With the recent implementation of ICD-10, part two of our series explores some ‘best practice’ clinical documentation initiatives (CDI) that are rapidly spreading throughout the country to better understand what you must do to survive and even thrive in this major systemic change.

Now that ICD-10 is here, the adage “Garbage in, garbage out” may summarize the challenge facing coding and billing departments when preparing claims. If the documentation that providers and scribes enter into the electronic medical record (EMR) isn’t detailed enough, the coders won’t be able to do much with it.
That’s where the clinical documentation improvement (CDI) initiatives come in that hospitals and health systems have embraced to educate providers about the more rigorous documentation demands of ICD-10.

Formally the International Classification of Diseases, 10th Edition, ICD-10 comprises approximately 72,000 procedure codes and 70,000 diagnostic codes compared to 4,000 procedure codes and 15,000 diagnostic codes in ICD-9. ICD-10 provides greater detail on medical services, and that granularity purportedly make it easier to track healthcare outcomes and quality. What this means in the electronic medical record is best illustrated by an example the Government Accountability Office uses: angioplasty had just one code in ICD-9 but a mind-boggling 854 in ICD-10. And the EMR must support the one specific code (out of those 854) that gets submitted for reimbursement.

For hospitals and health systems in the age of ICD-10, CDI plays a pivotal role in flattening the learning curve for providers and scribes. This blog looks at best practices for CDI engaging providers.

Sutter Health: Decentralize, Streamline, Identify Risk Areas

Sutter Health in Northern California has received recognition for its CDI initiative in the trade press. Sutter has 24 hospitals and surgical facilities, and each acute facility has a CDI team. In an interview, Sutter Health ICD-10 Program Director Danielle Reno outlined these practices the health system has employed.
Decentralized structure. Sutter Health’s organizational structure does not follow a cookie-cutter approach. Each affiliate has its own CDI team. “They often report up through locally based quality functions, but some CDI teams report up through the finance areas,” explains Ms. Reno. Their structure depends on what the local affiliate teams determine is best. “It’s a little bit different than most organizations, but it seems to work really well,” she says. Local CDI teams monitor MS-DRG pairs and triplets, as do two area-level CDI teams within Sutter Health. On the system level, the CDI team monitors CC (complication and comorbidity) and MCC (major CC) capture rates, Ms. Reno said. “There’s monitoring at all kinds of different levels,” she said.

Streamline the feedback loop. The idea behind CDI is to catch problems in the documentation before the coder assigns the code. In the early going of ICD-10, that will involve coders sending a lot of feedback to providers via the EMR. The goal is to get providers to the point where they’re putting enough information into the EMR to avoid those queries. To streamline the feedback loop from coders to providers, the Sutter Health HIM team updated and standardized its query templates for ICD-10.
Identify problem areas, compile tip sheets. Two potential problem areas the Sutter Health CDI team identified are orthopedics and cardiology, in which the documentation requirements are specifically rigorous in ICD-10 because of the exponential increase in codes. Ms. Reno explains that those specialists have been targeted for more intense education along with tip sheets, which each affiliated tailored to its needs by working with the central and area CDI teams.

Baptist Health South Florida: Involve Providers Early and Often

In an article in Becker’s Hospital CFO, physician leaders at Baptist Health South Florida presented three best practices for involving physicians in the CDI process—an initiative they’ve dubbed “CDI Miami.” They include:
Get physicians on board as soon as possible. If physicians haven’t been brought into the CDI loop, now is the time to do it. “They’re the ones providing the work and the documentation in the medical record,” Baptist’s Corporate Medical Director of Managed Care Lorena Chicoye, MD, told Becker’s. “If they don’t know the day-to-day impact, they’re not going to support you.”

Tell physicians why ICD-10 is important. Baptist has done this by educating physicians on the floor about the ICD-10 format.
Use peer-to-peer education. When Baptist assembled its CDI team, it gave preference to applicants with medical degrees and recruited a number of international physicians. Dr. Chicoye described them as “very multicultural, very interdisciplinary to work collaboratively with one another and then go on the floor and have conversations with physicians.”

Erlanger Health System: Try an “elevator speech”

At the American Health Information Management Association (AHIMA) CDI Summit in August, P. Roger DeVersa, MD, MBA, a certified CDI practitioner at Erlanger Health System, a five-hospital system in Chattanooga, Tenn., focused on how CDI has made him a better physician.

But Dr. DeVersa acknowledged that CDI is a low priority to many physicians, and they hesitate to respond to CDI queries because of competing priorities. Doctors don’t want health information management (HIM) staff to preach to them about CDI. The HIM team that works directly with physicians should be brief, clear and concise when talking to doctors about CDI. “Nobody’s going to listen to a lecture,” Dr. DeVersa said. “Develop a sales pitch or five-minute elevator speech.”

Huff DRG Review: Do Pre-Bill Review

Also at the Summit, James P. Fee, MD, vice president of Huff DRG Review, a consultancy that specializes in CDI, said incorporating a pre-bill review into the CDI initiative provides for a “second set of eyes” that can prevent unnecessary audits and penalties. A pre-bill review, along with a well-structured physician adviser program, can reinforce correct documentation and coding practices.
“As a practicing physician, documentation and coding is a means to which I relay the high-quality, cost-effective care I performed,” Dr. Fee said. “Bridging the clinical terminology with diagnostic terms, such as those in ICD-10, will facilitate this communication. Physicians are graded on the value of care provided reflective of risk-adjusted quality and cost. The pre-bill review will accurately define that population being treated.”

It’s an on-going process

With ICD-10 here, education of all the players involved in coding is just getting started. “Hospitals and other organizations are going to have to continue to encourage medical staff to work with their coders to ensure they get that accurate documentation on the charts,” said Melanie Endicott, MBA, a certified CDI professional and AHIMA director of HIM practice excellence. “It’s more administrative work for the providers, and they’d rather be spending time with patients, this is understandable. They just need to have that encouragement from up above, from the medical staff chief or whoever is their physician adviser or physician champion, to encourage them to work with the team, to get the documentation that’s needed, and over time it’s going to be less and less of a task.”

Many organizations include CDI as an integral part of ‘at risk’ (pay for performance) compensation models to encourage physician performance that adds to the quality and cost effectiveness of the care provided. Finally, many organizations are adding a scribe component to the healthcare team (mid-level practitioners who are certified coders) to add to the efficiency and accuracy of care and documentation flow throughout the system while lower per unit costs. These and other innovations will be discussed in more detail in part III of this series.

REFERENCES AND SUGGESTED READING

United States Government Accountability Office Report to the Committee on Finance, U.S. Senate. National classification of diseases: CMS’s efforts to prepare for the new version of disease and procedure codes. January 28, 2015. GOA-15-255. Available at: http://www.gao.gov/products/GAO-15-255
Chapman S. CDI Makes Its Mark. For The Record. 2015; 27(4):10. Available at: http://www.fortherecordmag.com/archives/0415p10.shtml

Adamopoulos H. Engaging Physicians to Prepare for ICD-10: Best Practices From Baptist Health. Becker’s Hospital CFO. November 25, 2013. Available at: http://www.beckershospitalreview.com/finance/engaging-physicians-to-prepare-for-icd-10-best-practices-from-baptist-health.html

Roop RS. Navigate the CDI Divide. For the Record. 2015;27(1):22. Available at: http://www.fortherecordmag.com/archives/0115p22.shtml

Bassett M. CDI broadens its reach. For the Record. 2013:25(1):18. Available at: http://www.fortherecordmag.com/archives/011413p18.shtml

American Health Information Management Association. Clinical Documentation Guidance for ICD-10-CM/PCS. Journal of AHIMA. 2014:85(7):52-55. Available at: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050701.hcsp?dDocName=bok1_050701

Hauger S. Advisory Board blog: Focus on the Margins. Focus on quality to protect your revenue: The evolving role of CDI. August 24, 2014. Available at: https://www.advisory.com/research/financial-leadership-council/at-the-margins/2014/08/use-quality-to-protect-your-revenue-the-evolving-role-of-cdi