September/October 2021

CDI Flexibility Key to Value-Based Care Success
By Lisa A. Eramo, MA
For The Record
Vol. 33 No. 5 P. 12

As we enter a new era of payment models, CDI specialists are once again poised to reinvent themselves.

If anyone embodies the definition of nimble, it’s the clinical documentation improvement (CDI) specialist.

When Medicare shifted from diagnosis-related groups (DRGs) to Medicare Severity DRGs (MS-DRGs), CDI specialists pivoted to capture complications and comorbidities. When the health care industry transitioned from ICD-9 to ICD-10, CDI specialists learned the new codes and documentation requirements. When COVID-19 struck, CDI specialists turned their attention to COVID-19–related admissions and/or temporarily moved into a direct patient care role to support organizational needs.

When UnitedHealthcare recently announced it would begin denying some emergency department (ED) claims for its commercial members if the services were deemed nonemergent, CDI specialists were ready to review ED cases and prevent denials. The payer delayed its policy just a few short days later. As regulations and payer targets have changed over time, CDI specialists have morphed their focus, always striving for documentation integrity that leads to accurate reimbursement.

As we enter an era of value-based care, CDI specialists are once again poised to reinvent themselves—this time with the help of technology and greater alignment with strategic initiatives. Experts agree that as organizations continue to shift toward value-based care contracts that provide greater financial stability, the role of CDI specialists will continue to evolve—but not without some bumps along the way.

Shifting Roles and the Use of Technology
One of the most noticeable changes in the CDI profession is the inclusion of outpatient documentation reviews—particularly in physician practices where patient risk and severity is often easy to capture. Nevertheless, the sheer volume of these visits necessitates the need for technology to augment CDI capabilities, says Julius Blum, vice president of solutions management at Streamline Health.

Computer-assisted physician documentation, for example, nudges physicians on the front end to document with greater specificity. Technology also prioritizes cases for CDI review and helps CDI specialists identify documentation improvement opportunities more easily. “There’s no way you could look at every document and find all of the opportunities,” Blum says. “You need technology to scan the existing documentation and find areas where there might be gaps.”

Matt Lambert, MD, chief medical officer at Curation Health, agrees. “With CDI moving to the outpatient side, CDI specialists might have 38 encounters a day to review. Or there might be a CDI team of two people, and the provider is managing 7,500 lives,” he says. “They need tools to keep up with this volume.”

These tools can also perform CDI reviews immediately before the encounter, Lambert says. “Technology has evolved to where we can do this. The APIs [application program interfaces] have matured,” he notes.

Outpatient providers need CDI specialists now more than ever, says Rose T. Dunn, MBA, RHIA, CPA/CGMA, CHPS, FACHE, FHFMA, FAHIMA, chief operating officer at First Class Solutions. “Providers in ambulatory settings are focused on addressing the specific condition for which the patient presented, but they are also factoring in the other underlying conditions without sufficiently documenting their assessment,” she says. “CDI specialists can help providers capture their complete thought process as well as the specificity needed to trigger one or more HCCs [hierarchical condition categories]. The additional conditions better define the complexity of the patient’s condition, support the treatment and/or procedures ordered, and help explain the cost of the care.”

Given the increase in the volume of records to be reviewed, why don’t more organizations hire additional CDI specialists? It’s about cost containment, Lambert says. “CDI specialists are highly trained and not inexpensive resources,” he notes.

Dunn suggests that physician practices use existing certified coders to fill the CDI gap and keep labor costs reasonable.

In addition, it’s difficult to keep up with ever-evolving risk models. Technology incorporates payer-specific risk-based contracts, absolving CDI specialists of the need to understand all of the nuances (eg, patient attribution, risk adjustment methodology, covered services, and triggers for episodic care), says Robert Tennant, vice president of federal affairs at the Workgroup for Electronic Data Interchange. This is especially important for CDI specialists working in larger organizations that participate in multiple value-based contracts.

“If you don’t capture the right data at the time of the encounter, then you don’t have the clinical information necessary to improve patient care, ensure care management, and support accurate reimbursement,” Tennant says.

Lambert agrees, adding that one of his clients has five different value-based contracts with five different quality initiatives. “Technology tells the CDI specialist, ‘This patient is in XYZ value-based care plan. There are 10 quality measures that plan has prioritized, and these are the three left outstanding for the year.’”

Aligning CDI With Strategic Initiatives
Another big change is the alignment of CDI with value-based care strategic initiatives and goals, says James Fee, MD, CCS, CCDS, CEO of Enjoin. “CDI should be involved in all of the strategic initiatives that align with an organization’s value-based care efforts,” he says. “Documentation becomes the foundation of the data that drives these initiatives.”

CDI programs can look vastly different depending on the organization’s goals, Fee explains. For example, some organizations are finance-driven and want CDI specialists to focus their reviews on the greatest source of net patient revenue. For many, this meant shifting from commercial payers to Medicaid and Affordable Care Act plans when the pandemic fueled unemployment. A report published by the Commonwealth Fund found that, as of June 2020, 7.7 million workers lost jobs with employer-sponsored insurance because of the pandemic-induced recession. This insurance also covered 6.9 million of their dependents, for a total of 14.6 million affected individuals.

Other organizations are focused on quality and want CDI specialists to review documentation and coding that directly impacts publicly reported outcomes data, including condition-specific cohorts and risk adjustment. “CDI leadership needs to have a seat at the table to understand these strategies and priorities,” Fee says.

Has the organization seen a growth in outpatient volume? If so, CDI specialists can review records for specific high-volume physician practices or focus on preventive care, Fee says. Has it ramped up its telehealth efforts as part of a larger patient engagement and retention strategy? If so, CDI specialists can build their knowledge of federal and payer-specific regulations and requirements.

Fostering Compensation-Driven Physician Engagement
Another area of change is physician engagement. Although the format and appropriateness of queries still matter, Fee says engaging physicians to improve their documentation under value-based care models is less about a specific action taken by CDI specialists and more about the compensation model under which physicians are paid.

“Value-based care requires provider engagement, leadership, and commitment,” he says. “To get that provider engagement, there must be local skin in the game supported by compensation plans. When you tie patient outcomes and other strategic initiative-related measures to compensation, you will see a change in how physicians document.”

Creating a Culture of Documentation and Data Integrity
As organizations continue to embrace value-based care, CDI specialists can expect to see a cultural shift—if they haven’t already. What does this look like? Dunn paints a picture of this new reality:

• CDI specialists and coders communicate regarding opportunities for provider education.

• CDI specialists and coders celebrate coding inconsistencies as learning opportunities.

• CDI-driven diagnoses are not coded unless there is sufficient documentation (ie, clinical indicators) in the medical record.

Blum agrees. “The best programs out there are the ones where there’s collaboration—where coders and CDI meet regularly to talk about cases,” he says.

As organizations hold on to antiquated metrics such as CC/MCC capture rate, a culture of documentation and data integrity is critical, Dunn says. “We need to revisit the reason for CDI. It is to promote comprehensive and clear documentation of the care delivered,” she says. “Focusing documentation improvement efforts on this primary purpose rather than pursing extremely marginal conditions will reduce opportunities for denials. It will also reduce query fatigue and allow providers to focus on their patients and documentation.”

Moving Beyond Traditional CDI Metrics
One of the biggest challenges associated with shifting CDI priorities commensurate with value-based care is that determining CDI’s direct impact on revenue is not as straightforward as it once was.

“If you think about it, CDI has been around for a while, and a lot of physicians have learned to document better,” says Cheryl Ericson, MS, RN, CCDS, CDIP, clinical program manager at Iodine Software. “They’ll proactively document acute blood loss anemia or systolic or diastolic heart failure. You don’t see the same dollar shift as you did five or 10 years ago when we were first starting with the MS-DRG system.”

Most CDI metrics are still rooted in a fee-for-service world, Ericson says. “We don’t have good metrics in the industry to reflect the shift toward quality,” she says.

Fee agrees. “The key metric in CDI has been the query—how many queries, query response rate, query agree rate. Value-based care is all about patient outcomes. So as we shift toward value-based care, the KPIs [key performance indicators] for CDI should change as well,” he says.

HCC capture rate is a logical metric to use; however, depending on the payment program or purpose, payers apply HCCs differently, Ericson says. For example, Medicare Advantage plans use CMS-HCCs to set annual capitates rates, but these diagnoses are used for different purposes in the Hospital Readmission Reduction Program. In addition, commercial exchange plans use HHS-HCCs. Varying application makes it more complicated to derive a true financial impact based on capture rates.

Some organizations are looking at patient safety indicator (PSI) rescue (ie, there was a potential PSI reported on a record, but the CDI specialist found an exclusion so the PSI was not reported). However, PSI rescues tend to be associated with low dollar amounts, Ericson says. “Right now, PSI 90 is used only in the hospital-acquired condition reduction program, and the biggest penalty for that program is 1% for the worst-performing quartile,” she says. “You don’t get a lot of bang for your buck from a value-based approach doing PSI rescues.”

Even case mix index (CMI) has its limitations, Ericson says. For example, an organization might assume that all is well if it sees an increase in its CMI. However, what if there are readmission-related penalties? Or penalties for hospital-acquired conditions? “I don’t know that organizations are making these kinds of adjustments,” Ericson notes.

In addition, COVID-19 has made CMI comparisons difficult. “Even though CMIs rose during COVID, it’s because you had the decrease in elective surgeries,” Ericson says. “If people didn’t have a dire illness, they didn’t go to the hospital. By laws of statistics, if you remove those low-lying and elective DRGs, you’re going to get a higher CMI. Once things level out again, it’s hard to maintain that high level CMI once the population is appropriately risk adjusted.”

Instead, Fee says organizations should consider payer-specific metrics such as net patient revenue and impact, observed-to-expected mortality rates, denial rates with associated overturn rates, and provider performance as it relates to the documentation of patient severity/risk, utilization, denials, and longitudinal patient quality outcomes.

Other metrics include the rate of retrospective queries and the number of new cases reviewed per day, Dunn says.

Looking Ahead
What will be the next big disrupter for CDI? Experts share their thoughts:

Patient-generated data. “It’s more fodder for further analysis to be done,” Blum says.

Tennant agrees. “The CDI specialist is going to have such an important job going forward,” he says. “I expect that their job will expand as the data feeds expand as well.”

Artificial intelligence–driven solutions. These are already disrupting CDI, and Fee suspects they will continue to become more advanced. “It’s about taking the focus off the query and moving it to a clinical workflow-integrated process with nudges that actually improve patient care,” he says. “The CDI specialist moves away from ‘chart reviewer’ toward ‘data synthesizer.’”

CDI specialists will become more involved in defining artificial intelligence rules, Blum predicts. It’s about understanding value-based payment programs and identifying alerts that bring value in terms of added reimbursement as well as improved patient outcomes, he says.

“HIM and CDI professionals can guide IT in nursing/social work, nutrition, and case management template modifications to capture social determinants of health elements and possibly feed that portion of these professions’ documentation to a physician progress note and/or the discharge summary,” Dunn says.

Bundled Payments for Care Improvements Initiative (BPCI). More organizations are beginning to experiment with voluntary programs that yield a risk-adjusted payment for a 90-day episode of care.

“CDI is still in its infancy for these programs, but it’s an area for potential impact,” Ericson says. “The interesting thing about BPCI is that organizations are able to choose the bundles in which they participate. They get near real-time feedback on their performance compared to the more traditional value-based programs where there is a three-year or longer lag between when data are collected and when bonuses or penalties are imposed. CDI efforts impact BPCI performance through the initial MS-DRG assignment that can place a patient within a bundle population. CDI specialists can also help risk adjust the patient’s expected resource use across the 90-day episode of care so the organization starts with a higher baseline.”

In-home primary care. “Often, in-home visits are longer and allow more time for patient engagement and risk capture,” Lambert says. “This extra time allows the provider to thoroughly review and act upon clinical insights discovered by CDI.”

— Lisa A. Eramo, MA, is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.