Fully utilize the specialized knowledge of your CDI specialist with these tips.
Having a team member with the specialized knowledge of clinical documentation integrity (CDI) can help your team keep your practice’s documentation and claims in tip-top shape.
But is your practice maximizing the potential of the CDI specialist’s knowledge? Adding or adjusting these responsibilities within the CDI specialist role can help your practice achieve documentation excellence.
Let CDI Specialists Audit and Educate, Too
CDI specialists generally aren’t clinicians and don’t provide care for patients — but they tend to have a ton of experience reading patient charts. CDI specialists can make great internal auditors because they’re so familiar with documentation that it may be easy to see patterns or trends, as well as any deviations. Coders can move to auditing and physician educator roles with sufficient professional development, becoming true resources for their organizations.
“I’ve been reading charts for so many years, and I understand and can contemplate, based on what’s written, what’s going to be happening or what’s missing when I’m reading that documentation. So, my expertise here is in the documentation, not the care,” said Heather Greene, MBA, RHIA, CDEI, CIC, CDIP, CPC, CPMA, CDEO, CRC, exam specialist at AAPC, in her RISKCON 2024 presentation, “The KPIs of CDI.”
With this expertise, CDI specialists can work with providers to make sure their clinical care is documented effectively and efficiently, making sure the revenue cycle management (RCM) team members have the information they need to do their jobs without taking up too much of the clinicians’ time.
CDI specialists can help providers with their documentation with via discussion of disease processes and possible treatments, including the generally accepted clinical pathways, and then offer training based on the results of audits and denials.
For example, if a patient has a history of cancer but does not actively have cancer or receive treatment for cancer, and a clinician’s documentation doesn’t make the distinction obvious, then a coder may choose the wrong diagnosis codes. In such a situation, the provider probably needs some training and guidance on documenting the patient’s history of cancer differently, so the coder can better understand the patient’s current condition. A CDI specialist may say something like, “Just so you know, the way you’re writing this makes it sound different than what you maybe intended” to the provider, and the problem could be solved fairly quickly.
Rely on Chart Review Skills
Although a CDI specialist wouldn’t question a physician’s clinical judgement, they could be extremely useful as another set of eyes looking at a patient’s chart. For example, if a provider documents that a patient has a certain condition, but the CDI specialist doesn’t believe the documentation supports the diagnosis, then they can give the provider a heads up. Or, similarly, if the physician documents that the patient presents with a bunch of symptoms that might be clinical indicators of a specific condition, but the physician doesn’t provide a diagnosis, the CDI specialist could gently bring the lack of diagnosis to the physician’s attention. Remember, the provider’s job is to focus on the patient and provide quality care; documentation may fall by the wayside in that process, even though it’s a crucial and long-term tool for any care team.
Many CDI specialists also have the knowledge necessary to see trends in clinical indicators, which is especially useful when caring for patients with chronic conditions. CDI specialists looking over documentation may notice that a patient with a chronic condition hasn’t been seen to check in on that condition and make a note that that patient may need an appointment, just to ensure they’re receiving an appropriate level of care.
Coders and CDI specialists can work in tandem to make sure that providers’ encounters are being coded accurately. If the provider is pulling level 5 office/outpatient evaluation and management (E/M) services at every encounter, both coders and CDI specialists may see some red flags and can use that as an educational opportunity.
Focus on Documentation Dos
One of the most important tools at a coder or CDI specialist’s disposal is the ability to query a physician. If querying a physician seems nerve-wracking, it may be helpful to remember that a query is not a judgement, but more of an evaluation of the totality of the documentation.
Greene said documentation should be legible, reliable, precise, complete, consistent, clear, and timely. “When you’re working or reading charts, if something is not clicking, this is what we’re trained to do: We should be able to see a picture of what is going on. And if we can’t, that’s when we know that there’s something amiss, and so we need to make sure that we’re querying on legitimate reasons,” she said.
This kind of querying, for purposes of documentation, may be different than a conversation with a physician concerning a disease process; in that situation, a coder or CDI specialist is asking the provider for assistance in understanding that clinical information, so they are better prepared to code or even ask questions in the future. For the purposes of documentation, a query helps illuminate anything that might need to be corrected, because doing so protects both the provider and the patient, and the continuity of care — not to mention the practice’s revenue.
Making sure an organization is utilizing a CDI specialist’s skills and expertise to the fullest potential is important for patients, providers, and practices.
Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
