Are Hidden CDI and Coding Problems Putting Your Hospital at Risk of a CIA?

By Susan Gurzynski-Wells, Senior Product Manager, Revenue Cycle at HealthStream and Beth Ottinger, Vice President, Product Management Education, nThrive | Posted: 09/22/2020

nThrive CDI & medical coding education solutions

The mid revenue cycle plays an incredibly important role in the success or downfall of a hospital or health care organization. Within the entire revenue cycle, the mid revenue cycle (MRC) is the bridge that connects clinical patient information to the business side of a health care organization, where patient treatments and procedures are documented and coded to drive positive financial and quality outcomes. Clinical documentation and medical coding provide the data that determines proper financial reimbursement and compliance. CDI and coding processes that are completed accurately and fully can result in a healthy bottom line, high reporting marks and improved patient satisfaction. Errors, though, can result in denials as well as potential Corporate Integrity Agreement (CIA) implications.

CDI and Medical Coding – A Quick Review of Their Roles

Clinical documentation integrity (CDI) facilitates the accurate representation of a patient’s clinical status that is translated into coded data. It ensures that the patient’s record provides evidence of medical care.

The documentation must be clear, precise, reliable, timely and legible in order to accurately represent patient condition and treatment provided. CDI facilitates clear definition of a patient’s clinical status that translates into coded data or coding.

“Documentation is really the only tool that captures a patient’s condition and justification for treatment decisions. Documentation tells the story of the patient’s journey and supports medical decisions; and provides the history and support for other caregivers treating the patient. It also provides the basis for medical coding which as we know is used for billing and reimbursement, as well as reporting case mix and quality outcomes,” notes Susan Gurzynski-Wells, senior product manager, Revenue Cycle at HealthStream.

Coding is defined by the American Academy of Professional Coders (AAPC), as “the transformation of health care diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes.” The data is coded by medical coders. There are different types of coding – inpatient, outpatient, evaluation & management and more. Medical coders translate physician reports into codes in order to help insurance companies and federal health care payors understand what was done in order to process the claim and provide reimbursement.

Appropriate reimbursement, quality scores and informed decision-making all depend on clinical care that is accurately and completely documented, and coding that most truly reflects the treatments and health state of the patient. When done right, CDI and coding ensures that a health care organization receives correct reimbursement, scores high quality marks and garners high levels of patient satisfaction and patient treatment outcomes. On the flip side, what happens when errors occur?

CIAs – From Little Mistakes Grow Big Consequences

Errors made in the CDI and coding areas – really, anywhere along the revenue cycle – can trigger big problems in the process downstream, resulting in heavy consequences for a hospital or health care organization. One consequence could be a Corporate Integrity Agreement, or a CIA, referred to by many as “the agreement.”

The Office of Inspector General (OIG), the enforcement arm of the U.S. Department of Health and Human Services, describes a CIA as “an agreement with health care providers or other entities as part of a settlement of federal health care program investigations arising from a variety of civil false claims statutes.” Health care organizations agree to the CIA’s obligations and in exchange, the OIG agrees not to seek their exclusion from the federal health programs, such as Medicare and Medicaid.

CIAs typically last five years and usually involve frequent, extensive, audits of claims and affiliated documentation, lengthy annual reports and a training and education program that must meet OIG approval and be quickly implemented. An OIG-appointed monitor oversees the organization, too. Compliance with CIA terms can be disruptive to daily operations and expensive – additional costs include additional staff, legal fees and more.

The CIA specifies “covered persons” who must undergo training, which can be daunting. Education often requires inclusion of the reason for the enforcement action, CIA requirements, federal health care program requirements, Anti-Kickback Statute, Stark Law and additional topics. The education and training program must be developed and ready to go usually within 120 days. In addition, there are often specific training requirements for certain groups, such as the Board of Directors.

The consequences of failing to meet agreement obligations results in substantial daily fines and/or exclusion from federal health care programs. The fines are called stipulated penalties.

The following are three examples of offenses and resulting penalties:

  1. Failure to comply with certain obligations: $2,500 per day
  2. False certification submission as part of certain reports:$50,000 per false certification
  3. Material breach of CIA (e.g., repeated violations): Exclusion from federal health care programs

Along with a CIA, the Department of Justice may impose hefty civil monetary penalties. Here are examples of real enforcement actions:

  • Hospice provider was fined $6 million and entered into a CIA for submitting claims to Medicare for care that was medically unnecessary or lacked adequate documentation.
  • Health care organization was fined $12.5 million and entered into a CIA due to improperly unbundled claims for surgical procedures that artificially inflated reimbursements.

A medical organization can find itself facing enforcement action even through common errors, such as inaccurate patient data capture, missing required signatures, insufficient clinical documentation, and/or lack of medical coding integrity.

How to Prevent a CIA

In the mid revenue cycle, collaboration is critical to successful revenue cycle management and compliance regarding medical record documentation. To obtain appropriate reimbursement, the medical record must reflect accurate, specific and complete documentation. Failure of a record to prove medical necessity is a key cause of claims denials, government investigations and ultimately false claims violations.

Coding and charge capture are driven by documentation, and the risk of missed revenue or allegations of wrongdoing due to compromised coding integrity are great. Claims denials and long appeal processes often keep payments in limbo for years. To mitigate risk in the mid revenue cycle, regular and thorough auditing along with education for improvement should occur when issues are identified.

Consistent communication of audit findings, potential compliance gaps, trends and risk analyses unite revenue cycle and compliance in a common goal – for example, claims integrity – and lessens the risk of federal audits and enforcement action that could include a CIA.

A strong education plan should always be part of the CIA prevention strategy. nThrive has a suite of industry leading competency education programs for your hospital or health care organization’s revenue cycle staff including:

In Conclusion

“Don’t overlook the critical importance of continual colleague education and awareness,” concludes Beth Ottinger, vice president of nThrive Education, “It is imperative for every single colleague with a role in the revenue cycle to understand the backstories of their job functions – why they do what they do. They need to know how what they do impacts processes like coding and billing, the organization’s ability to get paid, and ultimately patients. This knowledge helps prevent issues that lead to denials, increased AR days, or even CIAs, which all costs organizations money. With proper education, colleagues are better able to identify and communicate appropriately when something is amiss. To ensure the most efficient and effective revenue cycle, each and every colleague in that cycle must act as a front-line offensive player with the goal of proactively preventing issues and taking opportunities to identify potential issues before they actually occur or become systemic.”

Ensuring accurate data throughout the revenue cycle should be top consideration in order for continued participation in federal health care programs. Invest in training and education for each revenue cycle team member to ensure everyone understands their responsibilities for quality and correct data capture. Share the results of compliance audits with the revenue cycle teams to facilitate the vital role each plays in the success of the organization. And one final parting message – it can’t be stressed enough that education and communication forge the best path to preventing CIAs.

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