In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems.
The HIM Problem
To get physician buy-in on clinical documentation specificity, one provider formed an all-physician CDI team
The HIM Problem Solvers
Lorena Chicoye, MD, RPh, corporate medical director, managed care network development and medical management, at Baptist Health South Florida, Miami, FL
Mauricio Palma, MD, director, clinical documentation improvement (CDI) program, Baptist Health South Florida, Miami, FL
A Spoonful of Sugar Helps the Medicine Go Down
When Dr. Lorena Chicoye did a fellowship in faculty development, one of the most important lessons she learned was not to be a drone when giving presentations to colleagues. She was taught that a physician’s attention span clocks in around 15 minutes—and if you don’t engage them before time’s up, chances are they won’t remember what you’ve told them.
This advice served her well when she was tasked with heading up the clinical documentation improvement (CDI) program at Baptist Health South Florida. When her CDI vendor suggested that she should do a little marketing around their CDI efforts, Chicoye couldn’t help but notice that nicknaming the program “CDI: Miami—Criminal Documentation Investigations” would be an attention grabber.
“It was kind of interesting—not that I watch that particular show (“CSI: Miami”), however, they’re forever advertising for people to be extras on the show and crazy stuff, and a lot of people here, especially our male physicians, watch this show,” Chicoye says.
Now, whenever Chicoye or Palma do informational sessions on CDI for hospital staff, they start every presentation with the theme song from the TV show.
“It really breaks the ice,” Palma says. “When you go to these meetings and educate physician, they think you’re just telling them what to do. But you break the ice and tell them what to do but in a different way.”
The facility’s CDI program was supposed to start in 2010 in order to support ICD-10-CM/PCS, but due to implementation delays, CDI didn’t get underway until 2011. Chicoye was always mindful of the tension between CDI and physicians, as physicians frequently feel that CDI exists just to get in their way.
“We wanted physicians to become comfortable with the idea that people were going to be looking at medical records and asking questions about them,” Chicoye says. “In our case, and I made this clear, that we would NEVER be asking them anything about utilization. Our team, who is made up of all physicians would never ask them why this patient is still in the hospital. That’s another department’s job.”
Face to Face, Physician to Physician
While their approach to education sounds lighthearted, Chicoye is deadly serious when it comes to CDI. That’s why she decided that all of her CDI specialists should be physicians. Additionally, CDI specialists at Baptist are instructed to do face-to-face queries for each initial query of a given patient’s chart. Subsequent queries on the same chart don’t need to be in person, just the first query.
Face-to-face queries are Chicoye’s preferred method for a query, and she says it helps establish a rapport between CDI and physicians, even when their respective medical specialties are different.
This is especially challenging considering that Baptist Health has not yet converted to electronic health records (EHRs). Baptist Health currently has five hospitals and the CDI team has 19 physician members who are spread out through those sites.
Chicoye acknowledges that she’s very lucky that she was able to assemble a CDI team comprising all physicians. She was able to do this by hiring international physicians who came to the United States looking for residency programs. Since the US residency program is very competitive for international physicians, many take jobs in healthcare-related positions in order to make ends meet while they apply to residency programs. The CDI specialists in Chicoye’s department earn a salary on par with what CDI specialists make in any other facility, if not a little more due to Chicoye’s negotiation efforts.
She feels strongly that physicians respond better to questions about their documentation and other clinical issues when those questions come from other physicians.
“I believe that having the additional medical expertise under your belt, and having an MD on your badge keeps the physicians from running away from you, keeps them from questioning your medical knowledge,” Chicoye says.
She adds that her CDI specialists often graduated from the same medical schools as many of Baptist Health’s staff physicians—they were just lucky enough to get residencies first.
CDI Gets Results
Florida is a frequent target of Medicare’s RAC program, as it was an early pilot site for the program. However, Baptist Health’s CDI team does their best to “RAC-proof” the charts they review. Chicoye says that every time a RAC team came through and pulled charts for denials, none of those denials were based on charts reviewed by Chicoye’s CDI specialists. Usually, the charts that got denied for not meeting medical necessity were charts that “slipped through the cracks” on weekends, when CDI staff does not work.
Another marker of success, Chicoye notes, is that since ICD-10-CM/PCS went live, physicians go out of their way to reach out to the CDI team to confirm diagnosis codes and verify definitions for things like sepsis, encephalopathy, and functional quadriplegia.
“Which is pretty interesting to me,” says Chicoye. “For a group of physicians who didn’t want to get involved [in ICD-10]. They’re realizing they have to.”