The game you're in (and losing)

You're playing a non-obvious game...and losing. Worse yet, you don't even know the rules and some people don’t want you to.

Detractors on the internet suggest I'm promoting fraud by educating physicians on CDI (Clinical Documentation Integrity). Let me make something ABUNDANTLY clear: Fraud is illegal and wrong. Period.

Learning and playing by the rules is NOT fraud.

Let's use an American football example for this American problem: Joe Burrow and his receiver Jamar Chase know the rules of the game. You can only make one forward pass at a time.

They ALSO understand the defense.

Although Jamar has a set route to run, he reacts to the movement of his defender. Joe watches the defender’s move too, knows how Jamar will react, and throws the ball before Jamar even changes his route. Their expertise caused defenses to change their behavior.

What does this have to do with CDI? First, we must know the rules. This is understanding CC's and MCC's, HCC's, SOI, ROM, CMI and Denials just to name a few. These are the basics of the game…but MOST doctors don’t know what those mean. (Definitions below in Q/A)

In this analogy, the defense is the insurance company. We must understand their behavior for us to understand how we should act before they react. Then with persistence, we manage their behavior and keep them from taking complete advantage of us (denying everything without resistance from us).

Many physicians resist CDI education. It pulls them out of an only-caring-about-treating-the-patient mindset and exposes them to the business (aka reality) of modern American medicine. Is that you? If so, what you're saying is you don't want to play the game. I get it,

but you're already on the field. You're in a game you don’t know you’re in...and you're losing.

Furthermore, that beautiful moral duty of only caring about treating the patient holds you back when insurance companies have no such moral hindrance. You're throwing and catching with one arm tied behind your back and they're tackling you before you have a chance to catch the ball (and the refs never call pass interference).

In one example, searching the chart to capture HCC's (outpatient diagnoses) was being called data mining. Fraud exists and there have been examples of "gaming the system" that have resulted in lawsuits and OIG (office of inspector general) reports. HOWEVER, ensuring you don't miss a diagnosis is NOT fraud. Example:

A patient was admitted to the hospital, received IV fluids and developed pulmonary edema and respiratory failure. The problem?

The admission doctor, and those subsequent, failed to identify (buried in the chart) that the patient had ILD (Interstitial Lung Disease) and heart failure. The PCP had not documented it, and no one searched far enough in the chart.

If HCC capture had been a priority, those diagnoses would have been in the PCP note rather than buried in the chart, and the patient would have received better care because of it.

Is that data mining or proper patient care?

Do I wish the system was different? 100%
Do I wish doctors didn't have to know this stuff? 1000%
But that's not reality and until then, you and I will be learning & playing by the rules, one forward pass at a time.

AND WINNING.

Question / Answer

What was that alphabet soup you listed?

• CC's and MCC's (I discuss here: CCsMCCs — robertoubreMD.com)

• HCC's = Hierarchical Condition Category (The outpatient version of MCC's - kind of. Another issue for another day)

• SOI = Severity of Illness (How sick your patient is)

• ROM = Risk of Mortality (How likely your patient is to die)

• CMI = Case Mix Index (How sick your patient population is)

• Denials (Insurances rejecting your diagnosis and decreasing the amount they pay)

Is CDI promoting upcoding?

Morally sound CDI departments should encourage clinical truth. Nothing more, nothing less. Some perceive this as "upcoding" because physician language often isn't specific enough for coding language. When you document how sick your patient actually is, everything (such as reimbursement) falls in to place as it should.

Sounds like that admitting physician was incompetent.

Absolutely not. The chart is too vast and important information is not forward facing. This is where EMR's, AI technology, etc have MUCH room for improvement to help physicians and patients. Until then, this is where CDI departments help you and your patients.

Are we really "losing?"

United Health (Insurance company) made about $22 BILLION in PROFIT last year. More rural hospitals closed in 2022 than in any year in the previous decade. Physician burnout is rampant. 47% of US healthcare workers plan to leave within the next 3 years. That doesn't look like winning to me.

Shouldn't it be the job of coders to do this for me?

Inpatient coders ARE doing your hospital billing for you. They convert your documentation to ICD-10 codes. The coding guidelines are ridiculously complex. Believe me, you don't want to have to know them. But the core of coding is that everything is based off physician documentation. Nothing can be assumed. Example: Have you heard of the AI ChatGPT? It's answer (output) is only as good as the prompt (input). Same for coding. Better the input = Better the output. Coders cannot control input, only you can. CDI sits in the middle.

P.S. Geaux Bengals. Congrats to the Kansas City Chiefs.

That’s all for now. I hope that’s helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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