Clinical Documentation
Improvement (CDI)
Short Stay Acute Care Facilities
• Traditionally known as “hospitals”
• Can offer a variety of services by order of a
credentialed physician/provider who has
privileges at the facility
– “inpatient”
– “outpatient”
Short Stay Acute Care Facilities
Hospitals that accept CMS beneficiaries agree
to inpatient care reimbursement under the
Inpatient Perspective Payment System
(IPPS) and outpatient care reimbursement
under the Outpatient Perspective Payment
System (OPPS)
Medicare Reimbursement
• It is the responsibility of the hospital to know
when to bill Medicare Part A (IPPS) for inpatient
services and when to bill Medicare Part B (OPPS)
for outpatient services
• HOWEVER the hospital can only bill CMS
(Medicare/Medicaid) based on the services
ordered by the physician
Inpatient Services
• Traditionally referred to as an “admission” or
“Admit to”
– Most patients who spend the night in the hospital
believe they are “admitted”
– However, spending the night in the hospital does
not automatically qualify for inpatient services
Inpatient Services
• Uses a day as its basic unit
– Day begins at midnight
– Any part of a day = 1 day
• Patient admitted at 11:30 pm = 1 day
– Count first day of admission but not last day
• Discharge patients as early as possible the day of
discharge
• Time of discharge are when services are complete not
when the order is written
The Good and Bad of IPPS
• Inpatient services are only a “covered” CMS
benefit when medically necessary e.g., when the
services could not have been safely provided in a lesser
setting
• Hospitals must verify the medical necessity of all
inpatient stays/ episodes of care
• Short stay admissions are vulnerable to scrutiny
The Good and Bad of IPPS
• The IPPS uses a “bundled” payment system
differentiated by MS-DRG
– The MS-DRG payment covers all services rendered
by the hospital during an inpatient stay regardless of
the length of stay* (LOS)
IPPS Payment
• The bulk of the cost associated with an
inpatient stay is room & board
• CMS bases reimbursement on the G/LOS
– 95% confidence interval for LOS based on all
associated claims
– Always rounded up to whole number as inpatient
claims are paid per day
RAC Audits
The IPPS (MS-DRG) payment includes coverage for
several days of tx, the potential for overpayment
occurs when IPPS payment is made for a 1 or 2 day
stay
– Theoretical . . .
• if a patient is discharged in fewer days than the associated
GLOS the hospital makes $
• if a patient stays longer than the associated GLOS the
hospital loses $
High Risk Admission DRG
Hospital A will receive payment of $6,249
regardless of the services provided and how long
the patient stayed in the hospital under the IPPS
rules
– When patients in MS-DRGs like this have a one-day
inpatient stay CMS evaluates the possibility of
overpayment
• IPPS payment rather than OPPS payment
Purpose of Utilization Review (UR)
To ensure patients are receiving the correct level
of hospital services based on medical
necessity
• Procedure Only/same day surgery
• Observation/Outpatient services
• Inpatient services
Billing at the incorrect level of care is Medicare
fraud so a hospital does not bill for services
that don’t meet medical necessity
Step Two
• What type of hospital service was ordered by the
provider?
– Inpatient
• Appropriate for hemodynamic instability
• Patients who need immediate intervention/tx
– Observation
• When in doubt this is probably the right level of care
• Appropriate for stable patients with negative diagnostics who
are receiving additional diagnostics
Is the Order Valid per CMS Guidelines?
Not only must an order be present, but it must
be unambiguous
• “admit to OBS” is no longer considered a valid
order by Medicare as of April, 2009
– The term “admit” = inpatient setting
– The term “OBS” = outpatient setting
Is the Order Valid?
• The term “23 hours admission” is NOT valid
– 23 hour observation is an antiquated term
– An inpatient admission is billed per day, a patient
can be an inpatient AND remain hospitalized for less
than 24 hours
– Observation patients DON’T automatically “rollover”
to inpatient status after 23 hours the physician must
write a new order to cover care past the 23rd hour
Step Three
• In order to verify medical necessity, CMS
mandates the use of a “screening tool”
• UR staff screen for medical necessity by
performing an admission review
– Is the ordered level of care supported by
documentation in the medical record?
Observation Following Surgery/Procedure
• Requires medical necessity validation
• Observation is only justified if something
occurs during the procedure and/or during
recovery to necessitate an additional episode
of care
– Require 4-6 hours of recovery
– “monitoring” does not justify observation care
– The observation principal diagnosis isn’t the same
as that to justify surgery
How Do You Justify Patient Status?
• Document, document, document
• Not only does a hospital need justification for
the patient status, BUT the hospital is also
dependent upon physician documentation for
their CMS Quality Indicators and
reimbursement
Documentation Basics
• Observation care is for diagnostic workup so
inpatients should have “evidence of” a
concerning disease process to be admitted.
• Always provide the underlying etiology of a
symptom i.e., chest pain, syncope, abdominal
pain, documented in the H&P in the discharge
summary
– A diagnosis can be “possible” or “probable” in the
discharge summary if additional evaluation will
occur in the outpatient setting
History and Physical
• Specify in your “history of present illness” the
following:
– Onset of the new/ acute symptom
– Is it an exacerbation of a chronic condition
– How is the patient’s current condition different
from baseline?
History & Physical
• Specify the current status of all co-morbid
conditions
– State if resolved
• History of pneumonia dx by PCP resolved
– Remains acute
• History of pneumonia dx by PCP remains acute
– Is a chronic condition
Coding Guidelines
The principal diagnosis is the condition established
after study to be chiefly responsible for occasioning
the admission of the patient to the hospital
• Not the admitting symptom
• Link the symptoms to the underlying disease
process
– Fluid volume overload 2/2 ESRD
Documentation Guidelines
Avoid perpetuating the admitting complaint as the
Pdx, update your diagnoses each progress
note/daily
• Clearly state when the etiology of the admitted
complaint is determined if it’s symptomology
was present on admission (POA)
– Disease processes like pneumonia, SIRS, and sepsis
should always be noted if the symptoms were POA
Documentation Guidelines
Clearly state when a differential or working
diagnosis is ruled out or confirmed in the progress
note and/or discharge summary
– Unstable angina secondary to CAD remains likely
cause of the CP
– Pneumonia ruled out, abx stopped
Documentation Guidelines
There can still be “evidence of” a disease based on
presenting complaints even when not confirmed
with diagnostics
• Aborted stroke 2/2 TPA intervention
• Evidence of gram negative pneumonia (HCAP)
2/2 recent hospitalization and dialysis
The Value of a Concurrent Condition
Medicare identifies diagnoses (by ICD-9 codes)
that require additional resources during
hospitalization when not intrinsic to the PDx
These diagnoses are separated into those that
minimally  resource use (CC) and those that
greatly  resource use (MCC) this
stratification creates the “tiers”
What is The Clinical Documentation
Improvement (CDI) Program?
Because clinical terms don’t often correspond to
ICD-9 codes, many hospitals have a CDI program.
RNs and/or coders who work collaboratively with
providers and coders to bridge the gap between
the data contained in the medical record i.e., test
results, nurses notes, consultant notes, etc., and
what is available for coding.
How Does CDI Work?
The CDI nurse establishes and updates a
working MS-DRG based on the principal
diagnosis, principal procedure (if
applicable), and any concurrent conditions
that are classified as a CC or MCC based
on documentation by treating providers
i.e., H&P, progress notes, discharge
summary, etc.
Chart Queries
Whenever there is clinical evidence suggestive of a
more definitive Pdx and/or the presences of an
incomplete or missing diagnosis, i.e., a potential
CC and/or MCC, the CDI specialist will “query”
the physician to interpret the clinical evidence.
NOTE: Queries aren’t only to  reimbursement
Chart Queries
As with direct patient care, the CDI nurse
presents relevant findings to the physician for
review
– CDI staff don’t evaluate the “quality of care”
– The focus of CDI is ensuring provider documentation
reflects the clinical evidence in the medical record
and can be “captured” by ICD-9 codes
Chart Queries
• CDI staff are not allowed to “lead” a physician
to a particular response
– CDI staff can’t pose yes/no questions
– CDI staff can’t tell you what diagnosis to write
• When possible, CDI staff will give the provider
the diagnosis commonly associated with the
clinical evidence that can be captured by ICD-9
code
Chart Queries
• Coders can’t infer or assume so sometimes
CDI staff must ask for documentation that
seems obvious to the provider and/or to “link”
a symptom to a diagnosis
• A provider can always disagree or state the
condition isn’t clinically significant or is an
incidental finding
Reminders
• Provide rationales/medical necessity for all
orders justify the complexity of your patient
• Refer to the H & P to address ALL presenting
signs/symptoms with known, suspected or
possible diagnoses
• State when a differential dx has been
confirmed or ruled out