During a conversation regarding what basic elements CDI programs need at the onset in order to be successful, ACDIS Advisory Board member Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, Director Case Management Case Management and Clinical Social Work
University of California Irvine Health offered the following suggestions. Contact her at email@example.com.
- Selecting staff: Matching CDI key skills/qualification/experience to the CDI role and CDI needs of the facility (academic, community hospital, access hospital, product lines). Staff members also need to be an effective trainer and engaged learner to be able to internalize the CDI mission and explain it to physicians and ancillary staff. Having skills in communication/negotiation (vs. introverted) and knowing one’s own strengths and weaknesses goes a long way in being successful in this role.
- Assessing where to start: New program managers (or those tasked with starting CDI reviews) need to understand administrators’ top priorities and focus area for the program. The first task is to meet (or exceed) those expectations in order to move the program forward and meet some of the larger programmatic targets suggested by industry leaders. (Advancing beyond CC/MCC capture and straight Medicare record reviews.)
- Creating the return on investment (ROI): Regardless of whether your program is a single CDI staff shop or led by a manager and team of coworkers, those involved need to understand the mission and the metrics used to measure the program’s efforts toward its goals. Providing those metrics to the team and keeping that information sharing going through administrative outcome reports (showing quality progress and revenue/CMI capture) not only ensures transparency but effectiveness as well.
- Standardizing queries: As this is the CDI program’s most essential tool, spend some time studying the evolution of physician query practice guidance from AHIMA and ACDIS. Queries do need not be scripted. In fact, each must contain the critical clinical information related to that particular patient encounter. Yet, the program needs comprehensive policies and procedures in place as to how to draft a compliant query, how to follow up with physicians, how to track queries, and how to escalate matters if necessary.
- Building critical relationships: As CDI professionals essentially work as intermediaries between physicians and coders as translators between the clinical and coding languages establishing effective relationships with these core groups can’t be understated. CDI teams should meet regularly with HIM/coding staff to share documentation integrity concepts. They should feel enabled to ask coders questions about new guidelines and coding conventions. CDI staff also need to obtain input from other departments such as wound care, pharmacist, respiratory therapist, nursing, ICP, etc.)
These are just a few of the essential ingredients, to be sure. If you’re just starting out and want some additional information, feel free to reach out to Wendy or any of the members of the ACDIS Advisory Board. Learn more about them at our website.
A few weeks ago, ACDIS put out a call for members to nominate a colleague to be featured on the ACDIS Blog. We received a number of responses, but this one stood out. Kristi Repetto, RN, BSN, CCDS, director of CDI at Lee Health in Fort Meyers, Florida, nominated her colleague, Christi Drum, RN, BSN, CCDS, and had this to say:
“[Christi] is the ‘rock’ of our department. She has held a team lead role in the past and is extremely knowledgeable. She works collaboratively with our coding department to make sure both coding and CDI receive the same information regarding new updates, education, or query work flow. Christi is amazing!”
Drum began her career in CDI three years ago and, before that, worked as a nurse in the inpatient setting. She is currently a Florida ACDIS chapter member. Drum and her husband have two sons, ages 17 and 15, and one daughter, age six.
ACDIS Blog: Why did you get into this line of work?
Drum: I was looking for a career change away from bedside nursing that would benefit from my inquisitive nature, attention to detail, and readiness to learn new things, but would also benefit from my years of experience in critical care nursing.
ACDIS Blog: What has been your biggest challenge?
Drum: To accept that little in the realm of CDI is black and white. Chart reviews can be very subjective based on personal clinical experience and interpretation, not only for CDI specialist but for coding as well. Learning to adjust to this as a new CDI staff member was certainly a challenge for me.
ACDIS Blog: What has been your biggest reward?
Drum: My transition to the CDI educator role. I thoroughly enjoy training and orienting new staff members on all things CDI. I’m quite passionate about CDI and love to cultivate that in others. It is a very rewarding job to see others learn and become successful as CDI specialists.
ACDIS Blog: How has the field changed since you began working in CDI?
Drum: I think the biggest change for us has been the buy-in from the physicians. They were initially very resistant and reluctant to work with and learn from the CDI team. We have seen physicians begin to engage, increase compliance, and seek out CDI staff members for new education and learning opportunities.
ACDIS Blog: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on CDI Talk or through ACDIS?
Drum: ACDIS is a wealth of information and a crucial resource in this job. From sample queries and networking opportunities, to physician education and keeping abreast on current news topics, ACDIS offers it all.
ACDIS Blog: What piece of advice would you offer to a new CDS?
Drum: Be patient with yourself! CDI is very different from bedside nursing. It takes time and exposure to learn and remember the many different facets, rules, regulations, requirements, guidelines, Coding Clinics, etc. Also, never stop asking questions. So much in this industry changes so frequently. It is normal and beneficial to seek the help and advice of others in your field.
ACDIS Blog: If you could have any other job, what would it be?
Drum: Something that allowed and paid for international travel and sightseeing.
ACDIS Blog: What was your first job (what you did while in high school)?
Drum: I started working at the age of 14 at Chick-fil-A and worked there for two years. To this day, I still enjoy eating there.
ACDIS Blog: Tell us about a few of your favorite things:
- Vacation spots: Maui
- Hobby: Relaxing at the beach and kayaking
- Non-alcoholic beverage: Unsweetened tea with a little Stevia or flavored sparkling water
- Foods: Anything gluten free, but I particularly like the sweet treats
- Activity: Traveling to new places
Editor’s note: The ACDIS Blog occasionally introduces an ACDIS member to the larger CDI community. If you would like to be featured or know someone who would, please email Associate Editorial Director, Melissa Varnavas, at firstname.lastname@example.org.
I was looking through old drafts of blog posts and came upon some notes from ACDIS blogger Linda Renee Brown. She wrote that sometimes CDI professionals look for expert advice and that once they identify it, they follow it to the letter. But “What’s an expert?” she asked, and went on to quote an old teacher who broke the term down into its component parts stating that a “ex is a has-been and a spurt is a drip under pressure.” Clearly the teacher (and Brown) meant that anyone can self-describe as an expert but its up to us as individuals to do the extra research and ensure that the advice provided is actually sound.
In clinical documentation, as in any professional field, there exist any number of possible expert resources from which to draw advice and information. Programs instituted on the advice of a consulting firm may have benefited from its initial education and training. Those with extensive electronic health records and eQuery systems no doubt learn from the expertise of its designers and staff as well as the technological tools and resources available within the system.
All types of other experts also exist. The person who hired you, perhaps. The co-worker who offered you a kind word and simple advice which resonates even today. The coder who continues to lend you an ear as you try to decipher the latest recommendations from Coding Clinic.
Yes, even various publications can provide a certain amount of expertise. Coding Clinic of course serves in this role, as the AHA represents one of the four cooperating parties governing code assignment. So, too, does AHIMA and it’s publications, similarly due to its participation on that four-corporation governing body as well as its more than 75 year legacy representing the health information management field.
And, of course, we believe that ACDIS provides expert advice as well. It is the only association totally focused on the daily activities of those working to ensure the complete integrity of the medical record. That’s not why I believe ACDIS’ advice equals sound advice, however. Actually, I believe the strength of the education, insight, interpretation, and analysis provided to its members comes directly from the collaborative nature of the association itself. We depend on the input and opinions of our members. We bring those thoughts and ideas forward in a number of ways, through the Journal, ACDIS Radio, our quarterly conference calls, and more. We encourage your feedback and suggestions on those items and we continue to grow and reassess the state of the profession through your eyes.
As Brown wrote in her notes, “if you’ve been working in CDI for any length of time and you’ve allowed yourself—and have been allowed—to think for yourself and act for yourself and make judgments based on what you know in your core to be right, you don’t need an expert. You are headed in the right direction.”
Whether you’re looking for advice on a particular topic or have an opinion, thought, or CDI success story reach out to your peers here or via the ACDIS Forum. By sharing our expertise we all benefit.
Clinical documentation improvement (CDI) specialists and case managers share a common goal but often aren’t on the same page when it comes to improving documentation within the hospital, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, director of enterprise solutions for Zirmed, in Chicago.
Organizations should shift the focus of CDI from merely capturing as many comorbidities and complications (CC) and major comorbidities and complications (MCC) to truly improve the written picture of the patient’s condition.
This change in focus needs to do several things, according to Krauss, including:
- Recognize any barriers that exist between CDI and other departments they need to work with.
- Create a supportive environment and reporting structure for CDI that recognizes the limitations of strict reimbursement outcomes and realigns the focus of CDI toward processes and outcomes that incorporate the multitude of uses in today’s fee-for-value healthcare delivery model.
- Define and agree upon what constitutes true CDI. This should reflect effective communication of patient care, outcomes, and fee-for-value to the mutual benefit of all healthcare stakeholders, including the patient.
- Revise the job description for CDI to give these staff members more encompassing duties and responsibilities and to better define clinical duties and responsibilities.
- Develop expanded and more refined key metrics of documentation improvement that are valid and meet inter-rater reliability.
By encouraging CDI to take a more comprehensive approach to documentation you’ll not only improve their ability to work with case management, but also their ability to work toward more accurate billing and fewer denials.
Editor’s Note: This article is an excerpt from Case Management Monthly.
Another tradition in my household is to take some time around the dinner table on New Year’s day to talk about some of the things we’re grateful for that happened to us in the year that passed. Such reminisces often raise interesting thoughts. All together as a family, we each remember something slightly different, in different way, and when these thoughts come together they create a cohesive whole that gains additional significance.
So I thought I’d take a look back at our year in CDI and pull our little CDI family together in the form of salient quotes from the pages of the CDI Journal the past year. Some interesting themes emerged. ICD-10-CM/PCS implementation was threatened but eventually implemented. CDI programs continued to expand their scope from CC/MCC capture to quality concerns. Programs expanded scope into pediatric and outpatient arenas, too. Some things remained the same, too. Central among them remains the fact that CDI program’s core function is assisting physicians in crafting the most complete and accurate chart possible.
What quotes from 2015 will you take with you into 2016? Let us know in the comments section below!
“It isn’t about the code set per se, it is about documentation improvement. We have to continue to assess documentation quality, and that’s true regardless of which code set you are working within.” ~Kathy DeVault, MSL, RHIA, CCS, CCSP, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
“CDI staff are asking specific questions about ethical behavior. The new [ACDIS Code of Ethics] is founded on the real-life concerns of CDI professionals.” ~Michelle McCormack, RN, BSN, CCDS, CRCR
“You can train people on the technical aspects of the job, but teaching a person to think critically can be difficult, so it is incredibly important to hire the right person.” ~Lisa Romanello, RN, CCDS
“Documentation improvement programs need to become patient centered and follow documentation improvement opportunities across the care continuum, including ambulatory, inpatient, and postacute care.” ~James P. Fee, MD, CCS, CCDS
“Best practice would be to make your queries a permanent part of the medical record to demonstrate CDI/coding efforts in obtaining clarification regardless of the outcome.” ~Cheryl Ericson, MS, RN, CCDS, CDI-P, CDI education director at ezDI
“My biggest reward has been learning what CDI is all about and having the opportunity to continually grow in the field.” ~Fran Platt, BSN, RN
“Each CDI specialist and coding professional must be open-minded and willing to listen to differing opinions, and be able to contribute positively to the discussion of each case.” ~Walter Houlihan, MBA, RHIA, CCS
“Children’s hospitals are now paying more attention to how documented pediatric terminology affects APR-DRG assignment and its reimbursement, particularly since bundled payments are part of CMS’ game plan.” ~James S. Kennedy, MD, CCS, CDIP
“Switching to ICD-10 from ICD-9 is a very costly endeavor, and many healthcare facilities and healthcare-related companies have invested millions of dollars on systems and training.” ~Rebecca A. “Ali” Williams, MSN, RN, CCDS
“The opportunity to network and share documents, tools, and processes has allowed the profession to grow from a group of people who reviewed charts to a profession that drives patient care improvement through the support of accurate and compliant documentation.” ~Fran Jurcak, RN, MSN, CCDS
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.