Clinical documentation improvement (CDI) is the process of enhancing medical data collection to maximize claims reimbursement revenue and improve care quality.
In addition to its impact on patient care, the quality of data generated within the electronic health record and elsewhere in the organization is increasingly tied to cost efficiency under value-based reimbursement models.
Payers rely on clinical documentation and accurate coding to justify value-based reimbursement, which enhances an already strong imperative to ensure that documentation is complete and accurate.
Lackluster provider notes could result in value-based penalties. In some cases, healthcare organizations could have earned an incentive payment, but clinical documentation failed to demonstrate the achievement to payers.
Medicare also strives to improve clinical documentation among the program’s fee-for-service payments. CMS developed the Medicare Severity Diagnostic-Related Groups (MS-DRGs) in 2007, which aims to pay hospitals more for treating higher-risk patient populations.
Rather than rely on a cost-based reimbursement system, the MS-DRG codes, as well as their secondary complication/co-morbidity and no complication/comorbidity codes and their tertiary major complication/comorbidity (MCC) codes, reflect the severity of patient cases.
Neglecting to accurately document MS-DRG and supporting codes will result in decreased revenue.
The top barrier to effectively implementing a CDI strategy is a lack of understanding among staff about strong documentation practices, according to two-thirds of CDI specialists participating in a 2015 survey.
As payers attempt to accurately reimburse providers for patient conditions and improved outcomes, healthcare organizations are turning to CDI programs and staff to increase understanding of the importance of good documentation and help maximize revenue.
What are the benefits of a CDI program, how can organizations establish one, and what are the considerations for the program’s success?
What are the benefits of a CDI program?
Clinical documentation improvement can have a clear benefit for hospital revenue cycles.
Nearly 90 percent of hospitals that used CDI solutions earned at least $1.5 million more in healthcare revenue and claims reimbursement, a 2016 Black Book Market Research survey found.
The additional revenue primarily stemmed from case mix index enhancements generated by CDI programs, said 85 percent of hospital finance leaders.
Hospital case mix indices measure the average severity level of cases treated within the organization. Higher case mix indices indicate that hospitals are treating more complex cases and should receive higher reimbursements for their efforts.
Increasing case mix index can significantly boost revenue. After implementing a CDI solution, Arizona-based Summit Healthcare Regional Medical Center increased the organization’s case mix index by 20 percent, with major complication/comorbidity capture rising 37 percent and complicating condition identification growing 22.8 percent.
The case mix index and additional diagnoses capture translated to over $558,000 more revenue in just a few months.
In addition to revenue enhancements, CDI also advances patient care. Care team members can collaborate and create personalized treatment plans when they have access to an accurate and detailed patient record.
As a result, provider and organization performance on key quality measures may improve. For example, Heritage Valley Health System in Pennsylvania reported a significant patient care improvement after implementing a CDI initiative. Better documentation and coding reduced their predicted mortality rate by 27 percent.
In light of financial and patient care advancements, more hospital leaders are putting clinical documentation higher on their priority lists. The Black Book survey revealed that about three-quarters of hospitals put CDI on their 2017 budget agendas.
How healthcare organizations implement CDI programs
Healthcare organizations should consider the following steps to establish a sustainable CDI program.
First, healthcare organizations should evaluate their current clinical documentation, coding, and revenue cycle performance, advises Tammy Combs, RN, MSN, CDIP, CCS, CCDS, director and lead nurse planner of HIM Practice Excellence for AHIMA.
Providers should start by conducting a gap analysis to identify documentation issues in the following areas:
- Patient population
- Severity of illness and/or risk of mortality
- Patient safety indicators
- Hospital-acquired conditions
- Key quality measures
- Claim denial rates
- Hierarchical Condition Categories
Understanding where documentation challenges occur should help leaders to focus their programs on areas where revenue leakage is most prevalent.
Second, healthcare organizations are going to need a multi-disciplinary team to lead the CDI initiative. Coombs suggested that healthcare organizations consider the number of staff they require, credentials needed for CDI staff (i.e. RN, RHIA, RHIT, CCD, CDIP), equipment required, and office space.
The CDI team should also include clinical documentation improvement specialists, stated industry experts at Elsevier and QuadraMed. The specialists should have a Clinical Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification as well as nursing, pharmacy, or health information management experience.
In addition, the team should include stakeholders from across the health information management, utilization review, revenue cycle, and clinical departments.
Healthcare leaders should then decide on whether or not an automated clinical documentation solution is appropriate. Organizations have a number of options when it comes to software or outsourcing solutions from vendors.
Large and community hospitals have generally found success with outsourcing services. Nearly one-half of hospitals with over 200 beds have outsourced clinical documentation functions, such as auditing, reviewing, and programming, the 2016 Black Book survey found.
The number of large and community hospitals using outsourcing solutions almost doubled since ICD-10 came into effect in 2015.
Other hospitals have turned to software or system implementations from top vendors in the field. Black Book named Nuance Communications as the top-ranked CDI vendor in terms of client experience and customer satisfaction. The company also outperformed its peers in content management, abstraction, and speech recognition.
Other high-ranking CDI vendors included Optum360, nThrive, M*Modal, Navicure, FastChart, Streamline and 3M Health Information.
Selecting the right vendor and solution is critical to realizing financial gains, explained Mandy Rogers, a registered nurse at Summit Healthcare Regional Medical Center.
“One of the biggest boosts was the CDI software that we got because it really guides you and it helps you keep track of what you’re doing,” she said. “The other thing was that we got a four-day boot camp that our vendor brought. It taught us everything we needed to know; it gave us books that we still use right now, every day.”
While using the power of technology can certainly boost clinical documentation and coding accuracy, healthcare organizations may also want to consider a human solution.
Physician advisors are clinically experienced professionals that act as a bridge between providers and other staff to support CDI, utilization review, and claim denials management.
Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, a physician advisor at ProHealth Care in Wisconsin, explained that she is the physician closest to the nursing staff and other roles that manage documentation. She helps the providers and staff members ensure clinical documentation is accurate for claim submission and provides assistance when CDI staff need query physicians.
“I’m the person that they can go to to have that conversation and break it down for the physicians in a way that they can understand since it is coming from somebody who has a clinical background,” she said. “Coming from somebody who can say, ‘Yes, I know this is difficult. Yes, I know this sounds like a silly question, but here’s why we're asking it and why I need you to answer.’”
Finally, once CDI teams and solutions are implemented, healthcare organizations should create staff and physician educational campaigns to foster continuous improvement.
Health policies and claims reimbursement rules are constantly evolving. Ongoing education for physicians, as well as other staff who work within the medical record, is key to sustaining documentation advancements.
Healthcare organizations should consider regular webinars, articles, workshops, and team collaboration events, Coombs suggested.
Overcoming the challenge of physician buy-in
Implementing CDI technology helps to automate documentation and coding improvements. But just 13.5 percent of CDI professionals stated in a 2015 survey that a strong technology platform was the most important factor that will result in CDI program success.
CDI professionals overwhelmingly pointed to physician buy-in as the key to success. But physicians often view CDI efforts as another administrative burden.
Physicians spend about six hours a day performing EHR data entry, including clinical documentation, order entries, and billing and coding functions. As administrative responsibilities detract from patient care, physicians may resist adding CDI duties to their already full plates.
Providers are trained to understand how to take care of patients, explained Ugarte Hopkins, but their education doesn’t typically include understanding payer rules for clinical documentation, utilization review, and other factors that influence revenue.
Prior to her tenure as a physician advisor at ProHealth Care, CDI efforts were siloed. Nurses primarily managed CDI and coders stuck to coding. Physicians only came into the equation when nurses or coders had an issue arise in the medical record.
Consequently, providers were unfamiliar with how clinical documentation impacts claims reimbursement and even how documentation and coding worked in general.
Baptist Health South Florida’s Corporate Medical Director Lorena Chicoye, MD, also ran into this challenge after her organization transitioned to ICD-10. She discovered that many of her physicians had not even opened an ICD-10 coding guide despite the coding system’s looming implementation.
“We actually showed them the ICD-10 code books, which they had never seen before,” she stated. “Physicians don’t usually see coding books. They had never seen one before.”
To increase physician buy-in, healthcare organizations should include physician champions on CDI teams, the experts at Elsevier and QuadraMed advised. Providers may feel more comfortable learning from a peer, especially one who speaks the same language.
“Most of the issue that I’ve seen is a difference between ‘doctor-speak’ and the language of coding,” explained Rogers. Sometimes the physicians don’t quite get the difference between what the coders do and what we do, and they don’t always get why we’re querying them. That’s where I’ve noticed the biggest gap of understanding.”
Making CDI and coding resources available to physicians is also critical to increasing physician buy-in, Chicoye stated. While ICD-10 launched in 2015, her organization still had CDI specialists on the floor with physicians to review medical records for documentation and coding issues a year later.
Considering value-based care when improving clinical documentation
Revenue enhancements are an attractive entry point into CDI, but organizations should not forget the potential positive impact on care quality.
Value-based reimbursement calls on healthcare organizations to implement team-based care, in which providers from across departments and even community resources come together to develop personalized care plans.
Ensuring accurate and detailed clinical documentation is present for every patient is critical to keeping all providers updated on a patient’s condition. With better clinical documentation, providers can identify and correct care gaps.
Additionally, providers can glean meaningful insights about their performance on quality metrics from their clinical documentation and coding. But focusing too heavily on how CDI can maximize revenue can lead to data integrity issues that impact care quality, explained Catherine Porto, RHI, University of New Mexico Hospitals Executive Director of HIM.
“Under the Evaluation and Management (E/M) billing system we’re using, physicians have become so focused on the elements to get a specific level for their billing that they don’t really pick up the specificity or the diagnosis, and they don’t tie the two together with their assessment and plan,” she said.
“They just learn what the billers want and give them the bare minimum, because they don't always have time for all these other things. So the chart doesn’t become a clinical document anymore, and it doesn’t tell the patient’s story well.”
Lacking a comprehensive patient story can harm performance on quality measures. Without robust, accurate data located in the medical record, providers may be missing critical information that can help them to risk stratify patients, develop personalized care plans, and report quality data for incentive payments.
More robust data integrity also supports providers as they strive to improve quality performance. Comprehensive data can help providers catch a potential complication before it arises, shortening hospital stays and improving patient safety.
AHIMA and the Association for Healthcare Documentation Integrity (AHDI) suggest that healthcare organizations couple CDI efforts with quality assurance (QA). CDI may encourage providers to document more in the name of data integrity and value-based reimbursement. But more data does not necessarily mean quality data.
Common errors in data integrity and clinical documentation include misplaced additions or deletions of notes, misusage of medical terms, abbreviation use, incorrect patient demographics, and author identification errors.
“A QA program can effectively address each of these issues to ensure quality of care and continuity of care, and to decrease physician and clinician frustration while streamlining and supporting the documentation process,” the organizations explained.
As value-based reimbursement continues to take over the industry, clinical documentation requirements are unlikely to subside. Payers are pushing for more accurate provider and clinical data to not only tie reimbursement to value, but improve care quality overall.
Developing a CDI program can support providers as they transition to a data-driven, value-based reimbursement model.