Note from the Instructor: Is your CDI program stagnating? Get out of the rut and fast!

By Allen Frady, RN, BSN, CCDS, CCS, CRC

The basic tenant of learning CDI is learning how MS-DRGs work, and the tiered structure of CC and MCC levels. That is the first step, to be sure, but it is not the final destination. In the new era of quality based reimbursement, there are a number of growth opportunities. And yet, I believe many (if not most) CDI programs are either missing completely or performing poorly in meeting them. In the age of bundled DRGs, 30-day readmissions, hospital acquired conditions, Medicare Advantage Plans, patient safety indicators, quality reporting, and mortality rankings, if you find yourself having a harder and harder time justifying the value of proper documentation to your chief financial officer, take another look at the current state of affairs.

Let’s start with the ever present problem of denials. The ACDIS community has talked a lot this year about clinical validation, even releasing a White Paper on the topic. If your program has not moved into validating every diagnosis—ensuring the proper clinical indicators, treatment plan, and other supportive documentation is within the record for audit defense, then frankly you are behind the curve. An increased knowledge of standard practice clinical indicators, diagnostic criteria, compliance guidelines, coding rules, and general pathophysiology should be considered standard practice. In fact, we have developed an entirely new Boot Camp just for the express purpose of refreshing those clinical skills for CDI specialists with existing clinical knowledge and bringing CDI specialists from a coding background to the next level of review.

If you see your program stagnating, consider expansion into at least some of the following areas, including:

• Outpatient CDI
• Medicare Advantage audits
• Mortality reviews
• Quality reviews
• Hospital acquired conditions
• Medical complication reviews
• Patient safety reviews
• 30-day readmission reviews
• Outlier reviews
• Medical necessity reviews
• Denial reviews

While many of these areas already have reviewers in other departments, advanced CDI specialists are trained to read and discuss diagnoses in clinical terms on a more collegial level with the provider. Also, CDI specialists usually bring an unprecedented amount of coding and compliance knowledge to the table, helping them quickly determine what can and cannot even be reported as claims data. Although those rules don’t always apply to the quality abstraction criteria for some of the other data sets, CDI specialists can bridge that gap by working with other departments to facilitate a two-way exchange of information between CMS guidelines and those specific data collection agencies.

For our part, ACDIS is doing what it can to keep the wheels of progress moving forward here. We offer an excellent Medicare Advantage/Risk Adjustment Boot Camp as well as a terrific Quality Boot Camp. We also had our first ever ACDIS Symposium: Outpatient CDI, September 18-19 in Oak Brook, Illinois—let’s call it the “first annual” event as it was very successful with a waitlist of interested folks. Right now, the Outpatient CDI Workshop is underway, presenting some of the top sessions from the Symposium as webinars. Lastly, don’t forget to read our blog and the CDI Journal. Nearly every time I miss an issue and go back and read it, I find myself thinking, “It would have been nice to have seen that a few weeks ago before I had x discussion or reviewed y case.”

Lately, I’ve been hearing rumors that CDI is cooling down. Some of that is to be expected in what I call the “post ICD-10 hangover” era. Nevertheless, I find myself confused by the slowdown. With as many quality programs, documentation requirements, denials issues, public profiling concerns, etc. as there are (and it seems like more every day), if you’re unable to demonstrate the value of documentation and of your program than either you or your facility (or both) are failing where you need not fail.

There is still plenty of work to do, plenty to learn, and plenty to implement. The only enemy here is complacency.

Editor’s note: Frady is a CDI education specialist for BLR Healthcare in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.