December 2015

Tools, Teaching Lead To CDI Success
By Cheryl Ericson, MS, RN, CCDS, CDIP
For The Record
Vol. 27 No. 12 P. 8

Clinical documentation improvement (CDI) is not just an extension of coding. While CDI may have originated in the HIM department, the skill has evolved into its own unique profession. A CDI department needs its own identity within the organization, complete with its own budget, leadership, and policies and procedures. Additionally, both CDI and coding must be on equal footing to allow for discrepancies to be resolved to the satisfaction of both departments.

Keep in mind that CDI is not the same as concurrent coding. Although many CDI departments may assign codes during their review process to establish a working diagnosis-related group (DRG), CDI-derived codes aren't usually used to populate the final bill. Typically, the purpose of assigning codes during the CDI process is to allow CDI specialists to anticipate potential reimbursement or quality issues. They usually target key diagnoses rather than all diagnoses. In other words, CDI specialists have a narrower focus than their coding cohorts. This perspective should also affect workflow.

Educating Physicians
CDI specialists bring many benefits to an organization, but perhaps none is greater than their ability to interact with providers in an effort to improve documentation behavior. Record reviews are a means to an end for CDI specialists, so given the choice between spending 10 minutes in conversation with a provider regarding their documentation or completing another record review, the former wins hands down. Yes, CDI specialists must be held accountable, but overemphasizing the number of records reviewed may result in missed education opportunities.

Every interaction is a potential education opportunity for both the provider and the CDI specialist. Individualized education is often better received than generic education in a formal setting. However, providers must be receptive. For example, if possible, don't approach them at the end of a hectic day. Keep in mind that most providers are willing to be helpful, but no one likes to be attacked.

Rather than approaching a provider like a parent scolding a child, CDI specialists should act like an interested student. Begin the dialogue by explaining how the documentation was perceived and how it will be translated into coded data. However, keep coding lingo to a minimum. Explain how the current documentation will be translated into clinical terms that are unlikely to capture the complexity of the patient's condition.

Some of the most successful CDI specialists are active listeners who allow physicians to work through their thought process to arrive at the desired conclusion. It's important that CDI specialists keep their egos in check during any conversations with a physician. It isn't their job to explain to a provider how to make a diagnosis but rather to help them document conclusions in terms that can be accurately captured by coding.

Technology Issues
Computer-assisted coding (CAC) and EHRs are unlikely to make CDI departments obsolete. CAC technology is capable of recognizing words represented in coding nomenclature. However, if the provider doesn't use the right terminology, there will be nothing for the technology to highlight.

CAC may speed the coding process by allowing coders to quickly identify key words within the documentation, but it doesn't affect provider behavior—most importantly, it doesn't change documentation habits. In addition, most CAC technology doesn't understand context. It can assist with identifying phrasing that requires more specificity such as congestive heart failure or pneumonia—which many in the industry refer to as low-hanging fruit—but it is of limited value when it comes to understanding a disease process and clinical indicators supporting a missing diagnosis. For example, it will be of little help in a case such as hemorrhagic shock in a trauma patient with arterial damage who remains hypotensive with low urine output after volume expanders and a blood transfusion requiring dopamine titration.

What about the technology leveraged in an EHR? Unlike CAC, an EHR can prompt providers for specificity when they attempt to enter a congestive heart failure diagnosis, but how does the organization ensure the provider picks the term reflective of the actual clinical scenario?

Also, both CAC and EHRs are limited by the complexity of ICD-10-PCS, which—because it's unlikely that the surgeon will document all of the necessary elements in the same order as is required for code assignment—requires the identification of seven characters based on documentation throughout the operative report and/or health record.

What to Look for in CDI Software
Unfortunately, many CDI products are based on a coding platform. For the most part, the coding workflow is standardized and straightforward. However, CDI is anything but standardized and straightforward. A one-size-fits-all technology approach may not support all of an organization's CDI initiatives or the lifecycle of always-evolving CDI departments.

CDI departments need flexible technology that can support any workflow, whether revenue or quality based, or a combination of both. A common complaint of CDI solutions is their inability to customize workflow to fit an organization's specific needs. Too often CDI specialists develop supplemental manual processes outside of their technology solution to meet their unique needs. Technology is supposed to maximize efficiency, not be a barrier.

Staffing constraints often hamper CDI's efforts to provide proper coverage. A robust CDI technology may increase workflow efficiency, reducing the stress on overtaxed CDI specialists. Short-stay admissions, in which a patient is admitted and discharged before a concurrent review can occur, can be particularly stressful for CDI staff. These cases, which are vulnerable to denial, may be easier to handle with a software solution that can capture these admission types and integrate them into the daily workflow.

Patient flow also affects CDI coverage. However, technology that leverages the admission, discharge, and transfer feed allows CDI departments to better prioritize their review efforts by allowing them to easily identify those patients who are discharged or expired, or whose length of stay exceeds the geometric mean length of stay for the associated working Medicare severity DRG. If the technology can also capture the admitting diagnosis, CDI would have even more information available to prioritize the daily review process.

The work of CDI is often external to the coding process, resulting in CDI efforts being overlooked during coding. Technology that fails to integrate these functions can be problematic. The lack of a common platform where the efforts of both departments are immediately apparent limits integrated interaction and real-time problem solving that can prevent delays in the revenue cycle.

This can be particularly troublesome when it comes to querying. For example, the query process for CDI is often different than for coding because each department leverages different technology. As a result, the coding query may be part of the health record, but the CDI query becomes part of the business record. Industry standards don't allow for differences in query processes based on the professional background or role of the person performing the query function. Technology that fails to support a collaborative approach between CDI and coding is limiting the effectiveness of both departments.

A Niche of Their Own
CDI departments have become the norm. According to a survey conducted by The Advisory Board Company earlier this year, an estimated 81% of hospitals have some type of CDI process, an increase of 48 percentage points since 2006. As organizations better understand the relationship between clinical documentation and coded data, CDI's role usually evolves and grows.

It's recommended that organizations transition their CDI "program" into a full-fledged department. Commissioning CDI to become its own entity provides the department with a greater opportunity to contribute to the organization's success. As CDI efforts extend beyond their HIM origins, evaluate where the department best fits within the organizational structure. Lastly, provide CDI staff with the unique tools and resources needed to ensure they reach maximum efficiency and effectiveness.

— Cheryl Ericson, MS, RN, CCDS, CDIP, an AHIMA-approved ICD-10-CM/PCS trainer, is clinical documentation manager at ezDI.