Guest post: Point of saturation of CDI Programs: Myth or reality

By E.S. Damalie, MD, FACHE, FHFMA, RHIA, CCDS, CDIP, CCS

Naturally, most programs or processes get optimized at one point or another all things been equal. Such ‘steady state’ should reflect a high level of optimization holding all other factors constant. Do CDI programs ever get to this state?

Proponents of continuous improvement will argue that there is always room for improvement. But what markers and or indicators are used for the assessment of CDI improvement? Is it the case-mix index (CMI), CC/MCC capture rate, medical necessity denials rate, DRG downgrade denials, number of cases reviewed daily, or the complete clinical documentation improvement in the medical record for all parties involved in taking care of the patient? Clearly some of these parameters are finite and are not continuously expandable.

Remember: CMI cannot increase infinitely if service lines and all other conditions remain the same, so too with CC/MCC capture rate. You also cannot possibly have a zero denials rate be it for medical necessity or DRG downgrade.

CDI programs which have reached a steady program success rate with somewhat stagnant improvement measures should be looking at the scope of the CDI program to determine what other opportunities the team has yet to cover?

Is outpatient an option? Is clinical appeal a possibility? Will venturing into behavioral health be an option?

In doing so, focus should not be taken off what has been built up over the history of the CDI program.  A large part of any CDI program is trying to change providers’ behavior. If the focus is taken off that, providers often relapse back to their former state of poor documenters. And yet a program that is not continuously reinvigorated and energized will die a slow death.

How quickly any CDI program (CDIP) can reach that steady state/point of saturation depends on multiple factors such as the skill set of CDI staff, the functionality of the CDI program and the constancy of other factors such as service line, administrative support, general acceptance of the program by providers, consistent support from a physician champion, etc. (all designated as S factor in the equation below). This relationship can be summed up as:

Ps = Fcdip + PKcdip + S

Where:

Ps = Point of Saturation

Fcdip = Functionality of the CDI Program

PKcdip = Professional Knowledge & Skill set of CDI staff running the CDI program

S = Serenity Factor (which include such factors such as service line, administrative support, general acceptance of the program by providers, consistent support from a physician champion etc.)

Generally, a high functional CDIP will reach a steady state more quickly than a low functional one will. Having CDI staff with high professional knowledge and skill set will also facilitate the attainment of point of saturation quicker. Similarly, having a high/consistent element of administrative support, general acceptance of the program by providers, physician champion and favorable service line (Serenity Factor), will help the program attain Ps, quicker too.

Yes, CDI programs can reach that steady state depending on the indices used in assessing them. It behooves those running the program to look out for other areas the CDI program can expand to in addressing CDI program from the holistic stand point. In doing so, and also not allowing the initial gains made to go downhill, many a CDI program will stand in a position to play their key role in today’s hospital operations.

Editor’s note: Damalie, a physician and CDI specialist, is currently affiliated with Serenity CDI+ Solutions, which offers CDI, appeals and denials management, coding and auditing, and other revenue cycle services. Currently a fellow of both the America College of Healthcare Executives and Healthcare Financial Management Association, he also serves on the ACDIS CDI Practice Guidelines Committee, and as chairman of the Certification Committee for the Southern California Chapter of HFMA. He. The opinions expressed do not necessarily reflect those of ACDIS or its advisory board. Contact Damalie at serenityCDIplus@gmail.com.