Health Information Management Association of Hawaii May 2, 2013 Building A Great CDI Program! by Dana L. Brown, RHIA, CHC 1

CDI DEFINED CDI: – Clinical Documentation Improvement – Typically a concurrent record review Review occurs while the patient is “in house” and on the mind of the physician 2

Developing a CDI Program Initial steps: – Do you have a Mission Statement? – Determine the direction and goals of your program – Focus on Compliance and Integrity 3

CDI Program Components Placement of the CDI Program Qualified CDI Team Policies and Procedures Administrative Support Medical Staff Support Software & Tools Ongoing Communication and Education 4

Placement of the CDIP Where will the CDI program be within the organizational structure? Reporting? Management? » HIM » Case Management » Finance » Compliance 5

Building the CDI Team Who will be on your team? Nurses/Clinical: RNs/LPNs Coders: RHIA/RHIT/CCS Other: CPHQ 6

Skills of the Team Members Nurses: – Clinical Experience – Experience talking to physicians – Experience documenting in the record – Education – Personality 7

Skills of the Team Members Coders: – ICD-9-CM – MS-DRG assignment – Chart Review – Education – Personality 8

Educational Background of the Team Anatomy & Physiology Medical Terminology Pharmacology 2 year and 4 year degrees Clinical & technical training Certification 9

Traits of a CDI Specialist What traits make a good CDI specialist? – Inexperienced vs. Experienced – Detail oriented – Organizational skills – Clinical understanding – Understanding of coding rules – Personality! A necessity 10

Personality: A Necessity! What personality qualities make a good CDI specialist? – Quiet vs. Outgoing – Positive and upbeat – An educator type – Great at dealing with difficult people! – Handles pressure well – Willingness to interact with physicians & other key in the clinical arena 11

Coders & CDI: Teamwork No need for “us vs. them” Understanding must occur “We’re a TEAM!” 12

Understanding Roles… The CDI specialist’s role: – Concurrent chart reviews – Concurrent queries – Verbal interactions with physicians and mid-levels – Maintaining data from reviews – Interaction with the coders 13

Understanding Roles… The Coder’s role: – Retrospective chart reviews – Retrospective queries – Occasional interaction with physicians Most interaction is written rather than face-to- face – Interactions with CDI specialists 14

Working together the stronger the better! Has to be a team approach CDI specialists support the Coders Coders support the CDI specialists Develop communication Have routine meetings Discuss DRG differences Education for all Support the team! 15

Policy and Procedure Development Develop policies for: – The program’s approach – Initial Reviews – Concurrent Reviews – Frequency of follow-up – Queries – Reporting and Benchmarking 16

Review Policies Determine review methodologies: Timing of initial and concurrent reviews – After admission – After initial review Timing of follow-up reviews – Long length of stay 17

Query Policy Develop a strong query process: – Review AHIMA’s Query Practice Brief – Determine the “rules” How to query When to query Types of queries Retention of queries 18

CDI Program & Compliance CDI Program with focus on Compliance and Integrity: CDI must be included in facility Compliance Plan CDI activities approved by Compliance CDI activities dovetail with hospital &/or HIM coding audit activities (internal/external, regulatory agencies, RAC’s, etc) Regular and/or annual audits to validate program 19

Reporting and Benchmarking Policies Tracking your results: Manual tracking Automated tracking Reporting your impact: Query Response Rate “Impact” ($, CMI, Severity) By specialty or by provider 20

Administrative Support Necessary Involvement: – “Buy-in” has to be from the top down – Investment in the program Monetary Time Allocation of resources – Active participation in the CDI Team 21

Medical Staff Support Physicians understanding of role in CDI program is critical Choose a Physician Advisor or Champion – Well respected member of the staff Physicians must believe in the program and it’s benefits to patients and facility as a whole – and to them. 22

When Physicians Believe… Trust CDI specialist’s integrity Willing to interact with CDI Accepting of the query process Documentation improves 23

Software and Tools Software: – Electronic CDI computer program Tracks and trends Homegrown or “deluxe” – Automated queries – Automated tracking and reporting 24

Software and Tools cont’d. Tools: – Encoder – Coding books – CDI reference books – DRG books – Clinical resources – Internet access 25

Building a “Bridge” A successful CDI program will “Build a Bridge” joining CDI specialists and HIM Coders. The Corporate culture is that of “Bridge Builders” This “Bridge” will allow for ongoing interactions, improved communication, better documentation and greater success! 26

Building a “Bridge” (cont.) Ongoing Interactions: Regular, positive and professional interaction between CDI Specialists and Coders is the essence of a strong and successful program. 27

Building a “Bridge” (cont.) CDI Team Interaction: – Foster best interaction opportunities Formal Informal – Ask yourselves what are the best interactions and how do we achieve these ideals? 28

Building a “Bridge” (cont.) Interactions should be: – Positive, encouraging and supportive – No punitive results – Educational: Clinical Coding – Sharing of ideas and concepts 29

Building a “Bridge” (cont.) Interactions continued…. Don’t engage in us vs. them discussions Realize everyone has knowledge to offer Don’t focus on negatives…educate Remember we are all part of the same team – We are all working toward a common goal…good documentation and great patient care. 30

Building a “Bridge” (cont.) Communication Opportunities: Meetings… – Have all the participants of the CDIP come together to develop the plan for the program – Document goals – Determine how to present the message of your CDIP 31

Building a “Bridge” (cont.) CDI & Coder Communications: Keep the focus on: – The good of the patient – The good of facility – The good of your program 32

Building a “Bridge” (cont.) Results of Communication: – Trust is developed – Understanding of roles – Realization of the support provided Teamwork! 33

Building a “Bridge” (cont.) Communicating with the Medical Staff: – CDI Participation in physician meetings – Required interaction during review process Physicians want to document appropriately 34

CDI Team Education Regular education on coding Regular clinical education Attendance at local, state and national conferences 35

Medical Staff Education Orientation of new physicians to the CDIP Continued education through verbal query opportunities “Tip Sheets” & reminders Annual Reviews and Reporting 36

Maintain Your Program Continuation of education Continuing need for growth Continuing evaluation of the operation of your program – INCLUDE outside audits. Ongoing promotion of your CDI Program! 37

Monitoring of CDI Program Validity of queries generated Validity of working DRG assignments Validity of CDI specialist’s DRG assignments Missed query opportunities Retrospective query follow-up rate 38

Observation of CDI Query Process Supported by clinical evidence and what was the clinical evidence Asked in a non-leading manner Response by provider through appropriate documentation in the patient’s record 39

Successful CDI Program Components are in place Support from Medical Staff Support from Administration Measurable Success Program Compliance & Integrity 40

Success! Tangible: – Increased CMI – Increased Severity – How to measure success?? Intangible: Better communication Cultural dynamics – Compiance Program – reaudits – compliance plan outside auditors… – Etc.. 41

THANK YOU FOR JOINING US! Dana Brown, RHIA, CHC President Reimbursement Management Consultants, Inc. (800)