In the shift to value-based reimbursement mandated by the ACA, Clinical Documentation Improvement (CDI) is back in the spotlight. An accurate and complete medical record ensures maximum compliant reimbursement and, as quality and patient experience are measured and rewarded, is essential to demonstrating the level of care delivered to patients. Excellence in clinical documentation facilitates a streamlined patient experience throughout the patient’s time at the hospital. It also enables organizations to protect their revenue by providing crucial information to help confirm compliance and avoid insurance denials and costly litigation.
Most healthcare providers have a CDI program in place, but over the years, these programs plateau. Successful organizations regularly assess their CDI programs to continually improve performance and arm their teams with the most current information on coding guidelines and the documentation needed to support them. While specifics vary from hospital to hospital, high-performing CDI programs tend to have the following key elements in common:
People
Clinical documentation may be perceived as a compulsory and mundane operation, but the human side of it is critical for success. First, a hospital must assess if the Clinical Documentation Specialists (CDS’s) are trained appropriately and the team structure adequately supports the patient population. This may require standardizing job descriptions and recruiting additional team members. Given the frequency of coding changes, regular education and mentoring help ensure each CDS is up to speed on current clinical terminology and practices to the top of their skillset.
Second, hospitals must facilitate and support clinical documentation collaboration and communication across all service lines, from trained coders to physicians all the way to the C-suite. Physician engagement in the CDI program is particularly important because the physician’s documentation in the medical record influences all aspects of a patient’s care and experience in the hospital. An accurate and complete medical record yields the appropriate level of care and resources, and physician education ensures providers understand CDI and its impact.
Process
Effective and efficient CDI workflows and processes, paired with thorough team training, must be implemented and used daily to achieve clinical documentation excellence. For example, implementing a clear query process flow helps both coders and the CDS’s understand their individual responsibilities and create a system of accountability. In high-performing CDI programs, these processes incorporate face-to-face interaction and collaboration between coders, physicians, and other care team members, all educated on the importance of documentation and all working toward the same goal.
Technology
Leveraging technology such as physician and departmental dashboards to define metrics, monitor trends, and share data allows CDI teams to resolve issues, course correct, and continually recognize and accurately report the quality of care delivered. For example, a low physician query response rate – the percentage of records that elicit a response to a query posed by the CDS – could indicate a lack of physician engagement or understanding of CDI, which would then prompt additional physician education. A low query agreement rate – the percentage of queries agreed to by the physician compared to the number of queries posed – may indicate the team needs training on the latest coding terminology so the hospital is not at risk to lose compliant reimbursement. Having metrics and data reports on hand also helps senior leadership demonstrate the impact of CDI and sustain organizational focus on the program.
Executive Engagement
Finally, senior leadership’s stewardship of the CDI program is essential to supporting continual improvement and breaking down barriers to success. In high-performing CDI programs, the team often reports to and regularly meets with a member of the C-Suite, such as the CFO or CMO. Equipping executive leadership with key data, and educating them on CDI’s direct correlation to quality metrics and financial outcomes, enables them to communicate the program’s value to stakeholders, achieve buy-in across the organization, and unite departments behind a common aim: a complete and accurate medical record.
More an ongoing journey than a final destination, CDI requires continual focus and effort to ensure hospitals deliver quality care and achieve maximum compliant reimbursement. Is it time for your organization to renew attention to CDI? To start, consider how your hospital stacks up against the following best practice metrics:
• Coverage Rate – Greater than 85%
• Physician Query Response Rate – Greater than 90%
• Physician Query Agreement Rate – Greater than 90%
• Query Rate – Greater than 30%
If your organization does not meet these numbers, there may be opportunities to enhance your CDI program to increase your hospital’s’ compliant reimbursement and improve quality measures.
