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CDI Programs Drive Up Case Mix Index, Revenue

 |  By Rene Letourneau  
   February 16, 2015

Better clinical documentation can lead to immediate financial returns. Physician buy-in is key, ICD-10 is not.

As hospital and health system finance leaders look for ways to enhance revenue in an era of shrinking margins, many are turning their attention to their organization's case mix index. A higher CMI means more reimbursement dollars for providing care because it indicates that a hospital is treating a sicker patient population.

Increasing the CMI hinges on having clinical documentation that accurately reflects the severity level of patients' conditions. Without thorough records, hospitals can miss out on substantial revenue.

Employing Documentation Specialists

Heritage Valley Health System, a two-hospital, $450 million integrated delivery network based in Beaver, PA, set out about two years ago to improve its CMI, among other metrics.

When HVHS executives began working with a consultant in early 2013, they quickly zeroed in on the idea of rolling out a new clinical documentation improvement program built around CD specialists, says Joann Hatton, director of the utilization management/clinical documentation program.

"The CD specialists are actually out on the patient care units reviewing physician documentation and working closely with the medical staff to enhance the documentation in real time, doing a concurrent review," Hatton says.

"They can have a face-to-face interaction, as well as get clarification on paper, to ask physicians if they were thinking it could be this diagnosis or another and asking the physicians to agree or to provide another explanation. When they are able to get more clarification and specificity, then it helps the coders to code more accurately."

HVHS has hired and trained 11 clinical documentation specialists—four at Heritage Valley Sewickley hospital and seven at Heritage Valley Beaver hospital—and one supervisor to staff the program. Hiring existing employees who were well-respected by physicians gave the initiative immediate credibility, Hatton says.

"We were very fortunate to hire nurses in high-level nursing positions within our organization for a long period of time to be CD specialists. They were faculty in the school of nursing, supervisors in critical care units, and nurses in the cardiovascular labs and had already established good relationships with the physicians and were already held in high esteem."

Immediate Results Above Expectations

By having more complete and accurate information, HVHS is able to create documentation that paints a more precise picture of its patients' health and to get credit for their severity of illness—something it was not previously doing as well as possible, Hatton says.

As a result, the system's CMI has increased at both hospital campuses. In the program's first year, which spanned from October 2013 to October 2014, the system saw a 13.79% increase at Heritage Valley Sewickley and a 6.4% increase at Heritage Valley Beaver.

The results surpassed HVHS's expectations, Hatton says. "We were hoping to get a 5% increase in our case mix index based upon some of our preliminary assessment findings. We are really trying to capture a lot of comorbidities and anything at all that we can use to more accurately reflect the severity of how sick our patients are."

The CD specialists are particularly focused on the documentation for heart failure patients, Hatton adds.

"When we are able to get more detail out of physicians for patients with congestive heart failure, that gives more information to the coders, and we are able to capture a lot of comorbid conditions for the patient. I think our number one area for questions [with our documentation] is still around heart failure."

Creating Physician Buy-in

Hatton also says that by framing the program in the context of how it benefits physicians in their clinical work, she has been able to achieve buy-in.

"I didn't want physicians to say this program was all about the money, but that it was about getting credit for all the work they were doing. We are showing them the clinical attributes of the program, and the financial piece is just an added bonus."

For the most part, Hatton says, clinicians at HVHS have gotten on board with the clinical documentation effort thanks in large part to the strong leadership of the system's chief medical officer.

"We have a very active and engaged CMO, and when we were not able to address or correct a situation with a handful of physicians who I would say were a little skeptical, we took it to the medical staff leadership who were committed to ensuring the success of the program," she says. "But overall, it has been a positive experience."

Succeeding with Computer-Assisted CDI

When Summit Healthcare Regional Medical Center in Show Low, AZ, implemented a computer-assisted CDI tool on July 1, 2014, the hospital's finance leaders were trying to accomplish four goals: to improve revenue cycle workflows, to capture and effectively measure successes, to produce enough quantifiable progress to justify the need for the CDI program, and to find a tool that was compliant with both ICD-9 and ICD-10.

Before installing the CDI software, Summit relied solely on paper records and Excel spreadsheets, which made it nearly impossible to organize workflows and measure success.

"Computer-assisted CDI is somewhat new on the block as far as healthcare is concerned, but there are a lot of advantages to it as reimbursements move from being quantity-based to being value-based. It gives a better story on what physicians are really doing with the treatment of patients, and we've seen our case mix index improve, which is a way of combatting lower reimbursements," says Layne Sherman, Summit's director of charge capture.

"Part of it was a language barrier. Our docs are doing a good job, but we just have to show it in the documentation. CMS is saying, 'This is the wording, and you guys are missing it.' So, the documentation as it was before wasn't correct."

The results to date have been better than expected at the 89-bed hospital, Sherman says. The hospital's case mix index has increased by about 20%, with a financial impact of roughly $558,000. Additionally, the complication and comorbidity capture rate has increased 22.8% and the major complication and comorbidity capture rate has increased 37%.

So far, Summit has been focused on improving documentation for patients with sepsis, Sherman says, noting that he and other leaders have been buoyed by the early success of the CDI program to look at other opportunities for enhancements.

"In the first four months, we captured $500,000 in additional revenue because there's a big difference between sepsis and sepsis with complications, and we are capturing that now," he says.

"It's a progression, and we are now evolving to look for additional opportunities. Next, we may capture an additional $200,000, but it will have a different scope, and it will be in different areas."

Benefiting with or without ICD-10

While there is still doubt about whether or not ICD-10 will go into effect later this year, Sherman says the added specificity that Summit is now capturing in its clinical documentation will benefit the organization regardless.

"I don't think we'll worry about ICD-10 either way," he says. "ICD-10 is wanting more specificity, but right now, working in ICD-9 codes, moving toward more specificity actually increases revenue. Reimbursements are heading that way no matter what."


Rene Letourneau is a contributing writer at HealthLeaders Media.

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