Steady CDI During COVID-19 Changes
Clinical documentation integrity (CDI) assists in ensuring quality documentation across the continuum of care of patients. The role of the clinical documentation specialist (CDS) is to support the physician(s) and physician extender(s) in reporting all conditions and any treatments a patient receives while in the provider’s care. The accurate representation of the patient’s clinical status will translate into coded data. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes are submitted to payors and quality monitoring organizations that pay and grade facilities on the acuity of patients, the course of care, and patient outcomes. If reported incorrectly, not only will the facility suffer financially, but the scores will not accurately reflect the quality of care and the severity of illness of the patients.
As both the clinical treatment and reporting of COVID-19 changes, the CDS also must focus on documentation integrity related to COVID-19 patients. As always, documentation should be clear, concise, and easy to read. Documentation of COVID-19 is more essential than ever in this ever-changing regulatory environment. Consider our “CETAP” acronym to help remember documentation requirements to support COVID-19 diagnosis and treatment:
- Comorbid conditions such as:
- Morbid obesity
- Immunocompromised state
- Possible exposure
- Contact with positive COVID-19 individuals
- Testing and treatment:
- Previous tests and date(s)
- Order test, if clinically appropriate:
- Pending tests with clinical reasoning
- When test is final, document diagnosis
- Convalescent plasma
- Antiviral medications
- Any manifestations and treatments:
- Sepsis due to COVID-19
- Cerebral infarction due to COVID-19
- ARDS due to COVID-19
- Potential conditions that may develop in COVID-19 patients (and if any connection):
- Underlying bacterial pneumonia – identify suspected organism
- CHF, myocarditis, and arrhythmias
- Hepatic failure
- Renal failure
- Electrolyte imbalances
- Coagulopathy and DIC
As the healthcare environment continues to rapidly change, the CDS must be engaged in continual learning and promote consistent monitoring and management of the clinical documentation found within the chart. For each change that comes with COVID-19, that change is valid during a set time period. For example, beginning September 1, 2020, CMS requires that in order for hospitals to receive the 20 percent add-on DRG payment, there must be a positive COVID-19 lab test within 14 days of admission. Prior to September 1, 2020, the positive test was not required. Refer to MLN Matters SE20015 Revised for additional information. The chart below includes dates and guidance changes we have seen concurrently:
BKD Can Help
Along with documentation, coding, and reporting of COVID-19 encounters, a facility should be able to demonstrate strong compliance efforts. BKD’s CDI team can assist you in completing concurrent and retroactive documentation and coding assessments of COVID-19 encounters to help you demonstrate strong compliance practices and avoid potential payor audit recoupments.
For more information, reach out to your BKD Trusted Advisor™ or submit the Contact Us form below.
This information is only valid as of the date of this publication and is subject to change. The content was presented for illustrative purposes and your information only. Applying this information to your situation requires careful consideration of facts, circumstances, and timing of requirements. Consult your BKD advisor or legal counsel to apply to your unique situation and circumstances.