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A Physician to Lean On

By Jon Elion, MD, FACC

The clinical documentation specialist looked a little tentative stepping up to the microphone to ask her question. I had just finished a talk where I shared stories about clinical documentation improvement (CDI) from the point of view of a practicing physician. As her question unfolded, the reason for her hesitancy became clear.

“The medical director of our surgical ICU says we should document and code for malnutrition for our open-heart surgery patients, since we give them intravenous albumin postoperatively. He said that treatments are used to treat something. Since albumin treats malnutrition, he says we need to document and code for that. We are not comfortable with this—what should we do?”

I paused briefly before answering, as several medical issues were swirling through my head, such as the following:

• Albumin may be used after open-heart surgery as a “volume expander,” and to help regulate plasma volume and tissue fluid balance. But it is expensive and is not generally felt to be first-line therapy.
• Patients who are sedated and on a respirator are often given nutritional support, but giving nutrition does not constitute a diagnosis of malnutrition.
• Even if the patients described in question had malnutrition, intravenous albumin is not an appropriate therapy.

But, rather than go into a lecture about postoperative care of fluid and electrolyte shifts following cardiopulmonary bypass (that’s a mouthful!), I smiled and said, “You don’t have a physician advisor for your CDI program, do you?” She looked a bit surprised at my apparent clairvoyance, then sheepishly admitted they in fact did not have such a resource available to them at her hospital.

This scenario has played out repeatedly in the question-and-answer time of my talks. So far, 100% of the time when I counter with my question about the physician advisor, the answer has been “No.”

Why all the mystery behind the role of a CDI physician advisor, and what one may do for your program? One of the best answers to these questions is contained inside HCPRO’s CDI Strategies for February 3, 2011, where several potential responsibilities for a CDI physician advisor are described, including the following:

• continuing medical staff education;
• supporting CDI efforts among the medical staff;
• assisting with finalizing/closing queries by contacting the physician and discussing the case;
• providing second-level review of problematic cases; and
• serving as clinical advisor to the CDI specialists and coders.

What makes for a good CDI physician advisor? In their excellent monograph The Physician Advisor’s Guide to Clinical Documentation Improvement, authors Trey La Charité, MD, and James Kennedy, MD, CCS, CDIP, define some of the characteristics of the physician serving in this role, including the following:

• credibility with the medical staff;
• leadership experience;
• active clinical practice;
• credibility with hospital administration; and
• generic insight about clinical documentation and regulatory oversight.

By enlisting a physician advisor to serve as a resource and champion for your program, you’ll have that credible intermediary between your CDI team and the medical staff. You’ll be able to get answers to your questions, and all levels of your facility will have greater insight into the role that CDI plays. And, if I ever counter one of your questions by asking if you have a physician advisor for your CDI program, you can proudly announce, “Yes, we do!” But then again, if you did, why would you be asking me?

— Jonathan Elion, MD, FACC, is a practicing board-certified cardiologist in Providence, Rhode Island, and an associate professor of medicine at Brown University. He is founder of ChartWise Medical Systems, a Rhode Island–based company that recently introduced ChartWise 2.0.