Guest Post: The CDI evolution

by Juanita B. Seel, RN, CCDS

I have been a CDI specialist for seven years. I wanted to share with all of you how our program has evolved throughout the years.

When we first started our program in 2004, it was all about capturing the CCs (there were no MCCs at that time). It focused on moving the DRG to a higher weighted category. Physicians always asked, “How much money will this earn for the hospital?” We were called the “chart police,” “green sheet ladies” (our queries are bright green), and many more things I am sure.

I did not like the fact that we were seen as only trying to get more money for the hospital. To me, my job meant more than that. It was about capturing the true severity of illness of the patient being treated; it was about the most accurate risk of mortality being captured. It was about having the medical record stand on its own without the need to question diagnoses and codes for the record.

Fortunately, a few of the RN CDI specialists I worked with felt the same way. We soon started our own little movement to shift our focus away from DRG capture and to query the physician for any diagnosis not adequately documented in the chart—even if it actually lowered the DRG. We started looking for the consistency of documentation, the clarity of documentation, the correct description of diagnoses and clinical data to support all of these in the medical record.

When MS-DRG’s hit, we became more assured this was the way we wanted our program to be. I changed the way I presented information to physicians and focused more on clear, concise, and accurate documentation. I focused more on “you documented this, but did you really mean this.”

Our CDI department quit singling out queries for diagnoses that would raise the DRG to a higher level. We queried the physician for any diagnoses for which documentation was unclear, vague, or just plain not documented well. Our percentage of queries went from 15% to 35%. Our goal was to have the medical record stand up against any audit or review as far as documentation was concerned. We wanted to make sure the treatment plan matched clinically with the diagnoses in the medical record.

The strange thing was that when we did this, when we concentrated more on the accurate documentation, the money came. Our CMI stabilized (with a healthy fluctuation); our risk of mortality rates stabilized, and our severity of illness clearly indicated the illnesses—both acute and chronic—the patient was treated for. Physicians began to see us in a different light. We could discuss, sometimes at length, why the “coding language was so different from the medical language.”

Our program now has an 85% query response rate. We write an average of 700 queries a month, with an average chart review rate of 2,400 charts per month. We have a staff of five full time RNs, two part-time RNs, and one supervisor. We review charts at the main hospital and two outlying facilities. Our hospital has 700+ beds and the outlying bed total is about 125.

I am very proud of our program and how it has evolved. The point is, if a program will review the record based on the medical documentation matching the coding language needed, teach physicians what is needed in documentation and concentrate on the accurate documentation of all diagnoses in the medical record—not just CCs and MCCs—the money will come naturally, and auditors will not be taking away codes because of documentation issues.

Please feel free to contact me about our program. I love to brag about the work of our CDI specialists.

Editor’s Note: Seel, at the time of this article's original release, was the Documentation Integrity Supervisor at Greenville (SC) Hospital System University Medical Center and current co-leader of the South Carolina ACDIS Chapter. This article was originally published on the DCBA blog “CDI Talk” and is reprinted here with permission.