Clinical documentation improvement (CDI) programs have experienced significant transformation over the last decade. Under the new MS-DRG (Medicare Severity-Diagnosis Related Group) system—a major driver for many hospitals and health systems to invest in CDI programs—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, experiencing benefits in improved provider documentation and true Case Mix Index (CMI) capture.
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) now became the focus for CDI professionals. It was a challenging transition for many organizations as the review approach differed from MS-DRG methodology. With time, it became clear that the best approach was to implement an all-payer CDI review program. When properly performed, this methodology enables providers to capture the true clinical picture, securing appropriate revenue and quality metrics.
What’s next for healthcare payment reform?
Healthcare policies within the United States are changing rapidly. 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 called Bundled Payments for Care Improvement Advanced (BPCI Advanced). BPCI Advanced aims to support healthcare providers who invest in practice innovation and care redesign, to better coordinate care, improve quality of care, and reduce expenditures. BPCI Advanced is built on the foundation of the Bundled Payments for Care Improvement (BPCI) initiative, which began in April 2013 and ran through September 30, 2018. The model performance period of BPCI Advanced commenced on October 1, 2018 and will run through December 31, 2023.
BPCI Advanced will contribute to these goals through retrospective bundled payments for clinical episodes under a single payment and risk track. In this model, the participant will be expected to bear financial risk and redesign care delivery to reduce Medicare FFS expenditures while maintaining or improving performance on specific quality measures.
BPCI Advanced is defined by four main characteristics:
- A single payment and risk track with a clinical episode that includes the triggering inpatient stay or outpatient procedure, as well as the 90-day period starting the day of discharge from the inpatient stay or day of completion of the outpatient procedure
- 29 inpatient clinical episodes and three outpatient clinical episodes
- It qualifies as an Advanced Alternative Payment Model
- And preliminary target prices will be provided for each clinical episode in advance of the first performance period of each model year
Bundled payments and the role of CDI
The goal of the BPCI program is to build an affordable, accessible healthcare system that puts patients first and captures accurate population health data. A bundled payment approach combines payments for physician, hospital, and other health care provider services into a single bundled payment amount, promoting physician engagement with the care management team.
Challenges with early CDI programs include lack of physician engagement. The BPCI initiative somewhat eliminates this issue 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 enabling providers to capture the true clinical picture through accurate clinical documentation.
Next steps to revitalizing your CDI program include effectively training CDI professionals to review the BPCI population. 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, 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), and Discharge Dispositions.
As with any CDI transformation, there will be challenges and limitations. One potential challenge would be to have appropriate staffing to accurately capture every opportunity. The BPCI approach will require more time to complete the review and is also chiefly responsible to work collaboratively with the care coordination team for the best possible outcome. But health systems cannot afford weak CDI programs, especially 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.
Discover how our solutions can help your organization:
- improve clinical documentation to mitigate lost revenue and retain future revenues
- identify clinical documentation and revenue integrity opportunities for optimal reimbursement
- streamline the CDI process with robust analytics and automated worklist triage for improved efficiencies and optimized reimbursements
See how the right service partner can provide a better solution for your staffing needs here.
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