Why the world should care about CDI

by Katherine Rushlau

It’s a question asked by many new to the CDI field: “What is CDI?” When I first interviewed for the CDI editor position at ACDIS, I quickly Googled the term, finding translations like “customer data integration” and “capacitor discharge ignition.” Clearly, I had no idea what I was getting into.

While I soon learned the acronym “CDI” in the hospital setting meant “clinical documentation improvement,” I was still baffled by what exactly that meant. Finding out what specifically a CDI specialist does on a day-to-day basis, however, helped clear the fog. Laurie Prescott, MSN, RN, CCDS, CDIP, defines the role of the CDI professional as someone who makes sure the medical record thoroughly represents the patient’s condition, so hospitals and providers can get reimbursed appropriately. They query physicians and review the medical record to make sure the language used in the record will directly translate to an appropriate code. Statistics for quality measures, she says, are pulled directly from the codes assigned based on the documentation.

“CDI reaches into many dimensions,” says Prescott. “The better the documentation, the better the organization will be represented and, therefore, the stronger they will be.”

Unfortunately, CDI programs are still so new that even nurses and hospital employees often don’t know much about them. Often, Prescott says medical professionals—especially physicians—find the processes irritating because they don’t understand why the CDI specialist reviewed the chart or asked questions about the records.

Michelle McCormack, RN, BSN, CCDS, CRCR, director of CDI at Stanford Health Care in Palo Alto, California, and an ACDIS Advisory Board member, says the increased scrutiny of healthcare documentation from so many areas—including the federal government for policy and reimbursement development, private insurers, and researchers—means there is more pressure to justify treatment and payment. Documentation, she says, drives communication, and ultimately improves performance.

“I think it’s really important to have that ongoing learning and knowledge sharing,” says McCormack. “When [everyone in a facility] works together to break down those walls and understand what each person is doing, there’s much more than a financial or quality impact. It has a global impact.”

But why does this matter? CDI improves hospital reimbursement and quality measures that rank an establishment in the medical world. It seems like the only people who should be concerned about CDI and the role of CDI specialists are those who benefit from their work (hospital employees, patients, etc.), right? Wrong.

Anyone who lives in a city or town with a hospital, Prescott says, knows how closely hospitals are woven into the fabric of the community. They are as important as the local businesses in both a financial and romantic sense. In fact, the general public needs to remember that hospitals are, at their core, businesses. They have to function in the same way as companies, they have to generate enough income to survive, and they often have very tight profit margins. Even a little bit of money, Prescott says, makes a big difference.

“Everyone thinks hospitals have tons of money,” says Prescott. “In reality, what they’re putting out and getting back is so slim that, if you don’t pay attention to every penny and make sure you’re getting what you need, it can mean terrible things. I’ve worked in hospitals that have no money and everything falls apart.”

For example, hospitals struggling with funding can’t afford to purchase equipment they need to treat patients, which often means a potential patient will go to a different hospital.

They also have fewer resources—including the ability to pay the number of staff members they realistically need on hand. A hospital might need three nurses, but if money is tight and they can only afford two, that’s a sacrifice they have to, and will, make—a sacrifice that will directly impact the quality of care provided to the patient population or community served.

The increased precision of healthcare data is something everyone, including those not working in the medical field, can relate to, says Peggy Nail, BSN, CCM, CCDS, CDI specialist at University of Mississippi Medical Center in Jackson. The medical picture captured by the codes and documentation translates to rankings that we all use, including treatment success rates at individual hospitals and world health statistics that determine which regions are more susceptible to certain diseases. If you’ve ever used a site like HealthGrades.com to find a doctor, or HospitalSafetyScore.org to choose a facility for a surgery or procedure, you’ve used data determined by healthcare code assignment, and made more accurate by CDI programs and professionals.

“When we strive for detailed documentation, we provide the most accurate data for statistical and research purposes, which benefits us all,” says Nail.

CDI programs matter for all of us, not just those within a facility or organization. If the documentation isn’t correct, the code assignment won’t be correct, and neither the facility nor the physician will receive the reimbursement warranted for the care provided. Without accurate reimbursement, the hospital won’t have the funding.

A hospital is often considered the heart of the community; if it cannot remain financially viable due to the various pressures of today’s healthcare environment, it may have to close its doors. And that can be very traumatic for the entire community, says Prescott. Employees lose their jobs. Those who rely on the proximity of the hospital have to travel longer distances for treatment and care. It may sound grandiose, but CDI efforts actually can help keep hospitals that struggle with their business from disappearing, she says.

“Accurate documentation is the heart of CDI, because it is used to communicate a patient’s condition and give quality care to ensure proper reimbursement and accurate statistical representation,” says Prescott. “The documentation we put in a chart is making sure hospitals survive.”

Editor’s Note: Katherine “Katy” Rushlau joined the ACDIS team in January as the CDI editor assisting on all ACDIS publications and social media efforts; she is located in our HCPro offices in Danvers, Massachusetts. Email her at krushlau@acdis.org.