CDI Week 2021 Q&A: CDI pantry staples (back to basics)
As a preview of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. These Q&As will continue throughout CDI Week, September 13-17 as well. Brian Simpson, MS, RRT, CCDS, CCDS-O, CDIP, CCS, CRC, CDI specialist at Penn Highlands Healthcare in DuBois, Pennsylvania, answered these questions. He is a member of the central Pennsylvania ACDIS local chapter and of the 2021 ACDIS Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Editor Carolyn Riel (criel@acdis.org).
Q: What are some of the “pantry staples” that you think every CDI department needs to have?
A: To me, one of the most important pantry staples of a CDI department is definitely having a strong collaborative relationship with coding. There is always something to be learned from one another. Sharing knowledge is a cornerstone of a strong CDI department.
I would also say that having CDI software is key to success. Personally, I think of the software as a great resource. It can sometimes help you find things you may have otherwise missed. I think that both the relationship with coding and CDI software have made me a more efficient and productive CDI.
Q: What basics should a CDI specialist know when entering the field? Are there any staples of CDI you did not know when first becoming involved in CDI that you wish you had known?
A: I think that having a knowledge of coding concepts and guidelines would make for a smoother transition from the clinical world to that of CDI. It isn’t just the concept of a clinical review, but rather taking that clinical knowledge and information and merging it with coding guidelines. I think a perfect example of this is the use of combination codes. Knowing how different disease processes can be linked together to be more representative of total clinical picture.
Q: Just over one third of 2021 CDI Week Industry Survey respondents (37%) spend three to six months for onboarding and training of new CDI specialists. Over one quarter (27%) allot one to two months, and 18% only train new CDI for a few weeks to a month. How long is the onboarding process in your facility? Should training and onboarding time be customized for each CDI specialist? Why or why not?
A: My facility doesn’t have a structured training program when it comes to length of time. We typically look at the individual CDI background and experience. For example, a clinical staff member that has at least basic coding knowledge and understanding has an advantage and may not require as much training and education. I was very fortunate coming from a revenue integrity background, already having a coding certification. In my opinion, a coding certification like the CCS does not make you a coder. It does, however, give you a nice base of knowledge.
I think that one month could be enough for some staff, but I think that two to three months may be more reasonable. When it comes down to it, training should be tailored to each individual staff member.
Q: Most survey respondents (25%) said staff are assigned reviews by software protocols (such as prioritization software). Other respondents (between 15-18%) said staff are assigned reviews by service line, based on patient census patterns, or randomly. How are reviews assigned at your organization? What are the benefits of assigning reviews each of the ways noted above? Are there risks to assigning reviews randomly?
A: We typically do random assignments. If there is a specific area that someone may have more of an interest in, however, we do try to accommodate that. We are small department of only four members, so we do need to keep everyone comfortable in each service line. It makes it easier to cover when someone is on vacation or leave. We do use a prioritization system when it comes to doing our individual reviews. I think this increased our effectiveness and helps us address things such as potential ORs and procedures that may impact estimated length of stay. Our case managers rely on us to update our working DRGs on a daily basis. I personally don’t feel that assigning reviews randomly has a negative impact on productivity or job satisfaction. We seem to like a nice “mix” and don’t feel overwhelmed with any specific type of admission.
Q: In terms of concurrently reviewing for quality measures, 83% of respondents review for present on admission (POA)/hospital acquired conditions (HAC), 70% review for severity of illness (SOI)/risk of mortality (ROM) concurrent to stay, and 69% review for patient safety indicators. Which quality measures does your organization review for? How was it decided that these measures would be the ones to concurrently review? What are the risks of not reviewing for certain quality measures?
A: We try to review for quality, POA and SOI/ROM as much and as often as we can. We really didn’t have a specific program when it came to addressing quality measures. Initially, we started with hierarchical condition categories such as chronic kidney disease and atrial fibrillation. It seemed like the next step as we already reviewed for specificity and acuity. When it comes to addressing POA it seems to make sense when also considering HACs. I think a perfect example of this is the presence and staging of pressure ulcers. If this is addressed from admission, it reduces the possibility of a HAC.
Q: Only 24% of respondents noted rounding with physicians on the floor as part of their typical duties. Do CDI specialists round with physicians at your organization? Are there any negatives to CDI rounding with physicians?
A: We do not round with our physicians. Before the pandemic, we did participate in multidisciplinary rounds. As our providers became busier and we relied more on electronic queries only, our response/agreement rates increased. We are very fortunate to have a responsive medical staff. If we don’t get a response within 24 hours, we send the query again (along with a friendly text message) and very rarely have to address the issue again. I think it has worked so well because the providers don’t feel the immediate pressure of a face-to-face discussion. The electronic query allows our providers to address the query at a time that is more beneficial for them. I think the physicians don’t feel “put on the spot” the way they did when we rounded with them.
Q: Respondents to the 2021 CDI Week Industry Survey listed sepsis (67%), respiratory failure (48%), congestive heart failure (CHF) (46%), and malnutrition (46%) as the top queried diagnoses. Do these align with queries you and your team are asking in your facility? Why do you think these four diagnoses tend to be the “problem diagnoses” that many organizations struggle with? What tips do you have for writing effective queries on these diagnoses? Do you have any suggestions for educating physicians about effective documentation related to these diagnoses?
A: We don’t see as many issues with sepsis as we did, but we continue to spend a great deal of time addressing acute respiratory failure, CHF, and malnutrition. I think these are difficult diagnoses because the providers aren’t used to thinking about coding considerations. It is still a challenge to get specificity and acuity for respiratory failure and CHF. When it comes to malnutrition, they just aren’t aware of (or think about) the American Society for Parenteral and Enteral Nutrition (ASPEN) or the Global Leadership Initiative on Malnutrition (GLIM) criteria. For so many years it was about albumin levels and that is how they gaged the presence of malnutrition.
When it comes to queries, it’s all about the indicators. If you are asking about validity, include the indicators that go against the diagnosis. If you are asking about the presence of acute respiratory failure, make sure to add everything you can to truly reflect the level of distress. As far as educating physicians on these topics, I think the best way is one on one. It is much easier to explain the “why” and to help them understand what you are asking.
Q: The majority of respondents create their query templates internally with the CDI team, physicians, and/or coders. Does your facility use query templates? If so, how are those created? What are the benefits of using query templates?
A: We typically use the templates that are provided by our CDI software. We do, however, make adjustments when we feel it may help us address our question more effectively. It seems that very often the CDI software presents the provider with too many choices and selections. I think by keeping it more direct (without leading, of course) and to the point, we have a much better success rate with queries. One benefit of the templates can be giving the CDI specialist a better way of problem-solving a difficult topic. It may give us a different way to approach a diagnosis. A good example is COVID-19. We have a great software template that makes the issue of current versus sequela of COVID-19 much easier to address. It is very simple and to the point. We have had great success with our providers on the topic of COVID-19.