Implementing CDI Before PDGM

Clinical documentation has always been an integral and necessary function in home health operations, and it has now become a formal program: Clinical Documentation Improvement (CDI). QAPI is a portion of the overall CDI program, but CDI and QAPI are not the same!

Clinical documentation impacts financial results, quality and coding. All agencies have seen ADR denials from non-compliant documentation and survey deficiencies. Now more are seeing Condition-level and Immediate Jeopardy, resulting in Sanctions. Often these denials and deficiencies stem from non-specific and/or lacking clinical documentation.

In addition, the result of poor clinical documentation can result in low Star ratings, causing a loss of referrals. The 9 states that are in the Value Based Purchasing Pilot have seen outcomes lead to reimbursement losses.

And of course, PDGM will further increase the need to improve clinical documentation.

Therefore, having a formal CDI program has never been more important.

Several elements comprise CDI:

  • Focus on improving patient outcomes
  • Accuracy and consistency of documentation
  • Continued survey readiness
  • Understanding coding guidelines to support primary diagnosis
  • Gathering key data to query the physician and clinical team for accurate assignment of diagnosis
  • Full utilization of Electronic Medical Record (EMR)

A CDI program will protect an agency from liability claims, denials, and claim errors. It will identify missing or erroneous documentation in the EMR and OASIS, as well as improving Star ratings, Value-Based Purchasing Outcomes, and CAHPS scores.

As a profession, CDI was formally developed in 2007 in response to the DRG system for hospitals, but it gained steam with the transition to ICD-10. Many hospitals have certified CDI professionals using metrics focusing on compliance. In home health, increased ADR denials from TPE, RAC, and ZPIC audits have threatened the viability of many agencies.

In home health, CDI will focus on several areas: Face To Face, skilled need, and homebound status. Increased numbers of condition-level deficiencies can lead to sanctions particularly in the areas of patient rights, QAPI, infection control, comprehensive assessment, plan of care, and aide services. An effective CDI program can help alleviate concerns in these areas.

With the implementation of PDGM on January 1, 2020, clinical and other patient characteristics will categorize each 30-day period into one of twelve groups in the payment model, based on the patient’s primary diagnosis. The documentation in the clinical record, from the physician and clinician, must support the assignment of that diagnosis and any comorbidities. If the primary diagnosis does not fit into one of the twelve groups, it will be considered a “unacceptable diagnosis” and the claim will be a Return to Provider (RTP).

PDGM is the biggest change in home health since PPS, and CDI will be key in surviving the future. Let 5 Star Consultants help you be prepared. To find out more about our training options, which includes a webinar on CDI, consulting and coding capabilities, contact us today at [email protected] or call us at 866-428-4040.
© 2019 5 Star Consultants, LLC

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