By Rachel Mack, RN, MSN, CCDS, CDIP, CCS, and Gloryanne Bryant, RHIA, CDIP, CCS, CCDS
**Editor’s Note: This article is the second of a two-part series. The first part was published in the January issue of the Journal of AHIMA.
The first part of this article discussed the importance of providers auditing their own clinical documentation integrity (CDI) teams. More specifically, it focused on how to determine who should be audited, the scope of an audit, the timing of audits, and how to decide who should perform them. This installment covers how to handle the aftermath of a CDI audit—managing the responses of those who have been audited, making constructive use of audit findings, and using feedback to make the next audit cycle better.
Audit Results and Findings
After completing an audit, it’s necessary to share findings with staff members. These are often serious conversations, regardless of the results. Most clinical documentation integrity (CDI) specialists take pride in their work and being confronted about topics they are missing can be sensitive. Auditors should take care to document all audit findings and observations, as well as complete the following tasks:
- Present findings in an easy-to-read format. Auditing likely is performed partly via a spreadsheet, which is acceptable. However, for the individual being audited a spreadsheet is often difficult to read from versus the narrative structure of a Word document. Whichever format is chosen, ensure that it is consistent for all team members and easy to digest.
- Plot out plenty of time to discuss the findings. If a CDI specialist missed multiple query or coding opportunities, this meeting may take more than an hour.
- Send the CDI specialist their written audit findings approximately one to two days in advance of a discussion. That way if there are any cases they would like to review they can look those up before the meeting.
- Plan for a challenging discussion. There will likely be a lot of material to review and this may also be the first time a CDS has been involved in a conversation like this. Auditors should include their rationale for including certain coding scenarios during the review and be able to point to when they occur in a chart. Auditors should be supportive and show empathy during these conversations.
- Consider having another person in the meeting besides the auditor and the CDI specialist, particularly if auditors discovered multiple cases where the CDI specialist missed a query opportunity. This benefits both the auditor and the CDI specialist. Remember this type of audit or review should go into the CDI specialist’s personnel file.
Keep in mind there will always be low, medium, and high performers. Also, remember that no staff member is likely to have zero missed query opportunities—that’s just the nature of CDI. There truly is no such thing as “perfection,” due to a variety of issues. For example, many CDI specialists do not have access to a discharge summary, leading to possible missed query opportunity that is no fault of the CDI specialist. Also, there are coding changes and inpatient prospective payment system (IPPS) changes each year that can impact documentation and CDI opportunities. Additionally, there are the American Hospital Association Coding Clinic instructions and guidance that can impact code assignment and CDI work, therefore perfection is not a realistic goal to expect.
Preparing for Future Audits
What are next steps after the first round of audits is complete? That’s entirely up to the auditor, but they would be wise to keep in mind that audits brings more worth to their departments and organizations. If CDI team across the board had a less than 10 percentmissed query rate, these are very positive findings and CDI-centric audits can be pushed to once per year. However, if CDI specialists have higher miss rates, another round of audits should occur within the next six months or sooner. This decision and next steps can bepersonalized to each hospital’s needs. Also, consider auditing new CDI staff during the first month of work and then every six months until they have acceptable miss rates.
Assumptions: The Bane of CDI’s Existence
The author Isaac Asimov said “Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won’t come in.” This sentiment rings especially true when one decides to audit a CDI team. One of the biggest some have observed in the CDI community is related to education.
Many CDI leaders assume all of their CDI specialists are on similar footing or have had similar CDI training, but this typically isn’t the case.
One example of an unsafe assumption is when CDI managers assume that they know how much time staff spends on responsibilities unrelated to chart review, including on activities such as rounding, physician education, and reconciliation. CDI leaders might assume staff only spend two to four hours per week on this, when it could be much more than that. CDI leaders should communicate with staff to find answers to these questions before letting assumptions take over.
Making the decision to audit staff is an important one. The decision to do so can be a compliance-driven decision as well. Spoiler alert: It may not always go as perfectly as managers think it will, especially in the early or planning stages. Stick with it. Develop a plan to be successful and review your plan at least once a year to assess its effectiveness. Also, keep your CDI specialists involved in the process. We all should work together to achieve documentation accuracy and to ensure compliance is being met.
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