Four years ago, in these very pages, during CDI Week, I wrote about the art of CDI, comparing what we do to creating a fine painting. I wrote about seeing the patient in my mind and trying to create the fullest possible portrait of who they are and what they represent. At the time, I had been a CDI specialist for a few years and had progressed beyond the overwhelming challenge of learning and absorbing this role to being on the cusp of taking a leadership role in our profession. A lot has changed in the past four years, not only for me, but for our profession. I think it’s time to consider a little touching up of our portrait.
Back then, most of us looked at DRGs. Most of us looked at CCs and MCCs. Most of us looked at reimbursement. Many of us focused on Medicare.
Some CDI specialists grabbed for the low hanging fruit and called it a day. We might have talked about severity of illness and risk of mortality. We might have talked about quality and patient safety indicators and hospital acquired conditions and value based purchasing. We might have talked about reviewing all payors. We might have talked about what seemed at the time to be right on the horizon, ICD-10.
Some of our paintings were Rembrandts and some of our paintings were Elvis on black velvet. When we paint our portrait, are we painting from the heart, or we painting by number? Are we taking what we see and looking for every nuance, making the shading just right, or simply filling in the spaces that someone else drew for us?
I think many, many CDI programs have done their darnedest to be the former, and not the latter. I’m very proud of CDI teams that have moved beyond the low hanging fruit and have aspired to, and achieved, greatness. Do we still want to capture those CCs and MCCs? Of course we do. But what we really want to do is paint a masterpiece. Or more exactly, to help the physicians paint that masterpiece so that anyone can recognize what they’ve done as a great work of art. Because healthcare, just like CDI, is an art as well as a science. People are not just a collection of body parts and organ systems. After all the blood tests and radiology exams and other diagnostics, it’s the art and the skill of the physician that makes the difference between diagnosis and symptom, between recovery and illness. And we are here to capture the essence of that art and skill, carefully documented in our medical record. We’ve moved beyond clinical documentation improvement to a world of clinical documentation integrity.
We’ve grown so much as a profession. Thousands of highly skilled nurses and coders have transitioned into our world, and many more are coming. Certification in CDI as a CCDS or CDIP has validated the expertise of many experienced CDI professionals. CDI teams, under dynamic leadership that understands the value we add to our institutions, have gone far beyond the easy pickings of the CC and the MCC. They have carefully evaluated the needs of their facilities and trained their focus on severity and mortality and quality and readmissions and medical necessity and clinical indicators and observation cases and developing tools to help their physicians document and a thousand other areas that meet their organization’s current needs and will meet their future needs. They paint a picture with colors so vibrant, so real, so intense, you won’t know if it’s a photograph or a portrait.
Appreciate the skill of the artists, both healthcare provider and clinical documentation expert. Because they’re grand masters.
“Why do I need to know how to use a DRG Expert to take the CCDS exam? I don’t have to use that book to do my job.”
I hear this a lot. The reason you don’t use a DRG Expert is probably because you use an encoder. Since you can’t take an encoder into the exam room, you’re going to have to rely on the book.
Even if you don’t plan to (or need) to take the CCDS exam, you should still learn how to use the book. It can be a valuable tool for CDI specialists, and is often overlooked in the CDI community. You may find yourself without access to the electronic supports that calculate DRGs for you. Your system crashes. You seek new employment or pickup additional hours in a facility that requires manual research. You have to demonstrate your expertise or defend an assigned DRG. The list of reasons goes on and on.
The June 25 issue of CDI Strategies has an excellent article authored by ACDIS CDI Education Director Cheryl Ericson [more]
We’re happy to hear that you’re interested in joining the CDI profession. You do not need to have the CCDS credential to become a CDI specialist. The CCDS represents a mark of distinction for those who have been working in the field for a number of years. In fact, you must be a working CDI specialists for at least two years before you can sit for the exam.
If you are interested in becoming a CDI specialist we recommend that you first learn as much as possible about the field. Review the materials on the ACDIS website (much of it is free) and take lots of notes. If you have a local chapter in your area, call or email the leadership and ask if you can attend a meeting. If you have a CDI program at your facility, ask the program staff if you can shadow them for a day to learn more about the work they do. If you do not have a CDI program at your facility, reach out to neighboring hospitals and see if their program would host you for a morning or an afternoon.
Recently a question was posed in ACDIS CDI Talk about establishing CDI/coder DRG match rates. (Read the related Blog post.) Shameless plug here; if you do not visit CDI Talk, you’re not taking full advantage of your ACDIS membership. It’s the best national networking opportunity you’ll have outside the annual conference.
Anyway, being the shrinking violet I am, I jumped right in with my two cents (before taxes):
“I do not have a CDI/coder DRG match metric in my program. While I do expect the CDI specialists to understand MS-DRG and produce a working DRG, and I believe fervently in the importance of reconciling the DRG so that the most accurate codes are reported, I don’t actually care if the working DRG matches the final DRG. I do care that the CDI specialist understands how the DRG is impacted by the documentation and how changes in the documentation may impact the DRG. I do care that the CDI specialist and the coder come to an agreement that the final billed DRG is the correct representation of the documentation. But for me, evaluating a CDI specialist on his or her ability to see into the future leads to a lot of wasted effort on the coding process that should be spent on the documentation process, and generates a lot of competition between coding and CDI that should never exist in a collaborative environment.”
When I was a CDI specialist, the match rate stressed me most. I’m not a coder. Our differences make us both uniquely awesome and a great complement to each other. My CDI team includes both RNs and coders and that’s the way I like it. Most CDI specialists are nurses and will never be coders. And even though some CDI specialists are coders, that’s no longer their role.
The role of the CDI specialist is to identify and correct existing documentation issues and to prevent future documentation issues. It’s not to code the record. As a CDI specialist, I assigned many, many codes, and calculated many, many working DRGs. For me, this served to clarify how the documentation would impact the coding, and how a query would impact the coding, so I thought the process was important. In the end, though, the DRG I assigned was irrelevant; the final DRG was the coding specialist’s determination.
We didn’t always match. Sometimes documentation would come in after my final review that affected the DRG. Sometimes it was a matter of picking between two diagnoses that both met the definition of principal diagnosis; I picked one, they picked the other. Sometimes I just saw things differently than the coding specialist did.
Sometimes I accepted the coding assignment as a valid alternative to mine. Sometimes I would disagree with coding’s determination, and then began the process of reconciling the difference.
Sometimes they agreed with me, sometimes they didn’t. The reality is that it was their name, not mine, going on the coded record, and they would have to stand behind their coding assignment, so they always had the last word.
Q: What should I do if I see a non-compliant query in the chart? Should I remove it, let my co-worker know, or just leave it in the chart?
A: Addressing non-compliant queries can be tricky. The best course of action would be to share your concerns with your supervisor who can then either confirm your perception of the query being non-complaint or could let you know why he or she feels the query is acceptable. Ask your manager or supervisor to go over any internal query policies to help you better understand your facility’s compliance parameters.
Most facilities have standard query policies and procedures which reflect national standards (such as the 2013 AHIMA/ACDIS “Guidelines for Achieving a Compliant Query Practice” brief). They also have processes in place to help co-workers handle questionable query processes.
If there are no policies and procedures in place (or if you and your coworker are only the two CDI staff querying physicians at your facility) you may want to review the latest query practice information together and approach whatever management team is in place to develop such policies yourselves.
If the query is truly non-compliant, I would definitely want the supervisor to address it rather than you doing so on your own. It may be that the individual needs additional training or it may become a potential performance issue. In which case your manager or supervisor needs to know about the situation and may even need to have a documented conversation with the CDI team member who left the query.
You wouldn’t want to remove the query. The physician may have already reviewed it and responded in his or her progress note. If auditors or internal staff later question where that diagnosis came from, no query trail would exist and you may not be privy to those subsequent questions. If the supervisor or program manager determines the query was indeed non-compliant he or she may need to also circle back to discuss the situation with the physician and/or coding team.
When Jennifer Love, RN, BA, CCDS, accepted a CDI position Kindred Healthcare, one of the nation’s largest long-term acute care (LTAC) providers, she found a brandnew opportunity. As its name implies, LTACs provide care for patients with serious (acute) medical needs over a long period of time, usually between 20 and 30 days. Most CDI specialists work in short-term acute care (STAC) facilities. So Love saw the LTAC opening as a chance to broaden her CDI horizons.
“It is exciting to see CDI expand out like this,” she says. “I feel like I dove into the future.”
The payment system is essentially the same as that of STAC facilities—LTACs use ICD-9 codes and MS-DRGs for Medicare patients, for example. But whereas STACs look to reduce a patient’s geometric length of stay (GLOS), an LTAC patient is expected to require a longer treatment period.
LTACs treat a very specific type of patient, says Love. Patients can be morbidly obese, suffer from bed sores and acute renal failure, and have often undergone tracheostomies.
The top DRGs at Love’s facilities include:
- 207: respiratory system diagnosis with ventilator support 96+ hours
- 189: pulmonary edema and respiratory failure
- 592 and 593: skin ulcers with CC/MCC
- 870 and 871: septicemia or severe sepsis with mechanical ventilation 96+ hours; and with MCC
If a patient leaves the LTAC sooner (or longer) than expected, a number of questions need to be asked and answered, says Becky Slagell, BA, MHA, RHIT, CPHQ, regional senior director of case management for the Central Region Long-Term Acute Hospital Division at Kindred Healthcare.
“We need to ask ourselves why that patient was discharged earlier than patients with similar concerns. Was [he/ she] truly safe for discharge? Was [he/she] able to go home earlier than normally expected for that type of patient? Did [he/she] transfer back to a STAC? If so, why?” Slagell says.
“There shouldn’t be a high rate of COPD in a LTAC setting,” Slagell says. “That is a chronic condition that by itself does not require our level of care. When a CDI specialist sees that, they’ll look further in the record and see what the situation is. Is there an acute exacerbation of the COPD such as aspiration pneumonia or respiratory failure?”
This complicated level of care makes the role of the CDI specialist very important for this particular setting, says Slagell.
Complex metrics regarding physician response rates and staff productivity help the CDI manager quantify the CDI program benefits to facility administrators and to CDI program staff when presented properly. The manager helps communicate facility priorities to his or her team and to illustrate the needs of the CDI department to hospital administrators. Furthermore, the manager must maintain awareness of any changes in government regulations and industry guidance. Changes in the larger industry will affect the CDI team’s productivity, and any metric must be discussed within the context of these changes.
The manager should review not only the percentage of charts examined by the team, but also the number and type of queries needed each month. It is important to document the outcomes of these reviews. The aggregate data can then be used for process improvement and to support corporate compliance activities. The following is a list of items to review routinely and share with the compliance committee and administration when relevant.
- Trends in types of queries: one condition being queried routinely (e.g., a type/phase of congestive heart failure [CHF])
- Trends by physicians: multiple queries to the same physician regarding the same condition (e.g., a physician continuing to use the term urosepsis after repeated queries and communication as to the need for further specificity)
- Trends by individual CDI specialists (e.g., a CDI specialist continuously querying for specification that is already documented in the chart)
A change in ICD-9-CM Official Guidelines for Coding and Reporting may affect the query percentage for a period of time. A good example is the increased documentation specificity required for heart failure when coding guidelines were revised and reindexed to allow for greater specificity in reporting the phase and specific type of heart disease. Prior to the implementation of MS-DRG, it was only necessary for the physician to document “heart failure” or “CHF.” Both terms were considered CCs.
If one looks back far enough, many CDI teams’ data show a surge in queries for the period of time immediately prior to and following the implementation of the MS-DRG system.
In summary, team performance cannot be determined solely through measurement of query volume. Many factors influence this indicator and it should not be used to determine a program’s effectiveness, but rather should be used as an indicator of opportunities for improvement (e.g., physician education, form revision) or performance improvement over time.
When ACDIS put out the call for participation in its 2014 CDI Salary Survey last week more than 500 people responded. We need you to take a few minutes to complete the survey, too. Why? Because these surveys provide us with a snapshot view of how changes in the profession affect how you get paid for the work you do. And, you can use the results to make the case for changes in your own compensation! It’s true. We’ve heard from a number of ACDIS members who’ve analyzed the data against their own circumstances and got the compensation they deserved.
Last year about 25% of respondents said they earned $60,000–$69,999 annually; but the number of individuals earning $50,000-$59,999 decreased by 4% and the number of those earning $70,000-$79,999 increased by about 4%.
How have salary rates changes since last year’s survey? You tell us! Please complete the 2014 CDI Specialist’s Salary Benchmarking Survey. We will share the results in a special report later this year.
An average rule of thumb is for a CDI program to employ one CDI specialist for every 1,250 to 1,500 discharges per year. Consider higher staff ratios for programs that expect CDI specialists to perform multiple functions (core measures review, utilization management, etc.) and a lower ratio for programs that perform condition clarifications only. Other considerations include the amount of vacation time staff have available; programs that hired tenured CDI staff may have to adjust for higher weeks of vacation availability. As program expectations change, review staffing requirements to ensure that existing staff can accomplish the new goals with the resources available.
In general, a dedicated CDI specialist should have an average daily census of 12-15 new patients and between five and 10 established and follow-up cases. This census will allow for appropriate query follow-up and daily reconciliation of discharged cases. Therefore, the decision of how many new staff members to hire can be made by dividing the average daily census by 15. CDI leaders can further quantify that number by obtaining the average daily admission numbers.
Another variable to consider is if the CDI specialist is allowed to determine at what point they stop reviewing a case or if they are required to re-review the case periodically until discharge. This can also have an impact on the number of cases per CDI staff member.
Keep in mind that the CDI staff generally work Monday through Friday so their actual daily census will be higher, especially on Mondays. Increasingly, however, facilities appear willing to adopt a more flexible schedule. These schedules may include a rotating day of the weekend and/or different staggered shifts to make CDI specialists more available to the medical staff.
Q: I am the only CDI specialist in our 150-bed facility. I have held the position for three years, and am the first one to do so helping to build the position from the ground up. Being the only CDI, I am on several committees, responsible for continual physician education, continuing medical education presentations. I am a constant clinical resource for our inpatient coders, and do all payer reviews everyday which amounts to between 25 and 40 reviews and re-reviews per day.
We have no coding compliance person at this time and I have been asked to review charts for the coders which involve single CC/MCC and/or those that may have a complication as well. My query rate has since dropped and I am being asked why. I feel helpless. Are there standards for CDI productivity for a one woman show?
A: I have worked in small hospitals for most of my nursing career and as in any institution when you display your value, skills and talents, administrators begin to put more on your plate, at times overloading it. Unfortunately, in a small hospital there are less “plates” at the table and it can be easy to become overwhelmed.
The role of the CDI is an important one, and your organization sees that because they wish to have you involved in so many different endeavors. Your description above reflects the position I held in CDI for approximately four years before my organization decided to further invest in expanding the number of CDIs.
There are many reasons that might lead to a drop in query rate, one being that your physicians are learning. With the initiation of a program, the query rate is often higher and tends to level out as the physicians learn about the needed documentation. This means you have done such a great job that the issues are less, requiring less queries.
On the negative side, if you are feeling rushed to complete reviews the quality of your reviews may have dropped. As you know, it takes time to dig thorough the record to find potential opportunities. If time is an issue, we might not ‘dive’ into the record as deep as we should. Since you are alone, it might be a good time to discuss how to prioritize accounts with your supervisor. Are there certain accounts that you may be able to pass over?
I love that you review all payers but when you are working by yourself, this may not always be a reasonable option. Do you review every patient every day? How do you decide how often to review or when you can stop the concurrent review process on a specific account? This would be a great discussion to have with your manager or leadership team.
Are you seeing a drop in other measures applied to your program? Is there a rise in retrospective queries? This would demonstrate that perhaps you are not catching such query opportunities up front. If there is no rise in the retrospective query rate it might mean that you a capturing query opportunity quite well. How is the physician response rate? CC- MCC capture rate? CMI? Are your other measures seeing a decline as well?
As for performing second level reviews for the coders, perhaps they could put a system in place in which another coder first looks at the record before it hits your desk, especially for those records in which there is only one CC or MCC. This might decrease the number of reviews you are required to do in these instances.
Take a look at the 2014 CDI Productivity Survey published by ACDIS as well as other suggestions from the Association. This might give you some comparison, or offer tools that you can use when speaking to your manager. I understand creating new positions especially in smaller hospitals is next to impossible but the return on investment for CDI expansion is a positive one.
CDI practice can encompass a large variety of organizational needs from medical necessity to quality, core measures etc. It is important to not cast such a wide net that the person(s) performing the task cannot succeed. Also, if you are a member the CDI Talk list-serve is a perfect opportunity to “ask around” and see what others are being asked to do and with what resources.
I suggest after a little research you sit down with your management team and discuss what is the expected focus of your program? What is the mission and goals? Review your assigned responsibilities and ask assistance in prioritization of these tasks or perhaps identify others that could support you.
You should also consider the impact of ICD-10 on your organization. We expect coder productivity to drop up to 60% primarily due to PCS coding. The more investment up front in CDI, both to provide teaching and concurrent chart review, could help to ameliorate the impact of productivity drop. This is why many organizations (big and small) are increasing their numbers in the CDI department.
There were times when I felt quite overwhelmed too. It is difficult to be the sole CDI, as no one really understands what you do and why. And it is easy for all concerned to think adding just one more duty to the list won’t hurt. I had an excellent mentor when I started in nursing management several years ago. She taught me that when I was feeling overwhelmed and was handed a new responsibility, to respond “I am more than happy to take this on, can we discuss what task or responsibility I might be able to give up so that I might have the time to lend my skills and focus to this issue.” Smile when you say it, I was always amazed at how well it worked!