Strategies for Building a Strong Hospital CDI Program and Boosting Financial Success

Like many aspects of healthcare, clinical documentation is a complex yet necessary process. It is tied to more than just health information management functions; it is also essential to a hospital's clinical and financial performance.

Clinical documentation that is incomplete or unclear can impact clinical accuracy and productivity, as well as coding quality — not to mention timely reimbursement.

Developing a strong clinical documentation improvement program is one way hospitals can boost patient quality measures, yield optimal revenue and support effective patient care. As evident by the success of Harrington Memorial Hospital — a 114-bed community hospital located in Southbridge, Mass. — a strong CDI program can even help maintain or elevate a hospital's case mix index.

Why CDI is necessary
Ideally, clinical documentation accurately reflects a patient's visit. In addition to capturing details important for clinical care, the documentation should ensure the correct diagnosis-related groups are coded for reimbursement.

However, many providers fail to supply complete information because they don't know which details are necessary, or because they assume coders can infer details from the chart.

In reality, coders are forbidden to infer anything not directly stated in the documentation, so a lack of detail could significantly impact reimbursement, quality indicators, benchmark comparisons and case mix index.

For example, although a physician might treat systolic and diastolic heart failure the same way, properly coding congestive heart failure requires specific details about its type and characteristics. Yet coders under pressure to complete charts and maintain organizational cash flow may not have the time to query physicians — and might not feel comfortable doing so either. As Harrington has discovered, that is why CDI is so important.

Harrington Memorial Hospital's CDI program
Nearly six years ago, Harrington's physicians approached administration with concerns about coding. They felt coders were querying too frequently and requesting unnecessary details without considering other aspects of patient charts. In response, Harrington ramped up its CDI program.

To bridge the gap between providers' and coders' needs — plus improve coding productivity, quality and accuracy — HIM leaders began meeting monthly with hospitalists to discuss specific queries and the querying process. They also explained what coders were trying to accomplish and why certain conditions or procedures required more detailed documentation. Although providers were skeptical at first, support for the CDI program grew as they were shown how lack of documentation impacted case mix index, reimbursement and revenue — as well as severity of illness, co-morbidity and risk of mortality scores. Comparisons of providers using quantifiable data also illustrated how clinical documentation affects quality measures and related data.

In order to maximize its documentation potential, Harrington chose to engage outsourced coders who were trained to focus on total coding quality rather than just DRG accuracy. In addition, the use of industry-standard querying formats fostered an optimal approach to in-patient coding that addresses quality measures and reimbursement.

Harrington now funnels coding queries in a streamlined manner through the hospitalists' administrative assistant. With the help of electronic clinical documentation software, queries are submitted each morning and then efficiently directed to providers via the electronic health record. Prompts are sent to remind providers to respond to queries, and answers typically are returned to coders the following morning. Using this method, queries are easily tracked, ensuring providers are not overburdened by queries and that coders receive timely answers.

Six strategies for building a strong CDI program
Although no two hospitals or health systems are exactly alike, these key strategies can help build a strong CDI program in any organization:

1. Tailor a program to meet your organization's needs. There are many valid approaches to CDI, so those that are successful typically are aligned with the hospital's workflow and culture. Harrington didn't try to implement a "textbook" CDI program, for instance. Instead, it listened to the needs of its providers and coders and then tailored a program to meet those needs.

2. Collaborate with providers and coders. Effective CDI relies on cooperation, balancing the need for information with efficiency. Harrington's CDI success was due in part to the engagement, dialogue and eventual rapport that developed between physicians and HIM staff.

3. Use industry-standard querying formats. Industry-standard querying formats serve as valuable resources for coders. They provide guidelines about what reference materials can be used and how to craft effective queries.

4. Use technology to engage providers. Clinical documentation software and EHRs can be enlisted to automatically prompt providers for additional information when they enter specific diagnoses, medications or treatments — saving coders and physicians the time and effort associated with queries.

5. Take a global approach. Coders traditionally have relied on providers' dictated reports and progress notes to code patient charts. However, these documents may not supply all the necessary details. To meet healthcare's changing demands, organizations may need to tweak their approach and determine if additional resources will be required for coders.

6. Review a small sample of charts periodically. Some organizations review dozens of charts when auditing coders. However, if the same gaps or errors are found in a few charts, they'll likely be found in all. Therefore, to efficiently audit the CDI program, organizations should periodically select and review a small sampling of charts to identify and address any documentation or coding deficiencies. 

The impact of a strong CDI program
Combined with enhanced, outsourced coding expertise, Harrington's CDI program has contributed to a rise in its case index of approximately 5 percent since May 2012, which equates to reimbursement improvement of $1.8 million per year. The hospital also is seeing more accurate and specific documentation of diseases, which positively impacts not just reimbursement but also collaborative patient care.

Likewise, Harrington has used quantifiable data captured by CDI software and other technology to compare physicians and build buy-in from providers. By using hard data rather than anecdotal information to show the effects of better clinical documentation, physicians have been more supportive of the program and hospital leaders are better equipped to anticipate short- and long-term productivity and revenue challenges.

As Harrington has shown, hospitals and healthcare organizations can bridge gaps between providers and coders through a strong CDI program that ensures coders have complete information. With improved coding quality, accuracy and productivity, organizations can maintain revenue flow while promoting ongoing patient care.

Daniel Rossi is the director of health information for Harrington Memorial Hospital, a 114-bed community hospital located in Southbridge, Massachusetts.

George Abatjoglou is the CEO of IOD, a health information management company combining innovative technologies and services to reduce costs for healthcare organizations.

More Articles on CDI:
4 Key Findings on How Physicians View CDI Technology and Processes  
Clinical Documentation Improvement: What Executives Need to Know and the Financial Impact of Neglect
How Comprehensive Clinical Documentation Improvement Pulls ICD-10 Projects Together 

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