Clinical Documentation Integrity in a Virtual World

In 2015, clinical documentation integrity (CDI) managers began to consider the feasibility of a remote or hybrid workforce. Articles began appearing in industry journals asking if CDI program staff could work at home. Then, in 2020, the industry experienced a leap into the virtual world because of the worldwide COVID-19 pandemic.

Researchers suggest that environmental scans may be used to “inform decision-making on policy, planning, and program development.” An environment scan of the CDI industry reveals virtual CDI's impact, challenges, and future, including associated issues of staffing, recruiting, workflows, provider collaboration, and technology.

The Move to Virtual or Hybrid

CDI industry research and CDI professionals point to a change in the current CDI delivery model compared to a pre-COVID-19 timeframe.

CDI practitioner Karen Carr, MS, BSN, RN, CCDS, CDIP, says, “from the COVID-19 experience, we’ve learned there are many jobs that can be done successfully in a remote environment.”

Physician CDI consultant Wilbur Lo, MD, CDIP, CCA, and Brundage Group CDI Director Cheryl Ericson, RN, MS, CCDS, CDIP, add that, depending on the organization, 40 percent to 95 percent of the CDI professionals work remotely or in hybrid positions.

Martine Haas of the Wharton School of Business at the University of Pennsylvania recently commented that “remote will stay in some sectors, but fully remote is going to be less omnipresent than hybrid.” Based on these industry leaders’ comments and evolving healthcare industry staffing patterns, perhaps some but not all CDI professionals may return to on-site work in the future.

Remote and hybrid options offer an advantage to staff availability. Hospitals may find it easier to hire remote staff because they can be hired from any location. However, hospitals may not be able to hire as many CDI professionals directly since contract work through consulting firms offers higher salaries.

Even though remote staff may be more readily available, Ericson points to the importance of having solid policies and procedures to ensure contract staff is compliant. An added challenge for CDI staff and their leaders is that learning multiple CDI and health information systems can be demanding for contract staff.

CDI Professional Roles and Responsibilities

CDI is a collaborative, interprofessional practice. Ericson notes that nurses, foreign medical graduates, and health information management (HIM) professionals typically hold CDI positions. Foreign medical graduates are more prevalent in major cities and academic medical centers.

Additionally, much like coding staff, offshore CDI is emerging, yet can be problematic because of cultural nuances in the healthcare delivery system. English language issues, acronyms, and unfamiliar medical jargon from a different culture may make communicating with US providers burdensome for the contractors and less effective.

In the same way as pre-COVID CDI practice, promoting a collaborative effort between CDI and HIM coders is essential in the virtual world. Ericson observes that the CDI professional’s job roles and tasks are changing and bringing a host of advantages but also challenges.

Post-COVID, healthcare organization executives found that the CDI program can now be delivered at a lower cost because less on-site office space is needed for staff. Thus, the space can be used to enhance patient care delivery.

AHIMA’s CDI Practice Director Tammy Combs, RN, MSN, CDIP, CCS, CNE, says there have been improvements in provider communication using various platforms such as Zoom for face-to-face interactions, enhanced electronic communication via the electronic health record (EHR), and other CDI interfaced systems.

For example, CDI tools on the market today may include a suite of solutions that spot what is missing in patient documentation based on clinical evidence. CDI tools may also provide the option to access customizable CDI templates for improving provider communication.

Additionally, younger, tech-savvy providers are more comfortable with and have embraced electronic communication, replacing some on-site, face-to-face dialogue. CDI teams recognize that the human touch is still essential to a successful CDI program, even with remote workflows.

Communication Is Key

Not surprisingly, executives and CDI leaders have increased productivity standards for CDI professionals with improved communication techniques.

Anny P. Yuen, RHIA, CCS, CCDS, CDIP, principal at AP Consulting Associates, LLC , has observed the increase of productivity standards related to the number of CDI reviews performed due to the use of EHRs, which at times have resulted in a decrease in quality clarifications. Yuen adds that this is due to a decrease in face-to-face time with providers versus the past when a provider would interact more closely with CDI professionals.

“Due to the reliance on electronic communication, providers often respond without carefully reading the query,” says Yuen. “Also, due to the decrease in face-to-face with providers, the CDI professional has only the record to rely on, whereas in the past, having a conversation with the provider at the hospital may assist a CDI professional in determining whether a query is warranted after discussing a patient’s full clinical picture found in the health record.” 

Recently, as Medicare fee-for-service populations have decreased and Medicare Advantage populations have increased, Michael Stearns, MD, CPC, CRC, CFPC, says payer denials have increased based on clinical validation concerns. CDI practitioners in many organizations have maximized revenue for inpatient diagnosis-related group (DRG) claims because MCC and CC documentation has improved over the years after the MS-DRG implementation in 2007.

Because there is little room for increasing case mix, CDI practitioners must focus on outpatient opportunities and the potential for decreasing payment denials. Dr. Stearns, physician informaticist and director at Wolters Kluwer Health, points out that the Centers for Medicare and Medicaid Services (CMS) and the US Department of Health and Human Services (HHS) may be informed by AHIMA practice briefs when developing regulatory guidelines, and based on recent Medicare Advantage audit reports published by the US Office of the Inspector General (OIG), we may see greater use of clinical validation when determining whether a reported ICD-10-CM code is accepted for risk adjustment.

Dr. Stearns says operationalizing clinical validation best practices is an opportunity organizations should evaluate to optimize clinical support for reported conditions. This is especially true in light of the error extrapolation approach CMS is taking in the recently published Medicare Advantage 2023 Recovery Auditor Data Validation (RADV) Final Rule.

Organizations should consider who should perform clinical validation since a strong clinical knowledge base is needed. Additional training should be considered for CDI team members as needed based on their skill set and experience.

Using this guidance, CDI and coding teams can develop an interprofessional process based on their own facility’s denial rates and root causes for denials for specific diagnostic and procedural categories.

Silos can make the effectiveness of the interprofessional CDI/coding team challenging. Increasing numbers of healthcare organization mergers and acquisitions add to the challenges of CDI and coding professionals working effectively together. Improving clinical documentation integrity is the starting point. Coding improves when documentation improves. Yuen suggests “to be successful when appealing denials, every denials team should include providers, CDI, and coding professionals,”

Provider and CDI team training is another crucial process. According to Carr, effective remote provider and team training can include newsletters, health systems intranet articles such as a “CDI tip of the month,” or face-to-face web-based provider training.

Combs also predicts that the CDI industry will see remote work evolve from simple clinical reviews and queries to concurrent educators working alongside providers remotely during rounds and meetings. Dedicated CDI educators can focus on specific topics for providers needing specialty training. The virtual CDI team can evolve by building solid relationships with providers.

CDI Technology, Artificial Intelligence, and Machine Learning

As health system executives and CDI leaders search for a new way to increase revenue, CDI’s best practice models must also change. And technology plays a critical role in the evolution of CDI practice.

Dr. Lo suggests that “computer-assisted physician documentation (CAPD) systems, CDI and computer-assisted coding (CAC) platforms and [other] software are available to facilitate and streamline provider, CDI, and coding workflows.” However, there is concern about “noise” with false positive triggers and nudges for perceived conditions and query opportunities within these applications. Conversely, diagnostic conditions and query opportunities may be missed due to false negative results. Dr. Lo warns us that artificial intelligence (AI), machine learning, and natural language processing (NLP) applications are not substitutes for the critical thinking and analytical skills needed to address complex clinical and coding scenarios.

Ericson points out that query communication is a foundational system requirement, with many EHRs offering this feature. Some EHRs allow for concurrent rather than retrospective provider communication. Regrettably, CAC has increased error rates because inexperienced professionals pressed to increase productivity use CAC recommendations for code assignment without looking at the entire record. This practice often results in false positives.

“Functionalities may not be appropriate for all organizations,” Yuen says. “Therefore, it is important for leaders to understand how new software can enhance their existing process and to always think outside the box regarding future state processes.”

Thus, data integrity and analytics assessment are crucial and should include an understanding of inpatient and outpatient reimbursement systems. Pre-purchase user interviews should consist of interoperability issues between systems and workflow challenges. An example is the ADT system feed process causing duplicate patient accounts, data entry mistakes, and data integrity issues.

Additionally, with the CDI technology landscape changing minute to minute, Combs recommends that the CDI team work closely with providers and coding professionals to understand the new workflow and provide training on technology. The technology could pull part of the clinical record when the provider views the query. If providers are familiar with new features, the advantages of the technology purchase may be realized.

In the future, the CDI team will experience an evolving CDI practice, including AI, machine learning, and other technologies. Combs suggests that medical schools will offer clinical documentation education using technology to improve the provider experience after graduation.

One such program is currently underway at NYU Langone Health. In a recent American Association of Colleges of Nursing (AACN) webinar, Dr. Marc M. Triola, MD, associate professor of medicine, associate dean of educational informatics, and director for the Institute for Innovations in Medical Education at the New York University Grossman School of Medicine, explained their new precision learning tool. The NYU team created a clinical database from NYU’s clinical records within the EHR database using AI. The software evaluates each medical student and resident EHR entry and compares the notes to a recommended standard created using NYU’s clinical data and subject matter expert recommendations. This evolving innovation is called “precision education.” CDI professionals should monitor this critical milestone in clinical documentation education and be part of the medical education team’s new solution for clinical documentation integrity.

Conclusion

Combs suggests that the present time is a pivotal point for HIM professionals to expand their footprint in CDI practice. The HIM professionals’ knowledge and skill sets related to health data analytics, data science, disparate and interoperative information systems, reimbursement, and disease classification systems can make clinical information meaningful to the CDI team and providers.

The time is now for HIM professionals to advocate for their skills in those areas of value and demonstrate what they bring to the table in the healthcare industry through a confident, skilled approach to today’s clinical documentation integrity challenges.

Pamela C. Hess is program director and lead faculty for health informatics and information management, as well as an assistant professor for the College of Nursing and Healthcare Professions at Grand Canyon University in Phoenix, Arizona.