How Revenue Integrity Audits Improve CDI Programs

Strong provider documentation is only as good as the codes that are assigned and submitted for payment. Well run CDI programs are successful at ensuring that provider documentation accurately represents the conditions treated and procedures rendered during a patient’s stay; but, they are not as successful at ensuring that coders code/translate that documentation accurately to ensure appropriate reimbursement.

Revenue Integrity Audits help address the following:

  • Ensuring that coders code to the highest specificity possible with the current documentation.
  • Identifying missed query opportunities when documentation is unclear, not specific, or inconsistent.
  • Identifying query opportunities through discharge which are sometimes missed by CDI departments due to staffing and the volume of cases needing review.
  • Reviewing Discharge Summaries for inconsistencies with the body of the record which leads to query opportunities. These are typically not available for review by CDI specialists.
  • Mitigating inconsistent code assignment and eventual missed revenue enhancement opportunities caused by differing coder experience and skill levels.
  • Ensuring that production coders apply the latest coding guidelines and Coding Clinic advice appropriately. Also, many coding departments have outdated ‘internal policies’. Having an outside vendor review charts ensures that outdated coding practices are addressed and internal policies are updated/reviewed as needed.
  • Ensuring that present on admission status, discharge disposition, and add-on payments for new technology are reported accurately. If these are assigned incorrectly it could negatively impact reimbursement.

Revenue Integrity Audits act as a ‘knowledge stop gap’ to ensure coders have time to maintain both productivity and accuracy. These audits should typically provide worksheets with detailed explanations for all opportunities identified as well as weekly education sessions to ensure knowledge gaps are addressed as soon as possible.

The Bottom Line:  CDI programs firm up the “front end” of documentation capture at the provider level but do not address the nuances, issues, and inconsistencies in the coding department (especially if the coding department is outsourced to multiple vendors).

Documentation does not exist in a vacuum; it must be coded and reported accurately. When thinking of ways to build upon and improve your CDI program, consider the importance of ensuring that the ‘back-end’ coding process is optimized and is accurately translating the work being performed on the ‘front-end’ by your CDI program.

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