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Can Clinical Documentation Integrity specialists play a role in length of stay?

Have you ever noticed how fashion trends make their way back around every few decades? The same thing happens with healthcare hot topics. Recently the topic of length of stay (LOS) has made its comeback. Many hospitals are looking into their LOS and how it will correlate with the reimbursement they will receive for an inpatient stay. Administrators are paying attention to what the patients are being treated for, any procedures they may have, the use of hospital resources, and the medical providers’ documentation. Many facilities utilize a team of Clinical Documentation Improvement (CDI) specialists, typically nurses and coding professionals, to review patient encounters. CDI specialists ensure that the relevant conditions and diagnoses causing facility resources to be utilized during an admission or visit are appropriately captured in providers’ documentation, so the claim for reimbursement can be supported. Administrators and providers work closely with nursing staff, palliative care, case management and other ancillary teams to ensure quality patient care and plan an optimal discharge date. How can a CDI specialist help? Let’s dive into LOS and see what contribution a CDI specialist might have.  

A February 2021 data brief from the Office of Inspector General (OIG) in mentioned an increase in billing of inpatient stays at the highest severity – cases with either a comorbid condition (CC) or a major comorbid condition (MCC) – from fiscal year 2014 to fiscal year 2019. The OIG found that “the average LOS decreased for stays at the highest severity level, while the average length of all stays remained largely the same.” They also noticed roughly one-third of the overall stays billed at the highest severity level had relatively short LOS, and about half of the highest-severity cases only had one CC/MCC.

To review a patient’s LOS, CDI specialists need a few critical pieces of information. First, they need to know the patient’s current Diagnosis Related Group (DRG), and if that is coded to Medicare Severity Diagnosis Related Group (MS-DRG) or All Patient Refined Diagnosis Related Group (APR-DRG). If the former, they need to know the Geometric Mean LOS (GMLOS) for the patient’s MS-DRG; if the latter, the Average LOS (ALOS) for the patient’s APR-DRG. Lastly, they need the patient’s current LOS at the facility.

Given these pieces of information, the CDI specialist can formulate a plan for follow-up reviews of the patient’s case to make sure the appropriate information is captured to support the expected LOS, or pose queries for information to support additional admission time for the patient. Let’s talk through some scenarios.

Mr. Doe is admitted with a working MS-DRG of 872 (septicemia or severe sepsis without mechanical ventilation for greater than 96 hours without an MCC). The GMLOS for this diagnosis is 3.5 days, and Mr. Doe’s current LOS is two days. In other words, if Mr. Doe were the “typical” patient, he should be expecting to go home within the next 24–48 hours.

On a follow-up review of Mr. Doe’s chart, the CDI specialist notices that he is now over the GMLOS. Why? The CDI specialist can then search the provider notes to see if the patient has additional diagnoses, or if there is added documentation that could support a query for clarification to explain the additional inpatient days.
In Mr. Doe’s case, let’s say that the CDI specialist finds well-documented clinical indicators that support a diagnosis of acute respiratory failure that occurred on the third day of stay. The CDI specialist could then query for adding an MCC to the case. If the query answer is in favor of that diagnosis, Mr. Doe’s working MS-DRG would then change to 871 (septicemia or severe sepsis without mechanical ventilation for greater than 96 hours with an MCC), which has a GMLOS of 4.8 days, justifying the additional days.

Now, Mr. Doe is at LOS day 10. He was placed on mechanical ventilation on LOS day 4 and was removed from the ventilation on LOS day 9. His new MS-DRG would be 870 (septicemia or severe sepsis with mechanical ventilation for greater than 96 hours), which has a GMLOS of 12.4 days. Mr. Doe is now within his expected LOS for his condition.

So, does the CDI department play a role in considering patients’ LOS? Absolutely! Can CDI assume sole responsibility for the patient’s LOS? Not in the slightest. LOS, like so many other healthcare metrics, cannot be owned by one department. Rather, facilities can manage and support appropriate LOS through a collaborative team approach, with interdepartmental communication of patients’ GMLOS versus their actual LOS among case management, providers, administration, and the CDI department. For example, a facility in Cincinnati, Ohio, conducts a weekly deep dive into the 20 highest LOS cases in the hospital that week, with representatives from case management, administration, nursing, and CDI meeting to discuss plans for these cases.

The OIG recommends that the CMS target reviews on high-LOS cases with low severity levels, and low-LOS cases with high severity levels. Just like those high-waisted, acid-washed jeans have made their way back around, LOS is once again a hot topic of discussion among healthcare facilities nationwide.

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  • Last modified on Friday, 24 February 2023 10:17
TaraJo Gillerlain

TaraJo Gillerlain MSN, RN, CCDS joined 3M July 2022. She has an MSN from Duquesne Univeristy and a CCDS Certification from ACDIS.

Prior to 3M TaraJo was a CDI supervisor for a revenue cycle company.

She is currently leading the Data Governance project for the CT team.