Misconceptions of CDI versus coding
CDI is not just an extension of coding. The origins of CDI may have been the HIM department, but CDI has continued to evolve into its own unique profession. A CDI department needs its own identity within the organization with its own budget, leadership, policy and procedures. Additionally, both CDI and coding need to be on equal footing to allow for discrepancies to be resolved to the satisfaction of both departments.
CDI is not the same as concurrent coding. Although many CDI departments may assign codes during their review process to establish a working Diagnostic Related Group (DRG), usually CDI derived codes aren’t used to populate the final bill. Typically, the purpose of assigning codes during the CDI process is to allow the CDI specialist to anticipate potential reimbursement or quality issues. They are usually targeting key diagnoses rather than all diagnoses. In other words, the CDI focus is more targeted than a coding focus. This perspective should also affect their workflow. The value of the CDI is their interaction with providers with a goal of improving their documentation behavior. Record reviews are a means to an end for the CDI specialist, so given the choice between spending ten minutes in conversation with a provider regarding their documentation or completing another record review, the choice should be spending time with the provider. Yes, there needs to be a means of accountability for the CDI specialist, but too much of an emphasis on the number of records reviewed could result in missed opportunities.
CDI departments are unlikely to become obsolete with computer-assisted coding (CAC) and electronic health records (EHRs). The advantage of CAC is recognition of words represented in coding nomenclature. If the provider doesn’t use the right terminology, there will be nothing for the technology to highlight. CAC may speed the coding process by allowing the coder to quickly identify key words within the documentation, but it doesn’t affect provider behavior, that is, change the provider’s documentation habits. In addition, most CAC technology doesn’t understand context. In other words, it can assist with identifying phrasing that requires more specificity like “CHF” or “pneumonia,” which many in the industry refer to as “low hanging fruit.” But, it is of limited value when it comes to understanding a disease process and clinical indicators supporting a missing diagnosis like hemorrhagic shock in the trauma patient with arterial damage who remains hypotensive with low urine output after volume expanders and a blood transfusion requiring dopamine titration.
What about the technology leveraged in an Electronic Health Record (EHR)? Yes, unlike CAC, an EHR can prompt the provider for specificity when they attempt to enter the diagnosis of CHF, but how does the organization ensure the provider picks the accurate term reflective of the clinical scenario? Both technologies are also limited by the complexity of ICD-10-PCS, which requires identification of seven characters based on documentation throughout the operative report and/or the health record, because it’s unlikely that the surgeon will document all of the required elements in the same order as required for code assignment.
What to look for in CDI software?
Unfortunately, many CDI products are based on a coding platform. The coding workflow is pretty standardized and straightforward. However, CDI is anything but standardized and straightforward. A “one size fits all” technology approach may not support all the CDI initiatives within a particular organization or the lifecycle of a CDI department as most evolve over time. A CDI department needs flexible technology that can support any workflow, whether revenue or quality based, to a combination of both. A common complaint from CDI specialist regarding CDI “solutions” is the inability to “customize” workflow to fit the specific needs of their organization. Too often CDI specialists develop supplemental manual processes outside of their technology solution to meet their unique needs. Technology is supposed to be maximizing efficiency, not be a barrier to efficiency.
Coverage is often an issue for CDI efforts due to staffing constraints. A robust CDI technology will increase workflow efficiency, resulting in increased coverage. A particular problem for CDI staff are short stay admissions where the patient is admitted and discharged before a concurrent review can occur. CDI specialists need a software solution that can capture these admission types and integrate them into the daily workflow because these cases are often the most vulnerable to denial. Another potential issue that affects CDI coverage is patient flow. Technology that leverages the ADT feed will allow CDI to better prioritize their review efforts as they can easily identify those patients who are discharged or expired, or whose length of stay exceeds the GMLOS for the associated working MS-DRG. If the technology can also capture the admitting diagnosis, the CDI would have even more information upon which they can prioritize their daily review process.
Another problem is the lack of an integrated solution. Often the work of CDI is external to the coding process, allowing CDI efforts to be overlooked during the coding process. The lack of a common platform where the efforts of both departments are immediately apparent limits integrated interaction and real-time problem solving that can avoid delays in the revenue cycle. This can be particularly problematic with regards to querying. For example, the query process for CDI is often different than for coding because each department leverages different technology. As a result, the coding query may be part of the health record, but the CDI query is part of the business record. This can be a compliance issue as industry standards do not allow for differences in query processes based on the professional background or role of the person performing the query function. Technology that fails to support a collaborative approach between CDI and coding is limiting the effectiveness of both departments.
CDI departments have become the norm as an estimated 80% of hospitals have some type of CDI process. As organizations better understand the relationship between clinical documentation and coded data, the role of CDI usually evolves and grows. Organizations need to graduate their CDI “program” to a CDI Department and commission CDI to become its own entity to allow CDI to contribute to the success of the organization. They also need to evaluate where CDI best fits within their organizational structure as CDI efforts extend beyond their HIM origins. Lastly organizations need to provide them with the unique tools and resources they need to ensure the best efficiency and effectiveness as possible.