Q&A: Audit processes

Q: What is your audit process for your CDI team? Could you share the following info about your process?

• Team size
• Types of audits performed (charts, queries, etc.)
• Audit frequency
• Who performs the audit (supervisor versus manager versus second-level reviewer)
• Scoring system used, if applicable
• Audit results review process

Response #1: We have 22 CDI specialists on our team to audit. In 2024, we’re alternating each quarter between two different types of audits:

• Retrospective audit: 10 charts after final coding (ideally five with queries, five without). Typically, the charts chosen for audit are surgeries without a CC/MCC, low length of stay sepsis, symptom DRGs, simple pneumonia, etc. During these audits, we’re reviewing for missed queries, compliant queries, workflow, and reconciliation of chart.
• Concurrent audit: Five charts while the patient remains inpatient, looking at the same type of charts primarily for missed query opportunities that could still be sent. If the query is sent, we’re also evaluating for compliance.

Our CDI educator role is built to be 50% auditing, 50% education, so they handle all these audits.

We do not share scoring with the CDI staff. Instead, we focus on the educational opportunities and what they did well so that it doesn’t come across as punitive. For the manager’s copy, we have a very simple scoring system that shows the percentage of charts that had missed query opportunities and how many charts had workflow errors. We also count the number of noncompliant queries (with the intent to be 0).

We send the audit to the CDI specialist once complete for them to review. Then, we schedule a call with the CDI specialist, the educator, and the manager to review case by case and discuss. We ask them to look at the cases prior to the call so it’s more of a discussion rather than the educator just relaying the findings.

Response #2: We currently have five staff members and we audit charts, queries, and their productivity metrics twice a year. Our manager is the one who handles the audits. Currently, our goal is that our staff pass the audit with a 90% grade, but we’re about to raise that expectation to 95%.

After the audit, we meet with the staff members individually over Microsoft Teams® and review the results. Then, they receive the results after we discuss them during the meeting to rebut findings as desired.

Currently, we’re using a spreadsheet to list five charts, five queries, and five days of productivity per staff member per audit. Then, we use a formula to calculate their percentage grade.

Response #3: We currently have a team of 40 CDI staff, and our supervisor conducts quarterly audits on charts and queries. Once they’ve completed their audits, they meet individually with the staff member virtually for a one-on-one meeting. We do also use an external vendor that conducts an annual audit in addition to our in-house quarterly reviews.

Response #4: We have four CDI auditors, all of whom are RNs by background and hold the CCDS credential, who report to a different director. We do strategic audits along with a baseline assessment once a year. The auditors review 30 total charts per CDI specialist—15 with queries, 15 without queries.

If there are rebuttals to the audits, the issue will be adjudicated between CDI leadership and the CDI educator.

We use the following scoring system:

After the audit is completed, we send a spreadsheet with a case detailed scorecard to the team member and rebuttals are allowed. If the scores are below 94% overall, then the team member receives one-on-one education from the CDI educator.

We do also use an outside vendor to ensure the accuracy of our auditors’ findings.

Response #5: Audits are reviewed with the individual CDI staff by the CDI supervisors, at minimum every quarter. Cases are referred for audit by the leads completing second-level reviews, the CDI analyst identifying opportunities, and our outside consultant as they review records.

Our CDI leads prioritize their second-level reviews in the following order, with cases flagged in a work queue that only they can access:

1. Low acuity with discharge to hospice or mortality
2. Patients with a long length of stay and no MCC
3. Low weighted, targeted DRGs

The supervisors conduct random DRG audits if the CDI staff has not had at least five opportunities identified each quarter. Supervisors also conduct random query audits for each CDI as reported by our software reports.

Our consultant completes random DRG-focused reviews and reports back to the CDI team with education and identified opportunities.

Finally, our CDI analyst also plays a role in the audit process. When reviewing select DRG reports each month, patients with a geometric mean length of stay over two days are reviewed for potential opportunities and trends suitable for education for the whole team. Results of these audits are forwarded to CDI director, supervisors, and CDI educator.

The supervisors use an audit tool that includes the following information:

• CDI name
• Patient name
• Patient ID #
• Admission date
• Discharge date
• Whether there was a DRG mismatch with coding
  
  • If so, was the reconciliation process followed?
• Initial CDI review template completion
• Subsequent review template completion
• Missed query opportunities
• Compliance issues with sent queries
• Query escalation process follow-through, if necessary

Audits/notes from meetings with team are kept and summarized at the CDI specialists’ annual reviews.

Response #6: We have 50 CDI team members, including myself, one lead, and seven senior CDI specialists.

We conduct peer-to-peer audits of 10 charts which are reviewed by another CDI specialist on rotating schedule, at least five query records. We also have our senior staff members review random charts and do a separate review with a focus on DRG mismatches. 

For the peer-to-peer audits, staff are reviewed every other month. The senior staff reviews take place randomly, but if we have a staff member who’s struggling, the senior staff will review their work monthly and provide one-on-one education.

For the peer-to-peer reviews, the audit is sent directly to the staff member under review and the lead or manager is included on the email. If there are any disagreements with the findings, the lead or manager will mediate.

Initially, we weren’t sure how the peer-to-peer process would go but it has been fantastic. It not only allows CDI specialists to see how others review records but, because we’re 100% remote, it allows for some individual collaboration and actually helps them to get to know their peers.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.