What is the unintended consequence of this?

An organization dealing with staffing shortages has adopted a policy requiring clinical documentation integrity practitioner (CDIP) to stop reviewing any record after a major complication or co-morbidity is found.

What is the unintended consequence of this?
A . Increase in case mix index
B . Reduced risk of clinical denials
C . Increased number of records reviewed by each CDIP
D . Decrease in severity of illness and risk of mortality

View Answer

Answer: D

Explanation:

Severity of illness (SOI) and risk of mortality (ROM) are two metrics that measure the complexity and acuity of a patient’s condition, based on the number, nature, and interaction of complications and comorbidities (CCs) and major CCs (MCCs). SOI reflects the extent of physiologic decompensation or organ system loss of function, while ROM reflects the likelihood of dying. Both SOI and ROM are divided into four levels: minor, moderate, major, or extreme. These metrics are used to adjust payment rates, quality indicators, and performance measures for hospitals and other healthcare providers.

If a CDIP stops reviewing any record after a major CC is found, they may miss other CCs or MCCs that could affect the patient’s SOI and ROM levels. For example, a patient with pneumonia and sepsis would have a major CC (pneumonia) and an MCC (sepsis). If the CDIP stops reviewing the record after finding pneumonia, they would not capture sepsis, which would increase the patient’s SOI and ROM levels from major to extreme. This would result in underreporting the patient’s true complexity and acuity, and potentially lead to lower reimbursement, lower quality scores, and higher denial risk.

Therefore, the unintended consequence of this policy is a decrease in SOI and ROM levels for patients who have more than one CC or MCC.

References:

CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530

Q&A: Understanding SOI and ROM in the APR-DRG system

3M™ All Patient Refined Diagnosis Related Groups (APR DRGs)

Severity of illness | definition of severity of illness by Medical dictionary

Using Severity Adjustment Classification for Hospital Internal and External Comparisons