HOUSTON – Results of a pilot program suggest that a surgeon-led Clinical Documentation Improvement (CDI) program can improve the accuracy of diagnostic coding, validate the quality of care delivered, and help ensure that hospitals are fairly compensated for the complexity of care they provide.
A comparison of outcomes of cases from four surgical oncologists from the periods before and after implementation of a CDI suggested that the actual case mix index (CMI) was 9% higher than the original charts indicated, a change that would translate into a more than $700,000 increase in reimbursement, said Dr. Keith Gray from the University of Tennessee Medical Center in Knoxville.
“CDI is low-hanging fruit in the era of pay for quality and dwindling hospital margins. Physicians and hospitals can benefit, and surgical oncologists are the natural physicians in the hospital to lead this process, “ Dr. Gray said at the Society of Surgical Oncology 2015 Cancer Symposium.
CDI programs are collaborative efforts between clinicians and health information management professionals, designed to document the quality of care the institution delivers through improved diagnostic coding, he explained.
The benefits of CDI include more accurate reflection of the severity of illness of patients, better sharing of data among caregivers, optimizing of claims processing, and a stronger bottom line.
“We all think we have the sickest patients in the country, and that’s why our results don’t match up. Clinical documentation is an opportunity for you to prove that,” he said.
In the study, a physician extender trained in CDI audited and update all inpatient diagnoses made by four surgical oncologists in a hospital-based practice from November 2012 through May 2013. The diagnoses were listed as being present on admission or recorded during the inpatient stay.
The investigators looked at data on the CMI, average mortality risk, and average severity of illness for 489 patients treated during the study period. These data were compared with a control set from 482 patients treated from March 2011 through October 2012, the period immediately prior to the implementation of the CDI.
The authors found that with the clinical documentation program in place, the CMI, risk of mortality estimates, and severity of illness index all increased.
The practice’s mean CMI, for example, increased from 2.38 to 2.59 (P < .001), a 9% relative increase. Dr. Gray noted that every 0.1 change in CMI represents a $700/patient difference in reimbursement. Therefore, the change would translate into a $718,830 relative increase in reimbursement.
Similarly, the severity of illness index, based on patient comorbidities, age, procedures, and principal diagnosis also increased, from a mean of 2.32 for controls to 2.54 during the study period, translating into a 9.5% increase (P < .001).
Risk of mortality estimates – the likelihood of in-hospital death based on comorbidities, age, procedures, and principal diagnosis – also increased, from a mean 1.88 to 2.07, a 10% increase (P < .001).
Although the CMI, risk of mortality, and severity of illness all increased during the study period, compared with the control period, the percentage of cases above the average length of stay, a measure of quality care, declined significantly, from 45.6% pre-CDI to 31.1% after CDI was implemented (P = .0001). Other measures of quality such as the observed to expected mortality ratio, length of stay ratio, and percentage of cases above the average cost also improved, but the changes were not statistically significant.
“CDI is relatively easy to implement with the resources that we have in place, and there’s minimal additional training to become efficient in this process,” Dr. Gray said.
The study was internally funded. Dr. Gray did not report potential conflicts of interest.