Q&A: Non-traditional CDI settings
As part of the fourteenth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Kimberly Forslund, RN, CCDS, clinical documentation specialist at Maine Health in Portland, Maine, answered these questions. Forslund is a member of the ACDIS Furthering Education Committee. Though CDI Week 2024 has now passed (September 16-20), ACDIS wanted to continue highlighting additional expert advice from our committee over the next few weeks. For questions about the committee or the Q&A, contact ACDIS Editor Jess Fluegel (jess.fluegel@hcpro.com).
Q: According to the 2024 CDI Week Industry Survey results, 47.16% of respondents report their CDI teams review pediatric cases in either the inpatient or outpatient setting, and 5.02% have plans to in the next 12 months. How does your program review pediatric cases, and who reviews them? What advice do you have for those looking to expand into pediatric CDI?
A: Our team reviews all inpatient medical and surgical pediatric cases. While some programs have dedicated CDI specialists by service line, each of us reviews a mix of all records for all admissions (with the exception of behavioral health and obstetrics) that is not otherwise a medical admission. Module training with pediatric didactics was helpful for us in orientation as it provides a broad overview of med-surg pediatric topics and considerations. Designating someone with a peds background to be a resource and reaching out to coding with questions can be another avenue for adding pediatric reviews to the caseload.
Q: The most common pediatric setting/service line reviewed by CDI teams was general pediatric inpatient admissions (42.25%), followed by neonatal ICU (NICU) chosen by 41.76% of respondents, and pediatric ICU (PICU) chosen by 38.50% of respondents. What service lines does your CDI program look at for pediatric cases, and how was that decision made? Does your program have any plans to expand into other pediatric settings or service lines? How do these reviews usually differ from reviewing cases for the adult population?
A: Our CDI team has included pediatric cases from the beginning. We review as many as we can that are DRG payers until we clear the list of all admissions, then we move on to Medicaid records for adults and pediatrics. Pediatric records differ in that there are congenital anomalies to consider as well as status of “history of” vs. an active problem after surgical interventions for issues related to congenital heart disease, for example.
Q: When asked how they track their pediatric CDI impact, 24.96% of respondents said they don’t currently have a way to track their impact. Does your program track its impact, and if so, how? Do you have any advice for those looking to start? Why do you think this might be a struggle for CDI departments?
A: Our software can pull data based on a number of characteristics (tracking codes, payers, etc.) but we do not isolate pediatric data separately from the adult population for metrics. I think it might be helpful if your team does not currently review records for pediatrics and would like to get some baseline data for impact. Adding pediatric reviews to a program that currently only has the adult population might mean taking time from reviews (and current quotas for productivity metrics) to provide education and support during this learning curve.
Q: Besides outpatient and pediatric settings, respondents were asked about other settings they currently review or plan to in the future. Almost 65% said they currently review inpatient short-term acute care cases, 83.55% review inpatient surgery cases, and 75.25% review trauma cases. Among those making plans for the future, a much smaller 4.75% said they plan to review inpatient psychiatry cases, and about 3% plan to review inpatient rehabilitation cases. What settings outside of traditional inpatient care does your CDI program review, and which, if any, are you looking into for the future? Have you noted trends of any settings growing more or less popular in recent years? What holdups do you think there are, if any, to such expansion?
A: Our program reviews all medical and surgical records that qualify as inpatient admissions, with the exception of obstetrics and behavioral health (that is not otherwise medical). Occasionally we will start a review for a patient in observation status that may flip to inpatient. If they remain in observation through discharge, we mark it “review not needed” and complete the review, as some cases will flip back to inpatient after case management/utilization review teams go over it. Our team may include other areas (obstetrics, behavioral health) in the future if our team of 25 people is able to consistently review 100% of the records we currently take on, including Medicaid, but we have no solid plans at this point to add records outside of our current focus.
Expanding requires an efficient, experienced, and fully staffed program based on the average number of inpatient admissions. I suspect that proving success and advocating for more staff based on impact rates would be the minimum that our leadership would need to consider additional hires. Training in expanded areas would also entail taking the time and resources away from current reviews and giving support and education to those who are learning a new area of focus.