Effective clinical documentation improvement (CDI) programs are crucial for enhancing the accuracy and completeness of patient records, which in turn supports better patient care and compliance with regulatory requirements. I recently posed the question of what the crucial elements of an effective CDI program are to three CFOs and the consensus was a full staff of well-trained nurses who performed well in the traditional KPI CDI metrics, achieving the industry-established query rate, improving the CC/MCC Capture rate and growing the Case-Mix Index. This was the impetus for this post on LinkedIn to set the record straight and delineate the hard fast key elements of an effective CDI program that the CDI profession and CFOs must embrace and internalize.
- Clear Objectives and Goals: Define the purpose of the CDI program, such as improving clinical documentation accuracy, enhancing coding practices, and ensuring compliance with regulations. Set specific, measurable goals to track progress and success. Reject the traditional CDI consulting company and ACDIS-supported Key Performance Indicators that are predicated upon task-based activities, overlooking, and capitalizing upon the opportunity to move the needle on measurable sustainable documentation improvement.
- Leadership and Support: Obtain commitment and support from senior leadership to ensure that the CDI program has the necessary resources and authority. Appropriate resources does not necessarily mean the latest and greatest CDI software from Solventum or any of the other CDI companies pushing their software as the panacea for clinical documentation improvement. There is simply no substitute for CDI “boots on the ground” working in collaboration with Physicians, Case Managers, Utilization Review, Physician Advisors, Denials and Appeals, and Coding, using, and deploying a team-based approach to the achievement of meaningful sustainable physician documentation improvement. Engage physicians, clinical staff, and other stakeholders in the program’s initiatives. This engagement requires the establishment of a vision that inspires physicians to be willing participants in any CDI initiative as opposed to a captive audience mandated to answer queries that fill their email boxes. “Educate” versus “Queryrate” should be the goal and objectives of every CDI program.
- Skilled CDI Specialists: Employ CDI specialists with expertise in clinical documentation, coding, and healthcare regulations. This requires a total mind shift, new skill sets, and core competencies on the part of the CDI profession. Preparing for and achieving the CCDS designation from ACDIS must only be considered as the starting point for a long journey to acquiring and maintaining an elevated level of knowledge in best practice standards and principles of documentation that can be shared and reinforced with physicians. Drs Keith Stokes, Cesar Limjoco, and I are developing a comprehensive Master Class we call “Turbo CDI” consisting of fifty-two courses that offer and equip the CDI professional with strong knowledge and understanding of all aspects of physician documentation, providing the building blocks and fundamentals for CDI. Stay tuned for more details. Provide ongoing education and training to ensure they stay current with changes in documentation standards and principles, best communicating patient care in support of medical necessity, denials avoidance, clinical validation, quality of care, optimal compliant coding practices, and alignment with the achievement of a high performing revenue cycle
- Comprehensive Training: Offer training programs for healthcare providers, including physicians, nurses, and other clinical staff, to improve their understanding of documentation standards and best practices. Include topics like coding updates, documentation requirements, and compliance issues. All CDI professionals must commit to maintaining relevance in a wide range of documentation-related topics including but not limited to familiarity with and ability to operationalize payer documentation requirements governing coverage of services, limitations of coverage, diagnoses that are considered “covered benefits,” Medicare Review Process, Targeted Probe and Educate programs, etc.
- Effective Communication: Develop a system for clear and constructive feedback between CDI specialists and healthcare providers. This goes well beyond missed opportunities for diagnosis capture and should include feedback on all medical necessity and clinical validation denials from a denial avoidance perspective moving forward. My approach to providing “instructional feedback” is to review all clinical validation and medical necessity denials, identify specific areas of documentation ripe for improvement, meet one-on-one with the attending physician of record, and offer instruction on how to avoid in the first place as part of a denial’s avoidance strategy. Effective communication can take the form of newsletters, podcasts, tip sheets, and other documentation resources developed from knowledge and feedback of denials. Implement regular meetings and communication channels to address documentation issues and share best practices. I highly recommend CDI attendance at Multi-disciplinary rounds where immediate documentation-related feedback and education can be offered in real time. This is one of numerous forums available to CDI to communicate with physicians providing educational training and both positive and constructive feedback.
- Robust Documentation Practices: Standardize documentation practices to ensure consistency and completeness across the organization. Collaborate with physicians to create a structured format for ED encounters, H & Ps, Progress Notes, and Discharge Summaries Use templates or guidelines that facilitate accurate and thorough documentation. Partner with physicians to develop and encourage the use of dot phrases that incorporate the documentation requirements to pass the rigors of clinical validation imposed upon by the payers.
- Use of Technology: Leverage electronic health records (EHRs) and CDI software tools to support documentation efforts, track performance, and identify areas for improvement. Implement data analytics to monitor trends and measure the impact of the CDI program. Data analytics must extend beyond traditional industry-sponsored and perpetuated Key Performance Indicators that perpetuate the narrow interest of the CDI consulting companies earning large profits based upon maintaining the status quo in CDI.
- Regular Audits and Reviews: Conduct routine audits of clinical documentation to assess accuracy and compliance, incorporating elements of documentation supporting the goal of achieving patient-centered, outcomes-based, quality-focused, cost-effective care predicated upon access to complete and accurate documentation. Use audit results to identify areas for improvement and adjust the CDI program accordingly. Ensure the assimilation of payer nontechnical denials as part of an efficient effective results-driven approach to instilling a continuous quality improvement underlying principle of physician documentation improvement.
- Performance Metrics and Reporting: Establish key performance indicators (KPIs) to measure the effectiveness of the CDI program. I have included my time-proven time-tested top seven Key Performance Indicators in a previous post. The number and volume of clinical validation denials as well as medical necessity denials should be the top CDI measure of performance. Regularly review and report on these metrics to track progress and identify opportunities for further improvement. The CDI profession must take ownership of more meaningful, valid, and dependable KPIs beyond CMI and CC/MCC capture; these are misleading the CFO in CDI performance as CMI and CC/MCC do not meet the hospital’s financial obligations; net patient revenue and cash in the bank matters to fund continued operations. Witness the downfall of Steward Healthcare and its ultimate landing into bankruptcy.
- Patient-Centered Focus: Ensure that improvements in documentation contribute to better patient care and safety. Involve patient feedback and outcomes in evaluating the impact of the CDI program.
- Continuous Improvement: Foster a culture of continuous improvement by regularly evaluating the CDI program’s effectiveness and making necessary adjustments. Evaluating and trending the top seven and all the other ten KPIs can be used to promote and further ongoing improvement in CDI processes and serve as the jump-off point for the inclusion of additional CDI opportunities. Stay informed about industry best practices and emerging trends in clinical documentation and coding. I have discussed the critical nature of CDI maintaining up-to-date knowledge and relevance in all things CDI.
- Compliance and Regulatory Adherence: Ensure that the CDI program adheres to regulatory requirements and coding guidelines. This lies squarely in compliance partnering with CDI leadership to keep the CDI program on the up and up. Do not let the quest to capture CCs/MCCs and CMI to meet CFO mandates get in the way of doing the right thing in CDI. Stay updated on changes in healthcare regulations and adjust the CDI program as needed. This requirement lands on CDI Leadership with the duty and responsibility to educate and hold accountable their CDI staff.
By incorporating these elements, healthcare organizations can build a robust CDI program that enhances documentation quality, supports accurate coding, and improves patient care and organizational efficiency.
