In October 2007, a new system of classification called the Centers of Medicare and Medicaid Services’ diagnosis-related groups (CMS-DRG) was implemented. Under this system, each inpatient diagnosis is assigned an International Statistical Classification of Disease and Related Health Problems (ICD) code. The relative weight of the DRG, in turn, determines hospital reimbursement.
Hospital administrators quickly realized that DRGs can be adjusted upwards through major and minor comorbidity documentation, or by shifting principal diagnosis to a higher intensity leading to better reimbursements. This meant that under this new system of classifying inpatient discharges and payment adjustments, hospitals could maximize DRG-related reimbursements through accurate documentation. And severity of illness and risk of mortality (SOI/ROM) indicators could be modified to reflect a more accurate medical record.
But doing this meant constant dedicated efforts towards accurate documentation and efficient coding. Without timely accurate clinical documentation, hospitals wouldn’t just lose significant revenue on reimbursements, it could potentially jeopardize their reputation.
Who, then, would take on this burden?
Enter the CDI specialist. Or as we like to call them, CDI superheroes (CDISs).
The Role of CDISs in the Value-based Care Ecosystem
If we were to think of the healthcare industry of the 21st century as a human body, CDISs and the CDI department would be the heart of it. Hospitals rely on CDISs to stay competitive in the value-based care ecosystem.
The Revenue Generator
Payers rely on clinical documentation and accurate coding to justify reimbursements. And lack of information or assignment of DRGs with lower relative weight could result in lost reimbursements and value-based penalties for hospitals. Cases have been documented where healthcare organization missed out on incentive payment resulting from the failure of the documentation to demonstrate achievement to payers.
CDISs can help hospitals avoid such unprecedented mishaps. According to a 2016 Black Book Market Research survey, almost 90% of hospitals that employed CDISs and a strong CDI program earned at least USD 1.5 million more through reimbursements and healthcare revenue. Enhancement of key performance indicators (KPIs) like case mix index (CMI) through CDI contributed the most towards the additional revenue.
CDISs are responsible for appropriate documentation of SOI/ROM as well as accurate reporting of hospital acquired conditions (HACs). With quality care and positive patient outcomes becoming increasingly instrumental in driving healthcare revenue, these factors become the building blocks of the healthcare organizations’ revenue model. CDISs also document and monitor patient safety indicators (PSIs) and mortality outcomes, all of which define quality measures that affect the hospital’s bottom line.
Improving Brand Positivity
The publicization of hospital quality score in the age of healthcare consumerism places the reputation of healthcare institutions on the frontlines of competition. There are several contributing factors that influence hospital rankings. However, a large majority of these factors tie into the quality-based performance indicators such as quality of care, patient safety, positive clinical outcomes, and so on. All of these are, in turn, direct functions of documentation and hence are based on the efficiency of CDISs.
Moreover, with Medicare striving to provide continuously improving quality of care to patients, hospitals are often faced with Medicare-contracted Recovery Audit Contractors (RACs). Since the entire burden of documenting positive patient outcomes rests on their shoulders, CDISs can help hospitals prepare for RACs. A good audit report leads to positive scores with grading agencies and public authorities that are charged with evaluating hospitals for public information. Complete and accurate documentation can thereby improve the hospital’s public ratings.
Making CDISs’ Lives a Little Easier with Technology
The magnitude and intensity of a CDIS’s burden is quite evident. But these superheroes don’t need to go into battle completely unarmed. The advent of AI-powered technology like NLP can greatly ease the burden and improve their efficiency.
AI and NLP tools are assuming increasingly important roles in assisting CDISs do their jobs. Voice- and text-based NLP tools that convert unstructured electronic health records (EHR) into structured content is becoming an integral part of the CDI infrastructure. While NLP helps CDISs structure the clinical data repository and coding methodologies, AI helps identify cases with probable documentation gaps. These technologies not only help CDIS’ become faster and better at their jobs but also streamline the overall clinical documentation pipeline.
Take the instance of Halifax Regional Medical Center (HRMC). The hospital’s CDI team faced various challenges such as connectivity issues between encoder and EHR. To overcome these challenges, HRMC partnered with ezDI. After deploying ezDI’s NLP-based workflow automation software, the hospital experienced a 19% drop in time to code inpatient charts. In addition, HRMC witnessed a 6% increase in CMI and a 12% increase in complications or comorbidity/major complication or comorbidity (CC-MCC) capture rate.
And the importance of technology is only expected to increase. As value-based healthcare programs develop with time, the scope of practice for CDISs will continue to expand. From formulating queries for core performance measures to enhancement of documentation process, CDISs are already experiencing a quickly diversifying job description.
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