By Jocelyn E. Murray, RN, CCDS
There’s no question of the financial sustenance facility case mix index (CMI) provides. An elevated CMI level indicates an increased severity (or acuity weight) in surgical and life sustaining levels of medical care. Facility budgets are formed around the CMI, it is the acuity weight representing the average facility case and therefore reflects upon reimbursement. It makes perfect sense that this marker is a strong point of reference in the financial revenue department and a CFO focus. CMS.gov gives the following description of the CMI: the average DRG weight relative weight calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.
We know our financial leaders focus on the CMI on an ongoing basis, but is it a true indicator of our CDI operational assessment and program productivity?
In my opinion, the CMI is a good tool to compare area hospital performance at a similar acuity level for medical and surgical care. We know a comparable facility with a much lower CMI can be a direct reflection on missed documentation and lower acuity weighted diagnostic codes. CDI intervention then consists of a provider education plan to improve documentation and capture the severity. Pre-billed audits ensure the acuity is also captured in final coding. Both are standard elements of the CDI process and program interventions.
It can also be a useful tool to help identify how outpatient CDI focus programs in the ED, short-stay surgery, and observation practice levels help ensure CMI accuracy. The DRG for a patient admission that does not meet medical necessity, indicates the patient’s care could have been provided on an outpatient basis. It could also have a critical impact on the CMI.
The lower weight CMI, as reflected by the DRG in this case, is tossed into the bucket as part of the calculated averaged acuity level for the site. One or two occurrences of low CMI weighted inpatient cases may not be a concern, but a handful of cases would certainly have a detrimental overall effect.
In my first years of CDI program implementation, the facility had a significant drop in the CMI over a couple of months during the summer. I dug into the metric further and discovered the top two acuity case surgeons in both neuro and orthopedic were away on vacation. A significant drop in surgeries occurred, and a small number of high-acuity procedure cases were performed and made available in the in that period’s calculation. Of course, the surgeon’s absence had nothing to do with our CDI program productivity efforts. And yet, the CMI drop was brought to my attention by the chief financial officer (CFO) who questioned the cause as CDI productivity. Together, we reviewed my identified findings and took the opportunity to bring forward critical information to the leadership team. The CMI changes had no reflection on the CDI program impact in the absence of surgical caseloads available during that time period.
CDI programs (CDI) are working at more advanced levels in 2017 and need to focus on understanding how their CMI metrics are effected and how the program responds. One key performance of the CDIP is identification of the root cause with any metric change. Only then can you can establish a responsive goal and develop an individualized action plan for intervention.
In my case, a report identified the absence of two key surgeons and the effects of their absence on revenue for the facility. It was then up to the executive leadership and chief medical staff to strategize on how to prepare, plan, and focus actions for this type of revenue impact in the future.
Editor’s Note: Murray is a senior CDI consultant, HIM services, at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. She has expertise both in program assessment and enhancement to improve the quality, productivity, and effectiveness of CDI programs within an organization. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. Contact her at firstname.lastname@example.org.
Which credential/certification/licensure makes for the best CDI specialist? RN? RHIA? MD?
If you answered all of the above—or none of the above—you’re on the right track, according to a new Position Paper written by the ACDIS Advisory Board published on the ACDIS website.
To be blunt, no licensure or credential can identify whether someone will succeed as a CDI specialist. Not even ACDIS’ own Certified Clinical Documentation Specialist (CCDS) certification can guarantee that. We do, however, require anyone who sits for the CCDS exam to have two years of experience as a CDI specialist, so we feel good about the competency of our CCDS-credentialed professionals. CCDS holders must understand the basic core competencies and have demonstrated their skills in the field already.
But is that person a guaranteed fit with your culture?
Is that person dependent on an encoder or other computer assisted coding/natural language processing (CAC/NLP) tool that your hospital does not have?
There are many other factors that make up a good CDI specialist. As the new Position Paper explains, these factors include:
- Effective verbal and written communication
- Self-directed with an ability to work independently to complete the work at hand
- The ability to think critically
- A commitment to lifelong learning
The new Position Paper also notes that a strong clinical foundation is a must for any CDI specialist, and hiring an RN, MD, or an RHIA with strong clinical acumen will certainly fulfill that requirement. But, it’s no guarantee of success as the paper states:
“Credentials do not guarantee whether one will succeed as a CDI professional. Credentials merely identify the body of knowledge in which that person was originally trained. Prior bodies of knowledge certainly assist one’s success, and credentials and/or licensure provide identification of one’s stated profession and their level of education or achievement, but they do not ensure CDI competence. There is a number of necessary skills that cannot be ensured or captured by a credential.
It always comes down to the person. Why should CDI be any different?
If you’re wondering whether a Position Paper represents ACDIS’ official stance on an issue, you can find the answer here. Our recently published “Hierarchy of Authority” explains the order of significance of our published articles. ACDIS Positon Papers are peer-reviewed and represent the consensus opinion of the advisory board. We hope you find “ACDIS’ ‘Hierarchy of Authority’ of published articles” helpful as you navigate our website.
As with all aspects of the medical field, new technology shifts CDI. Sam Antonios, MD, FACP, SFHM, CCDS, a board certified internist and CDI and ICD-10 physician advisor for Via Christi in Wichita, Kansas, shared his thoughts on technology’s effects on CDI during the November 29, 2016, ACDIS Radio broadcast.
At his own facility, Antonios deploys new technologies, which gives him a unique perspective on implementation. “Technology needs to be viewed as something that is happening and cannot be ignored. It will influence and it will shape the future,” Antonios said. “We’ve gotta embrace it and learn to live with it. But not only that, learn how to [leverage] it as a competitive edge because there is a large and vast need for that type of skill set,” Antonios advised.
The typical workflow for CDI staff at Via Christi goes something like this: reviewing charts, recognizing opportunities, and sending queries to providers and physicians. Technology influences the way all these steps happen, according to Antonios.
Technology also changes the physical location of the CDI professionals within the hospital, according to Antonios. When paper charts were the norm, CDI specialists had to physically be on the floor of the facility. Now, they can work from their offices in the facility or even from home. While this shift improves things like commute time and efficiency, it can have a negative effect on CDI/physician relationships, Antonios warned.
The relationships between CDI specialists and physicians are important. Because of this, Antonios said that all parties need to be more intentional. Relationships can erode under this new system. “There’s gotta be strategies that compensate for that remote work. Otherwise, over the long run, those relationships are at risk. Those relationships are very critical to get the query back, for education, and for training for some of the residents,” Antonios said.
As far as Natural Language Processing, Antonios said that his facility is in stage two. The logarithms for the Natural Language Processing are getting a lot better in his opinion. In the next stage, the systems will not only pick up on words but also start to detect intent and underlying meanings. This could totally change how a CDI professional conducts the review process. As it stands right now, the Natural Language Processing systems are “hit or miss” for CDI professionals, according to Antonios.
Physician-facing Natural Language Processing could advance the CDI process even further. If the system made suggestions to the physician as they created and updated their records, it could limit the number of queries and speed up the CDI process. “I suspect that we’ve got three-to-four years to really see it mature,” Antonios said.
Although the advent of new technologies has many benefits, Antonios did acknowledge some potential drawbacks. Copy/past errors pose one of the biggest problems with electronic health record technology. The computer cannot tell what pieces of the record have been copy/pasted and therefore it can miss mistakes and opportunities for a query. It’s the “one thing that keeps tripping up all Natural Language technology,” Antonios admitted.
Sepsis detection presents another potential pitfall. Over the last month, Antonios’ facility tried to fine-tune the algorithm for sepsis detection. “We are still in the early stages of making sure that technology is as close to predictive prognostication such as a human being,” Antonios said. In some cases, the technology may have increased sepsis detection, but the mortality rates did not change.
CDI specialists “need to pay attention” over the next few years as Antonios foresees all facilities moving to completely electronic documentation. CDI staff need the skills to guide the physicians in optimizing their documentation. “I think of the CDI role now as a little bit of a hybrid to be similar to an informaticist’s role. [CDI specialists need to] become super users,” Antonios advised.
With all the new technologies, Antonios said that “no one in the hospital is better positioned to be at the elbow of physicians guiding them through best practices in documentation than a CDI.”
Editor’s Note: ACDIS Radio is a bi-weekly, free, webinar featuring ACDIS Director Brian Murphy with case study presentations and interviews with some of the CDI industry’s most cutting-edge practitioners. Tune in every other Wednesday at 11:30 a.m. ET. Register at https://acdis.org/acdis-radio. To review the remote CDI poll on the ACDIS website, click here. For more information on remote CDI, read this “Ask ACDIS” and this article. The February 2016 Quarterly Conference Call also featured a discussion of remote CDI, and this article offers some rational for remote positions.
Editor’s note: So we’re getting close to conference time! we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we caught up with Lara Faustino, RN, BSN, CCDS, a CDI s specialist at Boston Medical Center (BMC), who will present “A Visibly Invisible CDI Team.” She has 10 years of clinical experience in three large, academic medical centers in New England and extensive knowledge in both CDI and quality enterprises. During her career, Faustino developed best practice provider education for documentation, helped with her facility’s EMR transition, and developed training strategies and tools for the ICD-10 transition. Additionally, she was nominated by peers to the Massachusetts Regional Leadership Co-Chair status (2016) and served as the national 2015 BMC representative at the ACDIS national conference.
Q: How does your remote CDI position give you a unique perspective on the field as a whole?
A: I believe as technology advances, specifically the integration of the electronic health record (EHR) and tele health, I view a new angle on healthcare delivery (not just the field of CDI) as a whole. As the future state of virtual physical assessment evolves using iPads/iPhones from a remote setting, a successful CDI program will adapt to the same methods of communication to enhance the physician relationship.
Q: What are three things attendees can expect from your session?
A: Attendees can expect to learn about decisions that prompted the program to go remote; how to identify key strategies that support the success of a remote CDI Program; and the work/life balance.
Q: What one tool can CDI professionals not live without?
A: Specifically, from a remote CDI perspective, an excellent internet connection to an electronic health record!
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: My session will challenge CDI professionals to think outside the “walls” of a hospital setting – self-discipline, autonomy, and confidence and how to maintain harmony will all be discussed.
Q: What are you most looking forward to about this year’s conference?
A: Networking! I always enjoy learning from a variety of CDI professionals from across the nation and it always amazes me how very similar we are, or how vastly different we approach the same types of challenges.
Q: Fun question: Do you have pets and if so, what are their names?
A: I do! I have a dynamic duo of dogs that keep my days exciting (my office mates!). Their names are Max (Beagle) and Oliver (Golden Retriever), but we call them “Ham & Cheese!”
by Sue Egan, CPC, CCDS
Let’s face it, working with providers isn’t always a positive experience.
It can be tough providing them education or getting responses from queries. Busy providers typically don’t want anything to do with coding. When they hear anything about coding or documentation they often think it means more work on their part.
Luckily, I’ve had essentially a positive working relationship with my physicians over the years so coders and CDI professionals often ask: “What is your secret for getting along so well with doctors and engaging them to change behavior?”
Trust me, although it may be difficult, building a relationship with your providers can make both of your lives easier. Here are a few ideas that could help:
- Clarity supports both physician and facility reimbursement: Let physicians know that if the hospital is asking for documentation, it will better support their billed services as well. Complete and accurate documentation will hold up to increased scrutiny by payers.
- Demonstrate why: When you ask a physician to change the way he or she documents in the medical record, show them why that change matters. Show how accurate and complete documentation enables appropriate risk adjustments for the patients a physician treats. Remind physicians that good documentation can prove that the patients he or she treats really are sicker than others. This approach is more effective than stating the hospital will get a higher paid DRG.
- Pick your battles: Knowing when to step away will help you keep a positive relationship with a provider.
- Pick your timing: Regardless of how important your particular documentation improvement point may be, if the provider’s patient just passed away (or they’re having a bad day or any other difficulty), now is not the time to share—they won’t remember what you tell them. Let the provider know you recognize the situation and will reschedule a more appropriate time to discuss.
- Be available: That more appropriate time may not always be more appropriate for you but be as flexible as possible in your availability for one-on-one education. This could mean coming in early to meet with a physician before his or her first case in the morning or it could mean giving up a lunch period. Recognizing the physician’s workload demands and being flexible will yield many benefits to the relationship.
- Be prepared: Physicians will ask you a question once, maybe twice, where you can say, “I don’t know,” but chances are they won’t ask a third time. Be creative in your response. Instead, try saying, “You know, I just read something about that, let me go back and make sure I am giving you the most updated information,” or “I just saw something on this, I am not sure if it was CMS or carrier directed. Let me find it and get back with you.” Once you lose a physician’s trust, it is very difficult to regain it.
- Don’t waste their time: One of the biggest complaints relates to queries providers deem as a waste of time. Make sure the query is:
- Addressed to the right physician/provider
- Based on accurate information
- Relevant to the patient care being provided
- Walk in their shoes for a day: Offer to round with them. There you can provide real-time documentation advice and education to the provider. See how busy their days really are. In most cases, you will be amazed at how much they get done.
- Be a better listener: Providers often express frustration about coding and documentation guidelines which seem clinically incongruent or insignificant (e.g., family history for the 85-year-old patient). Sometimes a provider may just need to vent this frustration and you might just be the kind ear even if you may not have a resolution to offer. Listening and understanding go a long way in building rapport.
- Ask questions: Ask your provider how they translate a patient visit into medical record documentation. Questions that might solicit opportunities for improved documentation may include:
- What questions are they asking when interviewing the patient?
- What concerns do they have?
- What is the patient experiencing? Use this information to point out how the documented note can better demonstrate the patient’s current condition and treatment plan.
- Share the good as well as the bad: When a physician is doing a really great job documenting timely, accurately, and completely, give them a shout out. Or, when they answer queries in a timely manner that helps your CDI team, let them know. A quick note with a smiley face or even a gold star will be very much appreciated. Positive recognition given to one physician often results in other physicians inquiring how he or she can get recognition.
- Sports and (other interests): Engage physicians in discussions other than how they can help you or what additional elements may be needed in their documentation. Relationship building can be accelerated when you engage physicians in areas of personal interest. Gaining an understanding of a physician’s college coach, conference, and team standing, and discussing this information with a physician can go a long way to building a relationship. But sports aren’t the be-all, end-all. If you know a doctor has a particular interest (e.g., cooking, piano, horror movies, or painting), learning a little about that interest can go a long way. Expanding your knowledge is a good thing, and building your relationship with that provider is a great thing.
- Empathy: Remember physicians are busy with competing priorities. Providers often get interrupted while they are dictating and/or documenting their notes, and when they leave something out of their notes, it is not intentional.
One of our principal responsibilities is to make the physician’s job easier while ensuring that their data as accurate as possible.
Avoid approaches that make them feel like they have done something wrong. Let providers know your job is to make them look as though the care they provide is as good on paper as it is for their patients.
Editor’s Note: Egan is an associate director with Navigant Consulting and has been working with providers of all specialties for more than 25 years. This article originally appeared on Revenue Cycle Advisor. Opinions expressed are that of the author and do not represent HCPro or ACDIS. Contact her at email@example.com.
Editor’s Note: CDI professionals wishing to earn support from program administrators to attend the ACDIS 10th Annual Conference may adapt the following proposal.
To whom it may concern:
I would like to attend the ACDIS conference in Las Vegas, May 9-12, 2017.
Understanding the limitation of our CDI program professional development budget, I want to outline why attendance represents a worthy expense.
The acdis conference offers a diverse range of sessions on the latest trends and techniques to enhance not just my own professional skills, but will afford me education I can bring back to our facility to share with our entire CDI program. The 2017 conference features more than two full days of training and education and networking opportunities, with five concurrent tracks featuring a diverse range of topics including best practices for staff management, physician engagement, clinically focused chart reviews, and critical regulatory updates to improve every aspect of our CDI department.
Here is a link to the conference webpage, which includes the complete agenda.
ACDIS always offers pre-conference events that we may also want consider including a Risk Adjustment Documentation and Coding Boot Camp, another on Building a Best Practice CDI Team, and a third on The Physician Advisor Role in CDI.
The conference offers us an opportunity to meet and problem-solve with CDI experts. We can learn first-hand from the experiences of others which makes this an opportunity we cannot afford to miss.
Specifically, I want to attend the conference to get information or help with:
- <Fill in>
- <Fill in>
- <Fill in>
Here is an estimation of the cost to send me to the ACDIS Conference. The cost of conference includes the cost of some breakfasts and lunches:
Hotel: Three nights at $199*, for a total of $597 (hotels fill quickly so we should reserve as soon as possible).
*The hotel is charging a mandatory daily resort fee of $30 which includes access to the fitness center, Wi-Fi in the room, a daily newspaper, local and toll free numbered calls, and limited access to the business center including notary services and boarding pass printing.
Registration: $1,005 (early-bird discount is $905); ACDIS member $905 (early bird $805)
Airfare/travel is a cost I haven’t estimated.
I am requesting approval so we can take advantage of the early-bird registration rate of only $805 (if we’re ACDIS members) if we register before March 7, 2017. If we send the team, the fifth person registers for free (which we may wish to take advantage of).
If we are approved, we can further discuss which sessions might be best to attend to benefit our overall program. And, of course, we’ll meet after the conference to discuss significant takeaways, tips, and recommended actions to maximize our investment in our CDI program. I will also share relevant information with the team and other staff.
Thank you for considering this request. Again, if I get approval now, then we can save up to $200 on the registration, and keep our total investment to about $2,000. I look forward to your reply.
by Laurie L. Prescott, MSN, RN, CCDS, CDIP
CDI specialists depend on clinical indicators to support queries. Hospitals and physicians need clinical indicators to support the validity of documented diagnoses.
Clinical indicators include patient presentation, symptoms and complaints, lab and diagnostic studies, and ordered treatments such as medications, interventions, monitoring, and assessments. You can find clinical indicators in the documentation of nursing and ancillary staff. As part of our work with clinical validation, all CDI specialists and coders have to work with providers to ensure diagnoses are well supported within the record. It is not enough to obtain documentation of a diagnosis; we must ensure the record clearly supports its presence.
To concentrate on these issues, we have developed a new boot camp to help increase understanding of pathophysiological concepts. The Mastering Clinical Concepts in CDI Boot Camp is designed to assist in the process of clinical validity reviews by examining a number of diagnoses common to both CDI and audit challenges. The Boot Camp discusses diagnostic interpretations, signs and symptoms, and common treatments and covers interventions to strengthen students’ knowledge and competence in record review.
These concepts will assist CDI teams in identifying vague or missing diagnoses regarding neuro, respiratory, cardiac, gastric, liver, musculoskeletal, endocrine, and renal diseases among others and increase staff confidence in speaking to providers and working to ensure adequate documentation in the record. During class, we use real-life scenarios to drive discussions about challenging CDI reviews and help our students:
- Increase your understanding of key pathophysiological concepts
- Improve the quality of clinical indicators used when you query
- Cultivate critical thinking skills for use with data involving complex clinical concepts
- Improve your ability to distinguish evidence-based clinical indicators from other data in the record
I’m looking forward to teaching this new boot camp aimed at experienced CDI professionals looking to advance their careers with next step training. This course is also valuable for coding staff who wish to increase their clinical understanding of the records they review.
We look forward to seeing you in class!
Editor’s note: Prescott is the CDI education director for ACDIS/HCPro. She is a frequent speaker and author of The Clinical Documentation Improvement Specialist’s Complete Training Guide.
Q: If a patient is extubated post-operatively but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?
A: To determine if this represents acute respiratory failure, the values for impaired oxygen exchange can be used, along with the amount of oxygen being administered to the patient.
The ratio of arterial oxygen concentration to the fraction of inspired oxygen (P/F ratio) can be a helpful tool to identify respiratory failure criteria above for a patient receiving supplemental oxygen:
- The P/F ratio is an indicator of hypoxemia. This is a useful tool when a patient is on supplemental oxygen.
- The P/F ratio is provided on arterial blood gas (ABG) tests.
- A P/F ratio less than 300 suggests acute respiratory failure.
If an ABG test is not available, an estimated P/F ratio can be calculated:
- The calculation is pO2 divided by FIO2:
- The FIO2 is determined by the liters of oxygen the patient is receiving expressed as a decimal (e.g., 32% is .32).
An illustration of the calculation shows that if a patient is receiving 3L oxygen by nasal cannula, and has a pO2 of 40 mm Hg. That would be 40/.32, which results in 125 (acute respiratory failure). The P/F ratio is a useful tool to validate the presence of acute hypoxemic respiratory failure when patients are receiving supplemental oxygen. After following this formula, and acute respiratory failure is still in question, then a query to your physician is needed.
Editor’s note: This article was originally published in JustCoding. This question was answered by Robert Stein, MD, CCDS, associate director of the MS-DRG Assurance program for Enjoin. Join him for a webinar on this topic on March 21!
Editor Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we’ve reached out to William E. Haik, M.D., F.C.C.P., C.D.I.P., who has practiced medicine in Fort Walton Beach, Florida since 1980, and will be presenting “Sepsis: 1, 2, 3 – RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines.” He has received board certification in internal, pulmonary, and critical care medicine. Dr. Haik’s past professional accomplishments include: Chief of Internal Medicine, Director of Respiratory Care Services, Board of Trustees at his local hospital, President of the Okaloosa County Medical Society, and representative of the Government Liaison Committee for the American College of Chest Physicians. Dr. Haik’s coding background has included AHA’s Editorial Advisory Board and Expert Advisory Panel of Coding Clinic for ICD-9-CM as well as participation in the preparation of the original AHIMA CCS and CDIP examinations. He served on the original Board for ACDIS and aided in the preparation of the first certification examination. He currently serves as a final arbitrator for Medicare Part C MS-DRG modifications and as an expert consultant to the United States Department of Justice. He served on a multi-disciplinary committee which developed the 2010 and 2013 AHIMA Physician Query Practice Brief. Dr. Haik has conducted educational seminars and national teleconferences regarding physician involvement in DRG management, coding, and other related topics in association with HCFA (CMS), AHA, AHIMA, HCPro, and various state Quality Improvement Organizations. Since 1988, Dr. Haik has served as the Director of DRG Review, Inc., a physician directed hospital coding consultative service. The goal of DRG Review, Inc. is to educate medical and coding staffs in medical record documentation and coding compliance.
Q: As an MD, what do you bring to the CDI table that others don’t?
A: I think I bring a practical knowledge, a working clinical practice perspective. I have some coding knowledge as well, so I can merge the two.
Q: What are three things attendees can expect from your session?
A: Complete boredom! Just kidding! In all seriousness, attendees can expect to:
- Understand the clinical definition and coding nuances of acute and chronic respiratory failure;
- Understand the evolution of the definition of sepsis; and
- Understand how to apply the three different sepsis consensus statements and how, by understanding those, one can defend an adverse clinical documentation position from a RAC
Q: What is one tool CDI professionals cannot live without?
A: In my opinion, a CDI professional should have a few things in their toolkit. First, they should have a clinical background, a working knowledge of the coding clinics for ICD-10, a reference tool that answers certain clinical guide and their coding correlation.
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: We do arm wrestling during my talk! Just kidding. In reality, I’m trying to get them to think inside the box! I want to get everyone to think clinically as a physician would.
Q: What are you most looking forward to about this year’s conference?
A: It is in Las Vegas, need I say more? Seriously, though, I’m looking forward to hearing some presentations on quality – HCCs, VBP – such as that. I’m really looking forward to expanding my knowledge.
Q: Fun question: do you have any pets?
A: Her name is Mary-Kate – she’s my wife. Just kidding. Actually, I don’t have any pets right now. I have had three dogs, though. They were named Bitey, Gus, and Tucker.
ACDIS surveyed more than 400 CDI professionals about their facility productivity expectations and published a white paper on the topic in the fall. Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM, director of clinical documentation excellence for Wake Forest Baptist Health in Winston-Salem, North Carolina, and Judy Schade, RN, MSN, CCM, CCDS, clinical documentation specialist for Mayo Clinic Hospital, discussed their experiences, illustrating the same basic findings as paper during the December 28, 2016, episode of ACDIS Radio.
At Wake Forest Baptist Health, CDI review at least 90% of their total daily admissions, Hicks said. At Mayo Clinic, they aim for 100% of all Medicare admissions, Schade said. Both facilities also monitor other aspects of the CDI process, such as query response rates and query agree rates, but there are no set expectations because those numbers vary drastically on a day-to-day, case-by-case basis.
As far as the chart review expectations, Hicks and Schade also had slightly different answers. According to Schade, CDI specialists should review between eight and 10 new reviews per day. After that point, CDI specialists should complete re-reviews every two-to-three days depending on the original review. Hicks expects a total review number between 20 and 25 cases, with five to 10 of those being new reviews. Although Hicks set out more stringent total review expectations, Hicks and Schade agreed that a max of 10 new reviews was a reasonable expectation. According to the white paper study, the average for total reviews is between 16 and 20 per day, in line with Hicks’ and Schade’s comments.
As CDI expectations evolve, CDI programs may have many competing initiatives. The new white paper attempts to “identify a lot of variables” regarding what affects staff productivity rather than provide strict expectations regarding national averages, said Schade.
Nevertheless, some common themes exist. “One major variable is whether the medical record is paper or electronic. Paper charts mean CDI staff have to incorporate travel time to the nursing units into their productivity, while the electronic medical record enable the CDI staff to stay at their desk,” Hicks said.
The goal and focus of the review represents another big variable. “If staff are only looking for CCs and MCCs, they can probably review more records than, say, a CDI specialist who’s reviewing for MS-DRG assignment, hospital-acquired conditions, patient safety indicators, and severity of illness/risk of mortality. That’s going to take them longer,” Hicks said.
Experience and skillset also play a huge determining factor in overall productivity, according to Schade. “ICD-10 presented many, many challenges with diagnoses and procedure codes, so specializing has assisted in accurate and complete document coding and also providing a resource to coding,” Schade explained with regards to the Mayo Clinic’s model. According to the white paper, experience level was the largest variable (54%) to CDI productivity.
Hicks also indicated that other responsibilities influence a CDI specialist’s productivity. Technology, however, has also made it possible for CDI specialists to review files quicker and more efficiently than before. At Mayo Clinic, they combat the effect of other responsibilities by “performing 100% of reconciliation—that’s after coding and before billing—on all the records that were reviewed concurrently,” Schade said. This brings about a “complete and accurate view of the patient” at the end of the day.
With outpatient CDI—a relatively new area—Wake Forest is only reviewing the “raw number of cases reviewed,” Hicks said. Additionally, at the current stage, the process is very manual. Wake Forest hopes to develop technology to both improve efficiency and track the success of the program. Mayo Clinic is in the early stages of developing an outpatient CDI program as well, Schade said. She recommended that other facilities looking to incorporate outpatient CDI programs do some research on the ACDIS website, as that has helped Mayo get things started.
When it comes to CDI productivity standards, “there are so many variables that impact each individual CDI program and that was really reflected in the survey results [in the white paper],” Schade said.