CDI Week 2021 Q&A: CDI pantry staples (back to basics)

As part of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Maryn Griffin, MHA, BSN, RN, CCS, CCDS, CCRN, and PCCN alumnus, the clinical documentation excellence manager of second level reviewers at Orlando (Florida) Health, answered these questions. She is a member of the 2021 ACDIS Furthering Education Committee. Griffin’s contributions to this Q&A were prepared in her personal capacity and the opinions expressed herein do not necessarily reflect the views of Orlando Health. For questions about the committee or the Q&A, contact ACDIS Editor Carolyn Riel (criel@acdis.org).

Q: What are some of the “pantry staples” that you think every CDI department needs to have?

A: I believe the staple items for a CDI department consist of a mission statement, CDI software, coding collaboration, and a physician advisor. A mission statement helps to ensure that the department team members and organization are well informed on the objectives and goals of the CDI department and how they align with organizational goals. CDI software assists with the streamlining of workflow and processes to optimize the CDI professionals’ use of time and opportunity mining. Coding collaboration is a way to close the loop regarding opportunities that were found in both areas and a way to cultivate educational feedback that is beneficial for both teams. Lastly, a physician advisor is a champion and advocate of the CDI team who assists with provider education and supports physician compliance with clarification responses.

Q: What basics should a CDI specialist know when entering the field? Are there any staples of CDI you did not know when first becoming involved in CDI that you wish you had known?

A: I believe that when entering the field of CDI, a person should have an eclectic clinical background and a solid foundation in pathophysiology. I also feel that it is of great importance to know that CDI involves learning a completely different way of thinking. Even someone who was once an expert in their field can initially find it hard to adapt to being a novice in CDI. The information and data within the field of CDI are ever-changing so it keeps one on their toes and makes them a lifelong learner.

When our program first began, there was not as strong of a relationship with coding as we have now, and I personally have been able to witness how a collaborative and fiduciary relationship with coding benefits both departments and the organization as a whole.

Q: Just over one third of 2021 CDI Week Industry Survey respondents spend three to six months for onboarding and training of new CDI specialists. Over one quarter allot one to two months, and 18% only train new CDI professionals for a few weeks to a month. How long is the onboarding process in your facility? Does one month feel like enough training, in your opinion? Does six months or more feel like too much? Should training and onboarding time be customized for each CDI specialist? Why or why not?

A: Our department has recently decreased our orientation time from twelve weeks to eight weeks due to our experience with the additional four weeks not having a significant impact on the subsequent success of the orientee. This may be due to our model which includes a post-orientation mentor who is used as an at-the-elbow resource to the new team member whenever needed. The accounts reviewed by the new CDI specialist are also audited by their manager and department educators and they receive timely feedback regarding any opportunities that are found. Our department also reserves the option to extend the eight-week orientation if the CDI specialist has not grasped key concepts that would impede their success.

Q: Most survey respondents (25%) said staff are assigned reviews by software protocols (such as prioritization software). Other respondents (between 15-18%) said staff are assigned reviews by service line, based on patient census patterns, or randomly. How are reviews assigned at your organization? What are the benefits of assigning reviews each of the ways noted above? Are there risks to assigning reviews randomly?

A: Our department leverages both software prioritization and payer hierarchy for review. The software we utilize informs the CDI specialist which accounts have the most opportunity and the CDI specialist then uses that information to assist in the selection of those ranked accounts using our department’s review payer hierarchy.

There are benefits to all the review tactics listed but the riskiest, in my opinion, is the random option. This is because there may be missed opportunities due to the lack of focused reviews which yields an increased likelihood that high impact accounts will not be reviewed prior to discharge while low impact accounts will be.

Q: According to the survey, 84% of respondents noted performing concurrent reviews for quality/non-financial outcomes, and 43% of respondents performed pre-bill reviews for the same impact. These numbers were similar to those reviewing for financial outcomes. What do you think this data says about the move from solely financial-based initiatives for CDI? Why do you think is it important to incorporate non-financial reviews into typical duties for CDI specialists?

A: CDI programs hold a lot of value within organizations because the team can be utilized to support different avenues that align with varying organizational goals. Due to this fact, the expansion of CDI outside of the financial realm is to be expected because of the expertise, wide knowledge base, and attention to detail that CDI specialists possess. The field of healthcare is also experiencing a shift in culture inclusive of reimbursement methodology that is contingent upon quality of care. Due to such, the scope of quality reviews can impact the financial well-being of organizations and is an area that should be included within CDI reviews.

Q: In terms of concurrently reviewing for quality measures, 83% of respondents review for present on admission/hospital acquired conditions, 70% review for severity of illness (SOI)/risk of mortality (ROM) concurrent to stay, and 69% review for patient safety indicators. Which quality measures does your organization review for? How was it decided that these measures would be the ones to concurrently review? What are the risks of not reviewing for certain quality measures?

A: Our department concurrently reviews for the quality measures of SOI/ROM. This was decided because of the ease of implementation within our workflow and CDI software. The other areas have been tabled but are on the horizon of being implemented within the duties of CDI specialists in the near future. The risk of currently not including these other quality areas of focus is a higher likelihood of missed opportunities for concurrent clarifications regarding the exclusion of erroneous diagnoses based on errors or omissions within provider documentation.

Q: Only 24% of respondents noted rounding with physicians on the floor as part of their typical duties. Do CDI specialists round with physicians at your organization? How does rounding fit in with CDI query and physician education/engagement duties? What is the importance of rounding with physicians? Are there any negatives to CDI rounding with physicians?

A: Our department is big on physician engagement, and we round both on the medical units and with physicians. It is a department metric and a requirement of our CDI specialists. We have found that rounding with providers helps to build relationships and trust. It is also a great way to compliantly give real-time feedback and education regarding questions that providers may have and gives way to capitalizing on opportunities for verbal queries. The only downside that may come about from rounding would stem from the need for a CDI specialist to have a strong skillset with time management due to the need to balance both rounding and chart review time.

Q: Respondents to the 2021 CDI Week Industry Survey listed sepsis (67%), respiratory failure (48%), congestive heart failure (46%), and malnutrition (46%) as the top queried diagnoses. Do these align with queries you and your team are asking? Why do you think these four diagnoses tend to be the “problem diagnoses” that many organizations struggle with? What tips do you have for writing effective queries on these diagnoses? Do you have any suggestions for educating physicians about effective documentation related to these diagnoses?

A: The above listed diagnoses align with what our CDI team is asking providers. I believe that these diagnoses present the most opportunities because of their frequency of occurrence and the space of available specificity regarding the diagnoses.

Queries for these diagnoses have a standardized format with templates that have required areas of data entry for supportive clinical indicators. They are also tailored to the subject matter of the query regarding the current documentation requiring a diagnosis or the specificity of a documented diagnosis.

The education we provide to the physicians highlights the opportunities surrounding diagnoses with a focus on the impact of SOI/ROM and quality metrics that are externally reported. This helps to tell the story that our team’s aim is to have their documentation accurately display the acuity of their patients and dispel any belief that our department is solely focused on financial gain for the organization.

Q: The majority of respondents create their query templates internally with the CDI team, physicians, and/or coders. Does your facility use query templates? If so, how are those created? What are the benefits of using query templates?

A: My organization utilizes query templates that were developed internally by our department leadership team based on the types of queries that were needed regarding the scope of CDI, in addition to, the types of queries that were being sent by our team based on specific patient populations. The same templates are also utilized by the coding department for consistency. While our CDI department composed the query templates, any diagnosis definitions that are included within the templates were created with physician collaboration and buy-in since they are organizational definitions.

The benefit of utilizing query templates is standardization. This has proven to be helpful with provider compliance because they encounter the same format each time which aids with them knowing what the CDI specialist or coder is asking, and where to find the supporting clinical indicators that are being used to support the legitimacy of the question being asked.