November 5, 2012

The Emergence of the Physician Advisor
By Susan Chapman
For The Record
Vol. 24 No. 20 P. 14

Renewed emphasis on clinical documentation improvement has led some healthcare organizations to enlist doctors as counselors to their note-taking brethren.

As part of the increasing emphasis on clean, crisp patient charts, a familiar position has changed its stripes to help the cause. To boost the specificity of medical records, some healthcare organizations are using physician advisors as liaisons between physicians and clinical documentation improvement (CDI) staff.

In the past, physician advisors were generally employed as consultants to health plans, helping organizations determine the medical necessity of procedures, tests, and hospital stays. Now, they’re entering the realm of hospitals as healthcare facilities increasingly look for innovative ways to ensure compliance, accurate reimbursement, and quality patient care.

New Responsibilities
According to Wanda Cidor, director of clinical services with HIM vendor Precyse, not only are physician advisors serving as liaisons between the medical staff and the CDI team, they also are providing peer education in the form of large lectures, PowerPoint presentations, and one-on-one advising. In addition, they deliver real-time feedback and in-depth analysis of a physician’s performance as it relates to CDI by creating documentation report cards. In the role of educator, physician advisors often orient new physicians and staff so they have a clear understanding of the facility’s systems and requirements.

As a physician advisor for CDI at the University of Tennessee Medical Center, Trey La Charité, MD, has tackled several assignments. “I solicit participation from the medical staff and educate them on why compliance is valuable and how current coding methods differ from what they learned in medical school,” he says. “While I do instruct my fellow physicians individually, group education seems to work better and is overall more beneficial.”

Digging deeper into the reimbursement process is another possibility. “Query reviews and closeouts are other important functions for physician advisors,” Cidor says. “When there is a [recovery audit contractor] denial related to the DRG [diagnosis-related group], a physician advisor can assist with and draft the appeals.”

Cidor notes that physician advisors are critical to developing standardized queries and ensuring they are followed until their conclusion.

Because doctors focus more on patient care than documentation, another set of eyes on the chart can only help, La Charité says. “It’s important then that charts be reviewed, most often beginning with DRG payers,” he says. “Then when necessary, the CDI team sends charts to the physician advisor to assist with queries. But we have to be discriminating about what we approach physicians about.”

Position Requirements
According to Kingsley Ediae-holly, MBA, RHIA, a senior HIM consultant at Care Communications, CDI programs have become increasingly complex. “Therefore, physician advisors need to have soft skills,” he says. “While they don’t need to understand the entire process, they should have a solid understanding of how coding works.”

“And the individual must be clinically respected by his or her peers,” adds La Charité, citing that generally physician advisors are physicians themselves. “It’s important that the person continue to practice medicine and do so well. He or she must be able to communicate and educate well, have patience, and be diplomatic.”

Ediae-holly agrees: “Being diplomatic is key, particularly with physicians. If their role is to strengthen relationships between physicians and coders, physician advisors have to help their peers understand that while patient care is paramount, documentation is also important.”

Cidor offers a similar list of desirable attributes, further explaining that a good physician advisor should be board certified and licensed. “While it’s usually ideal if that physician is still practicing, sometimes a highly respected retired physician can also serve in that role,” she says.

All three experts believe it’s beneficial if the physician advisor is well known, influential, and respected. “Respect helps with credibility,” Cidor says. “If I’m a physician who doesn’t document well, an influential physician advisor can help with education and behavior correction so that the physician understands that good documentation can ensure continuity of patient care.”

Cidor adds that a physician advisor must be a strong collaborator who can draw on a solid peer network. “It’s also critical that the person be highly committed to the success of the organization and to the quality of patient care it delivers,” she notes.

Making the Case
Cidor, who has been involved with CDI since the mid-1990s, believes it is much easier now to convince hospital administrators of the need for physician advisors than it was just five years ago. “But the role must be clearly defined to show we’re not wasting a physician’s time,” she says. “We have to build a strong business case, centered around quality of care, severity of illness, risk of mortality, and reimbursement. We want our organization to have high quality scores, which reflect well on medical staff and the facility overall, and we want a well-informed physician advisor to lead that charge.”

La Charité says sometimes the need to employ a physician advisor presents itself. “If your [CDI] program is floundering, for example, make a pitch for a physician advisor,” he says. “There is a high return for a low investment. There is definitely a need for someone who is respected by the community to serve as the face of the program. It’s a lot harder for a physician to ignore another physician than it is for that doctor to ignore a nurse or a member of the CDI team.”

According to Ediae-holly, not every hospital requires that a person be solely dedicated to the physician advisor role. “It really depends on setting and hospital size,” he says. “The physician advisor can be the [chief medical officer] or even part time.”

That said, Ediae-holly adds, if a physician advisor is needed, the administration must know that it’s important not only for revenue but also for quality patient care. “Sometimes administrators don’t see that the quality of patient care benefits the hospital as much as reimbursement,” he says. “Good quality positively affects marketing, which brings more patients through the hospital doors.”

The Benefits
Physician advisors can strengthen collaboration between a CDI team and physicians, which brings greater accuracy and increased query response times. And while accurate coding helps facilitate proper reimbursement, many experts concur that the greatest benefit of having a physician advisor on staff is its effect on the quality of patient care.

“Physicians ultimately control documentation, which drives the hospital’s economy,” Ediae-holly says. “There is high demand for specific documents that allow coders to code to the highest level of specificity. This helps with quality patient care. We can have continuum of care with proper documentation. It’s not just about the revenue cycle. When a patient is transferred to another facility, perhaps convalescent care, for instance, then those physicians can look at the record and know what the best course of action is moving forward.”

Kathy Johnson, RHIA, vice president of coding services for Care Communications, says physicians are in control of their patients’ records and consider them to be extensions of the care they provide. She views physician advisors as being able to help CDI teams understand this dynamic and also enable physicians to realize that proper documentation helps attain the same goal they’ve always had for their patients: the best care possible.

How to Make It Work
To make the physician advisor role meaningful at any facility, Cidor believes there must be a well-structured CDI program in place. “There also needs to be a well-defined role for the physician advisor, a very strong education program, and robust technology to support CDI,” she adds.

Ediae-holly offers an organizational configuration that he believes best illustrates how a physician advisor can help an organization succeed. “I think it should be operated out of health information management,” he says. “There is the CEO, to whom the CFO [chief financial officer] reports. The HIM director reports to that CFO but has a dotted line to the CMO [chief medical officer]. The coding operations manager reports to the HIM director, and all CDI staff report to that manager.”

Some facilities do not have the CMO in the role of physician advisor, Ediae-holly says. Instead, they rely on the work of more than one physician advisor in a more informal arrangement. Generally, these individuals make fellow physicians aware that they are available if they have CDI questions.

Ediae-holly believes it’s possible for a CMO to carve out the time necessary to be an effective physician advisor. “This is the best approach,” he says, “based on my experience.”

From a physician’s perspective, La Charité notes that the advisor role adds to the list of tasks on an already busy schedule. “Initially, I received a stipend [for the additional responsibility] when I took this position,” he says. “Hospitals will not give you ‘protected time’ until you produce results.”

La Charité says there are several ways to measure results to bolster the case that a physician advisor needs to have dedicated time to meet his or her responsibilities. “We need to look at the case mix index, the CC [complication/comorbidity] and MCC [major CC] capture rates, and the risk of mortality and severity of illness scores,” he says. “If we’re making an impact, we should see an increase in that measure of how sick patients are in the facility. When we review the charts that have secondary diagnoses documented, we want to note the chances that a patient will die in the facility but that the patient was able to go home well. For many reasons—and this is certainly chief among them—it’s important to get physicians to state how ill patients really are. Coders are not allowed to jump to conclusions.”

The healthcare industry is beginning to realize the potential of electronic data to strengthen and improve care. Physician advisors have a place in that environment, Johnson says.

“Working together, the physician advisor and CDI staff are strengthening codified data,” she says. “Ultimately what you can expect is excellent quality care but also information to fortify long-range planning. So it’s not single faceted, not one purpose. When we look toward the future, develop standardized treatment plans, and offer new services to benefit patients and healthcare overall, we’re able to do so from data that are accurate.”

— Susan Chapman is a Los Angeles-based writer and author.