Tip: What do you say to your CFO to get support for additional staff and technology?

by Lorri Sides, RN

A CFO will typically see the potential of program expansion quickly. The CDI program manager or administrator simply needs to demonstrate the current effectiveness of the program’s efforts compared to the potential benefits of an expanded program—a cost-benefit analysis. Ask yourself:

1. What is the staff accomplishing today (e.g., volume of records, numbers of queries, percent of positive physician responses)?
2. What records are you looking at and why (e.g., Medicare-only reviews for MS-DRG shift or CC/MCC capture, all payers, Medicare plus some quality such as severity of illness and risk of mortality)?
3. What is the return on investment for the work currently performed (e.g., demonstrated benefits such as case-mix index improvement or PEPPER data)?
4. What steps do you need to take to expand your record review efforts (e.g., staff education, productivity decreases, additional technology, new staff)?

Start with CDI’s current successes and explain the vision behind potential expansion efforts. Dig into the existing data and specify, in concrete terms, what the existing HAC or POA rate is and how CDI can move that needle for your facility. If you do this, you’ll be seen as a change agent.

You may never be able to educate organizations and physicians on the various nuances of why a particular condition might be excluded from consideration as a PSI, or why a condition needs to be coded one way or another, but we now have the technology to easily identify these cases and automate rules to assist in rule interpretation and accurate reporting. This allows the CDI staff not only to see these opportunities for improvement, but to communicate these documentation needs effectively to physicians for the best overall results.

We’re not suggesting that we move backwards—CDI programs have made so much progress. We’re really saying that if these programs have done such a good job in this area, think about what they might be able to accomplish if they can expand their efforts into these quality opportunities, potentially with added staff and technology solutions to help them.

In one instance, when we audited how the program was performing, we found that a particular suggestion made by the technology did not get reviewed. Digging into the case further, we discovered that had the reviewer actually queried the physician, a host of other quality measures might have been affected, despite there being no impact on base reimbursement.

We need to better leverage CDI, to enable the staff to identify a potential PSI exception and query it or communicate it to the appropriate quality staff member. We need to educate CDI about the conditions that affect the Readmissions Reduction Program and enable them to work with the case management team to review the record together and further identify whether a particular condition meets protocols. I visited one facility that had its CDI team participate in integrated rounding—that’s out-of-the-box thinking, comparing in real time the clinical picture of the patient to what that patient’s claim would reflect.

Editor’s note: Lorri Sides, RN, senior director of product management for Optum360 in Bellevue, Washington, is a registered nurse with more than 20 years of healthcare experience. Lorri has worked in many different aspects of healthcare, affording her a unique view of the problems the industry faces today. She spoke with ACDIS Associate Editorial Director Melissa Varnavas about the benefits of expanding clinical documentation reviews into the quality arena.