Tuesday, 12 April 2016 04:49

CDI and Hospital Readmissions

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r mack“Do you ever have déjà vu?” –Bill Murray, Groundhog Day

Let me describe an awkward situation – it’s a Monday, and you are reviewing a patient who has discharge orders already in place. You have queried, obtained a response, and had a great interaction with a physician throughout this patient’s stay. The patient looks great – well, as great as can be expected for being chronically ill. You arrive to work on Tuesday morning and see that the patient is still here…but wait! He was discharged at 5:06 p.m. yesterday and readmitted at 2:13 a.m. today. So now you are reviewing an entirely new stay.

This is what is referred to in the industry as a “CDI (clinical documentation improvement) nightmare.” CDI specialists often refer to these patients as “frequent flyers,” and what used to result in a simple eye-roll is now a serious concern. The repercussions of readmissions can weigh heavily on hospitals, and often there is not much we can do to prevent them. However, a strong CDI and coding program can have an impact on the risk adjustment associated with readmissions.

What is a Readmission?

Per the CDI Pocket Guide published this year, a readmission is defined as “a patient who is admitted for any reason to the same or another acute-care hospital within 30 days of discharge. Certain readmissions are exempt, such as planned chemotherapy or rehabilitation.”

The U.S. Department of Health and Human Services (HHS) announced in January 2015 a new set of goals and a timeline for tying Medicare payments to quality or value through alternative payment models. Included in these “alternative payment models” for inpatient stays is the Hospital Readmission Reduction Program (HRRP). The Centers for Medicare & Medicaid Services (CMS) has set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016, and 90 percent by 2018, through programs like HRRP and Hospital Value-Based Purchasing (VBP).

The penalties associated with readmissions are much more severe than those of other pay-for-performance (P4P) programs. Hospitals may now lose up to 3 percent of reimbursement moving forward, depending on their readmission performance. The HRRP imposes these penalties on Medicare patients admitted with the following diagnoses: acute MI, heart failure, pneumonia, COPD, and elective hip or knee replacement (s/p CABG will be coming in 2017).

So, what does performance entail? How does CMS know how well your hospital is doing? Put simply, it compares your hospital to other hospitals across the country. If your hospital exceeds the “risk-adjusted national readmission rate,” then you will be penalized, and, per the CDI Pocket Guide, “for FY 2015, Medicare estimates that about 78 percent of hospitals were penalized an aggregate total of $428 million.”. Not only that, but CMS estimates that about one in five Medicare patients will experience a readmission.

Exclusions to HRRP

Fortunately, there are some exclusions to the HRRP program – these include admission for planned chemotherapy or a pre-planned surgery, rehabilitation stays, neonates, cystic fibrosis patients, palliative care patients, many/most HIV DRGs, and patients that leave against medical advice (AMA). As I have discussed in previous articles, it has never been more important to establish the correct principal diagnosis for a patient (for a multitude of reasons, not just HRRP!) and to make sure we are documenting if they are noncompliant or leave AMA.

I’m just a CDI Specialist – What can I Do?

“Once again the severity of illness based on comorbid conditions influences the risk adjustment,” the CDI Pocket Guide reads. “Sicker patients are expected to have higher readmission rates, so hospitals with a patient population reflecting higher severity will have their readmission rate adjusted downward and therefore are less likely to be penalized.”

What does this mean for CDI? It means that we are already assisting in identifying the best severity scores for our patients, indicating that we are already helping influence our hospital’s overall risk adjustment scores. There are several diagnoses that, if we can get them established in the record and final-coded, can and will affect risk adjustment. They are different for every readmission diagnosis, as each such diagnosis (for example, heart failure) has numerous diagnoses that influence the risk adjustment score. But several of them are similar across the board. Here are a few:

  • Protein-calorie malnutrition
  • Cardiorespiratory failure or shock
  • Sepsis/septicemia/shock
  • Dementia and other specified brain disorders
  • CHF
  • Stroke
  • Hemiplegia, paraplegia, paralysis, functional disability
  • Pneumonia
  • ESRD or dialysis, renal failure
  • Drug/alcohol abuse, dependence, or psychosis
  • Decubitus ulcers or chronic skin ulcers

This is just a small sample of some of the diagnoses that affect risk adjustment. CDI specialists are already identifying several of these throughout chart review – and this is a good thing! If we can get these diagnoses established in the record – regardless of “usual” CDI impact – this can help adjust your hospital’s risk scores in the positive direction.

What about Noncompliance?

Readers may be thinking, “okay, great, I can do all of this and help my hospital – but what if the patient is noncompliant?” Unfortunately, there is not much that we can directly do about noncompliance. Many patients are noncompliant due to financial burdens and limited health literacy skills.

However, if a patient is noncompliant, this needs to be documented in the record and established in final coding. Per ACDIS, “CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report [noncompliance], hospitals can use this documentation and coded data to help prevent or appeal denials … (and) if [it] is reported in the top nine diagnosis codes when it is transmitted on the UB-04, (it allows) the payor to have the knowledge that patient noncompliance may have contributed to the readmission. “As we already mentioned above, if your patient leaves AMA, it is imperative to have this documented, as this will exclude the patient from readmission calculations.

In Conclusion

The numbers don’t lie – patients who are sicker, with more chronic conditions, have an increased risk of readmission. It’s that simple. As a CDI specialist, it’s easy to feel powerless when it comes to readmissions. However, during your chart review you likely already are identifying ways to improve your patient’s severity of illness and risk of mortality (SOI & ROM) scores. Work with your quality team to identify all diagnoses that, if established in the record, can best benefit a hospital’s risk adjustment ratings.

About the Author

Rachel Mack is a CDI specialist for SCL Health, where she performs current chart reviews and audits. The focus of her work is on identifying missed opportunities to obtain an accurate and complete record for each patient. Rachel has nursing experience in CVICU, ICU, and home health, and has worked in clinical documentation improvement as a CDI specialist, CDI educator, and CDI consultant. She has written various articles for VBPmonitor and ICD-10monitor and has assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.

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Last modified on Thursday, 14 April 2016 10:12

Rachel Mack is a CDI Specialist for SCL Health where she performs current chart reviews and audits. The focus of her work is on identifying missed opportunities to obtain an accurate and complete record for each patient. Rachel has nursing experience in CVICU, ICU, and home health and has worked in Clinical Documentation Improvement as a CDI Specialist, CDI Educator, and CDI Consultant. She has written various articles for the VBPmonitor and ICD-10monitor and has assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.