The Need for Clinical Documentation Integrity in Critical Access Hospitals

By Kelly Bucci, Jennifer Wexler, and Melissa Koehler, RHIA, CHDA, CDIP, CCS, CCS-P, CCDS
Critical-access hospitals (CAHs) provide healthcare to residents that live in rural and remote areas. According to the Centers for Medicare and Medicaid Services (CMS), designation as a CAH requires the following standards:1

Located in a state that has established a State Medicare Rural Hospital Flexibility Program

Be designated by the state as a CAH
Located in a rural area or an area that is treated as rural
Located either more than 35 miles from the nearest hospital or CAH or more than 15 miles in areas with mountainous terrain or only secondary roads; or, prior to January 1, 2006, were certified as a CAH based on state designation as a “necessary provider” of healthcare services to residents in the area
Maintain no more than 25 inpatient beds that can be used for either inpatient or swing-bed services
Maintain an annual average length of stay of 96 hours or less per patient for acute inpatient care (excluding swing-bed services and beds that are within distinct part units)
Demonstrate compliance with the CAH conditions of participation (CoPs) found at 42 CFR Part 485 subpart F
Furnish 24-hour emergency care services seven days a week

Despite their small size and bed capacity, patient care at CAHs can be as complex as the care delivered in urban or university-associated hospitals.
In fact, patients living in rural areas with complicated health conditions are often evaluated, treated, and stabilized at a CAH before transfer to an acute-care facility for escalated care.
For that reason, CAHs must be just as prepared as noncritical access facilities to receive patients of varying acuity. This includes ensuring high-quality clinical documentation integrity (CDI).
The Difficulties of High-Quality Documentation
In Clinical Documentation Improvement; Achieving Excellence, author Ruthann Russo explains that quality clinical documentation is legible, reliable, precise, complete, consistent, clear, and timely.2
Hospitals around the country depend on CDI teams—usually staffed by health information professionals or nurses—to review, analyze, and improve clinical documentation in health records for the sake of ensuring a true representation of the patient’s health story.
CAHs are not immune to the necessity of a CDI program, but achieving high-quality documentation can be difficult due to their unique staffing model and resources available,.
As obvious as it may seem, accomplishing the continuous task of ensuring high-quality documentation has its own set of challenges for CAHs.
Due to their rural locations, finding and hiring staff with CDI qualifications and experience can be tough. Additionally, CAHs have to compete with larger facilities in surrounding metropolitan areas for acceptable salary and benefits packages to hire those candidates.
In some cases, when facilities cannot hire dedicated CDI staff due to lack of candidates or budget constraints, staff that are performing other nursing or HIM duties are often cross trained to also perform the CDI tasks.
Another CDI challenge for CAHs relates to the limitations of care that can be provided at these specialized facilities. Although most CAHs have clinical staff and resources needed to evaluate and stabilize patients presenting with a wide variety of illnesses and conditions, they are limited on the level of intervention or services they can offer patients.
Patients that require a higher level of care are transferred to facilities equipped to render the specific care needed. According to a 2011 study published by the Journal of the American Medical Association, CAHs transferred acute myocardial infarction (AMI) patients to other acute care hospitals 20 percent more than non-CAHs did (29.7 percent vs. 7.4 percent), and CAH inpatient admissions were significantly shorter than their urban counterparts.3
Given this data, one can easily see that CAH CDI staff are faced with crucial time constraints to review patient records, communicate with providers, and improve the clinical documentation at their facilities before the patients are transferred.
While CAH hospitals may transfer patients with complicated conditions due to the need for higher-level care, that is not to say that patients that are cared for at CAH are less sick than patients at other acute-care hospitals, or that they represent less diversity in the conditions for which they are treated.
The wide variety of patients seeking treatment at CAHs pose yet another challenging twist for CDI staff: they must be as well-versed in their clinical documentation skills as the patients’ conditions are varied.
Larger CDI teams have the ability to capitalize on the skills and experience of the entire group, whereas the smaller CAH CDI teams need to be familiar with a wider range of conditions to improve their facility’s clinical documentation, but with fewer resources. Being a small team—or a team of one—forces everyone to bring more knowledge and resources to the table.
Charge Capture and Reimbursement Differences
Hospital charge capture should be accurate, comprehensive, and compliant regardless of hospital size or reimbursement methodologies. In a hospital that is subject to prospective payment system (PPS) guidelines, accurate and comprehensive patient bills will lead to a more accurate prospective payment system as well as true cost report leading to a precise cost-to-charge ratio. Also, despite the bundled payment methodology trend in many geographical markets, there are still commercial insurers that reimburse as a fee-for-service.
For a CAH, the cost report and the established cost-to-charge ratio is utilized as the final bill to Medicare and other government payers. Capturing charges for Medicare and some Medicaid cost-reimbursed services may be the only way a hospital will get paid for those services. There are other steps to determine final reimbursement for such services, but the fundamental process of accurately capturing charges is paramount to comprehensive and compliant reimbursement. Like PPS hospitals, there are payers on the critical access hospital side that may reimburse on a fee-for-service model, which is driven solely by charge capture.
Hospitals of all sizes, reimbursement methodologies, locations, or designations should be consistent in charge capture practices regardless of payer. Hospital reimbursement methodologies are not generally one-size-fits-all.
Payer agreements with the hospital may include multiple reimbursement methodologies in one contract depending upon the clinical services rendered to the patient. Common reimbursement methodologies in an acute-care setting include:

Capitation Payments: A provider is paid to cover all services for a patient over a period, regardless of whether that patient is provided any services. There are different forms of capitation payments. For example, capitation may only include certain services (e.g., clinic/office visits) or could include all services provided to a patient.

Fee-for-Service Payments: A provider is reimbursed separately for each rendered service. The payer identifies the rendered services by revenue or CPT/HCPCS codes. The payer determines the reimbursement amount based upon each unique CPT/HCPCS code on the patient bill. There are several caveats to this reimbursement model. For example, the amount reimbursed may vary based upon location and some services may not be reimbursed separately at all.

Bundled Payments: A provider is reimbursed based on the expected cost for a procedure-based episode of care. For example, if it is determined that the cost to take care of a patient having a stent placement is $18,000 from start to finish, that provider will receive $18,000 for every stent placement performed. If a patient’s condition is more severe, or complications arise during that stent placement—thereby increasing the cost of that episode of care—that provider will still only receive $18,000.

Common reimbursement methodologies for a CAH include:

Reasonable Cost Payments: A provider is typically paid based upon some percentage above reasonable and allowable cost. The terms and conditions that dictate what is reasonable and allowable are complex. In general, the cost(s) must be associated with services that are reasonable, necessary, and related to the care of that patient. The cost must be adequately documented and supported (e.g., cost report).

Fee-for-Service Payments: The reimbursement methodology under the fee-for-service model in the CAH setting is like that under the acute care setting. It is also common to see reimbursement as a percentage of total charge.

Comprehensive, accurate, and compliant charge capture is a beneficial effort that often comes with challenges to success. According to Nancy Glidden, former CFO of several critical access facilities, the top challenges associated with accurate and comprehensive charge capture in her former facilities generally involve recruiting talent with necessary skills to implement a successful charge capture program. Specifically, she cited the following as being among the most challenging:

Having in-house expertise and available resources allocated to evaluating and maintaining the chronic disease management (CDM)
Finding appropriate resources to establish and maintain a charge capture audit and improvement structure
Creating an inventory, by clinical department, of the methods of documentation and charge capture protocols
Assessing the current-state risk of inaccurate charge capture in each clinical area and prioritizing the highest-risk departments for routine and comprehensive charge audits
Engaging the right resources to implement change and improvements in system technologies

Given the changing reimbursement environment, technology, and resource struggles often experienced by critical access facilities, there are areas of reimbursement opportunity. When asked where revenue capture practices could fall flat, Glidden cited:

Physician services charge capture and coding accuracy (capture of procedures in the ER and office settings, evaluation and management coding, in-hospital visits, and procedures)
340b drug pricing program, especially contract pharmacies
Overall comprehensive charge capture and proper matching of costs, charges, and Medicare claim data in the cost report
Managing non-reimbursable cost centers to reduce allocation of overhead in the cost report to areas where hospitals are not paid by Medicare
Capturing separately billable services in practices (chronic care management, transitional care, remote patient monitoring)

Insurance Audits
Self-auditing is important to the CAH to identify prospective coding and billing improvement. These might include revenue cycle management (RCM) workflow, process or operational improvement, interface order and charge audit, and chart-to-bill audits to identify potential opportunities.
Performing each of these audits to better understand any deficiencies within the organization will promote financial health and promote compliance with regulatory and insurance audit organizations.
Technology Challenges: Implementing a New Solution
CAHs frequently find that the financial technologies available surpass their operational needs. This is because many hospital software packages are designed for larger acute care hospital systems. Software costs often present a barrier for CAH.
This sometimes results with intentional reduction in software functionality of the technologies to satisfy internal budgetary limitations. Coupled with limited internal resources to support implementation, the degree to which a system is supported in-house versus by the vendor can impact efficiency. This can result in implementation sub-optimization. As a result, information systems are often underutilized, enhanced features are limited, and systems are sometimes used far beyond their expiry.
It also is important to keep in mind that implementations substantially change access to information. These changes often force unforeseen changes post-implementation. In this way, the CAH may find that a shift in information now mandates operational rebalancing after implementation.
For example, workflows involving documentation scanning, use of paper versus electronic software functions, and application of signature capture tools or electronic forms may substantially reduce resources needed in one area of the hospital but add resources in another. In many cases, CAHs do not retain external resources to evaluate contributing factors such as these prior to implementation and subsequently will struggle post-go-live to correct these issues.
Implementation support and trainers are too often inexperienced in leading practice implementation and lack enough knowledge to offer consultative support to the CAH. During new implementation, vendor training is frequently focused on tasks rather than best practice in use of the tools, complimentary information flows, or evaluation of workflow impacts. When there is too much dependence on the vendor to build the foundational data metrics and workflows, the CAH is left with little understanding as to how some modules of the system communicate (or whether they do at all) and work with other modules of the system.
There are also a variety of considerations in driving the implementation process. Some factors that impact software implementation involve the strategy around whether the solution itself is cloud-based versus hosted in-house.
The latter scenario would inevitably require internal IT resources for support and maintenance, and this is often not possible for most critical access hospitals. In addition to this, a centralized versus a decentralized approach for multi-facility CAH could impact how settings can or cannot be autonomously managed.
Of crucial importance is the chosen documentation method for the implementation. For example, is the capture of charges through a simple electronic superbill, rather than being generated from documentation? Will the EHR be truly integrated with the billing module or will it only be interfaced? If there are multiple ancillary systems involved, what is the defined system of record, and how will information be handled across these systems when the interface supports only unilateral communication? These questions need to be answered for a successful software implementation.

Centers for Medicare and Medicaid Services. Critical Access Hospitals. July 13, 2020.
Russo, Ruthann. Clinical Documentation Improvement: Achieving Excellence. Chicago, IL: AHIMA Press, 2010.
Joynt, Karen E., Yael Harris, John E. Orav, and Ashish K. Jha. “Quality of care and patient outcomes in critical access rural hospitals.” JAMA. July 6, 2011. DOI: 10.1001/jama.2011.902.

Axene, Joshua W. “Paying Healthcare Providers: The Impact of Provider Reimbursement on Overall Cost of Care and Treatment Decisions.” Axene Health Partners.

Kelly Bucci ( is vice president at Ni2 Health.
Jennifer Wexler ( is vice president at Ni2 Health.
Melissa Koehler ( currently serves on AHIMA’s CDI, Quality, and Revenue Management Practice Council.

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