Iodine Software Acquires ChartWise Medical Systems

Acquisition combines “Best in KLAS” workflow with Iodine’s market-leading clinical AI.

JUNE 10, 2021 — AUSTIN, Texas. — Iodine Software, a leading healthcare AI company, today announced it has acquired CDI Software and Services company ChartWise Medical Systems, overall winner of the 2021 Best in KLAS Award for CDI. The acquisition brings together two industry leaders and expands Iodine’s clinical predictions to more than 800 hospitals and health systems.

ChartWise represents Iodine’s second acquisition this year after recently acquiring mobile-based physician engagement platform Artifact Health. Iodine has experienced rapid growth over the last decade by applying its CognitiveML Engine to solve key health system mid-cycle revenue leakage challenges — the first healthcare application of its machine-learning technology. Today’s acquisition announcement further signals Iodine’s commitment to expand its machine-learning technology to the market.

“ChartWise has been a top performer in addressing the needs of CDI teams for many years. Not only do they open up access for Iodine to a whole new set of hospitals and health systems, they also bring capabilities and new product innovations that will expand our offerings to the clinical documentation teams we serve,” said William Chan, co-founder and CEO of Iodine Software.

Iodine selected ChartWise for its “Best in KLAS” performance in ensuring clinical documentation integrity, its expanded capabilities, which include an outpatient application, and the overall value it brings to smaller health systems. The acquisition also expands Iodine’s reach into a market segment the company had not previously accessed and establishes a foothold in several global markets. Additionally, today’s acquisition signals Iodine’s rapidly advancing strategy to expand its machine-learning technology to serve the broader healthcare market.

Iodine and ChartWise both were recently recognized by KLAS Research as top-performing CDI companies. KLAS is trusted among healthcare professionals as impartial research and performance benchmarking. In its most recent KLAS Clinical Documentation Improvement 2021 Report, Iodine earned the highest overall performance score. ChartWise was awarded “Best in KLAS” among CDI software, representing its fourth consecutive win in the category. The company has an “A” rating or better in every KLAS metric, demonstrating its customer-centric product innovation and responsive service.

“The key to success in the CDI market today is all about product depth and automation across the entire inpatient and outpatient continuum of care. Providers and payers need smart, proven workflow tools to optimize results for CDI specialists, physicians, and quality, HIM, and revenue cycle leaders. Iodine customers now have the benefit of the top three best-in-breed CDI solutions: Iodine, ChartWise, and Artifact — all under one umbrella,” said Steven J. Mason, Jr., President and CEO of ChartWise Medical Systems. “We are very enthusiastic about the opportunities this acquisition provides for our collective customers and other leading CDI-driven healthcare organizations.”

The ChartWise team will join Iodine immediately. Moving forward, the combined team will continue delivering innovative healthcare solutions utilizing machine-learning technology to help organizations achieve their desired financial, operational, and quality outcomes. ChartWise CEO Steven J. Mason, Jr. will join Iodine as Executive Vice President, ChartWise, and will lead the ChartWise platform.

Queen Saenz + Schutz PLLC is acting as legal advisor to Iodine Software. Canaccord Genuity acted as the exclusive financial advisor to ChartWise.

About Iodine Software
Iodine Software is a healthcare AI company that has pioneered a new machine learning approach — Cognitive Emulation — to help healthcare finance leaders build resilient organizations. Founded in 2010, Iodine’s technology unifies clinical concepts, evidence-based medicine, and deep machine learning to power revenue cycle solutions that maximize revenue capture and data accuracy. To date, the Iodine AwareCDI™ Suite has helped more than 500 hospitals recognize $1.5 billion in additional appropriate reimbursement annually. To learn more, visit iodinesoftware.com.

About ChartWise
ChartWise Medical Systems, Inc., based in Wakefield, Rhode Island, specializes in cloud-based solutions for Computer-Assisted Clinical Documentation Improvement. AI-driven, integrated, and comprehensive, ChartWise’s scalable Software as a Service (SaaS) assists physicians and clinical documentation specialists and features prioritization, electronic queries, flexible workflow, robust reporting, and denials prevention. Developed by renowned physician Jon Elion, M.D., ChartWise is the only CDI software designed by CDI customers for CDI customers, offering reduced risk, actionable data, and a proven fast ROI. For more information, visit ChartWisemed.com.

Iodine Software Acquires Physician Engagement Platform Artifact Health

Acquisition enables Iodine to add mobile-based physician query capabilities, addressing key health system mid-cycle revenue leakage challenge

Iodine Software, a leading healthcare AI company, today announced it has acquired physician engagement platform company Artifact Health. The acquisition brings together two industry leaders and expands Iodine’s clinical predictions and insights platform beyond clinical documentation improvement (CDI) teams to directly engage physicians through Artifact’s HIPAA-compliant mobile platform.

Iodine experienced rapid growth over the last decade by applying its CognitiveML Engine to solve mid-revenue cycle leakage — a problem that costs healthcare systems billions in lost revenue due to resource-intensive, highly manual clinical documentation workflows. More than 500 hospitals and health systems using Iodine report significant improvements to quality scores and increase earned-revenue capture. Today’s acquisition announcement signals Iodine’s commitment to expand its machine-learning technology to broader healthcare workflows.

Artifact Health is a pioneer of physician-centric CDI and coding workflow solutions. In 2016, Artifact collaborated with Johns Hopkins Medicine to help develop a cloud-based mobile platform that makes it faster and easier for healthcare providers to respond securely and compliantly to questions about patient documentation. Artifact seamlessly integrates with core healthcare systems, including all major electronic health record systems, to ease administrative burdens on healthcare providers and give them back valuable time for patient care. Artifact’s mobile platform is currently deployed to more than 80,000 healthcare providers at more than 200 hospitals.

“Artifact allows us to immediately improve the documentation experience for physicians,” said William Chan, CEO and co-founder of Iodine Software. “The acquisition also allows us to realize our vision of delivering a broader set of our machine-learning predictions directly to physicians.”

Iodine selected Artifact for its flexible technology, mobile delivery and seamless EHR workflow integration, which produce demonstrably better physician satisfaction and engagement. By adding Artifact’s mobile-based platform to Iodine, healthcare organizations can now automate physician queries and other administrative tasks that require more complex clinical judgment while delivering them directly to physicians’ mobile devices. Together, Iodine and Artifact deliver a powerful mid-revenue cycle solution that improves documentation integrity and ensures proper reimbursement so healthcare systems maintain long-term financial resiliency.

“Over the past seven years, Artifact Health has built a solid reputation for streamlining and standardizing the physician query process with efficient, convenient and easy-to-use technology that physicians find enjoyable to use,” said Marisa MacClary, CEO and co-founder of Artifact Health. “Iodine and Artifact share the same mission to design innovative healthcare technologies that improve patient care by reducing administrative burden. We are thrilled to join an outstanding company with superior technology and an amazing team.”

The full Artifact team will join Iodine immediately. Moving forward, the combined Iodine-Artifact team will continue delivering innovative machine-learning predictions that engage caregivers at their convenience. Ultimately, the combined companies will help healthcare organizations achieve their desired financial, operational, and quality outcomes.

Artifact CEO Marisa MacClary will join Iodine as Executive Vice President, Artifact, and will lead the Artifact platform.

About Iodine Software
Iodine Software is a healthcare AI company that has pioneered a new machine learning approach — Cognitive Emulation — to help healthcare finance leaders build resilient organizations. Founded in 2010, Iodine’s technology unifies clinical concepts, evidence-based medicine, and deep machine learning to power revenue cycle solutions that maximize revenue capture and data accuracy. To date, the Iodine AwareCDI™ Suite has helped more than 500 hospitals recognize $1.5 billion in additional appropriate reimbursement annually. To learn more, visit iodinesoftware.com.

About Artifact Health
Artifact Health provides the first mobile platform that streamlines the physician query process so hospitals can improve the quality of patient records and ensure full reimbursement for services. Already in use by thousands of physicians, Artifact simplifies a traditionally time-consuming, multi-step process, allowing physicians to respond to queries anytime, anywhere in seconds. By shortening average physician response time to queries by 20x, Artifact helps CDI specialists and coders receive more accurate responses faster, which can translate into millions of dollars in revenue for hospitals. Visit www.artifacthealth.com to learn more.

Iodine Software Announces Robin Damschroder Joins Board

MARCH 15, 2021 — AUSTIN, Tx. — Iodine Software today announced that it has appointed Robin Damschroder, Executive Vice President and Chief Financial Officer at Henry Ford Health System to its board. 

“We are pleased to welcome Robin to the Iodine board, especially during such a pivotal time in our growth trajectory,” said William Chan, CEO and Co-founder, Iodine Software. “She joins Iodine at an exciting time as we continue to further cement our place as one of the leading clinical documentation improvement solutions in the industry. Robin’s leadership experience at some of the nation’s largest health systems will prove invaluable to our future growth strategy.”

Robin Damschroder, MHSA, FACHE is Executive Vice President and Chief Financial Officer of Henry Ford Health System, a $6.5Bn health system that includes six hospitals, seven major medical centers and manages more than 650,000 covered lives. She also served as the COO, West Market – Saint Joseph Mercy Health System and has held various executive financial and operations leadership roles at University of Michigan Health System. She holds two degrees from the University of Michigan, Ann Arbor, MI – a bachelor’s in General Studies from College of Literature, Science and Arts, and a Master’s of Health Services Administration from the School of Public Health.

Iodine Software has seen record growth over the past year, unveiling the AwareCDI Suite in 2020 and receiving the top overall performance score in the 2021 KLAS Clinical Documentation Improvement (CDI) Report. Looking ahead, the company will continue to leverage the latest in AI and machine learning to help organizations achieve their desired financial, operational, and quality outcomes and build financially resilient organizations for years to come.

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About Iodine Software

Iodine Software is a healthcare AI company that has pioneered a new machine learning approach — Cognitive EmulationTM — to help healthcare finance leaders build resilient organizations. Founded in 2010, Iodine’s technology unifies clinical concepts, evidence-based medicine, and deep machine learning to power revenue cycle solutions that maximize capture and data accuracy. To date, the Iodine AwareCDITM Suite has helped more than 500 hospitals recognize $1.5 billion in additional appropriate reimbursement annually. To learn more, visit iodinesoftware.com. 

Retrospective Reviews: The Last Line of Defense for Documentation Integrity?

By Fran Jurcak, MSN, RN, CCDS, CCDS-0, Chief Clinical Strategist

Executive summary:

Even before the COVID-19 pandemic, hospitals struggled with mid-revenue cycle leakage. In 2019 (pre-COVID), Medicare and Medicaid underpayments had reached $75.8 billion¹ and 84% of healthcare leaders cited inaccurate clinical documentation and coding as the root cause of lost or decreased revenue.² The pandemic has only exacerbated the problem.

There isn’t a single root cause for mid-cycle leakage—it remains difficult for healthcare leaders to manage due to competing priorities, a lack of clinical knowledge, and a scarcity of appropriate software solutions. But healthcare leaders have options for mitigating mid-cycle leakage, and one of the most compelling strategies is to implement a thorough retrospective review process.

Download this whitepaper to learn:

  • Why retrospective reviews are necessary
  • Strategies for prioritizing what to review and how to implement a retrospective review process at your organization
  • The impact of machine learning on retrospective reviews

 

¹ 2019 AHA Fact Sheet: Underpayment by Medicare and Medicaid January 2021

² HIMSS and Besler Revenue Cycle Management Research Report – Insights into Revenue Cycle Management October 2016

Webinar Recording: Retrospective Reviews: The Last Line of Defense?

Each stage of the CDI documentation integrity process represents an opportunity for additional leakage of accurate and appropriate documentation, resulting in inaccurate coding of conditions being monitored and treated during the patient’s encounter. This results in inappropriate reimbursement for care provided as well as potentially imperfect quality reporting. And despite massive investments in documentation and coding solutions, earned revenue loss continues to persist — Medicare and Medicaid underpayments reached $75.8 billion in 2019*

Retrospective reviews are the last opportunity to resolve documentation and coding issues for billing and quality reporting purposes. Traditional reconciliation is inefficient and often ineffective for a number of reasons, including: inefficient process, understaffed CDI teams and lack of technology that supports accurate identification of opportunity. 

Listen to this webinar as Fran Jurcak, Iodine Software, and Dee Banet, Advent Health, discuss strategies for implementing a more robust retrospective review process, including: 

  • Why current approaches for retrospective reviews aren’t working 
  • Strategies for prioritizing what to review 
  • Solutions for automating the Retrospective review process 

*AHA Fact Sheet: Underpayment by Medicare and Medicaid January 2021 

Download webinar recording

Iodine Software is Top Performer With Highest Overall Performance Score in 2021 KLAS Clinical Documentation Improvement Report

Report states that Iodine’s AwareCDI Suite is gaining momentum among mid-size and large organizations, helping them achieve desired outcomes including improved workflow efficiency and visibility.

FEBRUARY 16, 2021 — AUSTIN, Tx. — Iodine Software today announced that it had received the top overall performance score in the 2021 KLAS Clinical Documentation Improvement (CDI) Report. The company also received the top scores in Client Support, Proactive Service, and Implementation and Training, further cementing its place as one of the leading clinical documentation improvement solutions in the industry.

Today, 84% of healthcare leaders cite inaccurate clinical documentation and coding as the root cause of lost or decreased revenue. Many CDI programs and associated software solutions focus on “improving” documentation, which, by itself, doesn’t stem revenue leakage. 

To solve these challenges, Iodine unveiled the AwareCDI Suite in 2020, which delivers true clinical documentation reliability and a significant reduction in condition and revenue leakage across the entire mid-revenue cycle. Powered by the company’s Cognitive Emulation machine learning approach — which was recently granted another patent (U.S. Patent No. 10,886,013) for detecting documentation drop-offs in clinical documentation — the AwareCDI Suite delivers:

  • $1.5 billion in additional appropriate reimbursement annually, 
  • $5.9 million average annual incremental reimbursement per hospital,
  • 75% median lift in productivity (per/CDI specialist query volume), and
  • 21% mean lift in performance (mean MCC volume increase).

In the 2021 KLAS Clinical Documentation Improvement Report, Iodine clients stated that, “New features — such as AI, NLP, broad reporting and ability to prioritize potentially problematic charts — helped them achieve their desired outcomes, including improved workflow efficiency and better capability”. Client relationships were also cited as a strength, with customers describing Iodine as “collaborative” and “proactive,” with strong training programs. In addition, survey respondents stated that the AwareCDI Suite is part of their long-term plan. 

“We are proud of our top performance score in the 2021 KLAS Clinical Documentation Improvement Report, as our team has continued to work tirelessly to help organizations achieve their desired financial, operational, and quality outcomes,” said William Chan, CEO and co-founder, Iodine Software. “The AwareCDI Suite is a full-suite solution designed to overcome leakage at every stage of the mid-revenue cycle. We are thrilled that over 500 hospitals are leveraging the AwareCDI Suite as a way to build financially resilient organizations for years to come.”

To download the full 2021 KLAS Clinical Documentation Improvement Report, visit klasresearch.com/report/clinical-documentation-improvement-2021/1637

About Iodine Software
Iodine Software is a healthcare AI company that has pioneered a new machine learning approach — Cognitive EmulationTM — to help healthcare finance leaders build resilient organizations. Founded in 2010, Iodine’s technology unifies clinical concepts, evidence-based medicine, and deep machine learning to power revenue cycle solutions that maximize capture and data accuracy. To date, the Iodine AwareCDITM Suite has helped nearly 500 hospitals recognize $1.5 billion in additional appropriate reimbursement annually. To learn more, visit iodinesoftware.com. 

 

(1) https://www.hfma.org/topics/news/2019/12/hospital-operating-margins-decline-21–in-2019–tracking-firm-fi.html
(2) Figures are based on a $6000 modeled base rate and actual measured MCC capture performance from the 2019 Iodine Performance Cohort Analysis of 339 facilities that compared measured MCC capture and CMI impact for the Iodine usage period 9/1/2018-8/31/2019 against pre-Iodine baseline performance.

Mid-Revenue Cycle Management: How to Measure, Manage and Minimize Leakage

By Fran Jurcak

Executive summary:

Razor-thin profit margins are not a new problem for hospitals. In 2019, one study found that hospital profit margins had shrunk by 21% on average year-over-year.¹

Enter COVID-19. According to an August 2020 KaufmanHall report, hospital margins were down another 28% through Q3, even with funds from the CARES Act and Coronavirus Aid and Relief Funds. If it weren’t for the stimulus relief, hospital margins would have been down 96% on average in 2020.² 

Yes, COVID-19 exacerbated the problem. But it certainly didn’t cause it. 

For many healthcare leaders, the heart of the problem is systemic—leakage from their mid-revenue cycle. In fact, 84% cite inaccurate clinical documentation and coding as the root cause of lost or decreased revenue.³ This is not just a problem with struggling hospitals. Even “average performance” in the mid-revenue cycle was below optimal for those surveyed. In 2019 (pre-COVID), Medicare and Medicaid underpayments reached $75.8 billion.4 

Today, COVID-19 has transformed the landscape of hospitals and health systems. While leakage was a problem before, it was predictable and manageable—thanks to consistent revenue and expenses. But for many hospitals, revenue projections have been completely upended. 

Before COVID-19, mid-revenue cycle leakage impacted every hospital’s bottom line. Now, it can mean negative operating margins. If operating margins remain negative, it can mean anything from downsizing staff and services to diminishing quality clinical care. 

Thankfully, mid-revenue cycle leakage is not an insurmountable challenge. Financial leaders are turning to increasingly sophisticated and automated solutions to overcome leakage, building transformational solutions to ensure organizations are financially resilient for years to come.

Download this whitepaper to learn:

  • Leakage throughout the mid-revenue cycle
  • Strategies to better capture earned revenue
  • The impact of machine learning on mid-revenue cycle leakage 

 

¹ https://www.hfma.org/topics/news/2019/12/hospital-operating-margins-decline-21–in-2019–tracking-firm-fi.html

² https://kha-paywall.readz.com/executive-summary-august-2020?preview=139977

³ HIMSS and Besler Revenue Cycle Management Research Report – Insights into Revenue Cycle Management October 2016

4 2019 AHA Fact Sheet: Underpayment by Medicare and Medicaid January 2021

Interview at AHIMA 2020: Reducing Revenue Leakage with Cognitive Emulation

Iodine Software was interviewed at AHIMA 2020 on how HIM leaders can leverage AI and machine learning to reduce revenue cycle leakage. Iodine has pioneered a new machine learning approach called Cognitive Emulation™, and most recently launched the AwareCDI™ Suite. Listen to a recording of the interview here and read the full excerpt below. 

AHIMA: Can you talk about the problems that Iodine is seeing when it comes to mid-revenue cycle leakage?

IODINE SOFTWARE: When it comes to the mid-revenue cycle, it’s critical that the full clinical picture as reflected in the evidence is correctly, accurately, and with detail documented, and then fully represented in the code. Unfortunately, this can cause problems due to the fact that humans are involved at every step, and that the underlying legacy software is focused only on workflows that aren’t holistically solving any of these problems. 

For example:

  1. There aren’t enough CDI personnel to review every case every day, which is necessary to ensure documentation integrity. 
  2. Even when pointed to and reviewing the right case, there’s a substantial loss of integrity at the point of decision to query. 
  3. When the query is written, there are fall offs both in physician response and agree rates. 
  4. And finally, there’s further loss of integrity at the coding step due to lack of clinical competency, poor communication, and failure to cross-connect evidence / documentation/code.

What this results in is lost “earned revenue”, which can significantly impact organizations. 

AHIMA: Could you help us better understand the magnitude of this leakage? 

IODINE SOFTWARE: Prior to the start of COVID-19, health systems were already operating on generally thin margins, with many finance leaders acknowledging that a significant root cause was leakage from their mid-revenue cycle and that “average performance” was still well below optimal results. For the average 250-bed hospital, that is $4.7-11M1 in revenue each year

Today, the world is different. Complacency has been fast replaced by a new urgency, and the traditional approach to solving this problem — hiring more staff — is no longer feasible as highly trained and specialized staff to do clinical documentation are in short supply.

We can no longer afford to effectively ‘earn dollars’ only then not to realize them, solely because of unintentional, clerical and clinical human error in documentation and coding. Failing to get this right could mean the difference between positive or negative operating margin, which impacts our real mission – delivering the highest quality clinical care, sustainably.

With this new normal as our backdrop, finance leaders are looking at how to best leverage technology to do things differently – now – and ensure their organizations are financially resilient for the next decade and beyond.

AHIMA: Can you tell me about Iodine’s Cognitive Emulation approach, and what makes it different from others on the market? 

IODINE SOFTWARE: Today, most healthcare technology solutions that support revenue cycle billing, coding and documentation teams use systems and workflows that “think” like computers – not clinicians. They leverage rules and check-lists, which only consider narrative documentation and can lead to unforeseen errors given the many nuances of the healthcare revenue cycle. 

At Iodine, we take a different approach. Cognitive Emulation applies physician-like judgment to the clinical evidence in a patient’s chart and leverages previous learnings to more accurately determine the likelihood a condition exists. Conditions often present in a variety of ways, and by relying on clinical evidence rather than ambiguous thresholds, Iodine is able to identify and learn from these unique instances.

We’re the only organization with the capability of quantifying the magnitude of this problem with precision. And now, we’re the organization uniquely equipped to address it. For each of the leakage points that I talked about earlier, we’ve built and deployed software modules, with each one emulating clinical judgement to solve this earned revenue leakage problem. All these components seamlessly integrate in a unified suite that we call AwareCDI, and powered by our core AI/machine learning technology, Cognitive Emulation.

AHIMA: How could an HIM leader leverage the AwareCDI Suite?

IODINE SOFTWARE: One of our newest products, and an example of how we apply Cognitive Emulation to the mid-revenue cycle, is Retrospect. Retrospective reviews are often the last opportunity to resolve documentation and coding issues prior to final submission of codes for billing and quality reporting purposes. With up to 25% of post-discharge reviews resulting in meaningful education opportunities or code changes that can lead to revenue impact, this final inspection is business-critical. However, this would require the review of every single discharged record to ensure full integrity of each and every outgoing code—which is impossible to do without technology.

At Iodine, we ease the burden on CDI and coding teams by automatically reviewing every record prior to billing. Retrospect provides reconcilers with clear and actionable information to review the right cases at the right time, calling out specific opportunities to clarify documentation and/or final codes in order to improve review confidence and query quality.

We have several clients that are currently utilizing the first version of Retrospect, and the results are pretty amazing.  What we are seeing in our early adopters is that about 30% of cases reviewed in Retrospect resulted in coding changes that impacted the final DRG. Through the use of our CognitiveML engine and prioritization, we were able to support a post discharge workflow that impacted final codes in greater than 60% of cases reviewed.  

To learn more about Iodine and the AwareCDI Suite, click here

¹ 2016 ACDIS Advisory Board Study 

The Truth About Organizational Definitions

By Cheryl Ericson, MS, RN, CCDS, CDIP

Let me start by saying I’m a proponent of organizational definitions. I have long advocated them as a Clinical Documentation Integrity (CDI) best practice, but I do think their purpose is frequently misunderstood. Although we like to think organizational definitions are a tool to minimize denials, they are really just an organization-wide strategy to promote consistency and have little to no bearing outside your organization.   

Contrary to popular beliefs, Centers for Medicare & Medicaid Services (CMS) does not “define” conditions like sepsis or malnutrition or morbid obesity. CMS provides guidance around when a particular condition is considered medically necessary so it will be covered by Medicare through National Coverage Determinations (NCDs) (e.g., gastric bypass defining morbid obesity as a BMI of 35 with the presence of complications due to morbid obesity) or Local Coverage Determinations (LCDs). But these NCDs and LCDs do not necessarily “define” the referenced conditions when it comes to publicly reported data. The same is true for quality measures adopted by CMS.  

The CMS Quality Measure titled “Severe Sepsis and Septic Shock: Management Bundle” supports best practice for the treatment of severe sepsis and septic shock which includes processes associated with Sequential Organ Failure Assessment (SOFA); however, the population eligible for this measure is defined by the assignment of either a sepsis or severe sepsis code. If you need evidence of a lack of CMS guidance defining a particular condition, look no further than the recent Office of the Inspector General (OIG) findings related to severe malnutrition where the OIG audited cases to “determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes for the treatment of severe types of malnutrition on inpatient hospital claims” (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000258.asp).  It is even hard to pin down commercial payers other than CMS when it comes to defining conditions. Often organizations receive information informing them a diagnosis was removed with little, if any explanation, of the criteria used to make that determination.  

So why bother with organizational definitions? To promote consistency across physicians, CDI professionals and Coding professionals. Often organizational definitions are a great way to engage physician leadership so they can become CDI advocates and to train CDIs. The reality is that making a diagnosis is a complex process and there is often disagreement across providers treating the same patient. Something else to consider is whether or not organizational definitions are too stringent and promote under-coding within an organization which can negatively impact financial goals. Just think about the debates that are occurring within the CDI profession over the use of Systemic Inflammatory Response Syndrome (SIRS) criteria vs. SOFA criteria for sepsis. Many organizations made the shift to SOFA criteria when it was first released only to return to SIRS criteria after the volume of sepsis cases decreased within their organization due to the stricter criteria. And what about those diagnoses that don’t have an organizational definition? What criteria should be used? Are we getting too bogged down in discussions about how to define a condition that we can’t see the forest from the trees? In fact, the whole concept of clinical criteria was such an issue within the CDI and Coding professions that the Official Coding Guidelines added the Coding Assignment and Clinical Criteria guideline a couple of years ago:  

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” (ICD-10-CM Official Guidelines for Coding and Reporting (FY 2021), Page 12 of 126).

Although this guideline was intended to provide clarity, I really think it just added another layer of confusion as some organizations mistook this advice as an excuse to stop clinically validating documented diagnoses. Really, this guideline only separated the coding function from the medical necessity function because those lines were getting blurred; however, the medical necessity requirement is still alive and well as demonstrated by OIG audits.  

It was once believed that organizational definitions could be helpful from a compliance standpoint, but that only occurs when the definitions are consistently used across all payers and for all situations. Unfortunately, what I’ve seen over the years is that CDI professionals often have one rigorous set of criteria they use before querying for a potentially missing diagnosis and a different threshold for clinical validation e.g., if the provider documents a diagnosis based on limited criteria. I get it, most CFOs view CDI departments through a financial lens and few CDI departments want to be responsible for removing a diagnosis complication/comorbidity (CC) or major complication/comorbidity (MCC), but this inconsistency is confusing and increases compliance risk.  

So that begs the question, “Have organizational definitions outlived their usefulness?” Perhaps it is time to re-evaluate the purpose of organizational definitions. Are they resulting in more harm than good? In particular, perform an analysis to determine if organizational definitions are yielding the desired impact, which is typically fewer denials. In addition, determine if organizational definitions have actually become a liability due to inconsistent application, or potentially leading to under-coding of valid diagnoses. Organizational definitions can be a great educational tool for CDI professionals, Coding professionals and providers, but they often have limited practical application outside of your organization, so be sure to evaluate their usefulness on a regular basis.  

Webinar Recording: The Documentation Improvement Process: Where and Why Leakage Happens

Each stage of the CDI documentation integrity process represents an opportunity for additional leakage of accurate and appropriate documentation, resulting in inaccurate coding of conditions being monitored and treated during the patient’s encounter. And despite massive investments in documentation and coding solutions, earned revenue loss continues to persist — to the tune of $5-11M in leakage for an average 250-bed hospital1.

Leakage occurs due to a combination of factors including both human issues and technological misalignment, and occurs even in the most mature and highest performing health systems in the country.  Minimizing this leakage is key to the success of any CDI program and top of mind for CDI and coding leaders.

View this on demand webcast in partnership with ACDIS featuring health system leaders from Iodine Software and The University of Kansas Health System for a discussion on:

  • The four distinct phases where leakage occurs (from finding the case, to getting it coded)
  • The challenges to managing a more accurate mid-cycle
  • Tactical steps and solutions to address leakage

Download recording.

12016 ACDIS Advisory Board Study