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May 2019

All-In for All-Payer CDI
By Elizabeth S. Goar
For The Record
Vol. 31 No. 5 P. 10

While expanding a clinical documentation improvement program comes with some risk and headache, the potential rewards are alluring.

While clinical documentation improvement (CDI) programs have been around for decades, they have remained focused primarily on the quality of documentation in government programs, including Medicare, Medicaid, and incentive efforts. An emerging trend, however, is seeing CDI initiatives expand to include improving documentation to meet the needs and expectations of all payers.

The effort is being driven largely by an increased emphasis on quality of care as the industry transitions to a value-based environment.

“With a value-based future and the focus of the industry transitioning from finance to quality, expanding CDI programs is of strategic importance for health care organizations,” says Chetan Parikh, CEO of ezDI. “There are numerous benefits, such as the ability to capture quality metrics for all payers across the entire patient population [and the] complete, compliant, and accurate documentation and data on hospital-acquired conditions [HACs], readmissions, and patient safety indicators [PSIs].”

Other benefits include optimal revenue capture and reimbursement, as well as authentic hospital profiling and quality reporting, Parikh says. “All these lead to a hospital’s positive brand image in the industry, especially among its patient population,” he notes.

The Decision to Expand
While the benefits of an effective CDI program can be felt across an organization, the first push to expand it to encompass all payers often originates with the HIM director or another leader who may have noticed areas for improvement. The catalysts vary, from a significant number of postdischarge coder queries to payer populations that aren’t undergoing CDI review that have historically carried a lower case mix index (CMI), says Autumn Reiter, director of CDI at TrustHCS.

“Additionally, an audit of the cases not reviewed by CDI may have also shown opportunity, leading to an increased interest in an all-payer review,” Reiter says. “This information is then normally brought to the attention of administration. It is then that the approval for an all-payer expansion is routinely given.”

Expanding CDI to all payers does carry a potentially hefty price tag. For example, additional staff may have to be hired.

“Finding trained professionals to take on the role and the additional overhead that can come from that can be a challenge for facilities,” Reiter says, adding that “although financial impact will likely be noted, this should not be the focus of an all-payer review—chart precision should be. The hope would be, that with increased chart accuracy, financial impact will follow. Even small increases to CMI and SOI/ROM [severity of illness/risk of mortality] can have a large impact for the facility.”

The benefits to be realized from expanding CDI can be widespread, Reiter says. For example, it’s likely to result in more accurate documentation for all patients. In addition, health care organizations can expect more appropriate reimbursement for services, properly reported diagnoses data, and improved quality metrics.

Brandon Martin, vice president of client solutions at Harmony Healthcare, says there are pros and cons to expanding CDI to all payers. The latter list is the shorter of the two and comes into play primarily when a facility attempts the expansion without adding staff, which runs the risk of inefficient prioritization that could result in missing high-priority Medicare cases and potentially reducing the clinical expertise of clinical documentation specialists if the expansion requires them to review new or different specialties.

On the pro side—assuming the reviewer possesses the necessary clinical expertise to properly evaluate the record—there’s an “increased opportunity to properly capture documentation that directly impacts hospital quality scores,” Martin says. “Providers without automated notifications/escalations of potential [PSIs] and [HACs] cases would mitigate quality score risk and optimize value-based payments. Reviews of all payers allows the opportunity to evaluate present on admission considerations and clinically evaluate potential exclusions for PSIs and/or HACs.”

Martin says a CDI program expansion to all payers is likely to decrease readmission and denial rates, creating an exponential return through expedited accounts receivable, lower collection costs, and fewer instances of outsourcing denied claims. Proper capture of SOI and ROM, and increased reimbursement under both Medicare severity diagnosis-related group (DRG) and all patient refined DRG assignments are also benefits, he adds.

Proceed With Care
While the risk of expanding CDI to encompass all payers is far outweighed by the reward, hospitals should nonetheless proceed with caution, according to Parikh.

There are various pitfalls that necessitate a cautious approach, such as “physician burnout, as many physicians have yet to come to terms with inpatient CDI and burdening them on the outpatient side will only increase the burnout. CDI burnout can also be an issue due to lack of resources such as staffing, human skills, or technology tools,” he says, adding that “outpatient CDI is much more complicated and different than inpatient CDI, hence navigating this path with a lack of expertise and skills can result in failed expansion.”

For health care organizations that haven’t previously undertaken any significant CDI expansion, starting small is the best approach. Doing so will help avoid falling “into the trap of blindly trusting any CDI process or tool without due diligence, seeking phenomenal benefits from them, and risk wasting massive investments,” Parikh says.

Instead, aim small and pilot various processes and tools to become familiar with them while looking for small-scale, quantifiable payoffs. This will support the business case for a large-scale expansion. A good starting point is “addressing pain points that your organization has, such as denials, medical necessity, and physician education,” Parikh says. “Always make it a strategy to take the perspective of as many peers or professionals who have already embarked on their CDI expansion journey [as possible]. This will give you valuable insights.”

Parikh adds that while most CDI professionals are already acquainted with the inpatient side, significant workflow adjustments are required to expand into the outpatient sector. The sheer volume of patients, multiple patient encounters, the different documentation requirements of various payers, and a short duration to review a record all must be taken into consideration when designing a workflow for outpatient CDI.

Artificial intelligence–driven technology can be leveraged for a smooth transition to outpatient workflow. For example, these tools can prioritize worklists based on hospital initiatives, streamline the query process, help CDI collaborate with other departments, and educate staff on the latest industry developments.

“Staffing for the outpatient CDI program will have challenges—for example, the number of notes to be reviewed will be reduced since the patients are seen more quickly. Hence, educating CDI professionals takes on added importance. Also, skill sets need to be upgraded and aligned with best industry practices,” Parikh says. “Before rolling out a CDI program, there has to be someone within the team who is an expert in outpatient CDI. If you do not have one, then hiring a consultant will be a best way forward.”

Martin goes a step further, recommending an experienced consultant be brought in to conduct a comprehensive department review. This analysis should include the following:

• a staffing assessment and plan;
• the creation of a workflow plan, including a prioritization plan for chart reviews; and
• physician education or, at minimum, ensuring they are aware of the expansion.

“Staffing assessment and delivery is the No. 1 variable for program expansion success. If the hospital is desiring to hire internally, a formal training program must be included to maximize the investment. Utilizing outsourced CDI consultants to supplement concurrent review coverage has [also] proven successful for numerous health systems,” Martin says, adding that “a plan on paper that lacks an understanding of the available talent in the market and the associated cost often sputters.”

Rollout Timeframe
According to Reiter, how quickly an expanded CDI program can be implemented depends on the following:

• the amount of available manpower;

• the success of educational efforts surrounding additional reviews and providers rendering services to these groups; and

• administrative backing.

“Some programs may have the ability to go all in and add the additional payers at one time, whereas others will be more successful adding payers one by one until all are under review. Keep in mind that it may take three to six months to really start to see the impact of CDI’s efforts,” Reiter says.

Whatever the final timeframe, Reiter believes every organization’s goal with CDI expansion should be to promote the accuracy of the records going out the door. An all-payer review will help facilitate this from all sides.

“If there are concerns on readmissions, increased chart coverage will allow for clarification on the reason for admission. The same can be said with clarifying hospital-acquired conditions. If CDI is reviewing the chart, they have the opportunity to ask the questions to clarify events that may appear unclear in the documentation,” she says. “All departments will benefit from an all-payer review due to the increased precision in the record that comes with a CDI review.”

— Elizabeth S. Goar is a freelance writer based in Tampa, Florida.


According to Brandon Martin, vice president of client solutions for Harmony Healthcare, any initial phase of a clinical documentation improvement (CDI) program is best performed by outside experts who have undergone a formal review to determine their experience and resources, including reference checks.

“New programs require early momentum and we often see investments that are wasted primarily because the added reviews are performed by less-than-expert clinical reviewers,” he says. “Utilizing a partner with expert staff virtually guarantees the opportunities for improvement are identified.”

Martin says outsourced consultants can be leveraged for other value-added services while performing reviews. For example, they can perform the following:

• real-time physician education;
• peer-to-peer reviews with newer clinical documentation specialists for live expert training; and
• query compliance reviews on staff and for internal templates.

“I’d say 90% of hospitals are better off outsourcing CDI expansion. Even the sharpest critical care nurse needs three to six months of formal training and probably an additional year of hands-on experience with weekly feedback to be what we define as a producer,” Martin says. “From there, they would need experience within multiple clinical settings and multiple environments to be considered a consultant.

“A mix of new clinical documentation specialists and outsourced personnel whose focus is on knowledge transfer is ideal. It solves short-term goals such as cultural acceptance and improved metrics,” he continues. “Long term, you grow your internal intellectual capital through the right partnership and ultimately reduce cost once that transfer reaches the producer-level employee.”