Case Study: Physicians hold the role of CDI specialists at Bronx-Lebanon

The establishment and enhancement of a CDI program at Bronx-Lebanon Hospital Center originated in 2010.  Robert Leviton, MD, the hospital’s chief medical information officer/physician advisor, Diane Johnson, director of HIM, and Mohammad Ahmed, MD, assistant director of CDI believed that an electronic medical record system’s integration with patient care, documentation, and revenue cycle management would be beneficial to all stakeholders.

“CDI will become even more significant in light of ICD-10, by providing a proven practice work flow that captures clinical documentation, provides enhanced opportunities for improvements, and permits billing that is increasingly dependent on the ability to code correctly,” Johnson said.

All Bronx-Lebanon Hospital CDI specialists are physicians who hold coding credentials from AHIMA, which makes its CDI program distinct from other programs. The trend of hiring foreign medical graduates or physicians at other institutes is also growing, due to enhanced CDI query response and agreement rates.

“As physicians, we have tremendous insight into the thoughts of the clinical staff, including detailed assessments relativity to the documentation needs,” Ahmed said.

The CDI program at Bronx-Lebanon started with the implementation of Allscripts Care Manager Program, as well as 3M Encoder and reference.  “Our CDI query and response rate is outstanding, since CDI staff place queries based on medical evidence and clinically significant conditions,” said Ahmed. CDI staff collaborate and provide accurate coding opportunities for the HIM and case management department by posting geometric mean length of stay on the patient’s electronic facility board.

Through concurrent review of a patient chart and after computing the initial DRG into Allscripts, CDI specialists enter principal and secondary diagnosis along with the procedures. Concurrent queries are directed verbally, as well as electronically. CDI staff continues to review the charts until the patient is discharged to ensure all necessary information is captured. The CDI staff also takes on a vital role in facilitating retrospective queries with collaboration of HIM coding mangers.

The DRG status in Allscripts is specified by DRG icon color. A blue colored DRG icon indicates that the patient chart is not reviewed by the CDI, whereas an orange DRG icon indicates that the chart review is in progress or waiting for final DRG. When a physician documents additional diagnoses or clarifies documentation in the patient’s medical record, the CDI specialist captures these changes and assign a working DRG by updating diagnostic codes, as well as electronically posting the expected length of stay (LOS) on the electronic facility board, thereby providing guidance to the clinical staff regarding the remaining LOS. The final DRG and codes are assigned by HIM coders for all discharged cases. A working and final DRG matching situation is indicated by a green DRG icon color, whereas the red DRG icon color draws attention to a discrepancy in coding data, either by the CDI or HIM coder. These charts are then reassigned to the HIM manager to reconcile the data.

“Our discrepancy rate is very low, an indicator of the program’s success,” said Ahmed.

Another key metric of the program’s success is its reporting structure, CDI program productivity reports are presented to the hospital’s chief medical information officer on a regular basis. Using the electronic format allows the CDI staff to be transparent. This practice enhances the coder’s efficiency and also opens an opportunity for educational dialogue between HIM coders and CDI staff. Numerous tools to help physicians learn about the importance of better documentation and update them about Centers for Medicare and Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organization (JCAHO) guidelines are also provided.

“Our CDI team at is not only hardworking and dedicated, but their unending efforts continue to serve as a model for CDI programs throughout the nation,” Ahmed said.