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Help Me Help You: Aligning Individual Strengths for CDI and Inpatient Concurrent Coding

Stephanie Jensen, BSN, RNClinical Documentation Integrity Program LeadNebraska MedicineOmaha, NE

Melanie Reineke, CCS, CPCHospital Coding and CDI ManagerNebraska MedicineOmaha, NE

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Understand Nebraska Medicine’s definition of concurrent coding– Identify benefits to concurrent coding process– Identify challenges to concurrent coding


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Nebraska Medicine – Fast Facts

• $2.9 billion academic health system• Two hospitals, anchored by an academic medical center, Nebraska Medical Center• More than 1,000 affiliated physicians across all specialties• 40 ambulatory clinics• 8,000+ employees• Partial ownership of two rural hospitals and one specialty hospital• Primary clinical partner of UNMC • 606 beds• 30,132 discharges• 945,876 outpatient visits• 92,009 ER visits• Average daily census: 469


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Nebraska Medicine – Services

• Patients from all 50 states and 47 countries• International reputation in oncology, transplant,

and biocontainment• Fred & Pamela Buffett Cancer Center • Lauritzen Outpatient Center and Village Pointe

Surgery Center opened in 2016• New ambulatory clinics under construction• Regional leader in cardiovascular and

neurosciences• Region’s only 24/7 trauma center providing

comprehensive care for adults and children• Named Best Hospital in Nebraska five consecutive

years by U.S. News & World Report


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Nebraska Medicine – Coding/CDI Staffing

Inpatient Coding Team• 1 coding quality lead• 1 education coordinator• 11 full‐time coders• 1 casual coder• 1 full‐time contract coder• (Average 12 coders per day)

CDI Team• 1 CDI team lead• 1 CDI quality lead• 5 full‐time CDI RNs at Nebraska

Medicine’s Main Campus• 1 full time CDI RN at Bellevue Medical

Center• 2 CDI quality RNs


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Key Objectives for Change

• Quality reviews– Vizient 5‐star ranking in 2016 and 2017 – Improve observed to expected (O/E) ratio– Real‐time Patient Safety Indicator (PSI) review

• Overall CDI/coding quality– ICD‐10 CM Guideline I.A.19: Code Assignment and Clinical Criteria– AHIMA Practice Brief: “Clinical Validation: The Next Level of CDI”

• Revenue cycle management– Decreased rebills– Top performer AR– Increase CMI 0.1 ($7 million)– Decrease DRG validations


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Traditional vs. Concurrent Coding Process


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Traditional Reviews

Patient admitted CDI initial review for working DRG

Subsequent reviews and queries with

updates to working DRG

Patient dischargedCoding reviews entire stay and

develops final DRG

CDI/coding reconcile differences between working and final

DRG

Account finalizedCDI DRG

reconciliation and possible rebill


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Traditional Reviews Summary

Pros Cons

Independent workflow Redundant work

Focused AR management DRG reconciliation process

Coders well rounded across service lines No coding subject matter experts


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Concurrent Reviews

Patient admitted

Coding develops working DRG

CDI reviews

Continue coding

Patient discharged

Coder accepts working DRG and finalizes account


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Concurrent Reviews

Pros Cons

Shared ownership of DRG Managing backlog

Expanded coverage Maintaining consistent volume accounts for CDI

Subject matter expert coders/CDI Tracking productivity

CDI able to assist with quality More labor‐intensive for coding

Robust clinical validation reviews


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Considerations When Developing a Concurrent Workflow

• Which areas will be covered?– Prioritize facility‐specific opportunities– Review denials and determine if there is a need for more focused CDI reviews

• How often should CDI be reviewing accounts?– Continuation of review after maximized DRG– Utilize the concurrent DRG assigned to develop follow‐up review priorities


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Considerations When Developing a Concurrent Workflow

• How will CDI and coding communicate with each other?– See if current process has system steps in place to use– Email each other with questions on reviews

• How will AR and workflow volume be impacted by PTO and holidays?– Cross‐coverage between service line– CDI can still assign a working DRG to a concurrent review


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Shared Utilization of CDI Program Software

• Workflow is based upon a 2:1 coder/CDI floor assignment– Focus on units specializing in cardiology, family and internal medicine, neurology,

oncology/BMT, and transplant patients– Coders assign patients to themselves and begin initial reviews based on floor assignment

pulls from “Ready” list– Coders follow patient throughout the hospital stay with the “Scheduled for Today” list

regardless if patient transfers location– CDI follows up on individual queries regardless of floor, but if a patient is transferred to a

different floor, multiple CDI staff may review one patient


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CDI Prioritization of Review

• CDI pulls work from their worklist based on PRIORITY setting and floor assignments:– Multiple CDI staff can review one patient if the patient is transferred throughout the stay

– Priority given to admissions within 48 hours– CDI performs daily reviews on high‐priority accounts– O/E aggregates have become part of the CDI review process


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Concurrent Communication Between Coding and CDI

• During the stay, coding and CDI communicate with each other regarding coding and query opportunities – Query requests to CDI – Any questions to CDI regarding POA or disease process– CDI findings of documented diagnoses that coders might have overlooked


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Shared Management of AR

• CDI will assign working DRG to assist with workflow and AR volume management. – Holidays– PTO– Mondays– End of FY

• CDI assigns codes with POA of U, which prompts coders to recognize that CDI started the case. Coding then validates CDI‐assigned codes and continues their coding process as normal.


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Opportunities Learned Along the Way

• Management daily workload with consideration to AR, work queue volume, and staffing

• When switching to concurrent, each team is dependent on each other in order to effectively manage the flow of work

• Increased CDI reviews beyond CC/MCC opportunities• Able to collaborate with providers on complex diagnoses/procedures• Focused education for both coders and CDI


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Impacts of Concurrent Coding


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Concurrent Coding Coverage Rates

0

10

20

30

40

50

60

70

80

90

Jan‐16

Feb‐16

Mar‐16

Apr‐16

May‐16

Jun‐16

Jul‐1

6Au

g‐16

Sep‐16

Oct‐16

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17

Jul‐1

7Au

g‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐1

8Au

g‐18

Sep‐18

Oct‐18

Nov‐18

Dec‐18

Payer Coverage

All Payers Medicare


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Expanded Tracking Query Impact

• Creation of additional query impact selections to help track non‐MCC/CC queries sent

• Aggregate and mortality coefficient – queries sent by CDI and quality related to O/E ratio

• Clinical validation – queries sent by CDI to clarify diagnoses that do not have strong clinical support


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Clinical Validation Query Rate

• In the first month of the program, 52 queries were sent that were specifically related to clinical validation of diagnoses that were reported within the medical record

Sepsis27%

Respiratory failure25%

AKI17%

Heart failure12%

• 27% Sepsis• 25% Respiratory failure• 17% AKI• 12% Heart failure• 4% Shock• 2% BMI clinical significance• 2% Encephalopathy• 2% Malnutrition• 2% Pneumonia• 2% NSTEMI


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Clinical Validation Reviews

• Created a clinical validation work queue for CDI to review the account prior to final coding submitted to billing

• Developed a clinical validation handbook to assist with the validation reviews and query writing

• The accounts are reviewed by the CDI team based on their assigned service areas

• Included diagnoses that are high payer denials• Education to providers on clinical validation reviews and queries


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Moving Forward With Our Concurrent ProcessNext steps …


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Concurrent Patient Safety Indicator (PSI) Reviews

• Collaborate with quality and quality coding coordinator to have CDI assist with PSI reviews

• Increased confidence with the coder assigning the working DRG/codes related to PSIs

• CDI will work with quality coding coordinator to send queries if needed for clarification, POA status, and/or excludes


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Partnering With Quality Department

• Support our organization’s Vizient quality metrics• Coding and CDI were able to collaborate with the quality team to assist with increasing reviews for quality opportunities

• Coordinated with the quality team to join efforts to increase education for providers identified to have quality opportunities

• Development of service‐specific education tools


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Pilot Program Neurology

• Partnering with quality team on specific DRGs • CDI performing concurrent aggregate reviews with Vizient risk model groups

• Identifying query opportunities while patients are still in‐house• Identifying education opportunities for documentation improvement for patient outcomes


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Sepsis‐3 Clinical Validation

• Supported organization’s transition from Sepsis‐2 to Sepsis‐3 criteria through utilization of our clinical validation process and provider education

• Coding and CDI were able to collaborate with the sepsis committee in developing hospital‐specific Sepsis‐3 criteria

• Coordinated with the committee to develop a Sepsis‐3 clinical validation template that aligns with the organization’s current definition


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Benefits to CDI and Coding

• Greater utilization of CDI’s clinical background• Allow inpatient coders to focus on specific coding areas• Ownership of clinical validation process by CDI• No longer have to reconcile DRG mismatches between coding/CDI• Deeper dives to assist quality with live aggregate O/E reviews on maxed cases


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Benefits to CDI and Coding

• Coders able to communicate real time with CDI regarding disease process questions

• Increased time for physician education and rounding• Improve accuracy of final code set sent for billing• Formation of stronger working relationship between teams


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Thank you. Questions?

[email protected]@nebraskamed.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


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