Seven Steps to Building an Effective CDI Program
More hospitals are considering clinical documentation improvement (CDI) programs, given hospital inpatient/outpatient care rise. These programs support better clinical care and outcomes, standardize documentation, demonstrate that treatment was medically necessary and increase payments tied to quality thresholds.
Providers spend a large part of their day working with Electronic Health Records (EHR), so they’re well advised to make that time more productive. A thoughtfully conceived and implemented CDI program results in a more accurate representation of patient clinical status. This status translates into coded data for quality reporting, physician report cards, and reimbursement.
Healthcare systems that implement effective CDI programs follow a standardized process. We outline these steps below.
Step 1 — Gather Your Data and Assess Your Current State
Mapping a path to the future state starts with a preliminary assessment of current clinical documentation. This should include a review of all documentation processes and two years of Hierarchical Condition Category (HCC) data and codes. You’re looking at the completeness and accuracy of your medical record documentation and reviewing the disease process, diagnostic findings and treatment information. The assessment may reveal weaknesses in clinical documentation that cause revenue problems.
Check for revenue leakage from high claim denial rates, low Risk Assessment Factor (RAF) scores, delayed payments and problematic quality reporting. Does your quality of care meet payer contract requirements? Are you in compliance with all regulatory standards?
Depending on your internal resources, you should consider engaging an outside consultant. An initial audit should also be part of your assessment. This will reveal baseline documentation issues for clinicians, administrators and coders. In addition, a competent audit will expose what your hospital does well and what it does less well. This helps you pinpoint areas for improvement.
Step 2 — Define Your Program Scope and Approach
Understanding your current deficits guides CDI program development. The objective is simple — you want your medical records to support improved care quality and hospital profitability. This means eliminating the gap between clinical documentation and accurate coding.
Engaging a CDI provider will help you define your program scope and approach. Look for experience in nursing, pharmacy or health information management. CDI providers should know current state, federal and payer-specific requirements for coding and reporting. They should also have a CDI certification from the American Health Information Management Association.
Your CDI program scope and approach will depend on the reporting and coding deficits you need to address. Does coding comply with the new Current Procedural Terminology (CPT®)? Compliance improves reporting for other clinicians, insurance companies and accreditation groups. New CPT® evaluation and management guidelines no longer focus on the patient’s medical history, exam and decision-making (MDM). Instead, they now focus on MDM and time. This makes detailed clinical documentation critical for demonstrating the medical necessity for CPT codes used in claims.
Step 3 — Develop Your Program Staffing and Infrastructure
Your CDI leader will help you assemble your team, drawing from your facility and adding new hires, if necessary. A successful CDI team includes a physician champion. Physicians may not welcome process change, so you’ll need one of their peers to encourage participation. This early adopter can show the way, demonstrating how CDI improves patient care and reimbursement. Build your team with a range of stakeholders with complementary skill sets. Draw from your clinical, administrative, health information management and revenue cycle departments. Everyone on the team should understand the program objectives and their specific responsibilities.
Once your team is set, it’s time to select your CDI model and tools. Again, your CDI provider can recommend one or more models and CDI software, depending on the deficits you intend to address.
Step 4 — Define Your Program’s Initial Workflow and Processes
Programs designed to improve quality can be intimidating or unduly burdensome, slowing their adoption. In addition, implementation requires a time commitment from the providers, and you’ll have to account for different workflows and processes. You can help ensure a smoother transition by defining new initial workflow and processes. These should align with your program objectives and intended documentation improvements.
Documentation improvement moves more efficiently when your program has mechanisms that fit within the daily workflow. Your team can develop more effective processes by reviewing key documentation issues. These include:
- Health record reviews — Do these occur before, during or after scheduled patient visits? If physicians aren’t reviewing records or being briefed before appointments, they’re missing an opportunity to improve their care quality and reporting.
- Provider queries are critical parts of CDI and are directed to the physician for additional documentation required to assign a procedure or diagnostic code. Document provider responses in the progress note or discharge summary or in a form that becomes part of the permanent record. Queries are essential when the coder looks at inconsistent, unclear, or incomplete information. A CDI specialist should monitor queries to identify providers and coders who may need additional education and training.
You’re not looking for perfection at this point. You’re starting and should expect to see changes in the program. Encourage your CDI team to be creative and flexible. Remind them that progress comes in small incremental changes that add up over time.
Step 5 — Provider and Stakeholder Communications and Education
Your CDI program will succeed or fail on the unit cohesion of your CDI team. Work on a communications plan to introduce them to best practices in documentation and coding. Share the program objectives, craft different messages for each stakeholder group and show them how the program moves forward. This includes your proposed timelines, progress reviews, desired outcomes and how these benefit each team member.
Clear communications and education will help physicians understand the importance of specific, accurate documentation. Remember that providers have multiple demands on their time. Therefore, keep exchanges brief and use their chart notes when offering suggestions. You should also confirm that providers see regular updates on the CDI program with data demonstrating program benefits.
The CDI team can introduce best practices to other providers with the program established.
Step 6 — Establish CDI Performance Expectations
Defining clear goals and staff performance expectations drives buy-in, commitment, and collaboration. Measure specific progress indicators, share successes regularly and continue to raise the bar with new goals.
Look at the number of daily or weekly chart reviews that the CDI team completes. Monitor query rates, corresponding response rates and the need for escalation. Track the number of codes needing correction. Peer review is a time-tested way to improve clinical documentation. Over time, you should expect your CDI program to deliver on the significant indicators of success — better patient care, reduced denials and optimized reimbursements.
Step 7 — Monitor and Measure CDI Program Outcomes
This is an ongoing program with an organic connection to what physicians and staff do daily. To help ensure sustainable progress, you want to record benchmarks that demonstrate results. You also want to monitor program compliance, coding changes and new carrier guidance.
Regular CDI compliance reviews help you assess the progress of the program and its commitment to professional standards. Analysis of your program’s performance data will reveal improvements in documentation and coding. This analysis can also reveal initiatives or activities that result in little or no benefit. Good and bad news both provide practical, actionable intelligence. Eliminating waste keeps your CDI program running lean and promotes sustainable growth.
To learn more about the benefits of a CDI program, talk to your Windham Brannon advisor or contact Ceakima Golden at Windham Brannon. We have the CDI experience to help you plan, implement and sustain hospital improvements for better patient care and profitability.