By Rachel Mack, RN, MSN, CCDS, CDIP, CCS, and Gloryanne Bryant, RHIA, CDIP, CCS, CCDS
Editor’s Note: This article is the first of a two-part series. The second article will be published on the Journal of AHIMA website in February at journal.ahima.org.
Beginning an auditing program for a clinical documentation integrity (CDI) team may seem daunting. Without an instruction manual to use as a guide, the process itself is the basis for numerous questions: How do we go about doing this? What counts as a missed opportunity? Where is there potential for noncompliance issues? How do we measure and display our findings? Can we use this to educate others?
It may seem that there are more questions than answers, but the most important question for CDI managers and directors is this: How can I really know how well my team is doing if I really don’t know what my team is doing? An auditing program will help provide the answer.
Many programs rely on numbers and data to pinpoint CDI program success—or lack thereof. For instance, if a program has a provider response rate greater than 95 percent with an agree rate of 92 percent, the numbers tell a positive story about provider engagement at that facility. If a CDI team has a query rate of 35 percent, it indicates alignment with query rates across the country (based on previous AHIMA and ACDIS surveys).
How can CDI managers determine if their staff members are truly performing at the highest possible standard by not missing any query opportunities and generating compliant (non-leading) queries? Again, an auditing program helps provide the answer. More than collecting numbers, the process of auditing staff for performance must focus on quality, ensuring that all diagnoses are accurately captured in the record. Auditing in CDI has been gaining traction in the industry, with many programs acknowledging that auditing is necessary to ensure program success. Furthermore, the Office of Inspector General (OIG), which performs healthcare audits, has been increasingly focusing on CDI. Performing internal CDI audits will help organizations prepare for the scrutiny of potential OIG audits.
Defining CDI Audits
While auditing can have many definitions, CDI auditing falls under a “Process Audit or CDI Review, or CDI Quality Review.” The American Society of Quality (ASQ) defines a process audit as one that:
“Verifies that processes are working within established limits … It evaluates an operation or method against predetermined instructions or standards to measure conformance to these standards and the effectiveness of the instructions. A process audit may:
- Check conformance to defined requirements such as time, accuracy, composition, responsiveness.
- Check the adequacy and effectiveness of the process controls established by procedures, work instructions, flowcharts, and training and process specifications.”
This definition aligns with the core identity of CDI, which is often built by both external and internal policies and procedures. The results of audits allow CDI leaders to implement guidance for their CDI program, identify knowledge gaps within their teams, and monitor physician compliance with a documentation improvement program.
Getting the first auditing program started can be overwhelming. When setting the stage, it is helpful to take a step back and focus on a simple approach that utilizes the basics of problem-solving. In essence, you must determine the who, what, when, where, why, and how.
Who Does the Auditing?
The two components determining the “who” of CDI auditing are figuring out who will be performing the audits and deciding who will be audited. For some teams, the answer will be straightforward (for example, if someone has been hired specifically for the CDI auditing role). For others, the answer may be more complicated.
Whoever completes CDI audits needs to be above reproach, showing expertise in communication (verbal and written), proficiency in technology, a high level of clinical knowledge, and experience in CDI. Moreover, the auditor should be respected by staff members. Three or more years of experience in CDI is highly recommended. The auditor should also have the CCDS and/or CDIP credentials to support their expertise.
Careful consideration should also be given to bringing in the necessary number of auditors. If your organization has a team of three CDI specialists, then a full-time staffer devoted to CDI auditing may not be necessary. But if your team is part of a multiple-hospital system with 25 CDI specialists, then two full-time staff members devoted to CDI auditing might be necessary to adequately address the need. Furthermore, having more than one person performing the CDI auditing role ensures reliable findings and can provide additional necessary support should the results of the audit prompt difficult conversations about potential changes.
Who Gets Audited?
Once an auditing staff is in place, it’s time to identify who or what gets audited. Which CDI specialists should the audits start with? A generalized approach could identify the organization’s top inpatient medical and surgical Diagnostic Related Groups (DRGs) and then narrow the field to focus on only those DRGs that are high-risk and symptom-driven and DRGs without a complication or comorbidity/major complication or comorbidity (CC/MCC) that exceeds their geometric mean length of stay (GMLOS). The benefits of this approach include identifying specific problem areas for the organization as a whole as well as providing a great catalyst for physician education, among others.
Another auditing approach is to focus on queries, which is an excellent way to review the organization’s CDI specialists for query compliance and to highlight popular query topics—again leading focus points for physician education.
If the goal is to determine how the CDI specialists are performing at the individual level, a CDI specialist audit is the best approach. A small team can audit each staff member accordingly. If your team is large, consider focusing on performance and data to assist in determining which staff member to audit first. For instance, if you have a staff member that has higher than normal (for your team) review numbers but much lower than normal query rates, this may point to possible missed query opportunities. If you have a staff member with very low physician agree rates, this could also point to the need for an audit.
Run reports with data that includes information like review rates, query rates/percentages, and query agree rates. Depending on the outcome, the CDI auditing program can plan which CDI specialists are a higher priority. Start with your “critical” audits—staff members who are not meeting expected productivity numbers, have clear process gaps or knowledge gaps, or have noncompliant queries. New staff members that are new to CDI are critical audits as well; they are at a dynamic point in their training where they are very manageable. You can help them become knowledgeable and effective CDI specialists by auditing them within the first month of the onset of their CDI role and then every subsequent six months. The organization can be assured of its new staffers’ compliance and adherence with CDI best practices. In turn, the new CDI specialists will be able to learn quickly, correct mistakes, and fill knowledge gaps in their review and query process.
When and Where Do the Audits Occur?
“Where” may seem like an odd component for auditing, but if you are leading a multiple-hospital system, then “where” becomes important and ties in with the “who.” Do you have a hospital or unit that needs more attention than others? Joining these two components of the audit together could lead you to better triage those staffers who need auditing first.
When it comes to “when,” it is important to audit charts that are as current as possible. This makes them more impactful. When the records chosen for audit are six months old, it’s possible for the auditee to say they have learned since the time the record in question was created and wouldn’t miss the same query opportunity at the present time. However, if a record that was discharged three weeks ago is audited, the identification of a potential missed query opportunity becomes a learning opportunity.
Another important component of “when” relates to auditing staff. Depending on how many records you choose to audit for each staff member, it may take up to a week for an auditor to complete their work. Keep this in mind when reviewing timelines for potential audits.
Remember Why You Perform Audits
You likely have multiple reasons to audit your staff. There may be an internal executive push at the organization, the addition of new or evolving leadership, or changes in your program’s goals. Ensure that those program goals align with your organization’s goals—and that these goals are transparent and understood by your CDI specialists. The ultimate end goal of auditing should be to ensure accurate and complete documentation and compliant CDI processes. Perhaps you have additional goals that are financial or severity-focused, but these should not be the main driver. Keep in mind that effective CDI auditing should support your staff to ensure accurate documentation at the highest possible standard.
Determining How to Audit
Start at the beginning of the record and work your way through. Review all documentation, labs, vitals, and cultures. Build your DRG as though you are reviewing the record from scratch but with the known caveat that you have all the information you need, including final DRG assignment. Assess for accurate principal diagnosis assignment, appropriate CC/MCC and severity diagnosis capture, and accurate procedure assignment.
Once that is complete, it’s time to assess the record with more critical thinking. Is there anything occurring with this patient that is not appropriately documented? Is there a series of abnormal labs with treatment and no corresponding documentation? Should a diagnosis have been requested for clarification of present on admission status? Was anything missed during review?
A very important part of the “how” is to make sure you are consistent. Review the record for accuracy and completeness of diagnoses and procedures regardless of payment impact. If you inform your CDI specialists that they missed a query opportunity for pneumonia specificity in one case because it impacted principal diagnosis assignment, but don’t mention it in another case because it doesn’t impact the DRG, this sends mixed messages and will not be as effective for improving the program overall. This is extremely important for physicians and physician education as well, as they often don’t understand why CDI specialists query on some cases and not others. When auditing, keep compliance in mind and whether each patient has accurate and complete documentation. The clinical documentation in the medical record should tell the patient story clearly and specifically.
There are also several auditing tools available online via AHIMA and ACDIS to assist you with auditing your records. In addition, several vendors offer software tools to help track and trend CDI audit results as well as the CDI process itself. When you are taking notes about missed opportunities, make sure you can build your case concretely. Remember: you will have to share these findings with your CDI specialists, so be sure to offer enough evidence to validate your findings. x
American Society of Quality. “Auditing.” https://asq.org/quality-resources/auditing.
Rachel Mack (firstname.lastname@example.org) is a clinical program manager at Iodine Software and Gloryanne Bryant (email@example.com) is an HIM coding and CDI compliance independent consultant.Leave a comment