CDI Operational Performance: A Construct

I recently engaged in a fascinating discussion with Dr. Jake Martin on the “Top 10 Key Components of An Effective CDI Program,” involving thoughts on how the clinical documentation integrity (CDI) professional can capitalize upon opportunities to drive operational efficiencies and performance. I felt that we both made a compelling case for transformational change in current CDI processes that go far beyond traditional record review, with focuses upon diagnosis and quality measures.

While these are inarguably necessary elements of every chart review, the components brought forth during our discussion served as a foundation for jump-starting a long-overdue journey for bringing CDI into the mainstream of the healthcare profession.

Ten Key Components: Moving Forward

The aforementioned 10 key components of a highly effective CDI program are characteristically interrelated and synergistic in nature. Each is designed to build on and support the other components to achieve true clinical documentation integrity. One notable point to consider is the industry-wide push for CDI to reflect “integrity,” rather than “improvement,” since in reality, the only person who can realistically improve the quality and completeness of medical record documentation is the physician. What the CDI professional can do, however, is guide physicians in better practices of documentation and charting within the electronic health record, serving as a primary resource and conduit for information on better approaches to physician documentation. The profession’s motto could be “helping physicians work smarter, not harder, through more effective documentation processes.”

The top 10 key components of an effective CDI program, in no particular order of importance, are as follows:

1. Mission and purpose: are you seeking to improve documentation or reimbursement? What’s the priority?
2. Processes versus tasks: the difference between teaching versus tasking.
3. Technology: tools to manage, track and trend progress of the program.
4. People: do they want to help, or just check items off their task lists?
5. Knowledge base: can your people teach principles of documentation?
6. Executive support: do you have permission to break down current silos, and do you have a physician champion?
7. Proactive mindset: do you believe in proactive, preemptive denials avoidance?
8. Measures worth measuring: are you measuring things that matter to the bottom line?
9. Quality versus quantity: can you endorse the quality of CDI reviews versus the quantity of CDI reviews?
10. Floor presence:  can you commit to CDI specialists working onsite versus remotely?

Let’s take a deep dive into the mission of CDI: what is it in the present day, versus what the mission of CDI arguably should be, serving as a beacon for skill sets, core competencies, and knowledge bases? An ACDIS article from May 2016 contains an excellent statement of the mission of CDI, as follows: (Mission of CDI). This forms a strong starting point for crafting an all-encompassing, true-to-form mission of CDI governing roles and responsibilities. Building upon the strong starting point, here is a more comprehensive CDI mission statement:

• The new paradigm of CDI may be defined as the completeness, consistency, organization, and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision-making. CDI supports positive outcomes in patient care, quality, cost, resource consumption, fee for value, patient reimbursement, and revenue cycle processes. This new paradigm requires a wholesale shift in the goals and objectives of any CDI program. The aim of CDI should be to improve actual processes of clinical documentation, striving to achieve meaningful and lasting changes in physician behavioral patterns that optimally reflect communication of patient care, regardless of stakeholders, including third-party payers. By focusing on primary outcomes of reimbursement, we are overlooking the vitally important component of true documentation improvement. Enhanced reimbursement should be thought of and treated as a byproduct of solid documentation, reflective of medical necessity for inpatient care, continued hospitalization stays, discharge stability, appropriate resource consumption, and utilization review/management processes under the Conditions of Participation. This should involve quality and efficiencies of care delivery, achieved outcomes, and accurate clinical validation of all assigned ICD-10 codes and DRGs.

Now, let’s examine the goals of CDI, to accompany the mission of CDI. The following represent an account of CDI goals that should guide all operational processes and roles:

Goals of an Effective, Sustainable CDI Program

• To achieve the highest order of specific, accurate, detailed medical documentation, to ensure the most precise final coding, so that the institution receives the optimal and appropriate reimbursement to which it is entitled, based upon care provided and resources consumed.
• To produce a medical record, which is the most effective communication tool for all healthcare providers rendering care.
• To enhance patient safety, as well as the efficiency and effectiveness of care efforts.
• To provide details of patient encounters for external reviewers of all types, free of ambiguity, inconsistency, or clinical incompleteness.

A strong CDI mission and accompanied supportive goals will serve as the foundation for building upon the other nine key components of an effective, high-performing CDI program. These other elements can be categorized into three distinct areas, consisting of people, processes, and technology. Each of these distinct areas operates under the theory of constraints, whereby each must be strengthened to achieve a high-performing CDI program that sees measurable, meaningful, sustainable improvement in physician documentation.

People and processes form the backbone of CDI, complemented by the proper technology. For a CDI program to be effective, there must be adequate support from the c-suite, including the CEO, CFO, CMO, physician advisor, and revenue cycle leadership. Providing the “right support” refers to not treating the medical record as a primary reimbursement tool only; not equating CDI to task-based activities consisting only of the query processes; blessing and approving the use of key performance indicators (KPIs) beyond the traditional metrics that are functions of task-based activities; and fully embracing the need for adequate physician leadership, including assignment of a physician advisor to oversee the program. Every CDI program must have a dedicated physician advisor who serves as a voice and torchbearer for all initiatives.

An effective CDI program also requires commitment to continual learning in clinical medicine and expanding knowledge and understanding of best-practice standards and principles of physician documentation. This requires a self-disciplined, self-learning approach to acquiring the knowledge and skill sets necessary to confidently review the record and identify real opportunities for working with physicians on a proactive, preemptive denials avoidance approach. All CDI professionals must incorporate such an approach into the regular daily chart review process, recognizing when physician documentation may lead to a medical necessity or clinical validation denial or level-of-care or DRG downgrade. All CDI professionals must operate under these ideals, well-executed through sufficient physician documentation that adequately describes the patient’s clinical story; without this, there is simply no need for CDI. An effective CDI program will recognize CDI technology as a tool versus a crutch, first and foremost, understanding that using a CDI platform to increase case mix index and CC/MCC capture without concomitant improvement in documentation quality and completeness will serve to generate more payer denials and increased compliance risk.

Taking Stock of Your CDI Program

Effective CDI programs work in tandem with physicians, physician advisors, case managers, utilization review staff, denials and appeals staff, and coding staff. CDI working in a siloed environment, as is the norm for most programs, is a lesson in futility, with payers winning through issuing more avoidable, self-inflicted denials. The time is ripe for all CDI programs to take stock of the people, processes, and technology being deployed. Utilize the above 10 key components of an effective CDI program as a checklist to take stock of opportunities to improve overall performance. Patient care outcomes and the financial health of your hospital or health system are dependent upon your ability to successfully serve as facilitators to physicians, affecting positive change in overall documentation patterns.