Interview with Dr. Keith Stokes: The Critical Role of CDI in Enhancing Healthcare Revenue

The revenue cycle is a cornerstone of financial health for medical institutions, involving everything from patient registration to final payments. Its complexity and scope make it a critical area for any healthcare provider aiming to sustain growth and ensure quality care.

To gain deeper insights into this essential process, I interviewed Dr. Keith Stokes, CEO of DocuComp LLC, who brings extensive experience from his roles across various healthcare settings. We focused particularly on the middle segment of the cycle - clinical documentation and coding - critical elements that greatly influence revenue efficiency and insurance claim denials. When this process accurately reflects the clinical care a patient receives, billing results greatly enhanced.

In our discussion, Dr. Stokes offered valuable perspectives on enhancing documentation accuracy, addressing the common hurdles in clinical documentation, the integral role of physician advisors, and the importance of Clinical Documentation Improvement (CDI) Specialists.

Join me as we dive into this interview with Dr. Stokes:

1) What is your background and what is your current role?

Dr. Keith Sokes:

My name is Dr. Keith Stokes. I am a board-certified, Family medicine-trained physician with over 17 years of experience working in multiple clinical and administrative capacities, primarily in the state of Mississippi.

I have practiced medicine in large multi-specialty, tertiary hospitals, critical access hospitals, long-term acute care hospitals, hospital-based primary care clinics, federally qualified health care clinics, and specialty care clinics.

During my career, I have served in multiple roles including clinic medical director, chief medical officer, hospital chief of staff, hospitalist medical director, utilization management committee member, and physician advisor. I am currently the CEO of DocuComp LLC and the medical director of Open Arms Healthcare Clinic in Jackson, MS.

2) Describe the revenue cycle and its components.

Dr. Keith Stokes:

The revenue cycle of a hospital system is the term used to describe the financial aspect of a healthcare system.

The revenue cycle is generally understood to be composed of three components: the front-end, the middle, and the back-end.

• Front-end: Involves patient access and registration, such as collecting accurate patient demographic information, obtaining accurate insurance information, pre-authorization, and collecting co-pays or balances.
• Middle: Centers on clinical documentation and coding, ensuring services rendered are captured accurately for billing. Thus, diagnoses, treatments, procedures, and therapies received by the patient must be documented accurately and specifically so that the subsequent charge capture and coding that derives from that documentation will be both accurate and compliant.
• Back-end: Covers billing processes, claims management, and revenue collection, crucial for closing the financial loop.

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***Important Note: This newsletter will focus on the middle components...

This newsletter zeroes in on the pivotal middle component of the revenue cycle—Clinical Documentation Improvement (CDI). CDI is critical for enhancing the financial performance of healthcare facilities. Accurate and detailed clinical documentation underpins proper coding, which is essential for appropriate reimbursement.

A robust CDI program not only minimizes denials but also streamlines the entire revenue cycle process, ensuring that hospitals are compensated correctly and efficiently for the services they provide.

3) What is the most important driver for getting clinical documentation right?

Dr. Keith Stokes:

The most important driver necessary for getting clinical documentation done right, or in other words, creating a successful clinical documentation improvement program is getting buy-in from your clinicians. They are the creators of the documentation from which accurate coding and successful billing are derived.

I like to describe physicians as the rate-limiting step in the clinical documentation equation.

4) Who typically is responsible for overseeing this initiative?

Dr. Keith Stokes:

Most hospital system CDI programs are overseen by a CDI director or manager, who is usually someone with a clinical background such as a nurse, rather than a coder or HIM specialist.

The reporting structure for the CDI manager tends to differ from hospital to hospital.

In some cases, CDI reports to the health information management director, while in other cases, CDI reports to revenue cycle management and or the finance director.

5) Can you give examples of documentation typically misunderstood or left out of medical records?

Dr. Keith Stokes:

The concept of clinical documentation is misunderstood by physicians because it is not taught very well in medical school or residency.

The primary concern during medical training is helping medical students and residents gain mastery in the practice of medicine. This means primarily taking care of patients by preventing, diagnosing, and treating disease.

Physicians do a very good job at doing what they have been trained to do. However, when It comes to communicating the practice of medicine and explicitly documenting our medical decision-making, our training still needs to be improved for the task. As a result, hospitals are experiencing an increase in clinical validation and level of care denials from a large segment of third-party payors.

Some examples that we see quite often while reviewing charts include clinicians misunderstanding how to correctly classify a non-ST elevation myocardial infarction (NSTEMI). Physicians quite often mistakenly document this condition as NSTEMI, type 2 MI.

However, both NSTEMI and STEMI are considered Type I myocardial infarctions by the ACC 4th definition of myocardial infarction criteria. Therefore, this misclassification may be considered conflicting documentation by an insurance company and result in a denial of payment for the hospital.

Also, the diagnosis of acute respiratory failure with hypoxemia is another diagnosis that is frequently denied due to a lack of clinical validity, as the result of the lack of specific documentation on the part of the clinician.

Lastly, we continue to see the term urosepsis in the medical record. Urosepsis is not reflected in ICD-10, as a result, it codes to a simple urinary tract infection. Therefore, the severity of illness nor risk of mortality to the patient that the clinician intends to demonstrate is not reflected by the term urosepsis. Instead, it may be more accurate to document that the patient has sepsis secondary to a urinary tract infection, which does reflect mortality risk to the patient.

6) What role does a physician advisor provide In the clinical documentation playbook?

Dr. Keith Stokes:

The physician advisor plays a key role on the CDI team due to their unique understanding of both the clinical and financial aspects of healthcare. Therefore, the physician advisor is often described as the bridge between the financial teams and the clinical teams of the hospital. I call this the bridge between the finance side and the bed-side.

Because physician advisors are fluent in the jargon of finance and clinical medicine and have credibility with the financial and clinical care teams, they can translate between both of these worlds, thus allowing for the breakdown of silos.

The actual role of the physician advisor varies depending on the hospital system that employs them, however, they usually play a large role in educating physicians on clinical documentation nuances. Physician advisors play a key role in helping their organizations navigate and maintain compliance with the varied and ever-changing rules and regulations of the healthcare industry.

7) Is there a clinical specialty that lends itself to a better physician adviser than others?

Dr. Keith Stokes:

The role of the physician advisor is increasingly vital in the healthcare field, especially within hospitals. No specific medical specialty makes one inherently a better physician advisor than another. In fact, many outstanding physician advisors come from diverse backgrounds, including OB/GYN, internal medicine, pediatrics, and emergency medicine.

For example, my specialty is family medicine, and my mentor, who trained me, specialized in obstetrics and gynecology. The key to being an effective physician advisor lies in having a deep interest in understanding the business side of medicine.

Additionally, possessing excellent communication skills and a passion for teaching is essential, as physician advisors spend significant time educating clinicians on how accurate, concise, and specific documentation impacts the perceived quality of patient care. This aspect of the role is crucial because documentation practices are not thoroughly taught in medical school or residency programs. As practicing physicians, physician advisors have the unique credibility needed to secure buy-in from medical staff, making them indispensable to the CDI team.

8) How important is it to have a clinical documentation specialist? What role does the clinical documentation specialist play on the team?

Dr. Keith Stokes:

The CDI specialist, or clinical documentation improvement specialist is extremely important to the CDI team because they perform most of the work of the CDI team.

A CDI specialist is responsible for ensuring that the documentation in patient medical records is accurate, complete, and reflective of the patient’s clinical status. They review medical records daily, identifying gaps or inconsistencies in provider documentation and querying physicians to clarify documentation when necessary.

CDI specialists also work closely with coding teams to ensure that codes accurately reflect the clinical picture, which is crucial for correct billing. They educate and collaborate with physicians to improve their documentation habits, which leads to more precise and thorough records over time.

9) What do you do if you can’t afford or just don’t have a CDI specialist?

Dr. Keith Stokes:

CDI specialists are not only important because of the role they play in accurately documenting the patient’s clinical care, compliance is also a huge part of their role. Accurate and complete documentation ensures that we meet all regulatory requirements and avoid penalties.

CDI specialists are well-versed in CMS guidelines and other regulatory standards, helping healthcare organizations stay compliant and audit-ready. Therefore, in today’s healthcare environment staffing this position is mission critical for hospitals. If your organization does not currently have a CDI specialist, you should identify a qualified staff member to be trained as a CDI specialist.

You should look for someone with a clinical background, ideally a nurse with experience in acute care settings, such as medical-surgical units and ICU. They should be a team player, with great communication skills, as they are likely to work closely with both the coding team and physician advisors.

10) What sort of data is collected?

Dr. Keith Stokes:

Data analytics play an important role in driving continuous improvement and quality in healthcare organizations. The CDI team typically analyzes and evaluates such metrics as the Case mix index, query response rates, query impact analysis, DRG validation and shifts, denials and appeals tracking, quality measure reporting, patient safety indicators, and provider performance metrics. By evaluating such metrics consistently, hospitals are able to identify documentation gaps that require additional training, initiate physician documentation programs, optimize coding, decrease denials, improve reimbursement, and enhance compliance with regulatory requirements.

11) What are three important lessons learned for those who are considering initiating a clinical documentation program?

Dr. Keith Stokes:

• One of the critical lessons learned is that physicians often have limited awareness of the importance of clinical documentation improvement programs. Understanding this reality is essential for successful implementation. The first step is to recognize that continuous physician education is crucial. Physicians need to understand how accurate documentation impacts not just hospital finances but also the quality of patient care and compliance. Therefore, a practical approach is to onboard a physician champion or advisor. This individual can leverage their credibility and relationships with the clinical staff, effectively communicate the value of the CDI program, and secure physician buy-in.
• Next, in order for the clinical documentation program to be successful, you must establish the unequivocal need for a change in the documentation practices of your organization. You can do this by demonstrating how your organization compares to your peers using objective metrics such as case mix index, denials and appeals, query impact and response rates, and provider performance metrics. Once the need for change is demonstrated, it is important to identify key stakeholders and sponsors in your organization who can champion the initiative. Clearly defining your desired outcome, analyzing the potential impact the change will have on your organization, and organizing a dedicated implementation team are crucial steps in the process.
• Lastly, implementing a CDI program is a significant organizational change and will inevitably face pushback. Resistance can come in various forms, including denial and loss aversion among staff. To manage this, it is important to prepare for resistance in advance. Stay committed to the goals, continue educating staff, and be ready to adapt your strategies as needed. Consistent evaluation and fine-tuning your processes are necessary but it's crucial to remain steadfast and not revert to old practices. The stakes are high, and persistence will lead to the program’s ultimate success.

Interested in deepening your understanding of clinical documentation or learning more about the role of physician advisors?

To explore these topics further or if you have any questions, feel free to reach out to Dr. Stokes at kstokes@docucompllc.com.

Visit his website at www.docucompllc.com for more detailed information and resources.

How can improved clinical documentation benefit your organization?

What steps can you take to enhance your team's effectiveness in this area?

Let's discuss this in the comments below.