Donald A. Butler entered the nursing profession in 1993, and served 11 years with the US Navy Nurse Corps in a wide variety of settings and experiences. Since CDI program implementation in 2006, he has served as the Clinical Documentation Improvement Manager at Vidant Medical Center (an 860 bed tertiary medical center serving the 29 counties of Eastern North Carolina). Searching for better answers or at least questions, Butler says he has the privilege to support an outstanding team of CDI professionals, enjoys interacting with his CDI peers and is blessed with a wonderful family.
Q: I need help identifying the principal diagnosis for the following situation. The patient presented with shortness of breath and hypoxia, and had emergent dialysis which resolved his symptoms. However the patient’s international normalized ratio (INR) was sub therapeutic due to his end stage renal disease. A high dose of warfarin had to be given, and the patient was admitted as inpatient. I am trying to decide if this would be a principle diagnosis of fluid overload (276.69) or abnormal coagulation profile (790.92)
A: The patient had fluid overload, was emergently dialyzed, and “symptoms resolved post dialysis” which suggested to me that the fluid overload was resolved, and they were prepared to discharge the patient. However, the INR was noted to be too low, and it was not possible to bridge with Lovenox injections on an outpatient basis, so needed to be admitted to manage the anti-coagulation (get the INR to goal levels). So, the reason for the patient becoming an inpatient was the INR, not the fluid overload that was resolved prior to the decision to admit, so I would go with 790.92.
Editor’s Note: This question was answered by ACDIS Advisory Board member Donald A. Butler, RN, BSN, CDI Manager at Vidant Medical Center in Greenville, N.C. Contact him at firstname.lastname@example.org.
Editor’s Note: This Q&A has been expanded from the initial version which published during CDI Week. You can read Butler’s comments there and visit the archives to read what previous participants have said.
Q: What are the basic metrics that CDI programs should use to measure their success?
A: To measure this process, I believe there needs to be four fundamental metrics that attempt to focus on what’s required to achieve the fundamental goal of CDI (accurate and complete documentation that is captured in the coding data):
Volume is simplest to measure. Just look at the number of cases reviewed (there are a couple of broad benchmark sources, the most reasonable to me are in the range of 1,800 to 1,900 cases per CDI specialist per year, with appropriate consideration toward adjustments based upon factors such as staffing, expertise, range of activity, focus of the program, etc.). Remember to define your target population, which cases do your CDI program focusing on, i.e., Medicare, all DRG payers, all payers. Then report what percentage of that target the CDI program is actually able to review and set realistic goals based on your staffing and benchmarked expectations.
The most common way to assess activity is to examine query rate/percentage. There are two manners this is reported. I prefer case query rate (how many cases had at least one query asked). Alternatively, you could divide the total number of queries by the number of cases reviewed.
I also find it helpful to report total query rate along with query rates for specific areas of focus. The generic term I use is ‘impact’ query rate, where impact, or outcome, of the query is defined by the individual program. For example, did the query potentially affect financial, mortality profiling, core measures, etc?
There’s a lot to do, but you can do it!
Read, research, and constantly learn: Cultivate strong internet search skills along with multiple and varied sources. Build a reference library.
Network and share: Tap into a group of expert resources such as those available on the ACDIS message board CDI Talk. Actively reach out and participate. Reach out locally, regionally, and nationally within the CDI community but reach out to other professions within your own organization too. You will need the help of clinical experts, HIM groups, UR/CM, CDI, quality… Develop a strong partnership with coding.
Think outside the box … w-a-y outside, like over-the-horizon-outside-the-box: Develop creative solutions, messaging, questioning, and learning to strengthen this crazy role.
Remember your first priority. Physician contact, discussion and relations: Be ready to respond quickly to any questions or requests. Seek the chance to help with something of interest (a physician project, data, etc.). Be persistence and patient, especially when working with medical staff. Become a unique knowledge expert within the organization as a result of working at the intersection of clinical, documentation, coding, data, profiling, quality, regulations, etc.
ALWAYS keep sight of the long term goal. NEVER allow a short term event to override the long term goal. Apply your knowledge to look ahead. What is coming from external groups, how can you estimate the impact, and how can the organization respond pro-actively to the future change?
Remember it takes TIME and EFFORT to get up to speed, no matter how much experience and expertise you bring as an RN or HIM professional.
Most importantly, you CAN succeed!!
During a recent CDI Talk conversation, I alluded to data available in the CMS IPPS Final Rule that CDI specialists can use to benchmark their progress and compare their efforts against national norms. It may take a little digging, development, and analysis but such effort is worth it.
One drawback, however, is its lack of comparability to hospitals similar to one’s own. Another drawback is that the data represent averages—and who wants to only be average? When you use this data to compare your individual organization’s performance against the national norms, keep in mind that an effective CDI program should likely be above those national benchmark averages. I say this for two reasons: First, many hospitals don’t have any CDI efforts in place and others have meager or ineffective programs so one can suspect the national reporting average to be lower than what an effective CDI program might observe as “average” at its facility. Secondly, best-in-class is never average. I believe we all want to be effective if not “the best” in our CDI practices. Despite these two drawbacks, the data is free and available to everyone, so why not take advantage of it?
The following analysis is based on the data contained in Table 5, Table 7A, and Table 7B. Table 5 is, of course, the MS-DRG table for fiscal year (FY) 2013. Tthe ICD-9-CM data used in Tables 7A and 7B is from FY 2011. The ICD-9-CM data is then pushed through the v29 grouper (FY12, Table 7A) and the v30 grouper (FY13, Table 7B). Both tables 7A and 7B’s primary purpose is to present data on length of stay (LOS) at different percentiles. It also provides the case volume across the entire Medicare data set for each MS-DRG. I used this table to forecast the possible impacts (assuming no changes in documentation) with the acute renal failure when it changed to a complication/comorbidity (CC) in 2010. (Read that article “CDI analysis can help facilities understand impact of MCC downgrade” on the ACDIS Blog.)
Since we have access to the DRG volumes and the DRG relative weights (RW), from Table 5, we can start to examine frequency, distribution, etc. So, let’s start slicing data. National discharge volumes equal 10,771,161 and the national case-mix index (CMI) equals 1.6045.
Let’s review some background before digging in deeper. Under the IPPS reimbursement system ICD-9-CM diagnosis and procedure codes are grouped into Major Diagnostic Categories (MDCs). Most of these groupings are by body system; however, there are a few exceptions. The exceptions are the “pre-MDCs,” HIV, and multiple significant trauma. Each MDC is further subdivided into Medicare severity diagnostic related groups (MS-DRGs), which can be classified as medical or surgical based on the presence of an ICD-9-CM procedure code that is classified as requiring additional resources by CMS and, therefore, impacts the DRG payment. The most basic initial MS-DRG organization sorts DRGs into three groups: Medical DRGs, Surgical DRGs, and an odd group called “Pre” which largely consists of the most aggressive cases (transplants, heart machines, ECMO, etc.).
DRGs 3 and 4 are, of course, the rather heavily weighted DRGs for patients that received a trach but don’t have a primary head/neck diagnosis. These are likely the most widely occurring DRGs among the “Pre” group (at many more and smaller hospitals than transplants, etc.).
|MS-DRG Type||% of total cases|
|Surg Without DRG 3 or 4||
|Surg Without Pre||
As an aside, note the very small difference in the percentage of total volume when eliminating DRGs 3 and 4: 0.2% of the total cases. Yet, in the table below, pulling out those few cases drives the CMI down for surgical cases by 0.0984 which is a 3.5% decrease.
Whenever I see an unexpected change (either up or down) in CMI, the first place I investigate the cause is in the general med/surg split and then the volumes of DRGs 3 and 4. Then I look to see if there were any changes in service line volumes due to various possible factors, such as a short term change in physician staffing among certain higher weighted DRGs, a change in facility focus or operational capacity, as well as any significant market changes.
Why DRGs 3 and 4? For a hospital with CMI 2.0 and 1,000 discharges a month, just one less DRG 3 case a month will drive the CMI down 0.002, which is an 0.8% decrease. One case is easily lost in the weeds if your focus is looking at case volumes.
Number of Discharges
|Surg without DRG 3 or 4||
|Surg without Pre||
With such a disparity in CMI between surgical and medical cases, and considering the relatively small slice of all patients that surgical DRGs represent, using the total CMI as a metric for CDI effectiveness might be considered fraught with risk.
At first glance here are the specific types of the DRGs as far as influence of secondary diagnosis on the DRG assignment:
|Pair CC or MCC||3%||1%||8%|
It is interesting to see where the volume variations between medicine and surgery are, specifically in the column for “None,” such as chest pain, TIA, and syncope, and the column for “Pair CC or MCC.” The volumes between the MCC pair and the triplet are similar for both medicine and surgical DRGs. However, as one can see below, the overall capture of secondary diagnosis is rather different between the medical and surgical DRGs. [more]
What new boundaries are CDI professionals exploring? CDI specialists discussed several areas of expansion during the 2011 CDI Week celebrations last September. You can read about them in the special CDI Week Q&As and in the CDI Week Industry Survey, which are still available on the ACDIS website. CDI professionals also frequently explore the boundaries of the CDI profession on the ACDIS Blog and on CDI Talk discussion strings.
And I know that those fortunate enough to attend the ACDIS conference in San Diego next week will certainly learn about new documentation improvement opportunities. Come to think of it, the conference has such good ideas every year—and a good idea doesn’t truly get stale—you should take a look back at conference materials from previous events to see what tips you may find and consider implementing.
Conversations regarding CDI expansion really should be considered aspects of program and organizational strategic planning. CDI managers need to consider where CDI specialists will focus their primary efforts over the next year, two years, even five years.
Yes, the regulatory environment governing healthcare is always changing and most CDI program directors can guess about how those regulatory changes will affect CDI, patient care, and the healthcare revenue cycle. But well-informed professionals can make some practical suggestions to position their CDI team appropriately for the future.
Warning, what follows is somewhat like throwing pasta against a wall—some ideas may simply fall and other ideas, like a good al dente macaroni will stick. Regardless, here are my thoughts about possible avenues for CDI program expansion.
CDI specialists should consider conducting record reviews for:
- Mortality/quality/length of stay/severity of illness profiling
- Surgical complications
- Hospital acquired and present on admission conditions
- Medical necessity support (both initial and ongoing stay)
- Evaluation and management documentation
Additionally, CDI programs may gain ground by exploring:
- Medicaid, third-party, private payer initiatives
- Outpatient CDI (e.g., emergency department, ambulatory, denials management)
- Documentation improvement opportunities in alternative settings such as long-term care, rehabilitation, psych, pediatric, and obstetrics units (ACDIS recently launched a new networking group dubbed APDIS-the Association for Pediatric Documentation Improvement Specialists)
- New government initiatives such as Value-Based Purchasing, Accountable Care Organizations, and payment bundling
- Proactive Recovery Auditor and external auditor defense
- Collaboration in development of clinical best practice, documentation, protocols, etc.
- Data mining and reporting (internal drivers and external reports)
- ‘Hardwire’ documentation improvement elements in EMR and IT systems
- Quality data versus coded data
- Why and where does a difference exist?
- What can be done to ensure both data sets are parallel and completely accurate?
- How can CDI contribute to clinical care and quality data measurements?
Of course, a number of previous posts directly or indirectly address exploring new CDI areas. As you investigate new ideas, try new things out, consider sharing with your professional colleagues—comment on CDI Talk, write a blog post, contribute a CDI Strategies quick note, or partner with other staff to write a CDI Journal article.
One of the repeated conversation themes on CDI Talk is how to orient a new staff member (within an existing program), or how a small program can start its own CDI efforts and train its own staff. Parallel to those conversation threads are participants’ real hunger for more avenues and sources of education.
Let’s look at some of ACDIS’ online poll data to set the stage:
- July 2011: How many total years of professional experience do you have in healthcare (CDI, plus other)?
- 20 years or more, 60%
- November 2009: How long did it take you to get up to speed as a new CDI specialist?
- 3 to 6 months, 32%
- 6 to 12 months, 34%
- June 2011: How long do you think it takes to achieve an “expert” level of proficiency as a CDI specialist?
- 2 years, 35%
- 3 years, 22%.
And here’s one final on-line poll data point to help me answer the question as to whether CDI managers are actually providing enough training to new staff members:
- January 2011: How long is your training period for new CDI specialists?
- 12%, 2 weeks
- 22%, 30 days
- 30%, 31 to 60 days
- 20%, 61 to 120 days
- 12%, approximately 6 months
- 3%, less than 6 months
It seems to me that those who indicated that it takes six months or more to get up to speed need more training than what I commonly consider necessary as part of orientation. This data suggests that what is these new CDI specialists need is more of a mini-college training program.
Obviously there is a rather significant challenge—how to provide the level of knowledge and training along with the
appropriate mentoring to actively promote and support the new CDI specialists so they can succeed. Of course, there is always the consultant option which proves to be relatively expensive. Plus, a ‘mature’ program should not need to rely on such an expensive option for new staff orientations. At the opposite end of the spectrum is the ‘sink or swim’ method.
Thankfully, home grown and self-supported possibilities exist to constitute a middle ground between these two options. At the very least, facilities should implement an orientation or mentoring process where the experienced individual’s guidance can make a huge impact.
I believe the biggest challenge facing those hoping to implement a CDI orientation program comes from a lack of targeted, written learning resources. I consider one of the largest draws for ACDIS membership stems from the need for learning, resources, and accessibility to a community of knowledgeable and supportive peers. ACDIS provides such a community, with a quickly growing resource base. (If you’re a member, you ought to know. If not, go look at every part of the ACDIS home page).
In addition, ACDIS offers a few helpful handbooks and guides that can be re-purposed for orientation, such as:
- The 2012 CDI Pocket Guide
- The CCDS Exam Study Guide
- The CDI Specialists Handbook, second edition
- The Physician Queries Handbook
Furthermore, the only independent (i.e., not part of a consulting package) seminar I’ve found is HCPro’s CDI Boot Camp. While the total cost (fee, travel, hotel) may be prohibitive for many there is also the online version as an option. Again, a mature CDI program ought to be able to handle at least some of the orientation process internally.
Even with the valuable resources of ACDIS, some holes in new staff orientation remain. AHIMA and AHA’s Coding Clinic for ICD-9-CM provide further guidance, but even those resources do not cover everything. Several major elements of an orientation program are not addressed by the resources mentioned. Just to get started, how about:
- Creating a tool that outlines in detail basic competency and knowledge expectations for the novice CDI specialist. This tool should also list areas for mid-level and advanced achievements to give new CDI staff a set of expectations for continued professional growth. There are some examples in the Forms & Tools Library, in the policies and procedures section (search for “staff orientation checklist), but not at the detail I envision.
- Curating a collection of vital subject articles and references. (Review the CDI Journal archives, the ACDIS Blog, and the Helpful Resources links just to get started on this collection. Add in other professional organizations and their publications such as the National Institutes of Health, AHIMA, AMA, and others and this would be a one-stop database of useful CDI knowledge.)
- Creating an outline of topics that the new CDI specialist needs to master before achieving their initial competency. Further, this outline ought to provide enough detail and referenced sources to serve as a complete training program guide.
- Sources would likely include the books and articles mentioned immediately above, along with sections of widely accepted texts such as coding guidelines, Faye Brown, and medicine texts like the Merck Manual.
Before starting to collect all those articles and tools, though, I should probably determine the basic elements of an orientation program! Below I’ve listed a few resources online which discuss this, including:
- The five key elements of a good orientation program
- The Community Tool Box: Developing Staff Orientation Programs
- Making New Employee Orientation a Success
After reviewing these, I must confess that my definition of orientation varies from those discussed above. Still, several points are important to keep in mind to successfully bring a new staff member up to speed in the CDI world:
- Provide structured, purposeful training
- Offer a straightforward sequence of topics or activities to enable learning
- Give new staff members a written agenda complete with goals and measurable objectives
- Provide ongoing, two-way feedback and evaluation
- Supply appropriate resources and support
- Actively integrate the new person into the team
- Celebrate and welcome the individual and his/her accomplishments as they gain proficiency in their new role
- Pair new staff with an experienced mentor and provide oversight of their engagement
- Offer engaging, interactive, as well as some self-directed education
However, as mature and professional learners, CDI specialists must be responsible and accountable for their education and success.
Honestly, for a new or developing program that has to add or replace staff, the right consultant is worth the money.
At some point CDI programs need to be able to hire new staff and train them in-house. Creating a comprehensive training program does require a lot of effort and maybe it is work that some of you have already done? If so, why duplicate work? Let’s see if we can compile a “best of” list of what program components others have found successful and create a tool that we can share. Post your information here to the blog, e-mail me, or contact Associate Director Melissa Varnavas email@example.com