Summer 2023

A Foundation for Optimizing the Future of Documentation
By Selena Chavis
For The Record
Vol. 35 No. 3 P. 14

Experts weigh in on best practices for establishing sustainable, successful clinical documentation integrity programs in a challenging health care climate.

Clinical documentation integrity (CDI) has carved out a strategic niche in today’s health care organizations. At a time when financial, clinical, and regulatory challenges are mounting across the industry, experts say the value proposition of effective CDI cannot be overstated. Yet, maintaining a sustainable, high-performing program is no easy feat for the average provider.

“Labor shortages (although improving), inflation, shrinking reimbursement with increasing denials on top of a looming recession create a reactive environment with less focus on long-term strategy,” says James Fee, MD, CCS, CCDS, co-CEO of Enjoin. “Hospitals historically drove the highest cost within a health system but also the greatest revenue/reimbursement. With outpatient volumes and outpatient revenue increasing in double digits month over month, CDI programs need to ensure the inpatient program is tightly managed, but at the same time make investments in fee-for-service outpatient and also in value-based care.”

Josh Amrhein, MHA, natural language understanding program manager at 3M Health Information Systems, notes that one of the greatest industry challenges that affect CDI is the evolving reimbursement landscape. “Risk adjustment is a hot topic for many CDI programs as they have evolved from just capturing complication and comorbidity (CC) and major complication and comorbidity (MCC) and are beginning to focus on different quality measures, such as hierarchical condition categories (HCCs) or Elixhauser,” he points out.

Like many areas of health care, CDI is not immune to the impact of labor shortages and burnout. Notably, 61% of providers surveyed in a recent Medscape report noted that bureaucratic tasks contribute to burnout, with some pointing to CDI as just another administrative challenge. In addition, burnout within the CDI professional community itself creates roadblocks to optimization of a program.

“We are hearing from customers that once staff leave a position, they have difficulties getting approvals for the position to be refilled,” Amrhein says, also pointing out that remote work has become problematic for some health care organizations. “Since the start of the pandemic, many CDI programs transitioned 100% to being a remote role. While many CDI programs remain remote, we are seeing from some customers that not being in the facility and in front of a provider has had a negative impact or has caused an increase in query response. Therefore some customers are beginning to request that CDI staff begin to have a presence in the facility and restart that rounding with providers.”

Shelby Humphreys, RHIA, CCDS, senior CDI consultant with Enjoin, says that burnout “contributes to lackluster review activity and stalls effective impact at an organization.” In addition, Humphreys notes that provider engagement is lacking with many programs, and there’s limited interest in understanding the goals of a CDI program and why it is a critical component to any success.

Misunderstanding goals is the number one challenge, according to Amy Campbell, MSHCA, RN, CCDS-O, outpatient CDI supervisor at Lifepoint Health. “As a [clinical documentation specialist], I am not teaching providers how to care for their patients but how to reflect their thoughts in the EHR. My goal is a thorough and accurate reflection of patients’ stories. To achieve my goal, I encourage providers to record these stories as accurately and specifically as possible,” she explains. “As value-based care gains more traction, providers are finding themselves working in a system without an adequate understanding or the time to learn the rules. Today’s providers must stay current on new treatments for conditions but also how to navigate shared savings programs, quality metrics, and improving health care outcomes for their patients.”

Fee emphasizes the need to reset how CDI programs prioritize top organizational goals and achieve small successes or gains to drive bigger initiatives. “Is it financial, or is it quality? Is it value-based care into population health?” he asks. “With many constraints, including burnout, focus with quick wins will establish the reassurance and financial stability to get the program back on track. Also, now is the time to look beyond traditional CDI impact but [on] how does CDI drive better patient care decisions improving patient outcomes.”

Best Practices: Laying the Right Foundation
CDI is and always will be about complete and accurate coding and documentation that captures the patient’s story. Yet, as health care organizations have continued to confront unprecedented operational challenges, it’s become imperative for their CDI programs to evolve to ensure they continue to have a maximum impact on patient care and revenue. Experts suggest the following best practices in today’s climate.

Create a Culture of Relationship Building and Collaboration.
Don’t let outdated thinking that coding and CDI teams are always at odds create barriers, Humphreys says. “With the right messaging regarding their shared goals, these two groups can find harmony. CDI teams need to be on showcase so that their purpose is known by all those impacted,” she suggests. “Create opportunities and establish consistency where CDI teams can partner with providers to support their education needs and work closely to encounter specific scenarios where clarification is needed.”

Fee adds that health care organizations should not forget to partner with the quality department. “CDI has reach into supporting validation of the circumstances of an encounter that may impact quality goals and measures,” he says. “The intersection of these two worlds concurrently can allow for faster review and reconciliation without slowing down the claims process of the revenue cycle when a case requires deeper review.”

Move Physician Engagement to Center Stage.
“Provider engagement is the bread and butter of all CDI programs,” Campbell says. “Providers must feel comfortable asking questions and hearing about ways to make documentation stand up to potential audits.” To that end, Campbell suggests identifying provider champions from each practice, including physicians, nurse practitioners, and physician assistants. Taking it to the next level, Amrhein says that programs should also have physician oversight.

Prioritize Education.
Training and education for your CDI teams is critical to their individual and group success, Humphreys says. “These staff need to strengthen their skill set and build confidence in order to provide the support and education needed by providers when working towards documentation integrity,” she stresses.

Augment Efforts With Technology
Creating efficient staff workflows and arming CDI professionals with the right data can go a long way toward optimizing the impact of programs and overall staff satisfaction. “Following the data and consistently asking the question ‘why,’ about the data also creates a successful program because that means that the customer is following the data to ensure that they are successful, but at the same time making necessary changes based on the data for success,” Amrhein says. “We want to see CDIs work smarter not harder. We know that health systems are working with limited resources, and we have seen success where technology is in place to augment the system.”

On the flip side, technology should not replace any human work, Amrhein emphasizes, as CDI is always going to require a human’s critical thinking.

Build Team Loyalty and Commitment.
At a time when retaining top talent is a priority, Fee says health care organizations that take care of their teams will benefit from more successful CDI programs. “Consider a career pathway that will allow growth professionally, incentivize continuing education, honor requests to take on new projects or challenges, and positively push folks to participate in activities outside of their comfort zone that they may not realize they have the skill set to be successful at,” he says. “CDI isn’t a ‘set and forget’ process; it is a critical tool that needs constant cultivation in order to stay relevant and effective at its purpose. Be there for your teams and they will be there for you, allowing for sustainable growth and success.”

Consider Roles Outside of Traditional CDI.
Not all clinical documentation specialists (CDSs) are registered nurses, Campbell emphasizes. “Anyone in health care can be a CDS that can improve the integrity of an EHR in some way,” she explains. “My favorite teams have been multidisciplinary where everyone is safe to learn and be heard. I have often said I am never too smart to learn.”

Measuring Impact
In terms of ROI, Amrhein says many 3M customers have traditionally focused on ensuring that at least one CC or MCC be captured on an encounter when applicable. In addition, there’s a trend in focus on the publicly reported data, such as U.S. News & World Report ratings. “While for many customers this has been a focus, I am hearing more from customers based on their ratings and comparison to competing organizations,” he says. “While the financial impact of a CDI program is important and a focus, I believe we are truly starting to hear more as it relates to the quality capture and how they are being ‘seen’ by patients.”

Fee says health care organizations should develop a set of strategic key performance indicators that are both industry specific and aligned with an organization’s strategic vision. Some to consider include the following:

• coverage rate of patient population in focus;

• review rate (instances of chart reviews performed for cases);

• re-review rate (instances of subsequent touches by CDI);

• query rate (how many queries are sent per case);

• provider response rate;

• response type monitoring:

- agree (response aligns with goal of question posed—diagnosis-related group [DRG], severity of illness, risk of mortality impact),

- disagree, or

- clinically undeterminable;

• financial impact per query (monitor relative weight shift if change directly impacts that DRG);

• case mix impact for total reviews (then consider specific markers when interest in showcasing by service line, payer, and/or provider);

• denial rates; percentage of write off net patient revenue; overturn rates, revenue recouped;

• case mix index–adjusted length of stay: geometric mean length of stay/case mix index for DRGs will define the length of stay adjusted for patient severity identified within documentation; reduction of avoidable days;

• observed/expected cohort analysis (mortality, patient safety indicators) using subscribed risk adjustment tools (eg, Vizient, PINC, hospital-specific reports); and

• population health: HCC recapture, new HCCs captured, non-demo risk adjustment factor score at patient, provider, clinic, and plan level; percentage of beneficiary visits and new visits with outreach; targeted quality measure performance.

Leadership and Team Development
Professionals agree that a multidisciplinary approach to CDI program development provides the best foundation for success. The composition of a team should take into consideration everyone from case management, coding, and quality to physicians, their advisors, and other ancillary clinicians. And as the owner of the patient’s medical record, HIM should be integrally involved.

“I believe we are seeing from our customers four different areas in which CDI may fall: HIM, revenue cycle, quality, or even physician services,” Amrhein notes. “I believe more times than not, though, we are seeing more customers fall into either HIM or revenue cycle. Those programs that have CDI expanding beyond just traditional CDI and are now becoming involved in quality may be found having their leadership from the quality department.”

Organization structures will differ, Humphreys says, noting that in previous roles, coding and CDI were led by the same corporate leaders, who reported to the HIM corporate leader. “This was an alignment that worked well. HIM has significant reach into the full revenue cycle of an organization and is recognized and respected among the [various] roles,” she says. “Grouping the CDI team under the realm of HIM and coding establishes this group as a cohort that is expected to work together toward a common goal. HIM is at the table of many committee groups, workstreams, and conversations that may discuss topics or initiatives where CDI and coding have an impact or potential influence and can ensure inclusion of these groups where needed.”

Team development requires ongoing education, Amrhein emphasizes. “Those [organizations] that put time aside in CDI education for providers are those that are more successful than those that sort of just drop and run,” he says. “I also believe that CDI programs need to get in front of physician leaders or teams on a regular basis. Providing insight to a service line’s data or impact tends to go a long way in understanding the true impact of CDI.”

— Selena Chavis is a Florida-based health care writer.