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.
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.