Maximizing CDI for Physician Queries for Accurate Reimbursement

Maximizing Clinical Documentation Improvement (CDI) is crucial for accurate reimbursement in healthcare organizations. CDI programs play a significant role in ensuring documentation is captured correctly, thereby influencing reimbursement. The effectiveness of a CDI program can be demonstrated through coding examples from a leading health system, highlighting its impact on accurate reimbursement.

Adhering to specific physician query policies is essential for issuing compliant and non-leading queries. AHIMA and ACDIS provide Guidelines for Achieving a Compliant Query Practice, serving as industry standards. Following these guidelines helps healthcare professionals navigate query processes and functions effectively.

The Centers for Medicare & Medicaid Services (CMS) process includes assigning diagnostic codes for each patient account and these codes are grouped into a specific Medicare Severity Diagnostic-Related Group (MS DRG). For instance, CMS assigns unspecified pneumonia diagnoses to MS-DRG 193, 194, or 195. Both the principal diagnosis (pneumonia) and secondary diagnoses, as well as procedures, can affect the DRG and subsequent reimbursement. Incomplete documentation can significantly influence reimbursement, making physician queries via CDI essential. Queries play a crucial role between coders and physicians in clarifying clinical indicators to identify the correct DRG, ensuring accurate documentation and reimbursement.

In conducting facility coding for one of the largest health systems in the country, inadequate documentation is a common scenario that coders encounter when reviewing documentation improvement opportunities. Highlighted are 4 examples where a query was necessary.

1. Diagnosis clarification.
• A 78-year-old patient with Parkinson's disease presented with multiple symptoms after slipping in the shower, including trauma to the shoulder and arm, headache, and a diagnosis of a compression fracture of the C7 vertebrae. However, there were inconsistencies in the documentation, such as coding a symptom (cachexia) instead of identifying an underlying cause. In reviewing the account, the coder also noted that dietary was consulted and the dietician documented the patient had a Body Mass Index of 17, muscle wasting, severe edema, weakness, and had experienced significant weight loss in the last 3 months. A review of lab reports noted multiple deficiencies in iron, zinc, and protein.
• Based upon the cachexia diagnosis, the lab findings, and the details documented by dietician, further clarification was needed by the physician.
• The coder placed a physician query to clarify if the patient was malnourished and the severity of the malnutrition.
• The physician response to the query was severe protein calorie malnutrition.
• By addressing this query and seeking clarification on the diagnosis, the reimbursement increased from $6,783 to $11,743, a difference of $6,210.29.
2. Procedure query clarification.
• A patient with a disability presented to the emergency room with altered mental status and aggression. The patient had previously experienced frostbite, resulting in toe amputations, and underwent debridement in the operating room.
• The documentation lacks specificity regarding the type of debridement procedure performed.
• By placing a physician query to clarify whether it was excisional or non-excisional debridement, the coder was able to accurately code the procedure, increasing reimbursement from $9,148 to $22,570.
3. Conflicting documentation.
• This highlights the importance of clarifying documentation related to a 70-year-old patient with a catheter-associated urinary tract infection (CAUTI) and a pressure ulcer. The documentation included a history of stroke, Alzheimer's, dementia, and hypokalemia.
• The presence of a pressure injury raised the need for a physician query to clarify the severity of the pressure ulcer or injury.
• With the query, it was confirmed as a pressure injury stage 3, resulting in a higher reimbursement of $11,316. Without the query, the reimbursement would have been approximately $7,000, a difference of more than $4,000.
4. Principal diagnosis clarification.
• An 80-year-old patient was admitted to the hospital with complaints of altered mental status and weakness, prompting an evaluation for a possible stroke. The medical records indicated the presence of a left facial droop and a documented history of Alzheimer's disease. Despite performing various diagnostic tests, including negative results for intracranial pathology on both head CT and MRI scans, there remained uncertainty regarding a specific diagnosis for the patient’s altered mental status as the notes referred to overuse and referred to decreasing the dosage.
• A physician query was necessary to clarify if the underlying causes of the symptoms were the result of medication overuse or an adverse effect.
• The query revealed medication overuse, leading to a coding change for poisoning and impacting the DRG and reimbursement accordingly from $5,400 to approximately $10,000.

CDI programs play a vital role in promoting collaboration between coders and physicians, ensuring comprehensive documentation, and optimizing reimbursement for healthcare organizations., and these examples demonstrate the importance of clarifying procedure details through physician queries to ensure accurate coding and reimbursement. With numerous levels of service, a variety of technologies, and expert services readily available, the team at AGS Health is fully equipped to support your coding and CDI needs.

Download our white paper, “Achieving Accurate Reimbursements by Maximizing CDI for Physician Queries," and gain valuable insights into how to effectively handle physician responses to queries and measure the impact of physician querying to improve reimbursement accuracy.