OptumInsight and ACDIS host a free webinar Wednesday, October 16, 1-2 p.m., (ET), featuring Shely O’Laughlin, Vice President, National Solution Leader for ICD-10 and Clinical Documentation Improvement and Cecilia Guardiola JD, RN, Associate Director, CDI Consulting. During the webinar the speakers will discuss the impact that CDI technology has on the role of the CDI specialist in the hospital environment, with an emphasis on case-finding, coaching and education, physician interventions, data analytics, and performance metrics. Additional agenda items include:
- Description of technology solutions for CDI
- Influence of technology on traditional CDI processes
- CDI specialist as coach: A role in evolution
- CDI metrics: Quantifying improvement in CDI process and documentation practices
- Practical implications for organizations considering investment in CDI technology
- Brief CDI Module demo
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?
The establishment and enhancement of a CDI program at Bronx-Lebanon Hospital Center originated in 2010. Robert Leviton, MD, the hospital’s chief medical information officer/physician advisor, Diane Johnson, director of HIM, and Mohammad Ahmed, MD, assistant director of CDI believed that an electronic medical record system’s integration with patient care, documentation, and revenue cycle management would be beneficial to all stakeholders.
“CDI will become even more significant in light of ICD-10, by providing a proven practice work flow that captures clinical documentation, provides enhanced opportunities for improvements, and permits billing that is increasingly dependent on the ability to code correctly,” Johnson said.
All Bronx-Lebanon Hospital CDI specialists are physicians who hold coding credentials from AHIMA, which makes its CDI program distinct from other programs. The trend of hiring foreign medical graduates or physicians at other institutes is also growing, due to enhanced CDI query response and agreement rates.
“As physicians, we have tremendous insight into the thoughts of the clinical staff, including detailed assessments relativity to the documentation needs,” Ahmed said.
The CDI program at Bronx-Lebanon started with the implementation of Allscripts Care Manager Program, as well as 3M Encoder and reference. “Our CDI query and response rate is outstanding, since CDI staff place queries based on medical evidence and clinically significant conditions,” said Ahmed. CDI staff collaborate and provide accurate coding opportunities for the HIM and case management department by posting geometric mean length of stay on the patient’s electronic facility board.
Through concurrent review of a patient chart and after computing the initial DRG into Allscripts, CDI specialists enter principal and secondary diagnosis along with the procedures. Concurrent queries are directed verbally, as well as electronically. CDI staff continues to review the charts until the patient is discharged to ensure all necessary information is captured. The CDI staff also takes on a vital role in facilitating retrospective queries with collaboration of HIM coding mangers.
The DRG status in Allscripts is specified by DRG icon color. A blue colored DRG icon indicates that the patient chart is not reviewed by the CDI, whereas an orange DRG icon indicates that the chart review is in progress or waiting for final DRG. When a physician documents additional diagnoses or clarifies documentation in the patient’s medical record, the CDI specialist captures these changes and assign a working DRG by updating diagnostic codes, as well as electronically posting the expected length of stay (LOS) on the electronic facility board, thereby providing guidance to the clinical staff regarding the remaining LOS. The final DRG and codes are assigned by HIM coders for all discharged cases. A working and final DRG matching situation is indicated by a green DRG icon color, whereas the red DRG icon color draws attention to a discrepancy in coding data, either by the CDI or HIM coder. These charts are then reassigned to the HIM manager to reconcile the data.
“Our discrepancy rate is very low, an indicator of the program’s success,” said Ahmed.
Another key metric of the program’s success is its reporting structure, CDI program productivity reports are presented to the hospital’s chief medical information officer on a regular basis. Using the electronic format allows the CDI staff to be transparent. This practice enhances the coder’s efficiency and also opens an opportunity for educational dialogue between HIM coders and CDI staff. Numerous tools to help physicians learn about the importance of better documentation and update them about Centers for Medicare and Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organization (JCAHO) guidelines are also provided.
“Our CDI team at is not only hardworking and dedicated, but their unending efforts continue to serve as a model for CDI programs throughout the nation,” Ahmed said.
It has been three years since ACDIS last surveyed its membership about physician query practices. In 2010, 382 CDI professionals participated. This year’s survey garnered 517 respondents, primarily CDI specialists.
“That’s really a tremendous response rate,” says Drew K. Siegel, MD, CPC, CDI specialist at the University of North Carolina (UNC) Hospitals in Chapel Hill.
The 35-question survey illustrates the importance of the physician query as the primary tool driving CDI efforts, but also demonstrates wide differences regarding query assessment, compliance, and policy review.
“The responses are actually quite varied, so there’s evidence that the query process [across facilities] is clearly not standardized,” says ACDIS Advisory Board member Timothy N. Brundage, MD, CCDS, physician champion at Kindred Hospital North Florida District in St. Petersburg.
That said, the 2013 survey does show some interesting trends, according to fellow ACDIS Advisory Board member Walter Houlihan, MBA, RHIA, CCS, CDI specialist at Baystate Health in Springfield, Mass.
“It is good to know that so many of us have the same challenges and needs when it comes to physician queries,” he says.
Editor’s Note: ACDIS members have access to the complete report in the July 2013 edition of the CDI Journal. The text of the report is available to all under the Featured Article section of the ACDIS homepage through the end of the week, August 23.
Q: I have come across an ethical dilemma. We have a small CDI program and a “home grown” application we use to report metrics to the chief financial officer (CFO). In this, we track whether a CDI specialist’s query captured a CC/MCC. If it is the first and/or only CC/MCC it gets counted for the financial impact of their job even if other CC/MCC later factor in.
I don’t feel this is appropriate, so, for the last few months, I have not counted those as financial impacts in favor of only counting those which truly show a difference. I predict there may be a drop in financial impact and that I will need to explain the reasoning to our CFO. Any advice you could offer would be greatly appreciated.
A: I would start by asking your CFO how he/she wants to measure the success of the CDI department and share with him/her the various potential metrics available and the strengths and weaknesses of each.
Many organizations want to see a return on investment (ROI) to “justify” the CDI department and its staff, but the value of CDI extends beyond direct revenue capture. For example, the data used to determine a Hospital’s Value Based Purchasing (HVBP) score is based the assigned principal diagnosis. A CDI specialist can therefore potentially impact revenue through the organization’s HVBP scores when they chose CHF as the principal diagnosis rather than acute respiratory failure if both meet the definition of a principal diagnosis. Personally, I think it can be tedious to count the money associated with every query, which can negatively impact your productivity, but if that is how your CFO wants to measure the success of the department, so be it.
If you’re not already actively using your hospital’s PEPPER (Program for Evaluating Payment Patterns Electronic Report), you’re missing out on a lot of valuable data. Data—including coded data—drives pay-for-performance, meaningful use, auditing targets, and more. Being ‘in the know’ about what your hospital’s data says in terms of the care provided is essential.
PEPPER provides Medicare claims data statistics for areas that the OIG, Quality Improvement Organizations, Medicare Administrative Contractors (MAC), and Recovery Auditors (RA) identify as being at risk for improper payments. It uses aggregated data to allow hospitals to see how they stack up against others in the state, jurisdiction, and nation.
The report, published by TMF Health Quality Institute, identifies potential over- and underpayments that hospitals can focus on internally. It also prioritizes specific target areas and provides guidance in terms of auditing and monitoring those targets.
Coding target areas include the following:
- Stroke and intracranial hemorrhage
- Respiratory infections
- Simple pneumonia
- Unrelated operating room procedures
- Medical DRGs with CC or MCC
- Surgical DRGs with CC or MCC
- Excisional debridement
- Ventilator support
- Single CC or MCC
PEPPER also targets the medical necessity of various conditions. In addition, it includes 30-day r-eadmissions to the same hospital or elsewhere and short stays (i.e., one- and two-day stays).
A hospital has an outlier if its percent in a particular target area is at or above the 80th percentile or is at or below the 20th percentile.
Various hospitals have shared information about how they’ve used PEPPER proactively. The PEPPER Web site provides testimonials about how hospitals are using the report.
If you haven’t already visited the PEPPER Web site, check out the following links:
- PEPPER User’s Guides for specific providers
- National-level data reports
- Medical necessity coding and audit tools to prevent improper payments
by Trey La Charité, MD
CDI professionals must educate facilities and physicians about the importance of accurately capturing the entire disease process because physicians, unfortunately, are frequently reluctant to document additional disease processes in the charts of patients who are obviously about to die. Let’s look at one example before discussing possible causes.
- “I don’t want to ‘penalize’ the patient.”
- “I don’t want to bilk the insurance company.”
- “I don’t want to stick the family with a higher bill.”
- “It just doesn’t feel right.”
- “Why do you need that? They are going to die. How much sicker do you need them to look?”
Editor’s Note: This article is an excerpt from the April 2013 edition of CDI Journal. La Charité is a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville, and an ACDIS Advisory Board member. Contact him at email@example.com.
For many CDI specialists just starting out, finding an experienced mentor can make all the difference. Mentors offer words of wisdom, a helping hand, and sometimes even a much-needed shoulder to cry on. But frequently, mentors gain from the experience as much as they give.
If your facility is interested in becoming a CDI mentoring site, contact ACDIS Associate Director Melissa Varnavas at firstname.lastname@example.org and consider the following items before getting started:
1. Connect with your CDI program manager. Whether you wish to be mentored or are ready to volunteer to help someone else, connect with your manager first to review time restraints, possible compliance concerns, and privacy policies.
2. Discuss mentorship parameters. Set up an initial phone call with both mentor and mentee to determine experience level and expectations, as well as both partners’ availability. For some, mentorship might mean having a friend available for an occasional phone call, but others may be hoping to job shadow for a day. Be clear on what the mentorship will include.
3. Review learning expectations. Mentors may want to establish a formal schedule for the job shadowing visit, as well as an evaluation form based on the previously expressed interests. Complete any confidentiality forms or other permissions up front.
4. Foster continued relationships. If you are being mentored, be sure to follow up with a thank-you card and highlight the lessons learned and helpful tidbits you gleaned from the experience. Mentors should follow up to identify any lingering concerns. If you are a first-time mentor, document the process and discussions and keep a running list of what you feel works and what doesn’t. In addition, ask your mentee to let you know what they felt was most helpful. You can use this list to formalize the experience
so you don’t have to reinvent the wheel the next time you mentor someone.
5. Pass along the experience. Once you have your program on its feet, consider becoming a mentor yourself. Mentors can be a resource even to experienced CDI staff, as well by way of job shadowing and one-on-one interactions.
“Every CDI department, every CDI specialist has its own strengths,” says Terri Leap, RN, BSN, MBA, CDI specialist at Wishard Hospital in Indianapolis. “So an exchange of learning can
always be a positive experience.”
Editor’s Note: This article originally published in the July edition of the CDI Journal.
From the non-clinical ACDIS Membership Services Specialist Penny Richards (follow her on Twitter at
- Drink plenty of fluids. A cocktail now and again is not a bad thing (but not at work or if you plan to drive).
- Eat more fruits and vegetables.
- Make a donation to a food pantry.
- Pay someone a compliment.
- Pat a puppy.
- Say “No” when you need to.
- Give yourself a break.
- Don’t take everything too seriously
From Dee (Schad) Banet, RN, BSN, CCDS, CDIP, ACDIS Advisory Board Member, and Director Care Coordination and CDI at Clark Memorial Hospital, in Jeffersonville, Ind.:
- Share your passion
- Always do the right thing for the right reason (integrity)
- Persistence is a virtue ( a ‘no’ today could be a ‘yes’ tomorrow)
- Assertive v. aggressive, a fine but important line in CDI (and my advice is—don’t cross that line)
- Education will get you everywhere
From Sharin L. Cancilla, RHIT, CCDS, former Michigan ACDIS Chapter state leader, CDI specialist at Botsford Hospital in Farmington Hills, Mich.:
- My advice is simple – educate, educate, educate! You’re either learning or you’re teaching. Go to classes, seminars and meetings and learn. Then go back to your colleagues, docs, and administration and teach them what you’ve learned.
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!!