April 2015

CDI Makes Its Mark
By Susan Chapman
For The Record
Vol. 27 No. 4 P. 10

Successful clinical documentation improvement initiatives reverberate from one end of the hospital to the other.

The goal of a clinical documentation improvement (CDI) program is typically straightforward: to ensure data accuracy. Achieving that objective leads to better care, greater patient safety, and accurate reimbursement. Indeed, as CDI programs garner data integrity, the benefits can be seen throughout the organization.

Core Measures
In larger health care facilities, CDI specialists are not responsible for addressing core measures, the overall quality standards that the Centers for Medicare & Medicaid Services and other accrediting bodies require hospitals to meet in order to receive reimbursement for care. "In our health care system, we have dedicated teams of nurses who address those quality measures," says Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of regional clinical documentation and coding integrity at Sutter Health West Bay. "Our CDI team and the quality group work together when necessary. For example, there is a core measure for congestive heart failure [CHF]. A core measure nurse may contact us when the record for a CHF patient is not clear.

For instance, a person who misses dialysis can retain fluid and then be placed into the CHF core measure bucket when, in fact, that may not be the case. In such a situation, we would give the physicians choices to help us create the most accurate record and assist the quality team at the same time."

Dianne Haas, PhD, RN, executive director of consulting services at TrustHCS, says CDI programs can help meet core measure objectives. "There are a lot of hospitals that utilize their CDI staff to help ensure their core measures are reflected accurately. There are also hospitals that include core measures in queries just to remind the doctors to include them in the record," Haas says, adding that CDI specialists will alert the quality team if they view patient records first.

Lynn Salois, RHIT, CCS, CDIP, director of coding at Medical Records Associates, says CDI specialists work closely with the quality team in acute myocardial infarction (MI) cases. "As a CDI person, I know that acute MI is a core measure," Salois says. "With MI, one of the things you're looking for is aspirin at discharge, which is part of the core measure. If the documentation does not have that, then the CDI specialist should ask why that is the case. It requires a little bit of detective work and documentation. A lot of this goes hand in hand with what the CDI team is already doing. If the staffing level supports their taking it to the next level, then it's a perfect fit."

Larger organizations may not have the bandwidth necessary for the CDI team to work on core measures, notes Cheryl Manchenton, a senior inpatient consultant and project manager at 3M. "However, I do feel that in any institution, CDI programs are uniquely qualified to provide flags for the core measure teams," Manchenton says.

Data Abstraction
While it's appropriate for CDI specialists to capture information for core measures, Salois believes having them also abstract data adds too much to their workloads. Evans concurs: "A person has to go into an in-depth analysis of a chart and enter it into a database. Abstracting for core measures takes an awful lot of time to do well, and CDI takes an awful lot of time, and you can't do both at the same time," he says. "Perhaps it is possible if the CDI reviews are limited, such as a person performing CDI reviews at a very small facility. Otherwise, it's not possible."

Michael Hite, managing director of revenue cycle solutions for The Advisory Board Company, believes sometimes it's a numbers game. "I've worked for a number of different companies and organizations. As margins shrink and hospitals work to maximize their capacity, to minimize overhead and reduce costs, frequently multiple people end up wearing multiple hats," he says.

Still, that shouldn't be a reason to spread staff too thin, Hite says. "The value of CDI is that those nurses are on the floor with the physicians, helping to manage the care of the patient while ensuring documentation is thorough and detailed," he says. "There is a lot of advantage to what a CDI person can do to benefit the hospital. For instance, I knew my CDI staff generated revenue for me. I wanted them to be on the floor doing what they were meant to do. So, in my opinion, CDI staff should not abstract quality data because it reduces the available time they have during their day to do what their primary role is: ensuring accurate representation of the episode of patient care."

Haas and Janice Amon, MD, CCDS, CCS, a CDI consultant at TrustHCS, agree that organization and staff size are key factors in determining whether CDI specialists become involved in abstracting data. "If you're a smaller hospital, it's not uncommon to have CDI staff do multiple tasks," Haas notes. "In a well-run shop, you want to let people have their specific functions and not comingle multiple tasks and functions into the role of one individual."

"It depends on the facility and on what the facility wants the CDI staff to be responsible for," Amon adds. "Smaller facilities need CDI staff to do everything for the hospital. In most facilities nationwide, they have a focused CDI program that does concurrent reviews without other responsibilities. But in other CDI programs, if the HIM director doesn't have anyone else to ascribe data abstraction to, then they assign it to the CDI specialists."

At a previous employer, Hite says there was such a huge demand for abstracted data that the task fell on the shoulders of the quality department, not within CDI. No matter who is responsible, he says communication must take place throughout the entire hospital on a regular basis. For example, it's a good idea to share the information gathered from CDI programs with other departments. However, Haas says a lack of interoperability can curtail the best intentions. "Many organizations don't have a CDI software program that works well with their encoder software," she says. "Lack of standardization creates problems across the board. There is no one product in health care that does everything and meets the work requirements of all roles in a hospital, and any glitch in the system can hamper the entire process."

Amon believes it would be easier for CDI professionals and the organization as a whole to share data if they were able to input and access information from one program. However, because hospitals often work on several platforms, it's too time consuming and costly for CDI specialists to take on tasks such as data abstraction.

Meeting Quality Control Standards
Compliance with AHIMA guidelines must be a priority, Evans says. "CDI teams should be subjected to such activities as peer reviews and file checks throughout the entire process until final coding," he says. "That would ensure that we are using the proper coding guidelines and asking the right questions of the physicians. We are setting the table for the coders so that they don't have additional questions for the physicians. Coders and CDI need to have a congruent practice. Ideally, you'd have a neutral third party audit to ensure the CDI practice is compliant with industry standards."

Hite says CDI and hospital leaders must address the following questions:

• Should the program focus on a single payer or cover all payers?

• How many charts per day can each specialist review?

• How many queries per day does the CDI department generate?

• What is the query response rate from physicians?

"We have to close that query loop," Hite says. "How often does a physician answer your question? You should also be tracking that response rate so that leadership can identify trends. For instance, if CDI repeatedly queries a physician, but leadership does not hold physicians accountable for responding, then that can lead to poor performance from the CDI team."

Hite recommends organizations determine a strategy for monitoring its CDI initiative. "Hospitals should be asking, 'Does CDI as a program report to the board, CFO, and physicians' medical executive committee? Is there transparency in their reporting, and how are they tracking and trending performance?'" he says.

A Full CDI Plate
Depending on the organization's size and complexity, Evans believes CDI staff can be victims of piling on. "At most hospitals, for CDI specialists, it's really hard to do anything more than CDI," he says. "In that instance, I would then say there is too much on the CDI staff's plates because of all the growing responsibilities that follow. Not only is there quality documentation and the work a person can get done with a patient still in the facility but there is also ICD-10 that we need to prepare for."

Manchenton says whether a CDI specialist's workload is too demanding depends largely on job performance and training. "Our expectation is that CDI is the only thing we do," she explains. "However, CDI specialists review, query, pursue the response, and then input the data into a software tool. Some facilities have CDI staff also handle physician education."

Like Evans, Manchenton believes adding ICD-10 into the mix will create greater demands on CDI specialists. "I also think there is a large amount of fear that CDI may not be well supported, based on ICD-10," Manchenton says. "That fear is not fully warranted, but we can't estimate ICD-10's impact until it is actually implemented."

With ICD-10 in the offing, Manchenton recommends facilities take stock of the workloads of CDI specialists. "Once ICD-10 impacts, then I would slice that workload down by one-third to ensure data integrity and accuracy. That takes some knowledge of quality guidelines and metrics," she says.

Haas says hospitals typically bank on the efforts of their best staff. "It's an age-old problem in hospitals: Administration looks to people who they know can get things done," she says. "Most CDI specialists are capable, competent people who don't always know how to say 'no.' That said, to get the biggest bang for your buck from a CDI specialist, you have to first be sure that they are adequately trained, have the tools that they need to maximize their work effort, and have medical and administrative leadership support, and then let them do their jobs. They have to work closely with the medical staff. Doctors don't want to feel that they are getting short shrift. Ideally, CDI specialists should be protected from having too great of a workload so that they can do their primary jobs."

Keep Learning
There are several ways for CDI staff to keep abreast of industry changes and expand their knowledge bases. Professional organizations, including AHIMA and the Association of Clinical Documentation Improvement Specialists (ACDIS), and hospitals themselves afford CDI specialists education opportunities. "There are a variety of ways CDI specialists can stay current," Manchenton says. "For a lot of CDI specialists, if there is a vendor that they're contracted with, they get vendor updates. There are also coding clinics. Some do their own research, using Google."

Amon says CDI teams should stay apprised of coding guidelines, attend coding seminars, and hold monthly staff meetings to discuss specific cases.

Manchenton advises professionals to be wary of online communities—but not totally ignore them either. "The least optimal way [to stay on top of the industry] has to be message boards and blogs," she says. "The advantage to those vehicles is that there are quick answers in a language CDI specialists understand. The disadvantage, of course, is accuracy. You don't know the person on the other end. Blogs are good just to know what information is out there but not good for creating policy and procedures, which is why webinars and seminars provided by organizations like ACDIS and reputable vendors are better overall.

"I would advise CDI specialists to educate themselves as much as possible, all the time," she adds. "Always research and educate yourself on disease processes. Ask when you don't understand. Be a constant learner. Don't let your program get stagnant."

Keys to Success
Evans believes organizations should be open to third-party audits. Additionally, if a CDI department consists primarily of registered nurses (RNs), it may want to add a coder to the staff. "That person could be the liaison who could teach RNs what to look for on the floor," Evans says. "Coders would be happy to work in a CDI program. A lot of nurses have a lot of questions about coding all the time and don't know where to go to get the answers."

Hite says executive-level and physician support can make or break a CDI program. "Physician leadership needs to support CDI," he says. "They can change the false perception that CDI is a burden and help other physicians realize the CDI team is there to help the patient, the physician, and the organization. The highest-performing organizations see CDI as part of the care team, not an obstacle. Organizations need to get to that level to realize the full potential of the CDI program."

"Everyone has to understand what the CDI team is doing—why you're doing it," Haas says. "For that level of communication to exist, you need support from the C-suite. And it's an ongoing process that needs cooperation, infrastructure, monitoring of results, and feedback so that you can course-correct when necessary."

Amon says physicians must take CDI queries seriously and provide accurate answers. Additionally, coders must be cooperative and supportive of CDI's needs. Manchenton mentions that program managers must hold CDI specialists accountable for their performance and reevaluate their roles on a regular basis.

"A great deal has been done over the last couple of years for hospitals to rework their CDI programs, particularly with ICD-10," Salois says. "It's more than just ensuring reimbursement. We have to be certain that hospitals capture the data accurately for quality patient care. If we capture the data accurately, we can improve patient care and assist with research to benefit patients in the years ahead."

— Susan Chapman is a Los Angeles-based writer.