across multiple facilities in health systems that continually get bought or sold can also alter CDI staffing models. All of these factors have created a healthy environment for CDI job seekers.
The CDI profession is made up of individuals from many different backgrounds, disciplines, and environments. The ability to be flexible and adaptable to change and work with people of all levels and skill sets is of paramount importance if one is going to be successful going forward in the CDI profession.
For those who want to get into the CDI field, there are more resources than ever. We believe the CDI profession is as strong as it has ever been and believe it will continue to evolve just as the landscape of health care does.
— Scott Entinger is principal at CDI Search Group.
The origins of the CDI profession can be traced back to the implementation of the Centers for Medicare & Medicaid Services (CMS) Diagnostic-Related Group (DRG) system back in 1983. It was during this time that CMS drastically changed its reimbursement process, creating a relationship between coded claims data and reimbursement. The DRG Prospective Payment System (PPS) was crafted in response to a congressional mandate to control medical costs associated with caring for the elderly and disabled. Prior to implementation of the DRG system, Medicare made interim payments to hospitals throughout the year, and reconciled those payments with the hospital’s “allowable costs,” as detailed on a cost report filed each fiscal year. Implementation of the DRG system resulted in a per-case reimbursement mechanism wherein Medicare paid a flat rate for each inpatient hospital claim, in hopes of promoting efficiency, thereby keeping healthcare costs down.
The DRG PPS classified “all human disease according to affected organ system, surgical procedures performed on patients, morbidity, and sex of the patient … accounting for up to eight diagnoses in addition to the primary diagnosis.” It is a classification scheme composed of classes of clinically similar patients who medically would be expected to consistently use a similar amount of hospital resources. DRGs were arranged by physician panels into Major Diagnostic Categories (MDCs) to support clinical coherence. Each MDC was constructed to correspond to a major organ system, when possible. Medical classes usually include a class for neoplasms, symptoms, specific conditions relating to the organ system involved, and “other medical disease.”
Because surgical procedures that require the use of an operating room have a significant effect on hospital resource consumption, the MDCs were further subdivided into medical and surgical groups. To address the possibility of a patient having multiple procedures related to their principal diagnosis, and because a patient can only be assigned to one surgical class, the surgical classes in each MDC were defined in a hierarchical order. Patients are assigned to the highest surgical class in an MDC hierarchy. Like within the medical class, there is a “other surgical procedures” class to account for infrequent procedures that are reasonably expected to be performed for a patient in a particular MDC. The goal of the MDC structure is to clinically align the principal diagnosis and procedure, but that is not always possible, so the DRG system also includes a surgical class referred to as “unrelated operating room procedures.”
Most coding departments have a dedicated work queue to monitor cases that result in each DRG, to validate the assigned codes and their sequencing. It is important to note that not all “procedures” result in a surgical DRG. Procedures that are diagnostic in nature will not result in a surgical DRG. For example, a cardiac catheterization only results in a DRG change when related to the affected organ system, e.g., the cardiovascular system, but it remains a medical DRG.
Both medical and surgical DRGs were further subdivided based on the presence of a complication and comorbidity (CC) or pediatric age (0-17). There were as many as 115 pairs of DRGs that could be impacted by the presence of a CC. In addition the principal diagnosis, up to eight additional diagnoses could be reported to reflect “other factors affecting the patient’s care or treatment.” However, it only takes one diagnosis classified as a CC to “move” the DRG for maximum reimbursement under the DRG reimbursement mechanism. The DRG system created a way for hospitals to differentiate themselves from each other by demonstrating that they are caring for patients who require more resources than the “average” patient. The CC list remained virtually unchanged for almost 24 years, except for the addition of new diagnosis codes like HIV. The stability of the CC list made it easy to incorporate identifying these conditions into the coding workflow. In fact, by the mid 2000s, nearly 80 percent of patients had CCs, in part due to better coding of secondary diagnoses, reducing the power of the DRG system to discriminate hospital resource use.
CMS is required under the Social Security Act to adjust the DRG classifications, a process referred to as reclassification, and adjust relative weights, referred to as recalibration, annually. Changes go into effect each Oct. 1, the start of the federal fiscal year. These annual adjustments are necessary to adequately compensate for costs under the PPS. CMS has refined the DRG system in response to issues like overpayments for patient transfers, improper payments to hospitals for nonphysician outpatient services, and monitoring of DRG upcoding. Examples of how these issues were addressed include the 72-hour rule, whereby related outpatient services delivered in the three days before admission are included in the payment for the inpatient stay, and transfer DRGs result in reduced payment for shortened length of stay due to transfer of the patient to post-acute care.
I started my career as a CDI professional in 2008, which is when the CDI profession really started to gain traction within the healthcare industry. I entered the field as the manager of a CDI program at an academic medical center, with the understanding that there was no guarantee that CDI was here to stay. In fact, consider the use of the word “program,” emphasizing that we were not a department, like coding or quality, because if we did not show a return on investment (ROI), then the “experimental” program would be abolished. I’ll speak more about the concept of ROI in a later article, when I discuss CDI metrics related to performance, but first, let’s continue examining how the CDI profession was created in response to the DRG payment mechanism.
Why did the growth of CDI occur in 2008? It’s because CMS updated the DRG payment mechanism to the Medicare Severity (MS)-DRG (version 25 DRGs) beginning with the 2008 fiscal year.
First, MS-DRGs no longer included pediatric age distinctions. Secondly, the CC list was completely revised, with implementation of MS-DRGs to reflect significant acute disease, acute exacerbations of significant chronic disease, advanced or end stage chronic disease, and chronic disease associated with extensive disability. The revision of the CC list resulted in an estimated decrease in Medicare patients with CCs from 80 to 40 percent. Lastly, the MS-DRG system also classified diagnoses as major complications or comorbidities (MCCs) based on relative resource use. At the time, approximately 12 percent of all diagnosis codes were classified as a MCC, plus 24 percent as a CC and 65 percent as a non-CC; of course, this has changed over time, especially with implementation of ICD-10-CM.
Another important change that occurred in 2008 was specification of a secondary diagnosis as present on admission (POA) (or not). The reporting of the POA indicator allowed complications that occurred post-admission to be identified. It is important to note that the use of “complications” was to identify a condition that occurred during the admission, but did not imply wrongdoing on the part of the provider. CMS always referred to CCs as complications and comorbidities, but with implementation of POA, they were better able to differentiate a comorbidity condition that existed prior to admission from one that occurred during an admission. This change was required by the Deficit Reduction Act, which also mandated documentation of Hospital-Acquired Conditions (HACs). Initially, CMS designated 12 conditions as HACs (the list was later increased to 14 conditions, and has not changed since the 2014 fiscal year). If a condition classified as a HAC is present on admission, it continues to be classified as a CC or MCC, whereby it can potentially increase reimbursement. However, if the diagnosis was not POA, then it was no longer to be classified as a CC or MCC, potentially resulting in a lower MS-DRG assignment and reduced reimbursement.
So, where are we now? In 2019, there were 759 severity-adjusted MS-DRGs, based on the patient’s clinical condition and treatment strategies, as defined by discharge diagnosis and procedure codes. Unlike the DRG system, the MS-DRG system currently has 335 base DRGs, many of which are further divided into two or three DRGs, sometimes referred to as a pair or triplets, based on the presence of a secondary diagnosis defined by CMS as a CC or MCC. MS-DRG assignment can also be influenced by discharge destination and use of a specific drug. Implementation of the MS-DRG system meant more opportunity to capture secondary diagnoses classified as CCs or MCCs, compared to the old DRG system, potentially resulting in higher revenue. It was around this time that the CDI profession also began separating from coding. That’s not to say that coders were not working as CDIs; rather, CDI was being seen as more than an “extension” of coding, allowing it to become its own entity. As hospital executives came to better understand this reimbursement mechanism, they saw the potential advantage of implementing a CDI program, to see if such a program could increase revenue.
Another significant change occurred beginning with the 2013 fiscal year. This change was not related to the structure of MS-DRGs, so it didn’t have a direct relationship with code assignment, but it did have an impact on reimbursement. Although the origins of CDI programs were aligned with implementation of the PPS and DRG reimbursement mechanism, many CDI departments struggled to continue that alignment as CMS moved to a quality-based payment structure. Beginning with 2013, CMS introduced mandatory quality programs, beginning with value-based incentive payment (better known as the Hospital Value Based Payment Program, or HVBP) and the readmission reduction policy (better known as the Hospital Readmission Reduction Program, or HRRP). These programs were followed by implementation of the hospital-acquired conditions penalty, better known as the HAC Reduction Program (HACRP). It is one thing to monitor cases for HACs as a program, which could result in the loss of a CC or MCC on a particular claim. It is another, much more complicated process to monitor the potential impact of each of these programs at a per-case level. I’ll discuss more about these programs and how CDI departments are incorporating a quality approach in a future article.
Although the initial CDI mission was to capture diagnoses classified as CCs and MCCs, many CDI programs have evolved beyond this focus and have tried to incorporate a “quality” approach. Ironically, the move to such an approach was not precipitated by CMS’s change in the Inpatient Prospective Payment System (IPPS) rules that incorporated quality as it was by the myth that focusing on revenue (e.g., the capture of CC and MCCs) was “leading” or “noncompliant.” Additionally, around this time there was increased visibility of the concept of mortality – and, luckily, the early mechanisms used to measure mortality using severity of illness (SOI) and risk of mortality (ROM) were closely aligned with reimbursement, so it was easy to “focus on quality” and “let reimbursement follow.” However, that relationship is not as clear as it once was. As a result of all these different influences, there is much inconsistency across CDI departments regarding how “quality” is defined and incorporated into workflow.
As you can see, there is a lot to examine when we look at where the CDI profession began, as well as where CMS Medicare reimbursement began, and how both have evolved through the years. We have evolved as a profession, so why haven’t our metrics? I hope you will join me as we explore this topic more in the coming months.
Health organizations around the world understand that keeping complex data organized is essential to providing a positive patient experience. In order for patients to have a successful health experience, clinical documentation must be accurately reported. If a patient’s information is not recorded and detailed well, errors will surface and it can deeply affect patients and providers.
However, those documentation mistakes can be reduced with clinical documentation improvement services. CDI is a process of accurately documenting patient care and communicating that information to other providers. CDI ensures that a patient’s health provider receives correct patient records and information, which will benefit patients and health organizations all the more.
Providing adequate billing practices and positive healthcare encounters are of the utmost importance. Healthcare providers face major issues related to inconsistent billing procedures and insufficient patient payment collections. Professional clinical documentation (CDI) experts assess a health organization’s current medical coding, billing, and payment collection process and provide helpful suggestions to overall improve the healthcare experience. ECLAT Health Solutions is a professional medical billing company that offers quality CDI services to clients including medical billing, coding, and collection procedures. We will determine how providers can increase accuracy, which will provide the many benefits of clinical documentation improvement listed below:
Insurance companies can deny a patient’s request for health care coverage for a variety of reasons. Claims that are illegible, not specific enough, missing information, and not filed on time can lead to insurers refusing to cover patient healthcare services. By utilizing a professional CDI, it will ensure claims are thoroughly completed, easy to understand, and filed on time, which reduces a patient’s claim from being denied.
Physicians learn that their language and documentation affect other departments such as reimbursements and quality data. Coders are in charge of reviewing physician notes on a patient and assigning Current Procedural Terminology (CPT®) and International Classification of Diseases (ICD) codes. In cases where the patient documents are illegible, incomplete, conflicting, and unreliable, coders will contact physicians for clarifying documentation. Professional CDI assistance will lessen clinical documentation incompletion, illegibility, and mistakes.
Clinical documentation improvement (CDI) will enable physicians to properly input information and complete data into patient records. This will smooth out the healthcare process for other providers that care for the patient and coders too. This allows medical coders to conduct medical reviews of reliable and completed patient documents and treatments and assign codes with precision.
Depending on the amount of staff you have at hand, choosing to implement CDI can be a difficult decision to make. However, when you decide to enforce professional CDI services to certain staff members, it will allow those to focus on what they are good at and will overall reduce documentation mistakes. ECLAT Health Solutions experts provide clinical documentation improvement services that will improve patient records and ensure data correctly reflects the diagnoses and procedures performed.
When patient information is accurately recorded and tracked, it provides a smooth healthcare experience for not only the patient but each individual who requires access to a patient’s health records including billing companies and health care practitioners. Implementing CDI will allow each provider and billing company to be on the same page in regards to the patient’s healthcare, and they will be able to care for them accordingly.
With ECLAT Health Solutions, our CDI professionals are AAPC certified employees or trained and certified by the American Health Management Association (AHIMA). As a medical billing and coding company, we will provide efficient medical coding and billing services that are precise and will improve health organizations from the ground up. With careful assessments of a client’s current billing and coding procedures, we will produce suggestions as well as quality resources to help clients receive the best CDI service possible.
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