Guest post: Physician advisors’ role in clinical validation, CDI expansion

by James P. Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer

CDI physician advisors use their clinical experience linked to evidence-based medicine and their ability to engage colleagues to mitigate risk, especially where clinical validity is questioned, a situation particularly necessary these days for complicated clinical and coding definitions for conditions such as sepsis, encephalopathy, and malnutrition diagnoses.

For example, strict application of Sepsis-3 criteria to define sepsis would lead a novice to capture the code for severe sepsis; however, the Official Guidelines for Coding and Reporting through ICD-10-CM and code indexing would indicate otherwise. Bringing together the two hemispheres of clinical and coding terminology is challenging, but it’s an important measure of a physician advisor’s success.

In fact, physician advisors align very well with recent descriptions of clinical validation. As per Denton et al. in 2016, in the article “Clinical Validation: The Next Level of CDI,” published in the Journal of AHIMA, clinical validation is usually considered an advanced skill requiring a strong understanding of clinical pathology, finesse, and excellent communication skills to avoid conflicts. Identifying financial opportunity is an important role of a well-trained physician advisor, but denial-risk mitigation also represents a priority for CDI programs in today’s healthcare environment.

Extending the triple aim of CDI—financial accuracy, quality measure performance, and accurate representation of a population’s (i.e., patient) risk—the physician advisor can assist in advancing a CDI program by fostering leadership buy-in and the long-term value proposition.

The growth of the physician advisor is reflective not only of the initial coding foundation established but also of the concept of lifelong learning and personal investment. As patient-centered, value-based care becomes the norm, physician leadership becomes central.

A well-trained physician advisor who understands the direct link between care delivery and CDI can negotiate program advancement beyond historical financial metrics. Broadening the value proposition to reputation through star ratings, outcome performance with penalty avoidance, and improved risk-based payment contracts will reignite the organizational investment in CDI. Also, aligning CDI with providers and their practices will guarantee physician support in CDI efforts.

The physician advisor’s role in CDI expansion

Medicare uses Hierarchical Condition Categories and related versions to modify payment to hospitals and providers in the form of incentives and penalties. This risk adjustment is a key component in the shift toward value-based care, accounting for differences in patient characteristics (including health status), which leads to variations in healthcare outcomes and costs.

These will be applied to both physician payment and hospital DRG-based reimbursement under CMS pay-for-performance programs. The financial impact on both provider and hospital can be substantial. Physician advisors are in a unique position to ensure accuracy when defining population risk and outcome performance.

For example, with the systemic adoption of the third universal definition of myocardial infarction, an organization will correctly identify acute myocardial infarction in 30-day cohorts. Also, merging clinical terminology of type 2 myocardial infarctions to the corresponding ICD-10-CM code will correctly exclude such patients from these cohorts.

Finally, with advanced knowledge of CMS risk-adjustment methodologies, the physician advisor can have a significant effect on expected population outcomes by driving improved documentation and coding. A physician advisor’s firm understanding of pay for performance yields improved quality outcomes and compliant reporting, thereby reducing the risk of poor reputation and financial penalties.

CDI physician advisors are critical to the long-term success of a CDI program; however, careful selection of an individual that possesses leadership skills, a broad knowledge of evidence-based medicine, and knowledge of inpatient coding, along with the willingness to commit, is imperative.

In addition, each CDI program should invest in comprehensive training and mentoring for the physician advisor, not only to reap the rewards but also to escape future peril.

Editor’s note: This article was adapted from the original, titled “Putting the spotlight on physician advisors,” in Briefings on Coding Compliance Strategies. Dr. Fee is CEO of Enjoin. He is board-certified in internal medicine and pediatrics and maintains a clinical practice in hospital medicine. Fee has extensive experience in hospital-based medicine, DRG management, and CDI, including documentation that impacts quality performance measures and risk adjustment across the continuum. Fee is a Briefings on Coding Compliance Strategies board member. Contact him at james.fee@enjoincdi.com. Opinions expressed are that of the authors and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.