Q: I am new to the CDI role and looking for suggestions as to how to work with the surgeons to help them beef up their documentation?
A: I smiled when I read your question, this challenge is not particular with you. Surgeons offer us a number of challenges. One of the reasons is that surgeons are reimbursed differently than other providers. When the primary care physician rounds on inpatient acute care patients they document their notes to assist with their E&M (evaluation and management) charges in mind. Depending on the extent of their assessment, the patient’s condition, and the amount of time the physician spends with their patient, the physician can submit a bill for the visit based on four levels. They will submit charges for every time they round on the patient.
When CDI professionals work with the primary care providers to improve their documentation it often can have a direct impact on their E&M levels as well. When we talk about how their documentation improvement efforts support their own billing as well as the hospital’s they can be more open to CDI efforts.
Surgeons are reimbursed differently. For example a surgeon performs a total hip replacement. He will be reimbursed one global fee which covers the pre-operative, peri-operative and post-operative care. Their documentation within the post-operative period does not directly affect their payment. They don’t have a tangible motivation to write a thorough post-operative note.
Now, I don’t want to put all surgeons in this category, as I have met many that offer excellent documentation starting with the pre-op history and physical. When I find a surgeon who documents well I will hold them up as a top performer and use examples from his documentation for others to see. Sometimes, a little peer pressure works wonders.
Another more tangible motivator, is to discuss severity of illness/risk of mortality (SOI/ROM). These measures are determined based on their documentation. Then discuss quality ratings and how patients, organizations, and even commercial payer contracts with providers are based on quality measures pulled from SOI/ROM data.
No surgeon wants bad ratings for everyone to view on the internet. Explain that your efforts as a CDI not only will improve reimbursement for the organization (which consequently buys new operating room equipment and pays for qualified staff to care for his patients) but also can effectively assist in increasing the SOI/ROM of his patients. So if his patients develop complications or die due to underlying comorbidities their level of SOI will demonstrate a patient who was at risk for such complications. There is much information on physician quality ratings on the internet to assist you in these discussions.
One of the most convincing reasons for establishing a concurrent documentation review program is the ability to discuss a patient’s record while the details of the patient’s case are still fresh in the physicians’ mind. Such interactions are as important for resolution of the medical record documentation as it is for providing ongoing education for the physician. Not surprisingly then, many experts encourage facilities to maximize opportunities for verbal interactions between the CDI team and the physician staff, whether it is on the patient care unit or through meetings in the physician lounge. To do so, however, CDI specialists need to exhibit a unique set of interpersonal skills. the CDI specialist must be both positive and professional in his or her interactions with physicians but they must also be able to interpret the physician’s body language at the time of the discussion and be able to weigh and recall a particular physician’s communication preferences over time. Such skills may be summarized by the colloquialism “know your audience.”
For example, Dr. Smith may respond well to e-mail communication but become visibly uncomfortable, aggressive, or reclusive when approached on the floor of a nursing unit. Conversely, Dr. Adams consistently ignores written queries left in the medical record and does not return phone calls. Approach him during his routine rounds, however, and he will answer multiple CDI questions happily.
Beyond understanding the physician’s preference for type of communication, the CDI specialist must also be aware of the personality type of the physician. A process-orientated physician, for example, may respond positively to a CDI specialist who explains how his or her documentation in the medical record translates through the HIM department, billing, and, ultimately, reimbursement and quality data reporting. A results-orientated physician, however, would see such discussions as a waste of time, preferring to understand how the process will affect him or her directly, instead. The ability of the CDI staff member to not only be aware of these different dynamics, but also to adjust their queries and education accordingly can appease wary physicians and earn physician support for the CDI program overall.
Q: I have heard that we should use materials from the physician’s world support our queries, such as publications from the American Medical Association. I tried searching for documentation tips related to medical necessity but was not able to find anything relevant. Do you have any suggestions about where I should start?
A: Physicians tend to “listen” or respect such definitions if they come from medical literature/research than if we describe definitions based on AHA Coding Clinic for ICD-9-CM or the Official Guidelines for Coding and Reporting.
Let’s say your CDI program wants to develop guidelines, standard definitions, for what constitutes acute and chronic respiratory failure. The CDI staff members will look to these definitions to determine whether a query is warranted, include them on physician educational tools such as newsletters or posters, and cite them as references on related query forms. Examples of good resources are the National Kidney Foundation, American Heart Association, and American College of Cardiologists. When I search for specific diagnostic guidelines, I like to pull examples from physician professional journals such as The Journal of the American Medical Association (JAMA).
When you cite these journals it lends you and your team a bit more credibility. So when the physician asks why you have initiated a query for a particular diagnosis you can show him/her where you obtained your information and demonstrate that it came from a clinical source. Including a copy of the article with any additional follow up conversations or education is another way to reinforce that you (and your CDI team) have done your research and the guidelines (both diagnostic and expected treatment) are based on evidence in medicine.
While such literature represents a good starting place, increasingly best practice is for CDI professionals to work with coders, physicians, and other non-physician clinical providers to develop a consensus definition for commonly queried diagnoses. So, for example, you might research clinical indicators for acute and chronic respiratory failure and cite the sources you find. Then you could review these with the coding team to assess the related coding definitions. Then bring all this information to bear, working with your pulmonologists on staff using their professional associations or publications to define the terms in question. [more]
There are only so many hours in a day. And only so many minutes to explain the complicated process of coding and reimbursement to a less than eager room full of physicians. In an hour-long session, Bryan P. Hull, MD, site lead for ICD-10 enterprise project and assistant professor of medicine at Mayo Clinic Hospital in Phoenix found he spent 30 minutes or more talking about the definition and purpose of the DRG system—over and over again.
“I knew there had to be a better way to do this,” says Hull.
Hull began researching online tools for video creation and came upon VideoScribe which essentially animates PowerPoint presentations making it seem as though someone has been videotaped hand drawing the presentation.
With a solution in hand, he just needed a story-line for his presentation and support from his CDI teammates, which he readily received.
“Some people stay up late at night thinking about the meaning of life,” Hull states at the outset of the five minute video, as an artist’s hand quickly sketches a cartoon image of a Greek philosopher. “Other people think about the possibility of life on other planets,” he adds as the artist colors an alien head in a thought bubble. “But in care management, other things keep us up at night; things like clinical documentation improvement.”
The video goes on to describe the role of documentation in quality reporting and the role of the CDI specialist in helping physicians capture that documentation. Hull provides two case examples of patients with pneumonia and walks through the different conditions, demonstrating how variables such as home oxygen, COPD, and other conditions affect the patient’s severity of illness, length of stay, and the DRG assignment.
Now, Hull goes to the meetings, runs the video, and makes himself available to support the CDI team members. “We start the video and the physicians recognize my voice and laugh,” he says. “They really get a chuckle out of it. It opens the door to the CDI team to take over the presentation and drill down into more detailed documentation improvement initiatives.”
Mayo has played the video at all its Phoenix divisions and even at the enterprise-wide CDI conference held in the fall. Now, Hull envisions adding other videos focusing on DRGs 177, 178, 179, and turning them into a collection.
“We’ve gotten a lot of feedback from the providers regarding the videos. We can measure the difference, the improvement in the documentation overall. While that may not be due specifically to the video we know that our training matters.”
Historically, healthcare organizations have been operating under the belief that when it comes to communicating with physicians, more is better. The tendency is to “cover the bases” and make sure they are sent details on everything, just in case. This is not effective. More is simply more. At high-performance institutions, teams carefully scrutinize the message and the target audience. This discipline demonstrates respect for the physician’s time, knowledge of their professional specialization, and an understanding of their needs.
Often the number of department within an organization sending messages to practices confounds the “relevance” challenge… A useful first step is to audit the current volume of outbound messages, the relevance for the practice, the timing and overlap… Next, find out what doctors need to know. Too often, physicians are not asked what they want or need to know; instead messages are “pushed out” with little regard for the physician’s needs.
Editor’s Note: This excerpt was adapted from The Complete Guide to Physician Relationships: Strategies for the Accountable Care Era, by Kriss Barlow, RN, MBA.
by Melinda Tully, MSN, CCDS
For providers, the days of earning full Medicare payment by simply submitting complete and accurate information are drawing to a close. In 2013, Medicare will begin paying healthcare providers and facilities based on the quality of care provided, not just the quantity of services.
Then, starting in 2014, base payments will depend on the outcomes of the care documented.
So how do we shape up before we face even bigger federal cuts? Simple. Clinical Documentation Improvement. CDI. It’s an acronym that everyone in the healthcare industry should become familiar with.
I sometimes like to think of CDI as investigative reporting for healthcare. CDI helps make sure the patient record is telling the true clinical patient story, including what care the physician provided and why, to ensure the record is coded and billed appropriately. For healthcare facilities and physician practices to thrive through these changes they need to understand the value of CDI and its direct impact on both patients and physicians.
Patients a Priority
Regardless of the rule or regulation, physicians will not change what they do until they see what’s in it for patients. While it’s easy to see how better clinical documentation can help patients, it’s hard to make that a reality in a typical healthcare setting where clinicians are juggling tight schedules and hectic patient workloads.
The most successful CDI programs work with clinicians to enhance the core training they learned in medical school, teaching them how to document a patient’s true clinical story during their workflow to best represent the complexity of a patient’s case and decisions made along the way. This helps keep patients safe, improves communication between clinicians and protects providers from lost revenue.
Quality scores are becoming more transparent to the public every day and high mortality rates and medical errors make headlines. While many CDI programs are led by finance departments, clinical documentation is not an issue reserved for HIM departments. Clinical leaders from many areas including chief medical officers and quality officers need to be involved in CDI to keep the patient’s best interests in mind.
For the last several years I have worked with physician leaders at a large academic medical center to identify and implement CDI efforts focused on improving quality. These efforts have transformed the organization’s performance metrics, improving mortality indexes so they more accurately reflect the severity of illness of their patient population. These quality indicators are important because decisions are made based on these types of quality metrics – whether it’s by patients seeking treatments or payers evaluating providers. The best part about this customer’s success is they have improved their documentation and now their clinical information is so good that when physicians look ahead to pay-for- performance, Accountable Care Organization implementation and bundled payments, they know they are in good shape for the future. [more]