Q&A: CDI internal audit tools

Q: Are any leaders willing to share their internal CDI audit tool? We are working to update ours for finding missed opportunities in the record.

Response #1: Each CDI specialist has four charts with CDI leadership randomly auditing one query each month to ensure the query was needed, compliant, and captured correctly. 

Physician Query Review

1. Was the query needed based on documentation in the record?
2. If the CDI template was available, was it utilized/designated correctly?
3. Was the query presented in a timely fashion? Did the CDI specialist allow time for adequate workup, test results, and initial physician documentation?
4. Were the query options appropriately deleted/modified?
5. Does the query include clear, concise, accurate, and pertinent clinical indicators?
6. Does the query include clear, concise, accurate, and pertinent treatment?
7. Does the query include clear, concise, accurate, and pertinent patient risk factors?
8. Was the provider query response accurately captured? (agreed, disagreed, unable to determine)
9. Was the baseline, anticipated and actual responses entered accurately?
10. Was the clinical validation box checked/unchecked appropriately for accurate capture of impact?
11. Was the date, time, and name of provider responding to the query accurately captured?

Reconciliation Review

1. Was the escalation process followed and documented?
2. Was the documentation required to resolve discrepancies at reconciliation contained within software?

Additionally, one of the four charts reviewed gets a deep dive to ensure quality of the CDI specialist’s review.

Quality Chart Review

1. Did the number of reviews compare to length of stay and opportunity?
2. Was the correct principal diagnosis (PDX) and/or alternate PDX chosen per last CDI review?
3. Are the appropriate procedures recognized?
4. Were all opportunities found that could impact PDX/DRG, increase severity of illness/rate of mortality, or add a second morbidity/co-morbidity to the chart?
5. Is the relevant clinical information contained within software to support codes/queries? 

We (CDI leadership) set our tool up to be a yes/no response and we also assigned parameters expectations. We share this metric along with query and review rates when we meet 1:1 with each CDI specialist during leader rounding.

Response #2: At our facility, each manager runs a monthly missed opportunities report for their region/CDI specialists, exports these to an Excel spreadsheet, reviews the missed opportunities, and determines whether there is a physician or CDI opportunity for improvement. The managers copy and paste each CDI missed opportunity case and discuss it with the CDI specialists on their monthly scorecard calls (we are 100% remote across the United States). 

For fiscal year (FY) 2025, we are using the CDI specialists’ opportunities for improvement as part of their monthly audit scores, as well as on their scorecards. The four criteria we are using in FY 2025 are:

1. Was the most impactful topic queried for clarification?
2. Was the query construction compliant and well written?
3. Were correct follow-ups done on the case?
4. Was the vendor technology “impact tab” correctly completed?

The health system’s physician missed opportunities report is then emailed to our physician education group, who trend and educate physicians on documentation where most needed. If the physician’s facility has a physician advisor, then the advisor may also be informed to provide one-on-one education.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.