The experience of Piedmont Hospital in Atlanta suggests that health systems can benefit substantially from implementing all-payer clinical documentation improvement (CDI) programs.
CDI programs are an integral component of effective revenue integrity initiatives under both fee-for-service and value-based payment. Healthcare finance executives understand very well the positive impact of ensuring complete documentation to reflect the severity level of patients’ conditions, drive quality outcome scores, and support accurate payment for services delivered. In fact, according to a 2016 report by Black Book Research, 85 percent of hospitals confirm documented quality improvements and increases in case mix index within six months of CDI program implementation. a
Revenue cycle executives are now targeting documentation improvement opportunities for non-Medicare inpatient encounters, outpatient services, and physician practices as part of overall enterprisewide revenue integrity programs. Traditionally performed only for inpatient Medicare patients, these all-payer CDI expansions drive even greater revenue improvement opportunities. By improving documentation across all care settings, health systems are positioned for success as volumes shift to outpatient settings and payment is linked to quality outcomes under value-based care.
One Health System’s Experience: The Journey to All-Payer CDI
Piedmont Healthcare, an integrated health system comprising eight hospitals and almost 100 physician and specialist offices across greater Atlanta and North Georgia, exemplifies this growing trend. In 2017, Piedmont initiated a successful one-year CDI program expansion from a traditional Medicare-only focus to CDI coverage of 90 percent of all inpatient admissions.
Piedmont previously had a long-standing, proven CDI program in place at its individual hospitals, having launched the formal department under its revenue cycle office in 2013. The health system’s revenue cycle executive team announced the strategic initiative to expand documentation reviews to encompass all DRG payers for inpatient admissions across all eight hospitals in June 2017.
A primary goal of the all-payer CDI program is to review every inpatient admission and provide a working DRG and probable discharge date to case managers at each acute care location. Where such information was available, it was to be used by case management as baseline data for Piedmont’s length of stay (LOS) reduction initiative, where appropriate.
Building a successful all-payer CDI program to provide working DRGs across every hospital required a rapid boost in CDI specialist coverage and capacity. Because the organization already used a proven CDI technology platform, software to accommodate the expansion was in place. Thus, the essential strategic steps required to complete the initiative were to engineer a new workflow and review process, and to add staff.
Establishing the New CDI Workflow
Reviewing 90 percent of all DRG admissions across eight hospitals is a tall order. CDI workflow had to change across the board to support this initiative. Leadership decided to begin by building and piloting a new CDI workflow at one of the organization’s smallest and most recently acquired hospitals, and then roll out the process to Piedmont’s other facilities.
Because obtaining a working DRG was the key focus, up-front CDI reviews were required in addition to the traditional ongoing CDI assessments to identify additional physician query opportunities and improve documentation specificity. Two tiers of CDI specialists were engaged, and the work was divided accordingly.
Admission review team. These CDI specialists review cases upon admission to the facility. Cases are automatically populated in the CDI software system for team access and the software prioritized cases for review. Cases with a medical diagnosis but no complication or comorbidity (CC) or major CC (MCC) appear first in the CDI specialist work list.
Each CDI specialist on the admission team has a quota to review 40 admissions daily and determine principle diagnosis, working DRG, and geometric length of stay (GLS) within 24 hours of admission. This information then is conveyed to the case management team through Piedmont’s CDI software. Because the health system still lacks coverage by a CDI specialist on Saturdays and Sundays, Monday is set aside as the CDI team’s day to review all weekend admissions. The admission team documents findings for the second CDI team, the DRG review team, to pick up.
DRG review team. Piedmont’s second team of CDI specialists reviews cases not only during the stay but also following the initial encounter to determine whether the admitting diagnosis is correct and to identify at least one CC or MCC where possible. This team comprises more advanced CDI specialists, who directly query Piedmont’s medical staff requesting clinical clarification in the documentation. Although the workflow for the DRG review team did not change as part of the all-payer initiative, work done by the admission reviewers helped them increase query rates and improve efficiency. Admission reviewers assign priorities based on query opportunity and other factors giving the second reviewers a specific focus going into the process. The creation of a working DRG allows the software used by CDI to set a priority for which cases should be reviewed first. These priorities are based on the identity of the DRG, and whether there is a CC or MCC on the case. For example, DRGs that have a high denial rate, such as those for sepsis, are given a higher priority than other cases. Clarifying queries also are suggested, as are recommendations for opportunities in the documentation for the CDI specialist to query the physician.
The CDI team’s query rate before admission reviewers were added averaged 13 percent, and never exceeded 18 percent. After changing the workflow to initiate CDI case involvement at time of admission, additional documentation query opportunities were identified. Today, the rate averages between 20 and 25 percent, an average of 10 percent greater.
Adding the admission reviewers also helped to improve the DRG review team’s efficiency: The first tier of CDI review ensures the right cases are quickly placed in the hands of the second-level DRG reviewers to eliminate any delays in clinical documentation assessments.
The revised CDI workflow also includes remote and outsourced CDI staffing. Staff rotate between remote and onsite support so each hospital has at least one CDI specialist onsite every day. Using a combination of outsourced and employed remote CDI specialists, Piedmont’s program has achieved the following benefits:
- Improved staff satisfaction with work-from-home flexibility
- More comprehensive CDI coverage across the health system to centralize and distribute work
- The addition of CDI specialists with at least two specialists assigned to each hospital through an outsourcing partnership to supplement in-house staff
- Direct reporting to Piedmont’s centralized revenue cycle department versus individual hospitals
Each hospital’s cases are reviewed equally by the remote CDI staff based on the previously cited criteria to achieve and maintain balanced coverage. The health system’s total investment to expand CDI coverage to all DRG payers and all hospitals was the addition of four CDI specialists—two in-house and two outsourced. Having identified financial improvements amounting to a combined CDI program impact of $500,000 per month, Piedmont plans to expand the all-payer CDI initiative to three newly acquired hospitals in 2019, with hopes of significantly expanding the program’s impact.
Testing the Financial Impact
Piedmont’s re-engineered CDI staffing and workflow was first tested at a recently acquired community hospital. The facility was previously staffed with only one CDI specialist, whose positive impact on revenue was calculated as averaging $20,000 per month prior to program changes.
Following the revised workflow and the addition of a part-time outsourced CDI specialist for $2,000 per month, the CDI program impact more than doubled within six months. Although each facility is different, the CDI program at the community hospital is attributed with yielding $65,000 to $70,000 in revenue every month, on average—an improvement of as much as $50,000 per month from new documentation opportunities made possible by the program changes.
Analyzing the Opportunity of Whole-House CDI
Along with CDI program expansion, Piedmont now tracks additional analytics. The CDI team reviews query opportunities to determine patterns and trends. In conjunction with denial audits, the data reveal targets for CDI engagement—by diagnosis, payer, and physician. For example, they have implemented a clinical validity process for sepsis, pneumonia, acute respiratory failure, encephalopathy and acute renal failure.
New workflows also are established based on identified risk, including, for example, a new embedded process to train registered dieticians on how to query physicians for patients with malnutrition.
Jane McKee, executive director, revenue cycle services at Piedmont Healthcare, says, “We need to understand documentation opportunities at each facility because each market is different due to varying case complexities and because CDI and coding don’t always impact case mix index.”
“Business intelligence helps us discern which documentation opportunities are appropriate and won’t result in denials or takebacks on both a proactive and retrospective basis,” she adds. “Over-aggressive documentation improvement can be equally detrimental as missed documentation opportunities for healthcare provider organizations.”
Ensuring Revenue Integrity Beyond CDI
During a recent revenue cycle executive focus group, the participants, including Piedmont’s McKee, discussed and verified the importance of expanding CDI beyond its traditional boundaries. McKee underscored the need for expanded CDI as part of the overall revenue integrity program.
“Our revenue integrity program is in transition as we focus on clinical documentation and chart capture,” she said. “We are trying to understand every staff touchpoint from the beginning of the cycle to the end of the cycle, including all clinical aspects—and CDI is a big component of our transformation.”
Nursing also is a champion of Piedmont’s expanded, all-payer CDI program and a defender of the team’s audits of denials and its focus is on centralization and standardization. Nursing collaboration with the CDI team is essential for several reasons. For example, it allows for:
- Discussions of working DRGs and the geometric mean LOS (GMLOS) during patient huddles
- Initiation of discharge planning based on clinical information, working DRGs, and GMLOS provided by the CDI specialists.
- Verification of possible patient safety issues that emerge during in-depth reviews with quality teams
- Dissection of clinical notes to determine whether all the appropriate documentation is included
Recently, The CEO of one of Piedmont’s hospitals attended the hospitalists meeting where a CDI specialist was present. The CDI specialist’s attendance allowed the physicians to ask questions about how the DRG is created, leading the CEO to request that the specialists always be present at hospitalist meetings.
Autumn Reiter, BSN, RN, CCDS, CDIP, CCS, is director CDI services, TrustHCS, Springfield, Mo.
Lori A. Dixon, MSN, RN-BC, CDIP, is director, clinical documentation improvement, revenue cycle services, Piedmont Healthcare, Atlanta.
a. “ New Generation CDI Proves Enhanced Patient Care and Reduced Financial Risk, Nuance Leads the End-to-End Coding Performers in the Era of Big Data, per Black Book Survey,” Black Book, press release, Oct. 31, 2016.