Podiatry Coding & Billing Alert

Have skills on your team ranging from clinical to coding expertise.

Follow these handy tips to build an effective CDI program in your practice.

Tip 1: Adopt Vital Rules to Enhance Your CDI Program

You should keep several rules in mind when it comes to your CDI program, Pritchett said.

Rule 1: Providers should always be involved in your CDI program from beginning to end.

Rule 2: Have skills on your team that range from clinical expertise to coding expertise.

Rule 3: Always follow the Association of Clinical Documentation Integrity Specialists (ACDIS), American Health Information Management (AHIMA), and Practice Brief updates.

Rule 4: Maintain regular reviews by nonbiased experts such as physicians, clinical staff, coders, billers, and admin staff who are not part of your CDI team. “This does two things,” Pritchett said. “It gives you a fresh perspective on your CDI team and makes sure that peer review is going on and those queries are actually being legitimately posed to the physician.”

Rule 5: Have written policies and procedures, which is a really important step, according to Pritchett.

“Policies and procedures indicate when and why to query a physician,” Pritchett said. “For example, I have seen in my career all sepsis encounters on hold for the physician’s query. All sepsis claims. This is not proactive.”

As a coder, you should not have to code the chart, then place it on hold for CDI review retrospectively, Pritchett added. Instead, for effective CDI, you should be working with your physician during the patient encounter for clarity, concise documentation, and the underlying condition documentation.

“I’ve also seen cases where the physician was nonspecific on sepsis, the laboratory results were positive while the patient was in house, and it’s still not documented,” Pritchett said. “This is really important because not only is sepsis categorized by the type of infection or ‘due to a bacterium,’ but also unspecified codes are bad and frowned upon by Medicare, Medicaid, and most commercial payers.

Tip 2: Apply Specific Measurements and Metrics

You can measure different aspects of your CDI program, Pritchett said. Measurements and metrics include the following:

• Rate of review: This takes into consideration how many patients were discharged and how many of those charts were actually reviewed. Also, in a CDI program, you should ask what your largest risk areas are.
• Rate of physician query: For example, if you had 200 discharges last week and queried 191 of those, what are you doing wrong? Pritchett asked.
• Agreement rate: How often does the CDI agree with a query?
• HCC capture rate
• Denial rate
• Provider and patient satisfaction

Tip 3: Successfully Query Your Physicians

Pritchett also discussed when you should query your physicians and how to query them the correct way.

Reasons you should query your physician include the following:

• There is a disconnect between physicians and coders.
• Many definitions in the CPT^® and ICD-10 are different from the way physicians learn to document.
• There is no documentation or lack thereof to support the billing and or claim charges.
• The documentation does not meet medical necessity.
• Documentation by the physician is conflicting, contrasting and/or ambiguous.
• Office of Inspector General (OIG) audit findings of Diagnosis Related Group (DRG) reporting
• Recovery Audit Contractor (RAC) findings
• American Health Association (AHA) Coding Clinic guidance and quarterly updates

When to query your physician: Querying usually occurs during the health information management (HIM) coding process, according to Pritchett.

Different types of queries include the following:

1. Concurrent: This type of query is initiated while the patient is still on the floor and encourages timely, accurate, and reliable responses from the physician.

2. Retrospective: Additional info is available in the medical record. A short stay where the concurrent review could not be performed or was not performed.

3. Post-bill: This happens after the claim is submitted or the claim is paid. A post-bill query occurs as a result of an audit or internal monitoring

When it comes to querying, you must make sure that you are not leading your provider, Pritchett cautioned. Leading is defined as implying there is an expected answer to your question or providing the expected answer to your question.