Home  |   Subscribe  |   Resources  |   Reprints  |   Writers' Guidelines

April 2017

How to Avoid CDI Snares
By Selena Chavis
For The Record
Vol. 29 No. 4 P. 20

Industry professionals weigh in on how to keep initiatives from getting tripped up.

Clinical documentation improvement (CDI) has carved out a strategic niche in today's clinical operations. Hospitals and health systems increasingly recognize the value proposition of these programs and are willing to dedicate the resources needed to make them impactful. Yet, even the best industry practices face challenges to ongoing optimization. As a result, their progress may plateau.

"Often, when a CDI program is initiated, there are remarkable results with an increase in case mix index [CMI] and responses from the physicians," says Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, chief operating officer at First Class Solutions, Inc. "However, the increased querying as a result of ICD-10, coupled with the routine querying to obtain a specific CC [complication or comorbidity] or MCC [major complication or comorbidity], creates excessive interruptions for the physician, and they become query weary."

Physician response is one problem, but sometimes initiatives simply lose focus or have the wrong focus, suggests Anthony Oliva, MD, vice president and chief medical officer (CMO) at Nuance Communications. In Oliva's last position as a hospital CMO, the organization garnered a nice bump in CMI and severity-adjusted mortality rates following implementation of a CDI program. After a year, however, the CMI faltered, and the severity-adjusted mortality reverted to nearly its previous rate because CDI review efforts had shifted away from a primary focus on Medicare to all payers. The result was a loss of approximately $1.2 million.

"Even though they had a better blended rate, they were losing the value of potential opportunities on the Medicare side," Oliva says.

Thomas Powell, MD, associate vice chancellor and chief medical information officer (CMIO) at the University of Arkansas for Medical Sciences, says many organizations struggle because they overemphasize case mix to compensate for revenue loss by developing strategies to upcode when the focus should be appropriate code capture. "The Centers for Medicare & Medicaid Services rapidly caught up with these initiatives," he says. "Systems that try to make physicians code and document for reimbursement can break workflows, making care less safe."

Juliet Ugarte Hopkins, MD, CHCQM, physician advisor for case management, utilization, and clinical documentation at ProHealth Care in Wisconsin, notes that lack of clear communication with providers can also cause a program to waver. "Without clear education to the providers that they can understand and appreciate as being meaningful, initiatives run the risk of falling flat," she says. "The providers will almost never be too interested in or excited about the information presented."

Dunn agrees, adding that promoting a program as a means to improve the hospital's reimbursement is a sure way to kill physician support. "Physicians and caregivers wish to have documentation that supports the treatment of the patient, so the emphasis must be on how clearer documentation will support the care by others and communicate clearly the rationale for treatments initiated or planned," she says. "The goal of any program that requires physician or provider [hospital] collaboration must have benefits for both parties."

Identifying Process Improvement Opportunities
The reality is that many pitfalls exist to disrupt long-term CDI success and sustainability. As such, industry experts agree that health care organizations must be resolute in their efforts to pinpoint problem areas and optimize documentation practices. The following steps can enhance a CDI initiative's outlook:

Define Your Program
As a first step, Powell suggests health care organizations define CDI to their staff. "As a chief medical information officer, I care about using improved, codified documentation to achieve adequate data quality in our electronic records to provide advanced analytics," he says, pointing out that revenue cycle initiatives tend to get the most attention and create the most controversy when CDI efforts are introduced. "The data can be used to drive improvements in patient care, patient satisfaction, process improvement and efficiency, system usability, and improved revenue cycle performance. Institutions should look to their informatics leadership, like the CMIO, to drive CDI initiatives, which seek proactively to improve information gathering."

Engage the Physician Community
If one isn't already in place, finding a physician advisor is advisable for organizations achieving subpar results, Ugarte Hopkins says. While CDI teams are made up of many knowledgeable professionals, she says when it comes to engaging the physician community, there is no substitute for peer-to-peer communication. "If nothing else, a fellow MD or DO can honestly empathize with the medical staff regarding the nonclinical demands that no one wants to deal with," Ugarte Hopkins explains, adding that taking this measure can help organizations identify problem areas and devise strategies to address them. "Having this 'in' gives your CDI and coding team a strong ally who not only can communicate with the providers but also can provide much needed education in a way the docs can understand and appreciate."

Review the Query Process
Dunn notes that a poorly managed physician query process can negatively impact a CDI initiative. She suggests assessing the type and frequency to determine whether physicians are at risk of query burnout. In addition, Dunn says coders and CDI specialists run the risk of becoming disillusioned with the process. "If they encounter resistance from one or more physicians, they may avoid querying those physicians," she says. "This does not help the organization or the physician. And if the physician's documentation is sufficiently unclear as to disrupt the care of the patient, then the patient will not benefit either. In these situations, a physician leader must intervene."

Reviewing the timeline for CDI queries is also important, Ugarte Hopkins says. "Does your process simply involve the query going out to the provider, waiting two weeks, and then closing it out if unanswered?" she asks. "It should be time-sensitive and not too long, involve reminders from the physician advisor along the way, and include all pertinent information the provider needs to complete the query."

Ugarte Hopkins, who says queries should be completed in no longer than eight business days, recommends CDI professionals include instructions on how to amend the medical record after discharge, in addition to information on whom to contact should there be questions or problems.

Assess Review Data
CDI optimization is often unrealized because review processes are too limited. Oliva notes that health systems get into trouble when they are not reviewing enough of the most appropriate cases that impact both CMI and severity. "Often, they are doing pretty good, and then all of a sudden their review rates for Medicare drop," he points out. "The reason we focus on the Medicare population is partly because they are a DRG [diagnosis-related group] payer, but a big chunk of why we focus on them is because they are the populace that is going to carry the risk of all those comorbidities that drive these opportunities."

Oliva recommends reviewing cases at least twice and preferably three times. "Many times, it's a third review that will give you potential for a principal diagnosis case or the opportunity for that second and third MCC to drive severity," he says.

Improving Without Creating New Problems
Identifying process improvement opportunities is one part of the equation. Putting them into action without disrupting workflows or creating additional problems is another. Powell says the best strategies start with the use of informatics experts such as the CMIO to engage leadership and clinicians in a joint initiative.

Ugarte Hopkins stresses the importance of unified participation and standardization. "Along with written communication, consider arranging for your physician advisor and a seasoned clinical documentation specialist to hit the road and meet with providers in their offices to make sure the information gets through," she says. "This is also a perfect way to make sure questions are asked and answered if there is any confusion or misconceptions."

In addition, Ugarte Hopkins says standardization and consistency are necessary. "While you want to take into consideration what will work best for your providers to accomplish the goals you have set and encourage compliance with the process, beware losing standardization as a result," she says. "If you allow each individual physician to request their own personal methods and timeframes of communications and reminders, your CDI team will spend half of their day creating a tailored experience for each provider."

As a best practice, health care organizations can collect data from select providers and construct an easy-to-follow plan for all physician stakeholders. Once designed, HIM leaders can educate the CDI team and the providers, tweaking systems as needed when process improvement opportunities are identified. "While some adjustments will make sense, avoid a situation where Doctor A wants a text page on day five and then a call to his cell on day seven, and Doctor B wants a message left with his office nurse on Mondays and Wednesdays," Ugarte Hopkins says.

Successful CDI initiatives don't skimp on resource allocation. Dunn cautions that if there is insufficient staff to consistently conduct CDI efforts or if staff are rotated or stretched too far, then clinical documentation education will not be sufficiently reinforced at the intervals necessary to result in physician practice change.

In terms of resource allocation, Oliva notes that some health care organizations make the mistake of diverting the attention of CDI professionals to areas outside their scope. For instance, quality metrics reporting and value-based care are receiving a lot of attention these days. As a result, some clinical leaders are tempted to use CDI teams to analyze hospital-acquired conditions and mortality reviews to identify opportunities around a particular diagnosis.

Don't fall into this trap, Oliva cautions. "Pretty soon what will end up happening is that they are spending a bulk of their time doing these things. Now, you've created a problem because they can't do the normal work they were used to doing," he says. "This falls into the same category as going out and reviewing all payers instead of Medicare payers, thereby decreasing the impact on the Medicare side."

According to Powell, successful, sustainable initiatives are possible when collaboration between team members exists and everyone is working from the same playbook. "Identify the essential elements of documentation that appropriately establish CMI, justify care, and tell the truthful story of the patient. Also, allow for noncodified 'artistic expression' in the notes," he says. "Work on lean workflows to efficiently capture these, not expecting the clinician to be a coder. The biggest myth is that the clinician has any idea how to code these cases appropriately."

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.


Designing effective clinical documentation improvement (CDI) models that drive consistent performance improvement is no easy feat. With that in mind, the CDI team at ProHealth Care in southeastern Wisconsin created an eight-business day model that is setting the stage for long-term success.

"These eight days start from the time the query is initially sent, not from the time the patient is discharged," says Juliet Ugarte Hopkins, MD, CHCQM, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care. "I have educated the providers that the CDI query clock starts immediately upon receipt of a query and does not stop ticking when away from the office, on vacation, or otherwise off-service."

When a CDI query remains open and requires attention, providers receive a precise series of reminders. For example, two days after a clinical documentation specialist (CDS) routes the initial query within the EMR, another message is sent to the provider in addition to a call to the office or a text page. If the query remains unanswered on days four, six, and the morning of day eight, the CDS informs Ugarte Hopkins via e-mail. She then sends communication to the provider about the unanswered query via fax, EMR message, or secure e-mail.

"Within my communication is identifying patient information, the date the query was originally sent, the date of discharge, and the diagnosis which is being queried, in addition to the time and day the query will permanently close," Ugarte Hopkins explains. "There is also generalized information regarding the purpose and importance of CDI queries and directions on how documentation can be amended in the electronic medical record following patient discharge."

Over the first three months of this new process, ProHealth Care's unanswered CDI query rate decreased 55%. Two quarters later, it fell 73% below the organization's baseline. While a significant amount of additional effort is being put into this process, Ugarte Hopkins points out that the work has clearly made a difference.

"Along with the electronic and paper reminders putting the work front and center in the minds of our providers, the process has also prompted thoughtful questions about what is needed and why. I have happily fielded questions from providers after they received a message from me, further strengthening the educational aspect of this process," she says.

— SC