Clinical documentation improvement (CDI) programs have experienced significant transformation over the last decade. Thanks to CDI specialists, hospitals and health systems are seeing better denial management, optimized reimbursements, and improved quality of care. Are you ready to revitalize your CDI program? Let’s take a look at how and why that happens.
The motivation behind CDI investment
The new MS-DRG (Medicare Severity-Diagnosis Related Group) system is a major driver for many hospitals and health systems to invest in CDI programs. Under these guidelines, capturing CC/MCCs (complication or comorbidity and major complication or comorbidity) became the focus.
Many organizations that have implemented an MS-DRG-focused review program have seen success. They’ve experienced benefits such as improved provider documentation and true Case Mix Index (CMI) capture. However, the introduction of APR-DRG’s (All Patient Refined-Diagnosis Related Group) changed this landscape even further.
Capturing severity of illness (SOI) and risk of mortality (ROM) are now the focus for CDI professionals. It was a challenging transition for many organizations, as the review approach differed from MS-DRG methodology. However, it became clear fairly quickly that the best approach was to implement an all-payer CDI review program.
It is this methodology that enables providers to capture the true clinical picture. This helps to secure appropriate revenue and quality metrics.
What’s next for healthcare payment reform?
U.S. healthcare policies continue to rapidly change. Risk adjustment models have emerged as an alternative and potential replacement for the traditional fee-for-service (FFS) payment model. The Centers for Medicare & Medicaid Services (CMS) announced the launch of a new voluntary episode payment model: the Bundled Payments for Care Improvement Advanced (BPCI Advanced).
This initiative aims to support healthcare providers who invest in practice innovation and care redesign to:
- better coordinate care
- improve quality of care
- reduce expenditures
It will contribute to the above goals through retrospective bundled payments for clinical episodes under a single payment and risk track. Its performance period commenced on October 1, 2018 and will run through December 31, 2023.
BPCI Advanced is defined by 4 main characteristics:
- A single payment and risk track with a clinical episode (this includes the triggering inpatient stay or outpatient procedure and a 90-day period starting the day of discharge)
- 29 inpatient clinical episodes and 3 outpatient clinical episodes
- Qualifies as Advanced Alternative Payment Model
- Preliminary target prices provided for each clinical episode before the first performance period of each model year
Putting patients and population health first
The goal of the BPCI program is to build an affordable, accessible healthcare system that puts patients first. It also strives to captures accurate population health information. A bundled payment approach combines payments for physician, hospital, and other healthcare provider services into a single bundled payment amount. This promotes physician engagement with the care management team.
Challenges with early CDI programs include a lack of physician engagement. As a step to revitalize your CDI program, the BPCI initiative helps to eliminates this concern. This is due to the nature of the shared risk reimbursement model. Historically, CDI programs have struggled to effectively communicate and obtain buy-in from the surgical department. An effective BPCI approach can cultivate good relationships with the entire medical staff. This helps to enable providers to capture the true clinical picture.
Revitalizing your CDI program must also include proper training for CDI professionals. One major focus with traditional CDI review is to focus on CC/MCC, SOI/ROM optimization. In contrast, BPCI focuses on the nature of procedures (e.g. whether it is an elective versus a non-elective).
Another important review focus is to validate assignments of:
- hospital acquired conditions (HACs)
- patient safety indicators (PSIs)
- present on admission (POA)
- discharge dispositions
The BPCI approach will require more time to complete reviews. It is also responsible for a more collaborative effort with the care coordination team.
But health systems cannot afford weak CDI programs. This is especially true under pay-for-performance reimbursement models and with the obvious benefits of BPCI. Leveraging expert resources to successfully manage this change is essential.
We’re here to empower you
Harmony Healthcare’s Clinical Documentation Improvement solutions support your organization with interim expertise optimize reimbursements and prevent future denials.
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