Florida Blue Clinical Documentation Improvement Program (CDI)

Transcription

1 Florida Blue Clinical Documentation Improvement Program (CDI) Why Are CDI Programs Important? Clinical documentation is at the core of every patient encounter. In order to be meaningful, it must be accurate, timely, and reflect the scope of services provided. Successful clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, public health data, and disease tracking and trending. Program Goals To effectively improve provider documentation and subsequent ICD-10 coding by way of actionable CMS compliant clinical queries in the acceptable CMS medical record addendum/amendment 30 day post visit time frame. Improved provider documentation is key to the following: Patient Safety World Health Organization geographical tracking of disease prevalence The Centers for Disease Control (CDC) & mortality rates Valid appropriate medical coding as supported and validated by the medical record 1

2 Components of a CDI Program? A CDI program includes a myriad of people, processes, and technology that must work together to ensure success. A successful CDI program articulates all of the following pieces: Coding Guidelines Code Assignment Documentation Requirements Quality Reporting Physician Champion Florida Blue Physician Champion A physician champion within Florida Blue will assist with query related peer to peer conversations The physician champion will be available by phone and Group to Identify Internal Physician Champion Provider group physician champion is necessary to assist with internal physician education and/or questions related to CDI Pre-Encounter Process Workflow Provider Education Team Reviews physician schedule 7 days or less in advance of member appointment. Identify Florida Blue member appointment date. Review CDI alert & group stats to review HCC coding opportunities that need to be addressed at upcoming appointment. Procure any clinical supporting documentation to share with the provider for chart prep and update CDI alert with any new conditions identified from the prospective review. Review medical record to identify existing and new HCC diagnosis opportunities (Examples: Encounter, Consultations, Hospitals Discharges, Lab Work, Diagnostic Imagining Readings, etc.) Note anything of importance in relation to the identified coding opportunities Send CDI alert along with any clinical support to point of contact (POC) in preparation for appointment. During office visit Provider refers to CDI alert HCC coding opportunities and validates applicable conditions in their medical record documentation. END 2

3 Post-Encounter Process Workflow Provider Education Team Reviews progress note within seven days of appointment. Review CDI alert response and compare with member s progress note to ensure all conditions are supported by the medical record documentation. Coder decisions based on clinical documentation: Provider resolves coder query by sending back amended progress note ( if questions, provider contacts coder to discuss and resolve). Always the physician s decision to amend or not. Condition(s) NOT Addressed Provider Education Team develops a CMS compliant query (when warranted) for the provider to review documentation and amend their note within 30 days of the date of service (CMS G-line) All Conditions Addressed & validated in the progress note Contact provider group POC with ICD-10 coding recommendations If Provider group already billed advise corrected claim or supplemental claim END Contact provider group POC with ICD-10 coding recommendations Sample CDI Program Alert Sample CMS Query Depression 3

4 Sample CMS Query Morbid Obesity Sample Coding Recommendation Claim Submission Corrected Claim Vs Supplemental Claim Corrected Claim If the ICD-10 codes on the original claim had completely different ICD-10 codes than the coding recommendation file a corrected claim with the accurate ICD-10 codes Supplemental Claim If the original claim was missing any validated ICD-10 codes but what was originally sent was partially accurate file a supplemental claim using CPT to add the additional ICD-10 codes 4

5 Incentives There is a $ per member per year incentive for members in which the CDI process is carried out timely There is a 30 day max timeframe from the date of service that all CDI activities must be completed The incentives will be paid quarterly Incentives Continued The CDI workflow includes: Responding to CDI alert post visit noting Yes, No, Remove/Resolve need to be addressed with progress note attached Responding to any CDI query with amend/addend progress note within 30 days of the date of service (when applicable) Claim filed for date of service in CDI workflow Questions? C

6 Appendix - Definitions CDC Centers for Disease Control CDI Clinical Documentation Improvement POC Point of Contact Query Queries are used to achieve compliant documentation and appropriate ICD 10 codes WHO World Health Organization Appendix - Resources AAPC/CMS Query Guidelines Association of Clinical Documentation Improvement Specialists The Centers for Medicare & Medicaid Services 6