As outlined in the 2019 Medicare Fee-For-Service Supplemental Improper Payment Data Report, the overall Medicare Improper Payment Rate was pegged at 7.3% translating into $28.91 billion paid to providers improperly. This is a marked improvement from 2018 when the improper payment rate was 8.1% which represented $31.62 billion. The bulk of those improper payments paid by Medicare in 2019, similar to 2018, were attributable to two related categories: 1) Insufficient documentation – 59.5% ($15,952.32) and 2) Medical Necessity 18.7% ($5,395.69.

Now, let’s look specifically at the improper payment rate for Part A IPPS hospitalizations paid under the MS-DRG system. The Rate related to MS-DRG hospital payments stands at 3.6% or $4.5 billion. Nearly 80% (79.8%) of improper payments to DRG hospitals was attributable to two of five categories consisting of 1) Insufficient Documentation and 2) Medical Necessity. Each of these categories relates directly to quality and completeness of physician documentation, with more than 50% of the medical necessity denials being avoidable with more effective and complete documentation. It must be documentation that best tell the patient story as well as the evolution of the patient care with progress notes that show and reflect the progress of the patient until discharge to home or post-acute care.

Addressing Improper Payments – Inpatient Payment Reduction Strategy

The impetus for the Inpatient Payment Reduction Strategy is to reduce the Improper Payment Rate further to below the 3.6% or $4.5 billion threshold attained in 2019. This will be done through a myriad of CMS contractors, utilizing a host of resources, data analytics and data mining techniques, probe reviews and prepayment reviews and others to prevent and/or recover improperly paid claims. This Inpatient Payment Reduction Strategy, just as the name implies, will incorporate a multitude of proactive preemptive approaches to further prevent and reduce improper payments, with the goal of alleviating ineffective pay and chase efforts in recovering improper payments. So, what are the ramifications for hospitals and their initiatives to enhance reimbursement through clinical documentation integrity programs? In short, Chief Financial Officers and hospital administrators may find that their CDI programs are creating unnecessary financial and compliance exposure which will be explained below. It may be that they have not factored these penalties into their booked financial reserves for the next few years.

Financial & Compliance Exposure Abound with CDI

A primary focus of most CDI programs is on increased reimbursement which may be measured by capture of CC/MCCs and increase in Case-Mix Index. Whenever such an expected outcome is calculated and measured in dollars without concomitantly addressing and improving processes, in this particular case physician documentation, one can expect financial and compliance risks. This is just the nature of the beast rooted in unequivocal evidence as witnessed by the increasing number of medical necessity and clinical validation denials coupled with hospital level of care and DRG downgrades. The culprit in the majority of medical necessity denials and a large number of clinical validations denials as well as level of care downgrades are attributable to insufficient or downright poor physician documentation patterns.

My personal experience is based on conducting CDI chart review to render an overall assessment of physician documentation quality and completeness. While reviewing medical necessity and clinical validation denials, and assessing financial recoupment risks on billed claims, it was consistently demonstrated that the weakest link in most CDI programs is overlooking the countless opportunities for affecting positive change in physician behavioral patterns of documentation.

Common documentation insufficiencies include the following:

• In the History and Physical there are insufficient components related to the History of Present Illness (HPI) that are critical in establishing medical necessity for any hospital level of care. There are eight elements in the History of Present Illness with a minimum requirement of four to be recorded as the basis for establishment of medical necessity for hospital level of care. A typical HPI lacking depiction of clinical acuity and severity of illness includes the following: “Mrs. Jones, a seventy-five-year woman presented to the Emergency Department at 2 AM with chest pain of two days duration, was treated with Morphine and Nitro, admitted to the hospital for further workup and evaluation. Currently she is not complaining of any further chest pain.”

• There are inconsistencies in documentation that detract from the clinical validation of CC/MCC diagnoses as well as principal diagnosis despite reasonable clinical indicators within the chart. A typical exam consists of the following: “ Physical Exam Constitutional: Alert and oriented x 3 well nourished, well developed speaking in full sentences in no apparent distress talking to the nurses. Assessment reads: 1) Severe sepsis; 2) Acute metabolic encephalopathy secondary to severe sepsis.”

• Inappropriate and/or inaccurate copy and paste without editing documentation in the progress notes and other areas of the medical record

• Lack of clear, concise, consistent, contextually correct and consensus driven (physician agreement of diagnoses) documentation that best tells, describes, reflects, reports, and represents the true patient story

Present processes of CDI do not in and of themselves lead to compliance, reduction of financial recoupments, and net patient revenue collections. This may be due to the fact, as stated above, that CDI programs are fixated upon outcomes of reimbursement that often times do not materialize or are sustainable. Two adages apply to current CDI programs; 1) You don’t necessarily get paid exactly as the claim is billed and 2) It “ain’t” so just because the doctor says so in the documentation. Just because a doctor documents a diagnosis that was recorded in the record as a result of a query does not mean the payer will recognize and allow the diagnosis. This is particularly true if the diagnosis is a CC/MCC that directly impacts the MS-DRG assignment and reimbursement. Physician documentation must clearly articulate the clinical facts, clinical information, and context supportive of the diagnoses in the record. CDI quite frankly is neglecting this critical concept of documentation in the quest to query the physician and increase the Case-Mix index.

Other Risk to Consider

Reducing improper payments to providers necessitates a concerted focused strategy to identify potentially aberrant patterns of provider documentation, coding, and billing. The OIG, as well as Medicare, has expressed a continued major concern with patterns of coding and billing advancing over time as evidenced in the introduction to the November 2018 Workplan, a scope of work, titled “Assessing Inpatient Hospital Billing for Medicare Beneficiaries.”

“In 2016, hospitals billed Medicare $114 billion for inpatient hospital stays, accounting for 17 percent of all Medicare payments. The Centers for Medicare & Medicaid Services and the Office of Inspector General have identified problems with upcoding in hospital billing: specifically, the practice of mis- or over-coding to increase payment. The OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing. The OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. We will then use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.”(OIG Workplan-Miscoding)

Sadly enough, my ongoing reviews of CDI programs consistently identifies instances of miscoding or overcoding, maybe not intentional. This may relate to the appearance of diagnoses in the chart, often times from queries where the physician documentation does not lend itself to support the diagnosis given the portrayed clinical picture and patient story told within the record. In some instances, aggressive approaches to querying the physician in the securing of a diagnosis leads to CC/MCC “phantom” capture, a phenomenon I refer to as a diagnosis that comes from nowhere out of the blue, setting the stage for auditors to refute the diagnosis under the guise of lacking clinical validation. and resultant increased CC/MCC capture rate. Key Performance Indicators as they currently exist in CDI are counterintuitive to lessening unnecessary compliance and financial risk.) They are all task based in nature, tell one how they will be measured, and they will perform accordingly. Leaving a query with the expressed purpose of CC/MCC capture without due process in improving physician documentation in support of a diagnosis increases financial risk and exposure over time.

The Ultimate in Financial Exposure- Aberrant Billing Patterns

Overdocumentation and aggressive query processes contribute to this unnecessary financial risk and issues of compliance through the potential generation of aberrant documentation, coding, and billing patterns over time. A CDI Director or CFO should certainly be concerned with repetitive billing month after month of DRG 470 and 469 – Sepsis with or without a MCC respectively as the number one billed DRG followed by DRG 189 – Pulmonary Edema and Respiratory Failure and DRG 177 – Respiratory Infections and Inflammations with MCC. Heightened compliance concern should be in order with an overall CC/MCC capture rate of 90% and a CC/MCC capture rate of 95% with MS-DRG 378 – -Gastrointestinal Hemorrhage with CC with 90% of the CCs consisting of an acute blood anemia diagnosis. These patterns of coding and billing are certain to raise scrutiny by all payers as well as the CMS contractor responsible for carrying out and executing the Inpatient Payment Reduction Strategy Program. While these identified patterns of coding and billing may be considered the extreme, similar patterns continue in many programs.

Don’t Get Caught with Your Pants Down

The time is ripe for CFOs and CDI leadership to open the hood, kick the tires, and stop only relying upon traditional CDI Key Performance Indicators to measure CDI program performance. Medical necessity and clinical validation denials in addition to DRG and hospital level of care downgrades are other essential Key Performance Indicators that must also be considered as alternative measurements of CDI performance. These clearly represent preemptive proactive denials avoidance measures of documentation integrity when said measures are trending down in the right direction. Take a close look at MS-DRG frequency numbers monthly and monitor CC/MCC capture rates accompanied by clinical validation and quality of documentation in support of documented, coded, and billed diagnoses and MS-DRGs. Conduct an encompassing outside objective detailed assessment of present CDI processes at your facility that surpass the traditional CDI industry wide measures to ensure your CDI program does not present you with unnecessary costly financial and compliance risks. Do not get caught with your pant down, opening up your facility to potential outside audits and identification of aberrant patterns of documentation, coding, and billing, especially in light of the OIG’s Workplan on overcoding and miscoding and now the Improper Payment Reduction Strategy Initiative. Engage Core-CDI for a discussion on embracing an encompassing objective CDI assessment that offers a detailed analysis and reporting of findings with recommendations on strengthening the real operational performance of any CDI programs while minimizing risk and ensuring real sustainable revenue integrity.