What’s Your CDI Review Strategy?

by | Jan 23, 2023

Coronary artery bypass–or CABG–is the most common form of open-heart surgery in the United States. Each year, approximately 500,000 of these potentially life-saving procedures are done in hospitals around the country.

But a patient who’s a candidate for this procedure may arrive with comorbidities such as diabetes, chronic anemia, or kidney disease that may put them at greater risk. The patient could experience an acute kidney injury or other conditions that affect the postoperative period and keep them in the hospital longer than expected for this procedure.

How are you handling these–and other complex clinical scenarios–in terms of clinical documentation integrity (CDI)?

Equally important: Are you getting reimbursed for the work your clinical teams are doing to care for these patients? And are your hospital’s quality scores reflecting your efforts?

It all starts with the codes.

I like to think of it like this: The DRG is the title of the story and the codes make up the sentences; they are the nouns, the adjectives, and the action verbs describing how sick a patient is.

Without an accurate, descriptive patient story, you’re not going to have the right coding–and that means you’re not going to capture the proper data or get paid the appropriate reimbursement.

Let’s think through two ways that concurrent review helps capture the complexity of your patients while also supporting teamwork.

1. Concurrent review captures clarification while the patient is still in the hospital–and the care team is still engaged in their care. This means your CDI team can use a variety of nudges and alerts to help the physician while they’re documenting. The end result: The physician captures all the necessary information for coding.

Also, CDI queries are often less disruptive to the physician’s workflow because there’s no struggle to remember a patient who has already been discharged.

2. Concurrent review supports relationship-building between physicians and CDI teams. CDI specialists who conduct concurrent reviews typically work at the same facility with physicians and share the same goals of wanting to deliver high-quality patient care. Also, the key stakeholders–from the CEO to the CFO to the VP of revenue cycle management to the VP of quality–share the same understanding of the role of clinical documentation integrity.

This is important in terms of buy-in from physicians and their acceptance of CDI queries. It’s also important because key stakeholders are aware of and support the concurrent review program.

It’s also about the ‘why.’

But what about the patient who had the CABG procedure? Each patient is different. The patient with a preexisting condition, such as chronic kidney disease, is at a greater risk and may stay in the hospital longer than expected. They may develop conditions during the postoperative period that need to be addressed and this has to be included in the story–or the codes.

Capturing the severity of the patient’s chronic kidney disease is a must; it translates into an accurate risk adjustment for that patient. Just as important as etiology causing altered mental status such as metabolic encephalopathy. That information must be captured in the patient chart before it’s sent to billing.

Also consider this:

If during the concurrent review, you only look at the first week of admission–and the patient winds up staying three weeks–all of that clinical detail gets lost. What’s needed? A retrospective review before the patient’s chart is sent to billing.

You must have the answer to this single question: Why was the patient in your hospital longer than expected? Looking at the chart retrospectively is the best way to fill in any blanks.

Why: If your care team had to care for a patient with multiple comorbidities, which could include a fluid overload and an acute kidney injury, that has to be captured in the patient story.

It’s hard work.

The fact is, it’s hard to get staff, and people don’t want to work weekends. Add to that, weekends are busy. That means all of those cases sit in the CDI queue on Monday. Here’s what’s going to happen: Something is going to be missed, even with the best of intentions.

I offer an example from my own experience from concurrent CDI work: When a patient was admitted on a Thursday, we’d review their chart on a Friday. But what happened if the patient was discharged on a Sunday?

The chart would probably drop out of the queue on Monday, often the day with the highest volume of charts to review. In general, approximately 20% of charts are lost to final review. And that translates to a lot of dollars.

Then there’s your hospital’s reputation. If you don’t code patients’ charts appropriately, it’s going to look like it took you longer to take care of patients than the hospital down the road. That’s a tough pill to swallow if the only difference is that the other hospital accurately captured the complexity of its patients–and you didn’t.

Retrospective pre-bill and post-discharge reviews give CDI teams the opportunity to read the patient story and bridge the gap between the clinical situation and the codes used to describe it. As the saying goes, “Hindsight is 20/20!”


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