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TBT: Monitoring CDI efforts for effectiveness

TBT to the 4th Annual CDI Week celebration!

TBT to the 4th Annual CDI Week celebration!

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, we’ve pulled from the fourth annual Clinical Documentation Improvement Week, in which Karen Chase, RNC, BSN, Assistant Director of Clinical Documentation Improvement at Stony Brook University Hospital in Long Island, New York, a 603-bed academic medical center, answers questions regarding program monitoring.

Q: Does your CDI department audit for query accuracy and compliance? If yes, can you describe your process?
A: Yes, but what I do is a manual process at this point. Unfortunately the only program we have is basic, with no computer assisted coding or query program. Everything is sent through e-mail and the staff CC me on all emails. I pick 10 queries per month for each CDI reviewer, pull the chart, and see if they are leading, appropriate, or if anything was missed. I also look to see if the chart was reviewed an appropriate number of times. I look to see:

  • Was the working DRG appropriate?
  • What was the CC/MCC capture rates for that CDI for that week?

It’s not the best way, but I’m not automated yet. We moved to an electronic health record two years ago, about six months after I started, and we are hoping to get a 3M program approved in the near future.

Q:What quality metric does your hospital administration find most helpful/compelling when evaluating the success of your CDI department?
A: In the beginning we tracked the case mix index and saw tremendous increases. But then we became stagnant and had to find other ways to measure our progress. Now we use mortality index, also CC/MCC capture rates by service line. We also take DRGs with triplets and compare quarter to quarter how many have CCs, MCCs, or no CC/MCC, such as DRGs 245-247, 280-282, etc. I have a dashboard with those metrics I show administration.

One of our improvements [last] winter was pneumonia (DRGs 193-195). Through documentation improvement, we brought our MCC capture rate from 19% last year to 27%. We also share success with Patient Safety Indicators (PSI). We also look at quality metrics—core measures metrics like aspirin on arrival—and try to help out our quality department in any way we can. We alert quality when there is a quality issue.

For example, if something flags as a PSI, they give it to me, our [CDI] people review it, and if it’s a documentation issue we can fix and query. If not, I toss it over to quality. Even though quality and CDI are separate, we work well together.

We also do mortality reviews. If a patient dies, I get that chart, we get it coded, and we have an ICU nurse who reviews them for documentation improvement. If she sees something that is a quality of care issue, it goes to the quality department. Quality does more retrospective reviews and we do more realtime reviews and we can pick things up faster with our concurrent reviews.

Guest Post: The (CDI) importance of serving others

Kelli Estes

Kelli Estes

by Kelli Estes, RN, CCDS

Any leadership book you read will quickly point out the importance of serving others! Who can we include as likely candidates for the CDI Team to serve? All healthcare providers: Physicians, nurse practitioners, physician assistants, coders, any variety of others.

Unfortunately, the idea of going above and beyond the proverbial call of duty to serve providers is often lost. I have worked in numerous hospitals where the CDI team exhibits heightened frustration over the lack of provider participation in the CDI program, and over the continued poor documentation that results. CDI team feels forced to find a way to work around this group of difficult providers in order to obtain the improved documentation, in the end, from another provider on the case. This tends to give a “pass” to certain providers who have the tendency to discount the importance of  CDI compliance.  sually this results in an incessant flow of behind closed door mouthing without ever obtaining a workable solution for the future. Sadly, this only sets the table for a negative attitude toward the group of difficult providers.

So what is the CDI Team to do? First, maintain the proper perspective!

Any well-oiled machine has all the moving parts working together at the appropriate time. CDI can be a very complex process that involves input from several different parties to get it all right. Undeniably, everyone has to own their part, but it would behoove any CDI team to provide whatever is necessary to encourage the providers to incorporate CDI into their busy and demanding schedules.

Before you “boo” this entire idea, think about those providers who require repeated queries for the same things, over and over. Most often when I ask CDI specialists if these providers answer their queries, the answer is yes. I remind them that this is still a “win” for the CDI team. Remember why the CDI team is in place. Undoubtedly, the vast majority of providers will begin to document certain conditions unprompted; however, don’t become discouraged when some providers require ongoing CDI queries; that is precisely why CDI is so valuable to the overall continuity of improved documentation.

Secondly, talk to the providers! Taking the initiative to set up a time to talk with difficult providers and explain the “why” behind your need for clarifying queries is a necessary step to facilitate CDI participation. Physicians often get saturated with a great deal of information when CDI programs are first implemented then fail to hear much else beyond that point. Ask providers how you can better serve them in future CDI efforts. Do everything you can to help them realize that you are there to help and be a credible resource for their future documentation improvement needs. Express your willingness to cater to their individual requests within reason. This will allow the difficult providers to recognize that the CDI team can help improve their documentation without completely disrupting their day.

Nevertheless, you may continue to face some barriers such as:

  • The CDI specialist (or team) does not understand a disease process well enough to discuss the need for clarification with confidence.
  • There is a lack of administrative support for fostering a collaborative relationship between the CDI program and providers regarding CDI initiatives.
  • There is no CDI physician liaison in place.

If any of these are the case at your facility, consider the following:

  • Employ the CDI team member most knowledgeable about a particular disease process when discussing with a provider.  Allow a newer CDI staff to come along for the conversation and be mentored.
  • Provide case studies to administration that demonstrate the positive effects of provider participation.
  • Provide other case studies that support the need for a physician liaison. In the meantime, use physicians with whom the CDI staff have a great relationship to discuss difficult cases prior to approaching providers.

Despite our best efforts, we will never completely rid ourselves of those challenges presented by difficult providers, but maintaining an attitude of serving the providers will always prove to be a successful approach to gaining a win for the CDI program.

Editor’s Note: Estes has spent more than a decade as a CDI specialist and consultant, presently with DCBA Inc., in Atlanta. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. Contact her at

Q&A: Determining standard clinical criteria for common diagnoses

Go ahead, ask us!

Go ahead, ask us!

Q: I understand that most CDI departments develop a standardized list of clinical indicators/criteria to support query efforts. Is this something we need to develop or is it available in the encoder process? If we need to develop this, how do we go about that?

A: While the AHA’s Coding Clinic for ICD-9-CM (ICD-10-CM/PCS) often lists clinical indicators for specific diagnoses, the publication should not be used as a stand-in for the provider’s own clinical judgment, as reiterated in Coding Clinic, First Quarter, 2014, p. 11.

CDI programs should work with the physician team to develop a standardized list of clinical indicators for the team to use in query creation, CDI and physician training, and record review. Such mutually developed criteria is particularly helpful for highly vulnerable or often miss-documented conditions such as levels of malnutrition severity, acute and chronic respiratory failure, acute kidney injury, encephalopathy, etc.

Research nationally established guidelines for these common, core conditions (e.g., ASPEN criteria for malnutrition, or RIFLE or NKIDO criteria for renal failure), then work with the specialty most closely related to that diagnosis (e.g., pulmonologists for acute respiratory failure). This criteria could then be consistently used by CDI and coding staff to initiate a query to support the diagnosis.

Guest Post: In search of the clinical truth

Cesar M. Limjoco, MD

Cesar M. Limjoco, MD

Editor’s Note: This article was originally published in CDI Monthly, by DCBA, Inc., and shared on the social media network LinkedIn. It has been adapted from its original and is republished here at the invitation and permission of the author and participants.

“Many CDI programs have set as their goals: accurate coding, maximum reimbursement, increased case mix index (CMI) and better risk-adjusted scores,” says Cesar M. Limjoco, MD, vice president of clinical services at DCBA, Inc. in Atlanta, Georgia.

“But are they missing the mark? Are they setting their targets low and setting themselves up for a fall?” Limjoco asks. “The goal sets the tone for one’s actions. The end justifies the means.”

CDI programs with preset agendas can slip into focusing solely on those priorities at the expense of the clinical truth, he warns. Like a racehorse wearing blinders to limit distractions, CDI specialists can be blinded to all but the racetrack before them. Without a broad perspective they may have a tendency to arrive at incorrect conclusions, he says. For example, if these end goals take precedence it becomes easier to see (and query for) a variety of diagnoses that may not be true given the entire picture of the patient’s condition, Limjoco says.

“As you may have heard before, medicine is both an art and a science. A provider does not come up with a diagnosis just from laboratory and other workup. There are false positive and false negative results. The provider has to marry the workup results with the clinical picture of the patient,” he says.


TBT: Pediatric efforts offer new CDI opportunities

Starting a pediatric CDI program? Read how.

Starting a pediatric CDI program? Read how.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article “Pediatric efforts offer new CDI opportunities” which originally published in the October 2013 edition.

“We’re seeing more and more children’s facilities starting CDI efforts,” says ACDIS Advisory Board member Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. “The largest growth comes from multi-hospital systems that already have CDI programs in place. They see the potential of expanding to their affiliated children’s facility.”

With roughly 500 children’s facilities in the nation, Gold sees both the probable benefit and difficulty inherent in such CDI expansion. Children’s hospitals do not have Medicare patients—the typical starting point for traditional, short-term acute care hospitals, he says. In fact, most are paid on a contract basis related to a certain percentage of the actual charges of the care provided “so there was little financial incentive for children’s facilities to implement CDI,” he says.

Furthermore, children’s facilities do not have the external scrutiny that adult hospitals face. Where typical healthcare facilities turn to HospitalCompare,  HealthGrades, and other public quality report cards, children’s programs have few options, says Gold. He notes that Parents Magazine publishes an annual “Top 10” list, but that it is based on anecdotal data from its subscribers and research. So it can be difficult to persuade administration to expand CDI efforts based on physician ego, or quality scores either.

At the Medical University of South Carolina (MUSC) in Charleston, Karen Bridgeman, MSN, RN, CCDS, CDI specialist, started building the case for expansion by examining data from the University HealthSystem Consortium and National Association of Children’s Hospitals and Related Institutions. This data allowed MUSC to compare benchmarks regarding patients’ severity, mortality, and facility case-mix index (CMI). They took the 25 top and bottom DRGs and divided them into two categories—high-volume, low reimbursement and low-volume, high reimbursement—for Medicaid, Blue Cross, and commercial payers.

The data suggested that a higher level of clinical complexity existed than was being depicted in the medical record, Bridgeman says. Asthma and bronchitis, seizures, and neonatal care fell into the high-volume, low yield bucket; that cardiothoracic conditions and Level III neonatal ICU fell into the high-yield, low volume bucket; and that chart review of pediatric patients could help with respiratory failure, cystic fibrosis, sickle cell, and chemotherapy documentation improvement.

“We found the physicians writing respiratory distress, but that just wasn’t clear enough to determine whether it was an shortness of breath or a respiratory failure,” Bridgeman says. “Sepsis and shock weren’t being documented at all.”

Q&A: Advance CDI efforts by expanding reviews beyond low-hanging fruit

Apple tree and the low-hanging fruit of CDI

There’s more fruit in the tree!

Q: At what stage should an established program most likely experience a reimbursement plateau? One may naturally expect the physicians to improve as CDI programs hammer them with education. After we’ve gathered all the low-hanging fruits and go for the mangos? We ran the top principal diagnoses and also top diagnoses for our system. We are a home-grown program, about three years old now. Our team made $6 million last year. I know there are many query opportunities and ideas for program expansion but how do we find the right areas for our facility?

A: I am unaware of any industry standards that identifies a timeline of expectations for a plateau of reimbursement/physician documentation improvement. If you have a relatively stable medical staff with few changes, the program should mature and demonstrate physician documentation improvement more quickly than an organization that experiences high turnover of physicians, such as a university or teaching hospital. A teaching hospital may never plateau as the influx of residents and the constant rotation among specialties means educating physicians and capturing the “low hanging fruit” never ends. Each organization will have their own rate of turnover and educational needs for medical staff.

Such programs would have a lower query rate but maintain increased levels of CC/MCC and severity of illness/risk of mortality (SOI/ROM) capture. In other words, the physicians have retained and applied the education, they require less questioning but their documentation supports higher reimbursement levels.

The second variable in this equation is that as a CDI program matures the staff will find “different trees of low-hanging fruit” to pick. At the beginning, you learn to recognize potential documentation opportunities amongst the apples and oranges and begin to see a decrease in queries related to these but you learn there are opportunities in the lemon trees and the mangoes.

Don't get overwhelmed! Just ask for help!

Don’t get overwhelmed! Just ask for help!

Lastly, organizations are constantly adding new services, new procedures and with each change CDI programs may identify entirely new opportunities. In other words, I have not seen in my experience a leveling off but more of an evolving focus as a program matures.

Self-education and participation in CDI networking are important in advancing your own career, your own knowledge, and your CDI program efforts. If you do not currently have tracking systems in place for individual CDI specialists’ and individual physicians’ query behaviors, you may want to. This might identify specific learning needs for individuals that could be targeted. For example, what diagnoses are the CDI specialists querying for? Does one CDI staff member miss sepsis opportunities or are there opportunities the entire team needs to learn about? If there a specific physician that needs intervention on a particular diagnoses?

Most successful CDI programs work closely with their coding teams. Expand on this collaboration by having the coding staff bring forward any trends or difficulties they’re seeing in daily practice. Ask to review any retroactive queries for trends and trouble spots. Identify any documentation improvement opportunities the CDI staff may have missed. The idea being, you and your CDI team won’t miss that opportunity next time.

If you do not have access to your organization’s Program for Evaluating Payment Patterns Electronic Report (PEPPER), seek out access. PEPPER is produced by CMS and it compares your organization to like organizations within your region. It identifies where you maybe an outlier for specific diagnoses and CC/MCC capture. You may be able to identify improvement opportunities in areas where you are a low outlier compared to your peers.

I often found my new fruit by reviewing the code set. Just opening up the code book and seeing what specificity was needed in code assignment for specific diagnoses often demonstrated for me areas of needed improvement. I would suggest doing that with theICD-10-CM code book. You can start asking questions related to ICD- 10 now so that the learning curve will not be so steep come October of next year.

Lastly, an exercise I suggest for new CDIs and one that might require repeating as the definitions do change is to take the list of CC/MCCs and highlight those diagnoses that are often seen within your population. You may find there is a “fruit basket” just sitting there that you never considered. If you identify codes that you have not thought to ask for look them up in the code books and learn what terms are needed to support their documentation. I promise you this effort will bring to light at least one diagnosis common to your population that you might not be capturing on a regular basis.

Wikipedia tells me there are over two thousand different fruits in the world so you have many to harvest!