Risk Adjustment: A Natural Evolution for CDI
by Laurie L. Prescott, MSN, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer
Prescott will present on clinical documentation improvement and risk adjustment at HCPro’s 2016 Revenue Integrity Symposium, September 26–27 in San Antonio, Texas.
When I think about risk adjustment, I think about my mother. She is 86 years old with osteoarthritis and a recent total knee arthroplasty. She is active in aerobics and volunteers at the hospital and her church. The only medications she takes on a daily basis are her multivitamin and calcium pill. Now that she has a new knee, she has no complaints and says her health is due to her clean living—no alcohol use and never smoked a cigarette. Now let’s compare my mother to her neighbor, a 75-year-old woman who perhaps has not lived as clean a life. She has smoked for more than 50 years and now is oxygen dependent with chronic respiratory failure. Her history also includes two myocardial infarctions and two stent placements. Lastly, she is a diabetic and morbidly obese.
One would think that the younger of the two women would demonstrate a lower risk score, meaning it would likely cost less to maintain her health, but that is not so in this case. My mother, at 86 years old, is the one with the lower risk score. We have worked with providers for years to better capture patient acuity in the inpatient setting, but it is also important to ensure both my mother and her neighbor’s health status is well documented in the outpatient setting.
Healthcare reimbursement is changing; both CMS and private payers are working toward payment methodologies that reflect quality of care versus quantity of care. In most cases, quality is measured based on patient outcomes. The concept of risk adjustment is now being applied to healthcare reimbursement and is also used to apply impact from quality monitors such as 30-day mortality measures, 30-day readmissions, and Medicare spending per beneficiary. Healthcare organizations must be aware of how documentation supports risk adjustment and take efforts to educate providers on the importance of complete and thorough capture of their patients’ health status to support accurate code assignment representing the potential risk their patients possess.
I see many clinical documentation improvement (CDI) programs working to expand into the outpatient arena and there appears to be a struggle to find an identity or focus for record reviews. Knowledge of principles of risk adjustment can provide that focus. Documentation for outpatient services and primary care is a slightly different beast than the more familiar territory of acute inpatient care for most CDI professionals. This different focus requires a melding of two skill sets, that of CDI specialists and coding professionals, to succeed.
Risk-adjustment documentation can be based on records from hospital inpatient, hospital outpatient, and provider services. Although CDI is firmly rooted in inpatient services, now it can extend to outpatient and even professional services. As more hospital systems purchase physician practices, there is increasing interest outside just inpatient documentation. The arms reach wider to ensure documentation on the whole is optimized, not just for inpatients, but for patients in all settings related to the hospital system so it can obtain accurate reimbursement. The CDI team is already clarifying diagnoses like specific manifestations of diabetes mellitus and possibly the significance of pathology reports for metastatic cancer, so why not extend the focus to conditions that may affect risk-adjustment scores?
As the world of healthcare reimbursement evolves, the importance of documentation and accurate code assignment will become even more relevant. We as professionals working in documentation improvement and code assignment must continue to grow and evolve as well. This is both an exciting and frightening time for us and we must expand our horizons to support providers in navigating these changes.
Editor’s note: For more information on risk adjustment, join Prescott at the 2016 Revenue Integrity Symposium, September 26–27 in San Antonio, Texas, as she presents the session “CDI and Risk Adjustment: Ensuring Your Patients' Risk Adjustment Scores Are Accurate.” Prescott is the CDI education director with HCPro. She serves as a full-time instructor for the CDI Boot Camp as well as a subject matter expert for ACDIS. Opinions expressed are that of the author and do not represent HCPro or ACDIS.