Lessons from the Case Management Society of America (CMSA) Annual Conference

Erica E. Remer, MD, FACEP, CCDS

On June 2, Dr. Ronald Hirsch and I had the pleasure of presenting in a packed room at the Case Management Society of America (CMSA) Annual Conference in Kissimmee, Florida. Our talk was entitled: Medical Necessity – A Team Effort: The Case Manager, the Physician, and the Physician Advisor. Ron handled the explanation of medical necessity, and my contribution was detailing how case managers can influence providers to do requisite supportive documentation.

In mingling with the attendees, I was surprised to discover that there were case managers who didn’t know what CDI (clinical documentation integrity) is. Even though CMSA comprises case managers from the whole healthcare continuum, CDI has spread to the outpatient arena over the past years so I would have thought they all might be familiar with it.

As I pondered this lapse, it occurred to me that different professionals read the record at different times during the encounter, and there is opportunity for synergy. Utilization/case management scrutinizes the emergency and admission documentation to see if medical necessity is met for the status and level of care to which the patient has been assigned.

In contradistinction, CDI professionals usually do not perform their initial review until 24-48 hours after admission. This presumably gives the providers time to sort out the clinical situation and get their documentation ducks in a row. Coders (including professional fee coders) do not see the chart until after discharge. Quality, Compliance, Legal, and Physician Advisors may touch the chart anytime during or after the encounter.

When I was a PA, I recognized that the critical care attestation being used in my organization was not compliant. It wasn’t in my purview, but it seemed like someone should care and act. If an encounter was escalated to me and I judged the documentation to be lacking in supporting medical necessity for status, I would address that deficit along with closing out the CDI query. It would behoove us to understand what other departments are looking for and keep it in mind whenever we are reading the record.

It might be advisable for case management personnel to be introduced to CDI tenets, and CDI specialists to be versed on medical necessity criteria. They might approach their assigned tasks a little differently. The MCG criteria may specify “persistent confusion,” and that might be sufficient, but the case manager could educate the provider on potentially documenting “metabolic encephalopathy” to be more specific and maximally risk-adjusting. The CDIS who is doing a second-level review on sepsis cases might recognize a medical necessity documentation deficit and counsel their provider to spell out why an inpatient admission was warranted. They don’t need to be fully cross-trained but being introduced to key elements and knowing when referral is indicated could be quite helpful.

Collaboration was also the theme in the afternoon when Dr. Ahmed Abuabdou (ACPA VP of Operations) and I participated in a panel with Amy Ehrich and Mary McLaughlin Davis as part of the affiliation between CMSA and ACPA. Our topic was the relationship between the case manager and physician advisor. Ahmed shared some PA successes from his institution, I harped on documentation as usual, Amy imparted some pearls from the payer side, and Mary gave the case management perspective from her large healthcare system.

In conclusion, don’t operate in a vacuum. Introduce your case management staff to the CDI team. Have them see how they can cooperate and collaborate. Get to know Quality, Compliance, and the Revenue Cycle. As a PA, you can increase your value if you are able to promote your colleagues’ and other departments’ agendas, too.