Use of Case-Mix as a Proxy for Judging Effectiveness of CDI Programs

The use of case-mix as a proxy for judging the effectiveness of clinical documentation improvement programs can be characterized as an unreliable imprecise measure of overall success. While case-mix over time can potentially increase over time as clinical specificity in diagnoses capture improves, there are a myriad of contributing factors that control the ultimate calculation of case-mix. Attributing improvement in documentation to increases and fluctuations in realized numbers is a misnomer and falsehood. Case-mix index can be considered at best to be an instantaneous approximation of revenue the Chief Financial Officer can collect under the best possible scenario. Unfortunately, the measure of case-mix is thought of as the standard measure of return on investment for clinical documentation improvement programs. From case-mix emanate other supporting key performance indicators that drive CDI operational processes which are inefficient, ineffective, counterproductive and counterintuitive. Present day Key Performance Indicators place an overemphasis upon volume of chart reviews versus quality of chart reviews. The actual impact the CDI professional can potentially have will come from a concerted focus upon identifying real opportunities for clinical documentation improvement that are sustainable over time.

Preferred CDI Key Performance Indicators

The preferred reliable standards for Key Performance Indicators consists of elements that accurately report achievement of meaningful improvement in documentation to the mutual benefit of the patient, the physician, all other healthcare stakeholders and the hospital. Let’s review some of these preferred Key Performance Indicators that we should be considering and subscribing to in reporting progress and strides of impacting positive measurable change in overall physician documentation patterns over time. Here are some suggestions to consider:

• Total number of retrospective queries post coding for documentation clarification per month
• Total dollar value of retrospective queries post coding for documentation clarification per month
• Average time in suspense per month of retrospective queries post coding for documentation clarification per month.
• Total number and dollar value of accounts per month:
  • DRG down-codes
  • Clinical validation denials
  • Medical necessity denials
• Average time spent appealing claims for DRG down-codes, clinical validation denials and medical necessity denials
• Average costs appealing claims per month for DRG down-codes, clinical validation denials and medical necessity denials
• Net days in accounts receivable
• Cash collection as a percentage of net patient services revenue
• Medical necessity claims denial rate
• Medical necessity final denial write-off as a percentage of net patient service revenue
• Cost to collect
• Net monthly Case-Mix trend (Monthly Case-Mix minus medical necessity/DRG down-code and clinical validation denial Case-Mix)
• Number and dollar volume of rebills for Higher Weighted DRGs rebilled each month
• Number and dollar volume of Higher Weighted DRGs rebilled each month that were disallowed by the BFCC-QIO
• Number and dollar volume of Higher Weighted DRGs rebilled each month that were ultimately denied for medical necessity or resulted in a reimbursement take-back for quality of care or coding issues.

The Ultimate Valid Reliable Measure of CDI Success

The ultimate measure of success in CDI advancing the needle in achieving meaningful solid improvement and quality of documentation is the establishment of a baseline assessment of clinical documentation prior to the initiation of any documentation improvement initiative using a valid and reliable assessment tool that can be developed and created internally for History and Physicals, Progress Notes, Operative Reports and Discharge Summaries. Each month the CDI specialists can use the tool to assess and grade the physician’s documentation utilizing a sample assessment of records providing feedback through a grade scoring system. A relatively decent tool is the Physician Documentation Quality Instrument-9 Item Version applicable to progress notes. Physician Documentation Quality Instrument .

The point here is that the CDI profession must recognize the imperative need to consider other more practical approaches to substantiating and measuring effectiveness, successes and overall achievement in documentation quality and completeness aside from the current mistakenly thought of Key Performance Indicators. CDI must come to grips we are merely spinning our wheels in continuing with present day structural and operational processes and claiming a stake in documentation improvement. I challenge you to pick up a medical record, review the entire contents from admission to discharge and objectively rate the quality and completeness of the documentation. I am confident you will reach the same conclusion that CDI as a profession has a tremendously long way to go in fulfilling our duties and responsibilities as documentation improvement specialists. Let’s begin by acknowledging that number of charts reviewed, number of queries generated, physician query response rate and agreement rate bears absolutely no resemblance to and does not correlate with quality and completeness of documentation. Instead these are no more than task-based measures and quite frankly there is so much more substance to documentation improvement than chasing diagnoses each and every day. Seize the opportunity to make a real difference in communication of patient care through a dedicated effort at advancing the quality of the documentation versus shallow chart reviews that produce shallow results of diagnosis reporting often-times out of context.