Clinical documentation improvement (CDI) — a once informal process to which few hospitals devoted significant attention — has now become the backbone of organizations’ financial viability. CDI is essential for patient safety, accurate reimbursement, quality ratings and more. And as the industry transitions to ICD-10, the focus on documentation integrity will only continue to grow.
Organizations must constantly seek ways to improve the efficiency and effectiveness of their CDI programs. The goal is to ensure that clinical documentation paints an accurate picture of clinical severity while also supporting medical justification for MS-DRG and code assignments.
As we head into 2015 — the year of ICD-10 — hospitals will continue to recognize the true potential of a strong CDI program. Look for best practices to emerge as programs and technology evolves. Here are ten ideas to consider for your 2015 CDI program.
1. Focus on quality — not reimbursement. Although MS-DRGs may have originally inspired a financial focus for CDI, many programs have evolved to incorporate ethical guidelines for querying and documentation. Thinking beyond reimbursement means thinking beyond CC and MCC capture to include documentation reviews for severity of illness (SOI) and risk of mortality (ROM) — both of which provide important information about a patient’s condition and the care provided. These indicators also provide payers, consumers and regulators with more accurate information about the costs incurred as well as expected outcomes.
Value-Based Purchasing has inspired many CDI programs to also include hospital-acquired conditions and patient safety indicators. Both affect important outcomes data and performance ratings. By monitoring the present-on-admission (POA) indicator as well as accidental versus intentional procedures, rule-out diagnoses, post-operative complications and more, CDI specialists can have an impact on the code assignment that affects outcomes data.
Programs that continue to focus on maximizing revenue may leave hospitals exposed to risk of penalties and paybacks when audited. The goal of CDI is to ensure quality documentation by identifying opportunities for compliant queries and clinical validation. If organizations can achieve this goal, then accurate reimbursement will be a natural outcome.
2. Expand CDI efforts beyond Medicare. CDI programs that bring the most value to organizations are those that expand beyond Medicare to include commercial payers. This expansion will become even more important when ICD-10 takes effect and insurers deny claims for unspecified codes. CDI programs should have already begun to revamp queries to accommodate more specific ICD-10 details. Consider building a library of ICD-10 cases that specialists can use to educate physicians. CDI specialists should be intimately involved in the organization’s dual coding effort so they can provide tailored feedback to physicians.
3. Appoint dedicated staff members to perform the CDI function. CDI specialists should be able to spend 100 percent of their time focusing on CDI. Ensure that the individuals performing the CDI function are certified CDI specialists who possess either a strong coding or clinical background. Ideal candidates will have a mix of both. Appoint a specific CDI manager — rather than a coding manager who oversees CDI — to ensure that CDI specialists have maximum support in achieving the organization’s goals.
4. Pair CDI specialists with coders. In some CDI programs, only those with a clinical background such as RNs perform the CDI function. In other programs, only certified coding specialists who have a strong clinical knowledge perform CDI duties. However, it is best practice to integrate the two disciplines as much as possible.
This can be accomplished by including a mix of coders and nurses within the CDI department. Ideally, organizations can pair one coder with one CDI specialist, both of whom perform reviews of the same records. This combination provides the best of both worlds during these reviews. If this pairing isn’t possible, ensure that coders and CDI specialists meet regularly to discuss cases, identify trends and address concerns.
Regular communication between coders and CDI specialists is particularly important when coding and CDI report to two separate departments. For example, coding may report to the revenue cycle while CDI reports to case management. When this is the case, ensure that a senior manager serves as a liaison between the two disciplines. Communication promotes ongoing dialogue that can lead to process improvement despite a disparate reporting structure. This dialogue is also important as functions move offsite or are outsourced.
5. Consider remote CDI options. Remote CDI may be a viable option for organizations that have a fully electronic record. Hiring remote specialists reduces overhead costs, and it can also alleviate staffing shortages. However, it’s best practice to require remote CDI specialists to report onsite for at least a couple of days per week to ensure a personal connection with physicians. The face-to-face aspect of CDI is important despite an increasing reliance on email queries.
Baystate Health, an 800-bed health system headquartered in Springfield, Massachusetts recently implemented a remote CDI program. Remote CDI specialists use natural language processing (NLP)-enabled CDI technology integrated with remote access to the organization’s EHR to identify documentation gaps. They then send electronic queries directly to physicians.
With remote CDI, Baystate has grown its CDI team from four FTEs to ten FTEs, thereby increasing the percentage of cases reviewed from 20 percent to 100 percent. The flexibility to work remotely is a strong recruiting and retention advantage as explained by Walter Houlihan, director of health information and clinical documentation at Baystate Health. The physician response rate and CDI specialist productivity have also increased.
Remote CDI may not be appropriate for everyone. If an organization uses a hybrid record or physicians have not yet bought into the program, it may not be appropriate to launch this type of option.
6. Appoint a physician advisor/champion. Every CDI program needs a champion — often a chief medical officer or medical director — who can advocate for physician buy-in and communicate the benefits of the program. If organizations have already appointed someone in this role, be sure to re-evaluate his or her participation and effectiveness. A physician advisor/champion should be enthusiastic, a good role model and have a true interest in documentation improvement.
7. Think beyond the hospital’s walls. As hospitals purchase physician practices — and coding becomes centralized for both facility services and professional fees — organizations increasingly incorporate practices into their CDI programs. Educating physicians about the documentation requirements necessary for professional billing naturally enhances hospital documentation as well.
8. Monitor and enhance CDI productivity. Ideally, CDI specialists will touch as many records as possible. However, staffing shortages often make it necessary to prioritize these reviews. Technologies such as NLP and computer-assisted clinical documentation technology provide organizations with the ability to streamline efficiency by identifying important data elements within a record and presenting a prioritized list of cases to review (e.g., those that might trigger a PSI or those without any CCs or MCCs documented). Some NLP technology has the potential to automate queries by recognizing documentation deficiencies and prompting for additional information in real time.
Increasing efficiency will be paramount as CDI specialists continue to expand the types of reviews they perform. How much time do specialists spend on each case? Is this time well spent, and does it achieve results? Can technology enhance efficiency? Ensure that specialists know what documentation to review and where to find it in the EHR. If additional training is necessary, provide that training as soon as possible. CDI specialists should be able to review 10 to 12 new cases per day as well as monitor cases in progress.
9. Implement and monitor performance metrics. Performance metrics help organizations keep a barometer on CDI effectiveness. This effectiveness is not always measured in increased reimbursement. Sometimes, it can translate to improved quality outcomes.
Performance metrics should include — at a minimum — the number of cases reviewed, time spent per case, physician response rates, physician agreement/disagreement rates, query response time, observed versus expected death rates, and DRG shift rates. Organizations should also drill down into these results to determine top diagnoses queried and physicians who are queried most often. Additional physician and/or coder education may be required.
10. Revisit communication strategies. Creation of a CDI program is a step in the right direction, but organizations also need to develop an internal public relations campaign around the program to make it truly successful. Do coders, physicians, nurses and other providers understand the CDI program’s goals and functions? Communication helps raise awareness and increase buy-in. Many organizations are even branding ICD-10 as a CDI initiative. If everyone understands the program’s goals for quality improvement, they’ll be more likely to participate and provide the documentation necessary for compliant coding.
Organizations that strive to examine and improve their CDI programs regularly are those that will reap the full benefits of this critical function in today’s data-driven healthcare environment.
Lynn Salois is the director of Coding for Medical Record Associates, LLC, where she oversees the daily operations and strategic planning of coding operations and clinical documentation improvement. She is an AHIMA approved ICD-10-CM/PCS trainer, Past President of the Rhode Island Health Information Management Association and a current member of the Massachusetts Health Information Management Association and AHIMA.
Pam McMullan is the sr. coding manager for Cape Cod Healthcare in Hyannis Mass, responsible for managing the hospital-based coding for both Cape Cod Hospital and Falmouth Hospital. She is an AHIMA-approved ICD 10-CM/PCS trainer.
