Resolutions: It's that time of year again

Review past successes and failures to plan future progress
by Lynne Spryszak, RN, CCDS, CPC-A
Are you like me and refuse to make New Year’s resolutions because you think you’re just setting yourself up for failure? Lose weight? Quit smoking? Exercise more? Spend less? Let’s face it, you can’t just decide to change your life without having a plan for how it’s going to happen. I’ve found that making resolutions with a cocktail wienie in one hand and a glass of champagne in the other is not conducive to clear thinking. My resolutions somehow always turn into planning how to win the lottery and retire!

On New Year’s Eve, however, I do find myself reflecting back on the previous year’s events and how decisions I made influenced those events. I also think about decisions I made as a result of anticipated or unexpected events. So, what does this have to do with CDI?

January is a good time to look back at your CDI program’s results for the previous year and identify its strengths and weaknesses (or, as we say in consulting—“opportunities for improvement”).

Program strengths and weaknesses
Take a look at the focus of your program and determine if you are meeting your goals. Most organizations evaluate performance by looking at calendar year data, so set aside some time in January to run some reports and analyze your program. If you’re not the data manager for your program, make an appointment to sit down with your data person/report developer/manager to review your past year’s CDI reports. Through this effort you’ll develop insight into what is being measured, how it’s reported, and who receives this information.

First, take a look at the organizational structure of your program. Ask:

• Is everyone on the administrative team aware your program’s performance?
• Is administration involved and invested in your success?
• What can you do to better inform your administrative team? 

If your administrators don’t usually attend your regular team meetings then see if you can set up scheduled monthly or quarterly invitations through their administrative assistants. These interactions give administrators the opportunity to know your team better, and I’ve found it’s usually easier to deal with people who know you. It’s unlikely you can change your administrative team, so focus on what you can change.

Program benchmarks
Look at the established benchmarks for your program. Every program is different, so now is a good time to determine whether those benchmarks established when your program was new are still applicable for your seasoned team. If you’ve been doing a great job changing your physicians’ documentation through education and mentoring, then keeping that high query benchmark on your report dashboard will make you look like under-achievers. If an outside consultant generates your reports, ask them to re-evaluate this metric in light of your experience.

Furthermore, your “dashboard” should be customized to reflect your progress, not someone else’s. Measuring your performance against others in your region (or the nation) is a good generic tool when assessing a facility prior to implementing a program, but over time these benchmarks lose value as programs mature. If you have 12 months of program data, use that information to reset your benchmarks.

Oftentimes poor results come from diminishing administrative support rather than lack of work on the part of the team, so take a look at what your organization is measuring and suggest metrics that will provide the type of data that can be used for CDI process improvement.

Data analysis
Use your data analysis to see if new responsibilities have affected your ability to do a good job on documentation improvement. In this past year were you asked to tackle such issues as: 

•  present-on-admission (POA) 
•  medical necessity for recovery audit contractor audit preparation
• CORE measures

Were these additional tasks being tracked on your CDI dashboard? If not, then it’s hard to make a case for declining CDI performance without the associated data.

Have you done a detailed analysis of your performance as compared to your staffing over the past year? Nothing speaks more directly to your chief executive officer and chief financial officer more than declining revenue. If you’ve found yourself spending more time on tasks that can’t be adequately captured in a revenue report and less time on those tasks that are, then this information should be captured on your monthly CDI reports or on a separate report so that you have this data available when you’re asked “what happened last month?”

RAC targets
In December 2009 the Region C RAC contractor, Connolly, announced a list of MS-DRGs that will be the focus of complex record reviews in early 2010. This came as no surprise to experienced CDI specialists as we’ve learned over the years that when we make something better it eventually becomes a target for audit by someone!

The states involved in this audit include:

• Alabama
• Colorado
• Florida
• Georgia
• New Mexico
• North Carolina
• Oklahoma
• South Carolina
• Tennessee
• Texas

If you live in one of these states then I guarantee someone in your organization will be tracking these DRGs on a report somewhere. If you haven’t been involved in your facility’s RAC team, at least on the periphery, then you’ll be in for a big surprise when you’re asked what you’ve been doing to focus on these DRGs.

The subject of RAC complex record reviews, and specifically, these DRGs, would probably be a good agenda item to examine at your next team meeting. Ask your counterparts in HIM to develop a report covering the period from October 2007 through December 2009 so you can see what your volume of cases is in these DRGs and work collaboratively to develop a process to ensure that any cases assigned to these DRGs have undergone a second review prior to final coding.

Our job is to ensure that the assigned codes are supported by the documentation, so assess whether your CDI team needs to make this a focus of concurrent review or if a back-end second review process by HIM will be sufficient.

Program documentation
Do you have CDI policies and procedures in place? If you don’t have CDI-specific policies and procedures, are you expected to adhere to HIM policies? Do the HIM policies cover physician queries and which outside agencies (CMS, AHIMA, AHA Coding Clinic) are considered the final authority? How do your policies and procedures look to an outside auditor?

If you do not have policies and procedures in place then now is the time to form a cross-discipline committee to draft them. If you do have policies and procedures in place, an audit of your CDI queries is in order. In CMS’ directions to state Quality Improvement Organizations (QIOs) the agency gives QIOs the authority to determine what is considered a “leading” query.

As a consultant, I’ve reviewed medical records a state QIO or RAC had denied, and assessed whether an appeal was appropriate based on the documentation in the record. I can tell you that many of these records included physician queries considered “leading” by the QIO. If your query audit shows that you’re not adhering to facility policy then this is not only a compliance issue, it may be a revenue issue as well when payment is denied to the facility.

I hope you all read Sylvia Hoffman’s holiday CDI Blog post. It is a great example of how humor can be successfully used to illustrate CDI’s goals. Maybe the suggestions I’ve given above are things you can’t, or don’t want to tackle. Okay, then focus this year on that one doctor (or group) that just can’t seem to get onboard with documentation improvement. Believe me, this can be a year-long project all by itself! But, even with this one goal, think of what this could mean to your program’s outcomes!

On a personal note, I am so proud to be a CDI specialist. I look back over my past 12 months—a year of travel and change—and am grateful for how much I’ve learned. My transition from facility-based CDI specialist and manager to other positions allowed me to see CDI programs through a different set of eyes, but I’ve always kept my focus on “how would this affect a CDI specialist?” when working with clients and administrators. My past experiences as a reviewer and CDI manager helped me develop better teaching tools and processes for new or faltering CDI programs.

Our profession may be relatively new, but our strength lies in our collaboration and willingness to learn from each other. Thanks to all of you who taught me so much. May your new year be filled with personal blessings and professional satisfaction!

Editor’s Note: Spryszak is a manager at Precyse Solutions, LLC, in Wayne, PA, an ACDIS Advisory Board member, and a previous winner of the 2009 Recognition of CDI Professional Achievement award. She spent the past five years as a clinical documentation specialist, and the last two years as program coordinator for the Clinical Documentation Management Program at Alexian Brothers Medical Center in Elk Grove Village, IL. Contact her at lspryszak@precysesolutions.com.