CDI, or Clinical Documentation Improvement, is as familiar to physicians who practice in the hospital as other acronyms such as ICU, OR, ED – but in the physician office, CDI is relatively unknown. However, with the implementation of the Merit-Based Incentive Payment System, or MIPS, CDI in the physician office will become imperative.
Most physicians will fall under the MIPS provisions of MACRA, the Medicare Access and CHIP Reauthorization Act. CMS estimates that of the 1.3 million providers under MACRA, 1.2 million will be under the MIPS program. The Quality component of MIPS is familiar to most physicians, as it is similar to the previous Physician Quality Reporting System. One new aspect of MIPS, however, is the Resource Use or Cost. This component will be 10 percent of the physician’s MIPS score in 2018, increasing to 30 percent in 2019 and beyond. The Cost score will be derived from claims data and will be based on the CPT and ICD-10-CM codes billed. Correct and specific ICD-10-CM coding will be key to physician reimbursement in this model. Medicare, and other payers implementing similar reimbursement strategies expect that a patient with a certain diagnosis will incur an estimated cost. If the cost to treat the patient far exceeds the estimate, then the physician’s Resource Use/Cost score will be low – he/she will be considered to be an inefficient physician.
A specific example to illustrate this: The physician treats a patient with diabetes. The only code he bills for this patient is E11.9 – Type 2 diabetes mellitus without complications. However, this patient has diabetic retinopathy, diabetic neuropathy, and diabetic chronic kidney disease. The payer’s estimated annual cost for a patient with diabetes with no complications is $1,400, but this patient incurs much higher costs due to his complications. The physician, therefore, appears to be inefficient, and his Resource Use/Cost score will suffer. The payer’s estimated cost for a patient with diabetic chronic kidney disease is $4,300. Had the physician coded as specifically as he could have, E11.319 for diabetic retinopathy, E11.40 for diabetic neuropathy, and E11.22 for diabetic chronic kidney disease, the higher cost would have been expected, and the physician would not be penalized for the care he is rendering.
One hindrance to CDI in the physician office setting is the use of electronic medical records and the implementation of “charge passing”, codes transmitting directly from the EMR into the practice billing system. Physicians may not choose the most specific, or even the most accurate, diagnosis code, but once those codes are passed onto the claim and filed to Medicare, there is no changing or correcting that information. Corrected claims will not be accepted for this purpose. Some practices use coders to review these claims before they are actually filed. This usually does not involve 100 percent review of the documentation, but it would allow some coding errors to be caught. For example, if a coder noted the following diagnoses on the claim: E11.9, N18.5, G62.9, he would be prompted to discuss with the physician that N18.5 – chronic kidney disease, stage 5, and G62.9 – neuropathy, are considered to be diabetic complications and should be coded as such. And if a coder is familiar with coding guidelines, understanding that certain diagnoses require additional codes, then when she notes G30.9 – Alzheimer’s disease on the claim, she can query the physician as to which additional code is appropriate, F02.80 – dementia in underlying disease without behavioral disturbance or F02.81 – dementia in underlying disease with behavioral disturbance.
This may require additional diagnosis coding training for physician office coders, and it will almost certainly require a change in mindset. Physician coders have focused on what is documented with the mantra “Not documented, not done.” But CDI requires a similar focus on seeing what is not documented, what should be there, what is likely true for that patient – and then querying the physician.
Electronic medical records have also contributed to some of the errors seen in that physician may not have been trained properly in diagnosis documentation and coding before having access to what is essentially the entire ICD-10-CM book in their EMR. The ICD-10-CM descriptions may not match the language the physician uses, although the code is correct. For example, in ICD-9-CM, the code for depression, unspecified was 311, and the description was Depressive disorder, not elsewhere classified. In ICD-10-CM, the code for depression, unspecified is F32.9, and the description is Major depressive disorder, single episode, unspecified. Physicians may not be able to identify the appropriate code without further diagnosis education. EMR vendors and office staff may try to set up shortcuts to assist the physicians in choosing the appropriate diagnosis code and create further issues. Two recent errors I have seen in my own auditing practice: 1.) physicians coding Crohn’s disease with small bowel obstruction when they intended to code for small bowel obstruction, unspecified and 2.) physicians coding psychophysiologic insomnia when they intended to code chronic insomnia. CDI in the physician office setting must include a detailed review of the ICD-10-CM code descriptions in the EMR.
CDI in the physician office setting does not have to be as formal a process as that seen in the hospital – it can be informal discussions with the physicians. It can be accomplished through real-time shadowing or end-of-day review, but it must occur before the claim is filed. A simple CDI process could look something like this:
- Coder reviews record for correct coding based on physician documentation.
- Coder talks with nurse and physician about code choices.
- Coder identifies incorrect codes chosen – discovers confusing language in ICD-10 description.
- Coder reviews with physician and makes changes in code descriptions to assist physician in most specific and correct coding.
The keys for coders will be continuing education, which may be in the form of informal chats with the physicians and clinical staff, review of ICD-10-CM guidelines and Coding Clinic guidance, review of medical policies which can be used to help guide physicians in documenting. And perhaps most importantly, respect for the physician’s priorities. The physician’s foremost interest is care of the patient, and CDI is simply helping the physician to understand that how he documents matters and providing the assistance he needs to make it so.
Medicare Quality Payment Program
Kim the Coder (also known as Kim Huey, MJ, CCS-P, PCS, CHC, CPC, CPCO, COC) works with clients to improve coding and documentation of services and to ensure compliance with Medicare and insurance company regulations. Ms. Huey is available for on-site visits for auditing and education as well as for on-the-record audits and general coding and reimbursement questions.