ai technology and clinical documentation: cdi compliance at the crossroads · provider burnout...

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AI Technology and Clinical Documentation: CDI Compliance at the Crossroads

Mel Tully, MSN, CCDS, CDIPVP Clinical Services and Education, Healthcare Solutions CDINuance CommunicationsAtlanta, GA

Amy Leopard, JD, MHAAttorneyBradley Arant Boult CummingsNashville, TN

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Understand the compliance risks associated with managing the complexity of clinical documentation needed for treatment, medical necessity, clinical decision support, payment, and quality reporting

– Identify the new risks presented by EHRs, clinical documentation software, and enabling technologies that provide interactive choices for medical record documentation and feedback on documentation quality

– Discuss compliance safeguards CDI professionals should consider to manage the quality and integrity of clinical documentation


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Clinical Documentation Integrity

• The primary objective of CDI programs is to improve the accuracy and protect the integrity of clinical documentation in the legal health record

• CDI programs assist the physician in providing the most accurate, concurrent, and compliant documentation of a patient’s conditions, complications, diagnoses, secondary diagnoses, past procedures, and proposed treatment

• Each of these factors is critical to establishing the medical need for an episode of care, supporting the particular treatment protocol and plan of care followed, demonstrating why a specific discharge plan was initiated, and providing an official record of the care rendered


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CDI Foundational to Overall Performance• Reform policies• Growing consumerism; quality• Value‐based payment models


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CMS: Errors Risk Improper Medicare Payments

Figure: FY 2017 Medicare FFS improper payments (millions) and % of improper payments by monetary loss and type of error

Most Medicare FFS improper payments result from documentation errors. CMS cannot determine whether the items or services were:

– Medically necessary– Billed at the appropriate level– Actually provided

Kim Brandt, CMS Principal Deputy Administrator for Operations https://www.cms.gov/blog/cmss‐2017‐medicare‐fee‐service‐improper‐payment‐rate‐below‐10‐percent‐first‐time‐2013


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How Specificity Impacts Expected Resources (Relative Weight) and Outcomes

329 Major Small and Large Bowel Procedure W MCC

Rel Wt Exp Mort

Exp LOS

Exp Cost Exp Readmit

Exp Payment

Secondary DX Acute Systolic Failure 4.91 9.51% 13.5 $30,302 18.69% $34,370

330 Major Small and Large Bowel Procedure W CC

Rel Wt Exp Mort

Exp LOS

Exp Cost Exp Readmit

Payment

Secondary DX Chronic Systolic Failure 2.46 0.73% 7.5 $16,681 12.25% $17,220

FY 2018 MS-DRGs relative weight at payment of $7,000 per case. *For illustrative purposes only - exp outcome values vary with different population and assessment methods.

331 Major Small and Large Bowel Procedure WO CC/MCC

Rel Wt Exp Mort*

Exp LOS

Exp Cost*

Exp Readmit*

Payment

Secondary DX CHF 1.67 0.13% 4.3 $12,851 8.93% $11,690


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Quality Reporting Is a Compliance Risk

Mandatory Risk Programs = 6% of Hospital Revenue at Risk Hospital Value‐Based Purchasing Performance Scoring

Hospital-Acquired

Condition Penalties

Readmission Penalties

Includes Value-Based Purchasing Program, Hospital Readmissions Reduction Program, and Hospital-Acquired Conditions Program

• Quality data must be accurate

• Significant interplay between compliance and qualityreporting as providers submit data on quality,severity, mortality, LOS, readmissions, and continuumof care that are material to Medicare payment.


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Traditional Physician Documentation Issues

• Lack understanding of coding language and standards

• Specialty focus only on care– Describe treatment without documenting underlying diagnosis

– Clinical indicators of a diagnosis but no documentation of condition

• Seasoned physicians not needing explicit statement where clinical evidence clear for higher degree of specificity or severity

Can computer-assisted physician documentation (CAPD) solutions help solve documentation issues?


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Challenges Organizations Face

Provider burnout

Deriving value from the EHR – rework causing burnoutUp to 40% of physician’s time is spent documenting

Quality & safetyAccurate data for quality ratings & risk scoringProvider reputation & organization’s brand impactedPublic transparency on quality is here to stayEfficient patient care & outcomes

MarginsAnnual operating expenses outpace operating revenuesOperating margins shrink to 2.7%Managing costs while providing quality of care

Healthcare costsCapturing appropriate reimbursements

Ensuring risk adjustment reflects patient population

Managing cash flow; reducing DNFB and unbilled procedures


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Compliance Risks of Managing EHR Clinical Documentation• EHR technology concerns• Risks associated with sophisticated EHR and new types of assistive enabling technologies


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HHS and OIG Re: Technology Risks

• “Common risks for hospitals are inaccurate or incorrect coding, insufficient documentation. Hospitals should be vigilant ... it is difficult for software purchasers to know exactly how software generates information.

• Prudent hospitals thoroughly assess ... software that impact(s) coding, billing, generation or transmission of info relating to federal healthcare programs.”

• “… troubling indications providers are using technology to game the system, possibly to obtain payments to which they are not entitled.

• False documentation of care is not just bad patient care; it’s illegal ...”

Joint Letter from HHS and U.S. Attorney General, Sept. 2012www.modernhealthcare.com/Assets/pdf/CH82990924.pdf

OIG Supplemental Hospital Compliance Program Guidance, 70 Fed. Reg. 4858, 4860-62 (2005)


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False Claims Act (FCA) Liability – Providers and Vendors

• Knowingly* – Present (or cause to be presented) a false or fraudulent claim for payment– Make or use (or cause to be made or used) a false record or statement material

to a false or fraudulent claim – Conceal or knowingly and improperly avoid or decrease an obligation to federal

government• Or conspire to do so ... • FCA also covers

– Vendors who knowingly cause a false record or material statement to be a false claim

– No need to deal directly with government for liability to attach if “cause” the submission of a false claim

*Knowledge: Actual knowledge, reckless disregard, or deliberate ignorance

https://www.justice.gov/opa/pr/electronic‐health‐records‐vendor‐pay‐155‐million‐settle‐false‐claims‐act‐allegations

See eClinicalWorks (May 2017): EHR vendor entered CIA and paid $155M to settle FCA allegations it caused submission of false claims for Medicare/Medicaid EHR Incentive Payments based on providers using EHR software not meeting HHS certification requirements (standardized drug codes, audit log of user actions, reliable record of imaging orders and drug interaction checks, data portability)


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Evolving False Claims Act Case Types

• Traditional cases– Upcoding: unable to support diagnosis codes assigned to increase reimbursement

• Developing cases– Medical necessity as a basis for a false claim– CDI process lacked safeguards to prevent the reporting of false secondary diagnosis

• Novel cases– Data mining from public use files to make allegations of improper payments


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The Robot Made Me Do It ...?

• How to verify inputs and outputs and explain predictions– Users may have little understanding of semantics, how technology works

• Bias, especially when using predictive models• Property rights in machine‐human collaboration

– What is the data I contributed worth?

• Imbalance due to differences in digital literacy, knowledge, assets• Interconnections, interoperability, and the internet of things • Certain clinical decision support not regulated by FDA if not a “device” – risk‐based approach• WILL AI fundamentally change the underlying legal concept of human responsibilities?

– Professional standards of care for reliance on software for medical judgment?

– Products liability and learned intermediary doctrine

See Steven Finlay, Artificial Intelligence and Machine Learning for Business: A No‐Nonsense Guide to Data Driven Technologies (2017) – Great reading lists and definitions in AI space

Social, legal, and ethical dimensions of AI


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How can we recognize relevant compliance risks with new technology and adopt compliance safeguards to

manage CDI compliance risks?


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What “Evidence” Is Required by Law?

• UHDDS Guidelines for coding and reporting secondary diagnoses allow reporting any condition that is:– Clinically evaluated, diagnostically tested for – Therapeutically treated– Increases nursing care or LOS for the patient


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From Conventional CDI to Advanced CDI with Computer‐Assisted Physician Documentation (CAPD)• Across care settings: inpatient, outpatient• Reimbursement methodologies• New clinical service lines and care settings• Capturing patient stories; entire encounter• Accelerated EHR technology adoption; clinical documentation software, enabling technologies• Physician engagement


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The Issues With Traditional Documentation

of a doctor’s workday is spent on data entry

43%

7.2 millionwords documented by a single doctor in just one year

4,000 clicksfor an average day of documentation

Docs are burned out• Not patient focused

Physicians focused on a screen and not their patient

• Mentally taxingDoesn’t following clinical thinking or workflow

• Time consumingUp to 40% of physician’s time is spent documenting

• Learning curveChallenging to learn coding/billing requirements

• Difficult to maintainIT can’t keep up with ever-changing requirements

LimitationsUser conforms to status quo


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Why Is This a Problem?Provider documentation drives decision‐making

• Getting credit for care provided• Accurately reflecting patient population

• Reimbursements payments• Quality profiles (institutional and provider)

• Inefficient use of resources

EMRs: Are We There Yet?Redesign must leverage existing technology that automatically completes documentation for billing purposes (e.g., natural language processing or NLP) so the clinician can focus on documentation for patient care purposes.Barry P. Chaiken, MD

98% of healthcare executives believe automated healthcare will be important to closing gaps in transactional care, continuous and collaborative care experiences.Clinical Innovation+Technology


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AI Components of CAPD

Robotic process application•Robot carries out specific steps repeatedly and reliably

Voice biometrics, facial, optical character recognition•Translators and voice‐activated virtual assistants to interact with technology, locate data

Natural language processing•Creating value from unstructured data•80% of EHR data unstructured

•Flag conditions that are suspected and issue alerts

Machine learning•Computer assisted diagnosis (images, pneumonia)

•Algorithms and predictive analytics to improve clinical recommendations

•Point of care for high‐risk, high‐cost

Augmentation – See “A.I. Versus M.D.: What Happens when Diagnosis is Automated,” by Siddhartha Mukherjee, The New Yorker (April 3, 2017) https://www.newyorker.com/magazine/2017/04/03/ai‐versus‐md


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Computers With Cognitive Intelligence and Human Talent• AI MRI analysis of blood flow through heart: 15 seconds (vs. 45 mins. by human)• Will human talent become obsolete and irrelevant?

Source: “Will AI Take Your Job in 2019?” Daily Mail, January 7, 2019 https://www.dailymail.co.uk/sciencetech/article‐6473413/Will‐AI‐job‐Expert‐reveals‐risk‐careers.html

Jobs AI Will Take Over First1. Sales and marketing researchers2. Insurance adjusters3. Security guards4. Truck drivers5. Consumer loan underwriters6. Financial and sports journalists7. Bookkeepers & financial analysts8. Fruit pickers9. Investment professionals10. Radiologists

Jobs an AI Won’t Be Able to Do1. Psychiatrists2. Therapists3. Medical caregivers4. AI researchers and engineers5. Fiction writers6. Teachers7. Criminal defense attorneys8. Computer scientists & engineers9. Scientists10. Managers (actually leaders)

JOBS AI CAN AND CAN’T DO


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CAPD AI and Innovation

Assisting humans, not replacing them. AI designed to amplify human intelligence, not replace it—making the tasks people do more accurate and efficient.Advancements in AI. Advancements in speech recognition, NLP models, deep learning approaches, and computer‐assisted physician documentation (CAPD) best practices accelerate clinical and financial outcomes.AI across industries. Providers benefit from the work successes across industries—enterprise, automotive, mobile, and more.

AI‐powered solutions and

services


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CAPD AI and Workflow

Enabling technologies for physicians and CDI teams to drive outcomes

Key evidence: use technology to capture physician narrative (unstructured data) for complete documentation

Clinical evidence identifies potential conditions

• Improve documentation efficiency

• Drive documentation of appropriate patient acuity and improve risk‐adjusted quality outcomes

• Achieve high physician query response and agreement rates while decreasing post‐discharge queries

• Accurate documentation for reimbursement

Outcomes analysis incorporates financial and clinical quality analytics, such as risk of mortality, severity of illness, and case‐mix index

• Expand payer coverage and CDI program effectiveness

• Assist CDI teams with worklist triage through automated encounter prioritization

• Workflow management strategies, references and support for an advanced practice CDI program

• Accurate coding for reimbursement

AI

Speech & computer‐assisted physician documentation

CDI workflow and computer‐assisted CDI


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CDI Specialists’ New Role: Compliance Leadership in a World of Technology• Documentation compliance safeguards• Close EHR documentation gap• Risk management• Quality, patient safety, and revenue integrity• Compliance leadership and exemplary professional practice


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Clinical review whether patient truly possesses condition

• e.g., clinically unsupported diagnosis?

• Beyond scope of coding, performed by clinicians (RN, CMD, therapist)

• As a clinical matter, hospitals may establish particular clinical definitions or set of criteria for establishing diagnoses

Clinical documentation strategies

• Clinical review of documented clinical indicators, risks, and treatment supporting diagnosis

• Direct dialogue with attending physician consistent with clinical scope of practice

• Physician verifies and updates legal health record to validate dx

Team Approach: Coding and Clinical Validation

Purpose: Ensure ICD‐10 codes supported by medical record

• Coding based on provider documentation

• Provider statement is sufficient

• Apply correct coding rules, sequencing

• Diagnosis is solely provider responsibility, and coders may not disregard documentation to code based on a particular clinical definition or criteria

Official source: UHDDS Guidelines for 2º Dx

• Clinically evaluated or diagnostically tested for

• Therapeutically treated

• Increases nursing care or LOS

Clinical validation (the clinical function) DRG validation (the coding function)

2017 ICD-10 CM Official Guidelines; Coding Clinic Fourth Quarter 2016,147-149; UHDDS Guidelines, Ch. 3


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Computer‐Assisted Physician Documentation (CAPD) Best Practice

• CAPD solutions analyze all notes from the encounter, enabling the discovery of undocumented diagnoses and identifying clinically significant and reasonable diagnoses

• CAPD can identify gaps in documentation, linguistic patterns and concepts, common words with cross‐meanings, and priorities as it reviews the entire EHR to assess the patient’s disease burden

• CAPD interactively prompts the physician for clarification to improve the quality of the documentation and presents the physician with patient‐specific clinical evidence supporting the documentation clarification request

• CAPD engine supports the professional judgment of the physician by providing clinical recommendations with an opportunity to review the underlying basis for the recommendations and individually accept or reject the recommendations


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CAPD Solutions Need to Follow Applicable Law and Coding Guidelines

• CAPD solutions must be informed by a comprehensive understanding of the applicable healthcare program laws and coding guidelines from the U.S. Department of Health and Human Services (HHS), including the following:– Medicare regulations on DRG classification for

hospital payment– The Uniform Hospital Discharge Data Set (UHDDS)

definitions for hospitals to report inpatient data elements in a standardized manner

– The uniform code set standards and official coding guidelines adopted by HHS under HIPAA

– Official coding advice from AHA Coding Clinic for ICD‐10‐CM and ICD‐10‐PCS

– CMS informal guidance on physician queries

CAPD clarifications are no different than the clarifications presented by CDI specialists. This

means the guidelines and policies for clarifications are the same regardless of how the clarifications

are put in front of the physicians.


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Risk Management Plan• Integrated, simplified physician workflow between EHR, documentation coding• Close EHR documentation gap


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Enabling Technology Readiness

Assessment Accurately project the impact on CMI

MDs, RNs, and HIM professionals identify clear, measurable objectives for CDI program

Implementation Comprehensive pre‐planning

Advanced documentation education for CDI teams and coding professionals

Flexibility to configure content

Physician training Physician training and support

Customized peer‐to‐peer education delivered by experts with IT experience and clinical backgrounds

EHR optimization and sustainment Optimization services extend use of EHR, refine workflows, and target training to improve efficiency, physician satisfaction, and ROI

Continued education: staffing, record reviews, CDMP classroom, physician days and rotations


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CDI Compliance

• Physician interaction– Identify explicitly what evidence presented led to the diagnosis being clarified– Physician affirmatively verifies diagnosis/condition via entries in the legal health record

• Physician has the license to practice and should have final word on physician documentation • Monitor documentation brought into record

– Worksheets and audit trail of clinical indicators for validity of clarification and response– Track physician response and agreement rates to gauge appropriate response

• How much tuning is necessary?• Prevent “leading queries”

– Offer only options highly consistent with all evidence currently documented– Offer multiple diagnostic options consistent with documented evidence when a diagnosis is ambiguous– Offer multiple options for each proposed clarification

• Include additional options such as “clinically undetermined” and “other”– Multiple choice issues: May include clinically significant, reasonable options as supported by clinical indicators

in the health record, recognizing there may be only one reasonable option (AHIMA Query Guidelines, 2013)

Clinical documentation tools don’t substitute for the professional judgment of the physician!


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AHIMA “Guidelines for Achieving a Compliant Query Practice” BriefPublished 2013, Updated in 2016 for ICD‐10‐CM

• The AHIMA Query Practice Brief defines a query as “a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.

• The AHIMA Query Practice Brief goes on to discuss leading queries and the use of multiple choice query formats:– On the query format: “To support why a query was initiated, all queries must be accompanied by the relevant clinical

indicators that show why a more complete or accurate diagnosis or procedure is requested.”– On leading queries: “A leading query is one that is not supported by the clinical elements in the health record and/or

directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.”

– On multiple choice query formats: “Multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that there may be only one reasonable option. As such, providing a new diagnosis as an option in a multiple choice list – as supported and substantiated by referenced clinical indicators from the health record – is not introducing new information. Multiple choice query formats should also include additional options such as ‘clinically undetermined’ and ‘other’ that would allow the provider to add free text. Additional options such as ‘not clinically significant’ and ‘integral to’ may be included on the query form if appropriate.”

AHIMA, Guidelines for Achieving a Compliant Query Practice, Journal of AHIMA 84, No. 2 (2016 update) (emphasis added).


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CAPD Compliance Best Practices Include the Following Oversight and Monitoring Activities Safeguards for the Query Process:

• Schedule testing and quality review of CAPD clarifications for clinical evidence and validity for each setting.

• Provide complete transparency and audit reports for physician response and agreement rates for CAPD clarifications. These reports should be readily available to the CDI staff, coding professionals, and quality reviewers. The reports should include sources of evidence and physician response.

• Train physician leadership, CDI staff, and coding staff on vendor design controls and clinical evidence‐based documentation strategies.

• Establish a reconciliation process for CAPD and final coding when discrepancies on DRG assignment occur.

• Establish a multidisciplinary steering group for oversight and compliance monitoring of the CAPD implementation and follow up on any deviations from that standard with corrective action consistent with the hospital’s internal compliance plan and reporting systems.

• Engage with the hospital chief compliance officer as an active voice and participant in CDI compliance oversight.

• Align the CDI program with the hospital’s compliance program for auditing, monitoring, and reporting activities and provide compliance education to the CDI team.


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The discipline of CDI and its use of compliant queries delivers great value to the healthcare system and to the patient, who deserves a clear, complete, consistent, and accurate health record to support continuity of care. CAPD solutions may provide hospitals with the tools and best practices to improve their clinical documentation and compliance.

Closing


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Thank you. Questions?

[email protected]@Bradley.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


ai technology and clinical documentation: cdi compliance at the crossroads · provider burnout...

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