This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Steven Robinson, MS, PA, RN, CDIP
Unity is strength… when there is teamwork and collaboration, wonderful things can be achieved.
Clinical documentation improvement (CDI) professionals have a worthy task to help identify and communicate opportunities and risks related to documentation inefficiencies in the medical record. And health information management (HIM) coding professionals are deeply devoted to identifying the correct category of codes to accurately represent patient care, resources consumed, severity of illness, and risk of mortality.
Despite clinical documentation specialists and coding professionals working diligently toward common objectives—accuracy, transparency, availability, compliance, information integrity—there is often a disconnect between applications of code methodology. This article explores root causes and offers thoughts on ways to bridge the gap.
Differing Priorities and Perspectives
HIM and CDI departments are different work streams for many reasons. Both have very important responsibilities to the organization, but they may have independent priorities. For example, CDI professionals reviewing for both the MS-DRG assignment and the most accurate APR-DRG assignment could deem a record incomplete, pending a provider query that might impact severity of illness or risk of mortality. On the other hand, the policy in HIM may be to finalize the record and proceed with billing if additional documentation does not impact the MS-DRG.
The differing perspectives as to what and how clinical scenarios are portrayed come from deeply ingrained learning of respective clinical and coding applications—and overreaching policies. In the example above, the conflict in opinion is: how important is the APR-DRG assignment, and should it hold up the billing process? Education may be needed to discuss the pros and cons of accurate APR-DRG (severity of illness and risk of mortality scores) assignment—not only with coding staff but also with middle and senior leadership. Sharing and reaching agreement on how to acknowledge APR-DRG assignment could promote a more cohesive approach, avoiding repeated nonproductive interplay.
According to Merriam-Webster, communication is “a process by which information is exchanged between individuals through a system of symbols, signs, or behavior.” While methods of communication can help define the intent of an exchange, most important are the expressions used to exchange information. Sincere, open-minded efforts that engage others, for the purpose of clarity and better understanding, can improve receptivity of the communication and resulting outcomes.
A Progressive Approach
Our approach to resolving any policy or practice conflict will determine the overall integrity of coding and documentation efforts, and the benefits to the healthcare facility. In addition, workplace satisfaction of these two highly valuable and respected groups is necessary to support work balance, motivation, and productivity. I believe that the ability of coders and CDI professionals to engage collaboratively can influence patient outcome profiles and fiduciary accuracy.
Fortunately, HIM and CDI leaders are keenly aware of the need for harmony in the work environment. Over the past few years, great strides have been made to align coding and CDI teams to comb documentation and accurately apply governmental guidelines. Here are several examples of such efforts observed in forward-thinking facilities:
- Directed or self-determined coding staff are setting up work teams with CDI professionals to make sure clinical applications are understood and properly applied. Work groups are meeting to reach agreement on audited cases where there are mismatches between CDI and coding.
- Managers of CDI and HIM departments are employing/designating a mutually agreed upon CDI and coding-credentialed auditor to review missed opportunities—such as all PSI designations without exclusions, lack of POA designations, bundled payment with low severity, and mismatches without resolution. Provider and staff educational initiatives are a result of those audited outcomes.
- Senior leaders are guiding efforts to help identify the most appropriate department for housing CDI—weighing pros and cons for the culture of the facility.
While encouraging collaboration, it is also important to recognize respective departmental lines between CDI and coding. Examples of departmental perspectives and practices might involve:
- Implementation of organizational policy regarding the timeline between patient discharge and billing the payer. Introduction of exceptions may be posted—such as high-value PSI/HAC exclusion or Severity/Mortality diagnosis drivers that increase two levels or more.
- Criteria initiated by CDI and/or coding related to querying a provider for more specific information.
- Distinguishing timeline guidelines for pre-billing records for coding versus timelines auditing records after discharge.
These different practices should be included in the educational initiatives for both departments and providers as appropriate. Further, it is important to draft policy that is clearly documented and available to all parties involved. Though various perspectives influence departmental boundaries, sometimes coding guidelines and/or AHA rules must be prioritized. In any case, people skills—ability to listen, communicate clearly, and understand mutual roles and responsibilities—are critical to meaningful collaboration.
Building a Culture of Collaboration
According to Diana Karff, RHIA, CCS, CPC, a medical technology reimbursement consultant and former instructor at the American Coding School, “The bridges we build with a CDI team cannot be complete without coding staff members who understand basic clinical pathways and anticipated medical and procedural interventions. Established clinical pathways provide the context for the documentation framework constructed by physicians.”1
How can CDI professionals and HIM coding professionals work together to promote communication and achieve common goals? First, they must be allowed to consider and act on building a bridge of communication. There are many avenues to achieve that goal. A collaborative team approach opens the way to discuss issues and explore solutions together. Here are six strategies to encourage communication, trust, and teamwork:
- Seek educational opportunities such as reviewing new issues of the American Hospital Association’s Coding Clinic as they are published (quarterly). HIM and CDI staff could alternate taking the lead, offering different perspectives.
- Review applicable CDI/HIM KPI dashboards monthly. Identify providers that need additional education or specialties struggling with concepts. Create an action plan.
- Celebrate CDI and HIM weeks together—take turns hosting and planning activities.
- Participate in professional events—conferences, seminars, webinars. Follow up with debriefing sessions.
- Promote educational initiatives on documentation trends—through newsletters, posters, online media.
- Hold meetings on a regular basis. Invite guest participants from various disciplines to discuss specific topics. Present challenging “problem” cases—show, tell, and invite feedback.
Building a culture of collaboration among coders, CDI professionals, physicians, and all other stakeholders requires unity around a shared set of governing principles. Together, we can promote positive values, set shared priorities, and achieve common goals that benefit our departments independently and the organization as a whole—improved care, resulting quality scores, and value-based reimbursement.
- Lo, Wil. “Document Like This, Not That: Coders’ Perspective.” Journal of AHIMA website, July 1, 2014. http://journal.ahima.org/2014/07/01/document-like-this-not-that-coders-perspective/.
Steven Robinson is vice president of clinical revenue integrity at RecordsOne. Robinson holds advanced degrees and a unique understanding of the complete clinical documentation processes and its impact on healthcare facility revenue cycle. His experience includes clinical documentation and quality leadership for over 250 healthcare facilities nationwide managing process improvement, throughput, and clinical documentation consulting engagements.