Expensive Conditions Require Focus on Data and CDI

The Healthcare Cost and Utilization Project (HCUP) released a report in May 2016, National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013, outlining which medical conditions were the most expensive to treat.

This report provided statistics by payer as well as overall, and it encompassed 35.6 million inpatient stays and $381 billion in healthcare expenditures. Medicare/Medicaid accounted for 46 percent of the aggregated costs, with commercial insurers accounting for 28 percent and the uninsured at 5 percent. The top 20 conditions accounted for 47.7 percent of the costs and 43.7 percent of the inpatient stays across all payers.

By identifying which conditions require the most money for treatment, an organization can focus its clinical documentation improvement (CDI) and coding efforts on these conditions.

The most expensive condition to treat across all payers is sepsis or septicemia, which accounted for $23.7 billion in spending. Sepsis accounted for 6.2 percent of the medical expenses, but only 3.6 percent of the inpatient stays across all payers. Sepsis has been the most expensive diagnosis since 2009, and childbirth was the previously most expensive condition. The remaining top four conditions were osteoarthritis ($16.5 billion and 4.3 percent of hospital stays); liveborn ($13.3 billion and 10.6 percent of hospital stays); complication of device, implant, and graft ($12.4 billion and 1.8 percent of hospital stays); and acute myocardial infarction ($12.09 billion and 1.7 percent of hospital stays). These first five conditions account for over 20 percent of all hospital stays.

Medicare patients had the following conditions as their top five most expensive: septicemia (8.2 percent of aggregated costs and 6.0 percent of inpatient stays); osteoarthritis (5.1 percent of costs and 4.1 percent of inpatient stays); congestive heart failure (4.1 percent of costs and 4.7 percent of inpatient stays); complication of device, implant, and graft (4.0 percent of costs and 2.7 percent of inpatient stays); and acute myocardial infarction (3.8 percent of costs and 2.5 percent of inpatient stays). As you can see, the only difference between the overall results and Medicare is that the liveborn category is replaced by congestive heart failure. This seems appropriate, as not many Medicare patients are newborns.

Medicaid patients had a different set of top five conditions, including liveborn (10.5 percent of Medicaid costs and 23.1 percent of inpatient stays); sepsis (5.3 percent of costs and 1.9 percent of inpatient stays); mood disorders (2.5 percent of costs and 3.2 percent of inpatient stays); complication of device, implant, and graft (2.3 percent of costs and 0.9 percent of inpatient stays); and pneumonia (2.0 percent of costs and 1.8 percent of inpatient stays). The younger population in this payer group accounts for the variety in the listing, as well as a couple of new conditions.

This data can be utilized to focus education on these top conditions. Sepsis has frequently been a target of clinical documentation improvement (CDI) programs and now we have identified one of the main reasons – it is a condition that consumes many healthcare dollars and inpatient days. Some suggestions for continuing the focus on sepsis include clinical documentation education for the key clinical departments that treat sepsis, reviewing your organization’s sepsis statistics, designating key clinical indicators for sepsis (as these may vary from hospital to hospital or practitioner to practitioner), and identifying potential sepsis patients early in their hospital stays.

The development of a clinical validation process to assist in clinical documentation is also encouraged for those difficult cases, or cases that may generate different clinical opinions. This practice is encouraged by the new American Health Information Management Association (AHIMA) Practice Brief on Clinical Validation. Documentation tips may be posted on those units that treat the majority of the sepsis cases to promote good documentation for this condition.

As for osteoarthritis, the 2017 update to the osteoarthritis codes made a change in that primary will be assumed if the type of osteoarthritis is not specified. The specific laterality and affected bones/joints are other key factors in clinical documentation. The procedures associated with this condition are also key factors – arthroplasty versus open reduction and internal fixation versus fusion. For arthroplasties, is cement used? For spinal fusions, what was the number of vertebral joints and levels involved, and was a total discectomy performed? For open reductions/internal fixations, did the coder or CDI specialist review? After the incision or before the incision? Or was the procedure an intramedullary nailing?

The principal diagnosis of liveborn is easy as if the baby was born on current admission. The secondary conditions are more difficult with regard to documentation. Prematurity, complications of birth (e.g. hip dislocation during birth, aspiration during birth, etc.), sacral dimple, maternal conditions that affect the newborn (e.g., crack baby syndrome), large or small for gestational age, and congenital conditions (e.g. pneumonia, patent foramen ovale) are all conditions that provide more information regarding the patient’s severity of illness and risk of mortality.

Patients suffering complications of a device, implant, or graft are those who are having difficulty from a previous surgery. The specifics for these patients are what type of device, what is the specific complication (hemorrhage, displacement, infection, etc.), and additional conditions that may have resulted from the complication, such as acute blood loss anemia. The documentation of long-term conditions that are currently under treatment or are monitored or impact the patient’s current condition may impact the reimbursement too.

The clinical documentation for acute myocardial infarction should include when the myocardial infarction occurred, whether the patient had a recent myocardial infarction, what vessel was involved with a thrombus/embolus, if known, and any other known complications, such as post-infarction angina, rupture of cardiac wall, rupture of papillary muscle or thrombosis of the atrium/ventricle/auricular appendage, etc.

This article documents some considerations for the top five most expensive conditions across all payers nationally. It is suggested that each organization review its own specific statistics to determine which areas should be the focus of clinical documentation improvement. Remember that there may be differences based on payer. It is important to provide the government a clear picture of the severity of illness, consumption of resources, risk of mortality, and utilization of services for each patient in order to promote better decisions regarding how healthcare expenditures are made.

To read the aforementioned report in its entirety, go online to:


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