Six Top Tips That Can Transition CDI From Financial to Quality Benchmarks

By Amy Rector, BSN, RN, CCDS, CDIP Senior Director, Clinical Documentation Improvement and Charge Audit Services | Posted: 01/17/2019

CDI Transition

Historically, the purpose of a CDI program is to validate, clarify diagnosis and ensure that the patient’s documentation is as specific as possible, reflects severity of illness and captures all the hospital resources consumed. If all documentation is clarified concurrently, fewer coding queries are initiated, then coding can be completed immediately. CDI aims to obtain the best supportive documentation possible for each diagnosis so the correct DRG is assigned and all diagnoses are well supported in case of an external audit. Accurate documentation results in correct coding, optimal CMI and DRG assignments, and reimbursement of every dollar to which a health care organization is entitled.

While optimal reimbursement is still vital to a health care organization’s revenue integrity, there is a heavier focus on documentation that impacts quality measures. Why the change?

Today’s reimbursement models are quality based. This shift in focus ensures appropriate reimbursement for the high-quality care a health care organization provides; it mitigates penalties for inaccurate quality scores.The trend toward patient consumerism means patients are shopping around for health care. A hospital’s quality scores are readily available on the internet. Inaccurate quality scores can impact an organization’s reputation and may cause a patient to go elsewhere for care. How does a health provider whose CDI program is already understaffed and is struggling to achieve benchmarks for chart reviews and query rates make the shift to quality? Here are the top six recommendations for successful transition:

  1. Conduct a department assessment:

    Arrange for a third-party assessment to ensure that your departments are structured to meet the challenges associated with value-based requirements. The assessment provides a review of records and process, technology, CDI knowledge and staffing. It offers recommendations for improvement and identifies missing opportunities that could improve quality scores and denial avoidance.

  2. Drive collaboration within the organization:

    Traditionally we talk about collaboration between the CDIS, coder and physician. Collaboration is important for the CDIS and Coder to learn from each other and validate the DRG assigned after coding, ensure that diagnoses are not missed and query responses are coded and thus billed. CDIS speak to physicians frequently about queries and may utilize queries and denials to teach what is necessary for documentation and what documentation needs are specific to their specialty.

  3. Build a team:

    Create a cross functional team that includes the quality department, and possibly finance, that meet to discuss issues related to complications and HACs, and how CDISs can assist in getting that documentation concurrently.

  4. Target the critical points:

    Focus on high impact areas that are based on analytics, where quality penalties may be impacting revenue. Track reasons for queries – how many PSI or HAC, quality vs. DRG change.

  5. Educate, educate, educate:

    It is critical that physicians and hospital leaders understand documentation and its impact on the rest of the revenue cycle, not just for reimbursement but for third party denials, additional CC/MCC’s, clarifying conflicting documentation, complications and cause as well as POA indicators for HAC’s.The team should focus education on the physicians who most need it and are specialty focused.

  6. Engage with a CDI partner:

    A partner can help you achieve the CDI areas recommended in this article. A reputable CDI provider helps protect against denials and compliance risk. nThrive offers technology-wrapped CDI services to protect health providers from denials and compliance risks; we provide the CDI specialists who use our exclusive CDI technology to help you improve documentation outcomes. Our teams help health providers achieve quality goals and satisfy the requirements of value-based care.

nThrive is the comprehensive Patient-to-Payment resource in health care. We integrate our knowledge and expertise of the entire revenue cycle in a way that provides unmatched benefits for health care. We are accountable to our clients, not payor or provider owners. As a result, our solutions are unbiased and focus on what's best for our clients. nThrive empowers health care for every one in every community by transforming financial and operational performance, enabling health care organizations to thrive.

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