Taking CDI Reviews to All Payers: Eight Lessons Learned

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 Jana Armstrong, RHIA, CPC


Nearly all clinical documentation improvement (CDI) programs are successful. Most demonstrate positive results, including improved case mix, better clinical documentation, and stronger collaboration across revenue cycle teams. But CDI teams are ready to do more.

According to a 2016 ACDIS focus group, CDI directors want to expand their programs beyond Medicare inpatient cases. Next-step targets include non-Medicare payers and outpatient settings. However, while the desire to grow CDI programs exists, expansion requires sufficient resources and executive support.

One Midwest health system recently concluded a pilot program to ascertain the impact of a 100 percent all-payer CDI program. The goal of the pilot was to prove to senior leadership, through metrics, that funding the program would position the organization for value-based reimbursement. This month’s post explores the pilot program’s initial justification, three key components, and lessons learned.

Established Program Ready for More

In 2015, the organization’s CDI program had a team of 8.5 full-time equivalent staff members covering 98 percent of all Medicare and DRG discharges. Query rates were stable at 30-40 percent of cases reviewed and physicians responded 98-99 percent of the time with an enviable physician agree rate of 91 percent. The program’s software delivered strong data abstracting and trending information for CDI managers and the organization’s partnership between CDI and coding was strong.

With a solid CDI program in place, the organization welcomed a new physician with recent experience in all-payer CDI at a large, urban health system. The physician was a strong supporter of CDI programs and suggested the CDI team review 100 percent of cases. He eagerly became the CDI director’s internal champion for CDI program expansion.

Justifying an All-Payer Pilot Program

The new physician inspired the team to ask: What gains could the organization achieve by implementing whole-house CDI? The answers came quickly:

  • Quality metrics across the entire patient population, not just Medicare
  • More accurate data on mortality, hospital-acquired conditions, readmission, and patient-safety indicators
  • Improved reimbursement and fewer denials by all payers

And as the organization was already moving toward value-based reimbursement, administrators needed the ability to collect and track the effect of clinical documentation under new quality payment models.

Implementing the Trial Project

With medical staff and executive support, the first step was to identify additional cases for CDI reviews. For example, with elective surgical procedures patients may only be admitted for one to two days, as with knee replacement procedures, leaving insufficient time for a typical review before discharge. Additional CDI specialists were needed to cover the burgeoning workload, so the CDI director engaged an outsourced CDI services company to provide experienced staff via the remote CDI model.

Next, the CDI team targeted non-Medicare payers for family, internal, and general medicine. Since these cases hadn’t been reviewed in the past, the remote CDI staff quickly identified new query opportunities for non-Medicare cases and a 45 percent query rate was immediately achieved. Proof in point that many opportunities exist to improve documentation across all payers—not just Medicare.

Two factors were critical to making the all-payer pilot a success: additional CDI support and physician participation.

Secure Remote CDI Support

A team of two dedicated CDI specialists and a floating specialist were brought on board to enable expanded case reviews. The outsourced specialists worked remotely with full secure access to the organization’s EHR and other systems. They were also integrated into the internal CDI team—attending staff meetings and learning nuances of physicians, coding professionals, and workflow.

The pilot project was seamless for coders and physicians. And though the facility has a history of using remote coders, this was the first time they leaned on remote CDI specialists.

Physician Engagement

The organization’s physicians had always viewed the CDI team as a valuable resource. The CDI team is an integral part of freeing up physicians to spend maximum time delivering patient care. For this pilot, the CDI director and team aggressively addressed physician engagement on multiple levels.

Throughout the pilot, they continued to drill down on metrics and provide medical staff—from chiefs to residents—important CDI trends and specific quality report card data. The pilot program identified eight best practices for strong physician engagement:

  • Identify in-house physician champions and nurture relationships to bridge the gap between physicians and CDI staff. Champions can help circumvent bad habits by modeling correct documentation practices and engaging in informal discussions with peers.
  • Schedule tailored presentations on topics physicians care about, such as risk factors and mortality rates. Limit presentations to no more than 10 minutes to hold attention.
  • Conduct joint educational sessions with coders and physicians where everyone hears the same message. This can illustrate how CDI helps all stakeholders do a more thorough job and save time.
  • Take time for one-on-one coaching with physicians to review data and discuss specific documentation gaps.
  • Position the CDI team as a critical link in quality metrics (national report cards), and partner with physicians to help improve their scores.
  • Keep the information flow a two-way street—ask questions and gather information, then provide physicians with key analysis on topics of interest.
  • Be flexible with schedules—come in early or stay late. This way, physicians see that you are committed to a successful process.
  • Set reasonable expectations for all parties involved, including the physicians.
Eight Lessons Learned

The all-payer pilot concluded in February 2017. Data is being reviewed to determine next steps. While the overall impact is yet to be determined, the project yielded eight lessons learned for other CDI directors and organizations considering program expansion, or a hybrid blend of remote and onsite CDI specialists.

  1. Have remote coding in place and easy access to IT staff for remote CDI specialists.
  2. Secure administrative buy-in regarding the value of your efforts. Be prepared to demonstrate the value in financial terms.
  3. Enlist a physician champion to support a hybrid model and clearly define which CDI functions will be managed onsite versus from home and other remote locations.
  4. Devise reporting mechanisms ahead of time—both format and frequency—to keep the senior team apprised of progress.
  5. Set benchmarks at the beginning and act on your findings. Recommended data points include: current MCC and CC capture rates, physician query and agree rates, CDI and coding DRG mismatches, and CDI data by physician and service line.
  6. Compare your program with a similar institution.
  7. Create a culture that welcomes feedback from all parties involved. Communicate often, and let people know what is working, what is not, and what needs to change.
  8. Be willing to make workflow alterations to maximize positive results.
CDI Programs Prepare

The all-payer pilot project was successful because the existing CDI program was already solid and a remote workforce was accepted. The workflow was ironed out, team members were attentive to detail and had already maximized their positive results. Previous glitches, such as CDI specialists spending too much time in the encoder, had been eliminated before the pilot began.

With CDI expansion becoming the norm rather than the exception, today’s CDI professionals will be performing many more reviews across a greater number of care settings. The advice in this post sets a solid foundation for the CDI journey ahead.


Jana Armstrong is the executive director of advisory services for TrustHCS. She currently oversees the Coding Auditing, CDI Auditing, CDI Staffing and Education divisions of TrustHCS.

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