In reviewing the above Survey Results our Hiteks CDI Editorial Board had the following comments:

• To deliver effective queries with minimal interruption to physician workflow – 24%

This was the highest survey response from all CDI attendee responders at the meeting, showing their underlying concern for continuity of the physician’s clinical workflow but at the same time their need to deliver an effective query that will adequately handle the clinical question of the moment.
Delivering effective queries with minimal interruption to physician workflow helps boost communication. When it takes too many steps to answer a query, communication between physician and hospital administrators deteriorates, making the process impractical and ineffective. All too often, physicians acknowledge the query, but don't address it. When queries get flagged within the EHR and they require a physician signature. Communication with each team member needs to be followed up on. System audits can reveal new areas of weakness, and allow you to actively manage template requirements and queries.

• How to achieve more granular levels of CDI compliance by physicians – 16%

The open question that many CDI Specialists still have is how do they get more detailed information, specificity and compliance from their physicians? Health care systems require documentation to fill in coding and quality gaps and to help provide continuity of care. Correct and complete documentation is required to support ICD-10, comply with quality measures, and ensure care management protocols are followed. This is continually important in the world of value-based reimbursement.
Vendor supplied Specificity tools can provide correct coding and more detailed documentation, but physicians need to be educated on how to adapt and learn these new tools. Decision tree tools embedded in CAPD software can drill down to the specifics of each diagnosis for physicians and keep them on track. CDI teams can create training programs to help physicians navigate specificity calculators during the patient documentation process and teach them how to apply the tools.

• Shifting CDI Focus from reimbursement to concentrate on quality outcomes – 13%

CDI programs began with a focus on reimbursement, but are also shifting to concentrate on quality outcomes. 30% percent of survey respondents felt that there was no need to shift CDI focus away from reimbursement to more of a quality-driven initiative. Fourteen percent ranked the shift from reimbursement to quality to be of low priority while three percent ranked the shift away from reimbursement to be of the highest priority. This is not at all surprising given the penchant for the status quo in CDI consisting of the repetitive query process.

A sense of apathy and content with a task based daily routine of chart review searching for CC/MCCs culminating in queries with the goal of achieving a 30% query rate and specific objectives of CC/MCC capture rate appears to be the standard in the industry. An underlying principle of CDI should be improving quality as relates to not only just accurate and complete reporting of process measure. Quality in CDI must also embrace quality and completeness of documentation, documentation that communicates the care provided in a clear, succinct, concise and organized fashion. Quality of documentation by definition entails insuring the record totally speaks for itself, facilitating the communication of care to the extent another physician can assume care where the first physician left off. Documentation is of sufficient quality when it adheres to the following key elements:

• Right Care
• Right Time
• Right Reason
• Right Venue
• Right Clinical Judgment & Medical Decision Making
• Right Clinical Impression
• Right Plan of Care Congruent with the Assessment
• Right Clinical Documentation

The Physician Documentation Quality Instrument-9 Item Version can be used as a means of assessing the baseline documentation quality, used periodically on an ongoing basis to assess and judge the improvement in the quality of documentation achieved as a direct result of clinical documentation improvement activities.

• Particular Physicians could benefit from additional Training - 11%

As our Fourth highest response from attendees, physician education should be an integral component of all documentation efforts at any facility. It is common knowledge that to accurately capture and code true patient severity, clinical documentation integrity (CDI) programs need to exist to help bridge the gap between the language physicians speak and back-end CDI and coding efforts that lead ultimately to billing.
11% of respondents indicated that none or limited numbers of physicians could benefit from additional training. There appears to be a misnomer and/or misunderstanding of the additional training physicians can materially benefit from. There are two schools of thought as they relate to physician training on appropriate clinical documentation. One school consists of the capture of diagnoses with appropriate clinical specificity with an unrelenting focus upon diagnoses that are considered CC/MCCs impacting reimbursement, case-mix increase and/or severity of illness/risk of mortality reporting or patient safety indicators/hospital acquired conditions. A contrasting school of thought is physician knowledge sharing and training on best practice standards and principles of documentation. This goes well beyond capture of diagnoses incorporating how best to communicate fully informed, coordinated and quality focused patient centered care.

Physicians consistently strive to do the right thing for their patients and when it comes to documentation that accurately and completely communicates patient care, physicians are generally lacking the knowledge, skill sets and core competencies in effective documentation. CDI can capitalize upon the opportunity to address and fill the void of physician knowledge in documentation through investment in developing, understanding and practically applying techniques of physician documentation that effectively capture and report the patient’s clinical story, adequately describing, showing, telling, depicting and reflecting the patient’s severity of illness, medical necessity for hospital level of care, amount of physician work performed and support of assessment and rationale congruent plan of care.

The time is ripe for CDI to transform itself from a transactional, reactive, “knee-jerk” industrial approach to chart review to one embracing proactive, forward-thinking, balanced and tailored approach to chart review that actually achieves measurable and meaningful improvement in communication of patient care. Meaningful, measurable improvement in documentation entails subscribing to a philosophy of performance with purpose, refusing to accept short-term documentation improvement results produced by repetitive reactionary queries as a sustainable model. CDI must not continue to be content with the status quo of CDI chasing diagnoses day-in and day-out, using physicians as targets as opposed to a more realistic constituent and business of medicine partner.

• Stronger CDI reporting and data analytics support – 10%

10% of respondents felt CDI directors needed stronger reporting and data analytics support. We feel that CDI metrics will continue to grow more and more as important to CDI departments around the country.  Understanding CDI metrics can be a little confusing at first, but reported CDI metrics measure and reflect the success of a CDI program. They also identify areas where opportunities exist for improvement. Metrics commonly reported include case mix index (CMI), review rate, query rate, response rate, response time, and quality/revenue impact are becoming more and more popular for CDI use.
Additional Reporting on quality metrics such as PSI, HAC, SOI, ROM, and core measures are very helpful. Many vendors offer reporting packages for their CDI/CAPD software. If not, ask your IT department to help setup a program to pull these KPI’s into a report you can use effectively.  Hiteks works closely with Epic to help get the right data into the Epic reporting environment, especially in the 2018 version of Epic.  Hiteks also focuses on both CDI workflow and Physician gaps in documentation.

• Expansion into outpatient and other settings – 9%

While it seems like a low number, 9% of our survey takers said they were planning to expand into Outpatient and other settings.  This is actually misleading as it was right in the middle (6th highest out of 10) and also may not yet be as prevalent as improving processes on the inpatient side.  This is in contrast to the more than 30% of respondents to the 2017 CDI Industry Survey who said they plan to expand to some sort of outpatient service in the near future. Outpatient CDI reviews impact medical necessity of care, charge capture, professional billing, quality data, and risk adjustment.
New outpatient programs should focus on specific areas, and those areas to be impacted, should be defined.  One of the best plans would be to start with something simple, but still something that would have an impact overall. So many CDI programs when expanding start with HCCs (Hierarchical Condition Categories). Many family practices within a healthcare system are experiencing poor risk adjustment factor (RAF) scores. An Outpatient CDI program could be started to educate key lead physicians at these practices, and once that is done to move on systematically to other physicians within the practice.   The biggest improvement we’ve found comes from organizations who develop a systematic approach to the M.E.A.T. criteria for the major conditions like Heart Failure, Diabetes, Chronic Kidney Disease, etc.  Hiteks has focused our efforts on these key areas with a query library that allows for better “Monitoring”, “Evaluation”, “Assessment”, and “Treatment” logic to ensure cases are not denied and the physician can benefit from our suggested additions to the record given the data evidence.

• Shortage of qualitied CDI specialists – 8%

Most industry experts will agree that CDI staffing is an issue. Revenue cycle roles such as Patient Access reps, Back-Office specialists, CDI Specialists, Case Managers, and other revenue cycle roles are either short in supply or limited on what they have available for qualified professionals in their market.
As our question asked, 8% of respondents felt there was a shortage of qualified CDI specialists. As organizations now expand their CDI programs into outpatient settings and across all payers, the need for trained clinical documentation improvement professionals continues to grow. This fact coupled with ongoing budget limitations can limit program expansions into outpatient and other settings.

• Need to increase clinical specificity for ICD-10 - 4%

Valid ICD-10-codes have been required for claims reporting since October 1, 2015. But ICD-10 diagnosis coding to the correct level of specificity—a more recent requirement—continues to be a problem for many in the healthcare industry.

Coding specificity is a shared responsibility between the provider and the coding professional to create a clear clinical picture of the encounter. Providers have an obligation to document conditions to the full extent of their clinical knowledge of the patient’s health. Unfortunately, non-specific documentation and coding persists. This is an ongoing problem, even though the official guidelines for coding and reporting require coding to the highest degree of specificity.  Better tools are now available to end-uses in the EHR to add specificity, but they are not always used.  Therefore, CDI reinforcement is necessary.

Third-party payers are making payment determinations based on the specificity of reported codes, and payment reform efforts are formulating policies based on coded data. The significance of over-reporting unspecified diagnosis codes cannot be overstated. In the short-term it will increase claim denials, and in the long-term it may adversely impact emerging payment models.  Calculating and monitoring unspecified diagnosis code rates is critical to successfully leverage specificity in the ICD-10-CM code set.

• The need for more timely & accurate revenue cycle management – 3%

Revenue cycle management success is the heart of any healthcare organization. CDI programs should be doing a timely review for appropriate reimbursement regardless of the positive or negative impact. Defined as the clinical and administrative management of claims management, payment, and revenue production, revenue cycle management is in essence one large financial circulatory system. Successful revenue cycle management is truly about going back to the basics, especially when it comes to ensuring accurate, timely, and compliant claims reimbursement.

• Inaccuracies and Poor CDI Outcomes from use of existing CAC systems in the marketplace – 2%

The CDI respondent results indicate either that current experiences with computer assisted coding (CAC) is not prevalent enough in the workflow of CDI, or perhaps that the CAC systems in place are functioning fine. With the advent and rollout of the new ICD-10 classification system vendors were rushing to market CAC to fill a perceived niche created by provider concerns with productivity decreases associated with a new coding classification system. Because of the rush to market of CAC, these systems are far from perfect and but in most instances assign ICD-10 codes as a starting point to the coding review. Much rework is created as a result of CAC with coders finding themselves “recoding” the record again. Providers would be best to invest in computer assisted provider documentation (CAPD) capitalizing upon strong robust natural language processing and allows the physicians and CDI to validate the findings of the computer.

Current interest in Outpatient CDI is growing as healthcare facilities seek ways to improve the quality and completeness in documentation of diagnoses. Unfortunately, there appears to be misguidance and misunderstanding as to what constitutes outpatient CDI. Outpatient CDI unfortunately is assuming the same direction as inpatient CDI that primarily focuses upon capture of diagnoses. In the inpatient arena, the unrelenting focus is upon CC/MCC capture while in the outpatient setting the primary focus is upon HCC capture and reporting.

Instead of diagnoses capture representing HCCs with subsequent reimbursement, outpatient CDI should be focusing upon promoting, advocating for and achieving complete and accurate documentation that adequately and clearly describes, shows, tells, depicts, reports and reflects the reason for patient encounter. This is the essence of the MEAT criteria, which is
M-monitoring, E-evaluating, A-assessing, and T-treatment.  M.E.A.T. is at the heart of HCC coding and clinical documentation and is defined as follows:

• Monitor-signs, symptoms, disease progression, disease regression
• Evaluate-test results, medication effectiveness, response to treatment
• Assess/Address-ordering tests, discussion, review records, counseling
• Treat-medications, therapies, other modalities

M.E.A.T. is supported by Hiteks’ latest upgrade for its NoteReader CDI and CDS/BPA Trigger software.. The communication of patient care should provide a clear account of the patient story supportive of the physician’s clinical judgment, medical decision making and thought processes while establishing medical necessity for the visit as well as any ancillary diagnostic workup and/or therapeutic services ordered and/or provided, including the following areas:

• Identification of nonspecific diagnoses that otherwise would serve as HCCs
• Chronic renal failure without stage
• Pressure ulcer without stage
• Diabetes without complications
• History of colon cancer when patient on radiation therapy or chemotherapy
• History of kidney transplant

• Medical Necessity-establishment of medical necessity (LCDs/NCDs)
• Scrubbing of physician orders in CPOE- diagnoses matching
• Scrubbing of physician orders-frequency limitations
• Scrubbing of physician orders- limitations of coverage (Dermagraft without ABI >=.65; Remicade without trying steroid, Rituxan without IgE; Aranesp with H & H beyond parameters to insure coverage)
• Scrubbing of physician orders-adherence to Choosing Wisely Campaign best practices
• Scrubbing of physician orders- adherence to ACR guidelines-red flag MRI
• Scrubbing of physician orders- congruence of order with documentation in patient encounter
• Plan of care-incongruency of plan with assessment
• Order for PT/OT and no diagnoses to support therapy
• Order for PT/OT and no supporting symptomatology in CC and/or HPI
• No mention of back pain in CC/HPI and order for PT/OT

• Problem lists-management and streamline of process
• Incongruency in diagnoses
• Chronic renal failure stage II and Chronic renal failure stage III in problem lists
• Note states patient is not a smoker, problem lists states chronic tobacco abuse
• Neuropathy listed in problem lists along with diabetes -no linkage
• Diabetes mentioned in note, neuropathy in problem list, patient on Neurotonin

• Evaluation & Management
• Missing components of E & M
• No chief complaint
• No PFSH
• No ROS
• Physical Exam incomplete based upon HPI
• Physical Exam over documented based upon HPI
• History of Present Illness
• Incomplete
• Missing
• Copy and paste from previous encounter
• Assessment
• Copy and paste from previous encounter
• Nonspecific diagnoses------nonspecific ICD-10 codes
• Inconsistency in diagnoses/symptoms with rest of patient encounter
• Syncope in assessment, HPI, patient denies syncope
• Seizure disorder- HPI patient denies seizure disorder
• Incongruence of assessment and Physical Exam-
• Acute respiratory failure
• PE: Alert and oriented X3 in no acute distress
• Acute encephalopathy second to severe UTI
• PE: Alert and oriented in all four quadrants, resting in bed talking to wife on phone
• Healthcare associated pneumonia
• PE: Lungs clear to auscultation, no rhonchi, wheezes or rales appreciated

Hiteks’ primary focus is on helping physicians strengthen the quality of the documentation based on known improvements of medical necessity/clinical justification in outpatient practice for labs, medications, procedures and other M.E.A.T. requirements for a set of prioritized 50 clinical diagnoses (specified in HCC).  Hiteks facilitates good communication of patient care and alleviate denials (denials avoidance) through improving documentation of medical necessity in office notes.  We reduce costs downstream because we are focused on upfront documentation.

Based on the latest guidelines for Heart Failure management, Hiteks has organized its software to automatically review the patient record and make suggestions to physicians to improve on monitoring, evaluating, assessing and treatment, with corresponding additions to the documentation:

Screening for Heart Failure (patient age >50)

• Identify patients at risk for HF (no mention of LVSD((EF <= 50)) or symptomatic HF- dyspnea, leg edema, fatigue)
• Obesity
• Known Coronary Artery Disease
• Smoking, current or past history
• Diabetes
• Hypertension
• Order a BNP
• If BNP level >=50, order echocardiography
• Refer to cardiologist for further investigation and management

Biomarker Evaluation & Assess
Ambulatory ACA/AHA Stage C/D HF
            Stage C- patients with an established diagnosis of heart failure
Stage D-  Patients with refractory heart failure requiring advanced intervention (i.e.    biventricular pacemakers, left ventricular assist device, transplantation)

• Ambulatory patient with new onset dyspnea or NYHA Class II-IV
• Order BNP or NT proBNP for purpose of establishing diagnosis
• For prognosis or added risk stratification
• Order other biomarkers of myocardial injury or fibrosis
• ST2 receptors, galectin 3 and high sensitivity troponin

Treatment of Chronic HF with reduced ejection fraction (<=50)
For ambulatory patients with chronic HFrEF, patients should be on ACE inhibitor or ARB or ARNI in conjunction with beta blockers and aldosterone antagonists in patients with chronic HFrEF to reduce morbidity and mortality

• See page 21 of the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Table 3 Drugs Commonly Used for HFrEF