Guest post: The world is my ashtray—Looking at the CDI process, part 1

CDI Blog - Volume 13, Issue 25

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by John Zelem, MD, FACS, and Tabitha Hapeman, RN, BSN, RN-BC

One morning, I was playing golf with my golf mate, Mike. As we traveled along, we saw litter: empty cups, wrappers, napkins, cup covers, straws, and more. Mike made the comment to me that littering like that was unnecessary and uncalled for: “Have you seen the large number of cigarette butts all around, especially in front of building and around the course?” I found it disconcerting when they were discarded on a green or tee box. Certainly, his observations were correct. He then emphatically said: “I don’t get it; do they just think that the world is their ashtray?” 

Cigarette butts are garbage, pure and simple. There is no known redeemable quality to them (but wait till later in this article). We truly know where they come from and what they are the result of. That’s easy. They are the end result of smoking a cigarette or cigar and are not biodegradable where they lie. This isn’t going to be an article debating the merits of smocking; it’s about the discarding of the product and thinking that “the world is my ashtray.”

While it may seem unrelated, I will use this analogy throughout this article for the CDI process.


When a patient is admitted to the hospital, an initial utilization review should be done. The earlier this is done, the better. A case manager typically does this review by applying commercial criteria.

Physician documentation is critical to this review process although that documentation is not always present in a timely manner. If the patient meets inpatient criteria, it is generally considered de facto evidence for inpatient admission as most screening tools are rather stringent. If the patient does not meet inpatient criteria, one of several actions occur:

  • The case manager will speak with the attending physician
  • The case is referred to a physician advisor for a second level review

There can be challenges with getting the proper documentation to support the acuity with which a patient presents to have an inpatient level of care. There tends to be variable periods of time for a CDI specialist to get involved, but when they do, they comb through the documentation intently. They are looking for specificity and accuracy in the medical record. Many times, it is lacking or unclear, and they may reach out to the attending physician in either a direct conversation or through the query process.

If something is not documented, it didn’t happen. In healthcare compliance and coding, there is no deviation from this principle. It can’t be coded if it isn’t documented, and, if it can’t be coded, one cannot bill for it. Therefore, a query is an attempt to get this specificity and accuracy documented.

When trying to contact and talk to the attending, the CDI specialist may run into one of several of the following scenarios:

  1. The curmudgeon: These physicians are often difficult to work with and cantankerous. That was me and it was not uncommon for me and others to say “…and what medical school did you go to?” Usually did not result in a very productive conversation.
  2. The runner: This is the doc who starts walking down the hall and spots a CDI specialist ahead, so they run off in another direction.
  3. The invisible man/woman: This is the doc who makes rounds at 6 a.m. or after 9 p.m. just so they didn’t have to see a CDI specialist or discuss the case with anyone.
  4. The evader: In today’s world of technology with various devices, texting, cell phones and more ways to communicate, these physicians evade responding. This type of person is not seen as much. Yet, when they do appear, they do have ways of ignoring calls and texts saying, “I never got it.”
  5. The pleaser: Essentially this is the doc who says that he/she will do what is asked and then goes ahead and does whatever they want.
  6. The collegiate: This is the doc where there is actually a great conversation and gives the information needed.

Physician advisors are becoming more prevalent in the CDI world and so they may also experience some of the responses outlined above, but they may have greater success than the CDI specialists. Physicians may not play as many tricks when it is a peer they are talking with.


While the reasons cigarette butts may not end up in the ashtray range from simple laziness to convenience, the reasons behind lackluster documentation may be more complex:

  • Top three physician barriers from an American Hospital Association survey:
    • 66.5% lack of understanding of importance
    • 47.5% lack of time
    • 38% lack of interest
  • Lack of hospital leadership commitment
  • Technology as a barrier
  • Lack of ongoing physician education
    • Lack of knowledge quality scores
    • Lack of a streamline query process
    • Not knowing what “skin they have in the game”
  • No CDI work done on weekends, holiday, and/or or evening

In the next part of this Blog series, we’ll discuss how the cigarette butt issue and CDI process are connected and share ways to “recycle” instead of littering.

Editor’s note: Zelem is the president and CEO of Streamline Solutions Consulting, Inc., in Florida. Find him on the internet at or Hapeman is the manager, resource management center, at Sentara Healthcare in Norfolk, Virginia. Find her on the internet at Opinions expressed are those of the authors and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.

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