Conference Q&A: ‘The Physician Advisor’s Role in CDI’
Editor’s Note: Over the coming days and weeks, we will post a series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. Today’s post features James S. Kennedy, MD, CCS, ACDIS Advisory Board member and a director at FTI Healthcare in Brentwood, Tenn. Kennedy will co-present the ACDIS pre-conference event titled “The Physician Advisor’s Role in CDI: A collaborative approach for success.” The two-day session takes place Tuesday and Wednesday, May 8-9, 8 a.m. to 4 p.m.
Q: What role should CDI physician advisors play in audit review and data analysis?
A: Clinical Documentation Improvement (CDI) physician advisors are critical to the entire process of ensuring the integrity of coded administrative data (ICD-9-CM and CPT) and its application to physician and hospital quality and cost efficiency measurement.
CDI is the process of preventing and reconciling inconsistent, incomplete, imprecise, conflicting, or illegible documentation to bridge the gap between treating physicians and coders. Physician advisors must be able to analyze data derived from these codes to target their efforts and should review the results from documentation audits as to hone their message.
Examples of these activities include:
- Data Analysis: ICD-9-CM coded administrative data is primarily used to determine, measure, and report severity and risk adjusted outcomes and cost data for various metrics. These include cost, length of stay, complications, mortality, readmissions, and the like.
Risk and severity adjustment means that the actual metric being measured (observed) is compared to the likelihood of that metric occurring (expected). CDI ensures the integrity of the expected metric, usually increasing it since many clinical descriptions are incomplete or imprecise, thus reducing the risk-adjusted metric.
Take for example the Colorado Hospital Report Card. Note that Colorado reports an actual mortality rate and a “risk-adjusted” mortality rate. There are instances when the risk-adjusted mortality is less than the actual mortality since the death rate is less than expected. There are others, however, where the risk-adjusted mortality rate is higher than the actual.
Another aspect is measuring complications of care. Some facilities code incidental serosal tears as “accidental lacerations.” Physician advisors would want to analyze Patient Safety Indicator data at their hospitals (e.g. from Thomson-Reuters, the Delta Group, and the like) to determine if the data driving these metrics is accurate.
For example, look at the website “CareChex,” a division of the Delta Group, to see how it ranks overall surgical care in Chattanooga, Tenn.
Physician advisors should partner with their chief quality officer to learn how these risk-adjustment methodologies work and how the definition, diagnosis, documentation, and coding of these conditions factor into them.
Armed with this information, the physician advisor can help develop systems that work with providers to accurately capture these metrics.
- Chart Audit: Physician advisors are integral to the chart review, given that they recognize the clinical scenarios that are often not documented completely and precisely. Imagine a patient admitted with a pH of 7.02, pCO2 of 100 and a pO2 of 40 and stupor requiring mechanical ventilation but only described as respiratory insufficiency with CO2 narcosis. This patient has acute hypercapnic respiratory failure and could potentially be labeled as having a metabolic encephalopathy. The physician advisor recognizes these scenarios and can help concurrent reviewer and coders recognize the circumstances whereby query would be prudent.
AHIMA published a nice summary of the role of the physician advisor, and you read more about the role in the January edition of the CDI Journal.
Q: How can a physician advisor help achieve buy-in from the medical staff for CDI efforts?
A: The best ways I know to achieve buy-in from the medical staff are to:
- Make CDI an academic exercise, emphasizing the definitions of clinical conditions. These can include:
- Transient ischemic attack versus stroke. Note that the 24-hour time frame is completely eliminated.
- Acute myocardial infarction vs. accelerated angina. Note the critical role of properly calibrating troponins and equating elevated levels with “symptoms of ischemia.”
- Acute kidney injury. Note that it is only a rise of the serum creatinine of only 0.3 mg/dl
- Ask the quality officers of your hospitals to generate individual physician reports regarding their own cost efficiency and outcomes, outlining the actual and the expected outcomes. Should a physician see that their expected mortality rates is higher than expected and that CDI is a strong solution addressing the “expected” component, his or her participation and interest is likely to increase!
Q: How involved should the physician advisor be in the day-to-day operations of the CDI program?
A: Given that most physician advisors have their own private practices, they do not need to be involved with the direct day-to-day operations of initiating queries. They should, however, be available at designated times to support concurrent reviewers and coders regarding the clinical circumstances assessments of clinical situations requiring query and to aid in their construction.
If at times a physician does not respond, the physician advisor may potentially have a collegial conversation about a query. One must be cautious, however, to frame this conversation about defining a patient’s condition without putting the physician on the defensive.
One of the fun things a physician advisor can do is support the development of the electronic medical record as to make the capture of complete and precise documentation less onerous to the practicing physician.
Q: What are you looking forward to most about this year’s ACDIS Conference?
A: Wow….what’s not to look forward to? ACDIS is everything a CDI professional, coder, or physician advisor would want—clinical conversations, problem solving, medical informatics, and collegial interaction with like-minded individuals working to solve the challenges we all share.
It’ll be great to be with old friends and make new ones! Not to mention that all this occurs in downtown San Diego, in a phenomenal setting (this is a beautiful hotel), right next to Balboa Park (let’s rent a bicycle and ride!) and close to Sea World, the ocean, and all that makes southern California great!
I must say, however, that the most anticipated event for me is the Physician Advisor pre-conference where Dr. Trey LaCharité and I spend two days training physicians from all over the nation to understand and embrace CDI principles.
I feel that this contributes to the professional practice of medicine and empowers physicians to successfully negotiate healthcare reform. Needless to say, I’m very excited about the conference!