Data is everywhere. Is your organization making full use of the data available at your fingertips to improve your clinical documentation improvement (CDI) program? Joni Dion, RHIT, CDIP, CCDC, CPC, and Bonnie Peters, CDIP, CCDS, CCS-P, CPC, COC, CPC-I, CPC-H, from the Berkeley Research Group in Hunt Valley, MD, shared their recommendations for taking control of data to help drive outcomes and step up a CDI program during their presentation at the Clinical Coding Meeting on Saturday.
There are many types of data available from numerous resources that can be used to evaluate and improve a CDI program:
- Program for Evaluating Payment Patterns Electronic Report (PEPPER)
- Office of Inspector General’s work plan
- Present on Admission (POA) indicator data
APR-DRGs take into consideration resource intensity and the differences in a patient’s complexity of illness. They include four severity of illness (SOI) levels. A secondary diagnosis’s impact on the SOI will vary based on the principal diagnosis. This makes capturing any and all secondary conditions present in the clinical documentation by the clinical documentation specialist (CDS) critical and ensures an accurate final APR-DRG is assigned that reflects the clinical picture of the patient. Conditions that might not normally affect an MS-DRG could impact the SOI of an APR-DRG, such as suicidal/homicidal ideation, vitamin deficiency, and dependence on supplemental oxygen or a respirator.
When reviewing your facility’s data, pay close attention to things such as: DRG shifts, SOI variances, and case mix index (CMI) reports before and after your CDI program is implemented. Tracking and trending your data will allow you to identify areas where education is needed to improve the documentation and impact the coding and DRG assignments and/or quality measures.
Dion and Peters indicated that internal data mining is an opportunity to review areas common within your facility such as septicemia as an additional diagnosis, present on admission (POA) indicators, and mechanical ventilation of greater than 96 hours. POA indicator definitions must be clearly understood. Quality initiatives—such as inpatient quality reporting, value-based purchasing, hospital readmission reduction program, and hospital-acquired conditions (HACs)—are all driven by accurate documentation. The CDS is responsible for ensuring the medical record clearly indicates if a condition was present on admission or not. Any HACs identified are referred to quality for review.
A team or cooperative relationship is critical for the success of a CDI program; the partnering together of quality, CDI, coding, and health information management, case management, providers, and patients will result in complete and accurate documentation. A team approach will build alliances, achieve successful outcomes, improve reimbursement, optimize quality initiatives, and result in complete clinical documentation for quality patient care.
CDI and coding teams should work collaboratively by reviewing issues of Coding Clinic and annual coding updates, discussing retrospectively generated queries to understand the reasons they were generated and how they can be done concurrently, reconciling concurrent CDI worksheets with final coding, and jointly participating in documentation and coding education. It is also recommended that a CDI steering committee be established, which must include executive management representation for the CDI program to be a success. This committee is essential to ensure medical staff support by determining key metrics that can be reviewed at a more strategic level and guiding corrective action if necessary.
Critical to any CDI program is a physician champion or liaison. “The physician champion is an advocate on your behalf,” Dion explained. This physician needs to be well known and highly respected by the medical staff, should be a specialist in family practice or internal medicine, and must have a history of good documentation themselves. The physician champion will work closely with the CDI staff, interact with the medical staff, and discuss issues related to the documentation process other providers find hard to accept. The champion will also attend meetings related to CDI matters, and should act as a powerful advocate for high quality provider documentation.
Passionate about CDI, Dion and Peters build CDI programs from the ground up and strictly adhere to compliance in their queries, using the AHIMA Practice Brief “Guidelines for Achieving a Compliant Query Practice.” This Practice Brief is available in the AHIMA HIM Body of Knowledge at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018. Writing compliant, ethical queries is the cornerstone of the message that Dion and Peters want to convey.
The key to a successful CDI program is a team approach that will identify areas of vulnerability and develop an action plan to address them. Reviewing data identifies trends, which allows for the development of corrective action plans that drive appropriate and needed education for healthcare providers, coders, CDI specialists, and quality staff. After all as the saying goes, “you can’t manage what you can’t measure.”