Is implementing a CDI program and hiring a CDS really worth it?
A lot has been said lately about developing Clinical Documentation Improvement (CDI) programs in hospitals around Australia. But is it just another new procedure to spend money and resources on? After all, some would argue that the coding and auditing teams have managed pretty well in the past.
We would have to say there’s a good reason why CDI is becoming essential in our hospitals and that it’s not just a nice process to adopt. That’s because CDI has tangible benefits across all areas of operations and patient care.
Indeed, it doesn’t just facilitate correct funding.
Let’s look at the basics
If you aren’t quite up to speed, CDI starts with improving case documentation from the moment of patient assessment and treatment – rather than after they have been discharged.
Effectively, by documenting cases in-situ, the integrity of the documentation is elevated, leading to improved analysis and hospital casemix. What’s more, no matter whether you sit on the clinical or administration side of the fence, CDI offers further benefits every step of the way.
How does it work?
As soon as documentation is generated by clinicians, it becomes clinically coded using the International Classification of Diseases (ICD-10-AM) and Australian Classification of Health Interventions (ACHI) codes. This is where coding problems begin – as the language, level of details used by clinicians and hand writing can be difficult to translate into the codes required by ICD-10-AM or ACHI to reflect the complexity of each case.
As a result, the level of service and procedures that were provided by the hospital aren’t always captured by the clinical coders – resulting in incomplete records for ongoing health workers to follow and less reimbursement for the hospital.
The answer of course is coding education in order to reduce the disconnect between doctors and coders. Which is also were CDI comes in – but driven by a Clinical Documentation Specialist (CDS) who can inform clinicians of best practice. They can also identify missing details – such as specific information about secondary morbidities.
Why a Clinical Documentation Specialist is important
Essentially, a CDS works alongside of clinicians on the wards themselves.
They are the perfect conduit between medical staff and clinical coders – as they usually have sound clinical background themselves and a thorough understanding of procedures, case conditions and medical terminology.
Because the CDS resides where the action is, they are in a good position to ensure records are taken in real-time (which helps to free clinicians up to do what they do best) and pick up any anomalies in clinical notes. Also if a coder has a query, the CDS can easily get clarification from the treating clinician on the floor – without the coder needing to take up the clinician’s time or wait long periods for answers.
The benefits are as diverse as substantial
Many hospitals adopting a CDI program and a CDS quickly find that with improved document integrity, operations across the board also improve dramatically.
- ongoing patient care and satisfaction
- underlying morbidity awareness for additional diagnostics
- historic case substantiation
- administration efficiencies
- overall communication across departments and teams.
Key drivers for implementing a CDI and CDS
You may be surprised at how many reimbursable procedures slip through the cracks. Busy doctors can often miss documenting less obvious details when completing case reports late at night; additional diagnosis and treatment from allied health professionals can be overlooked within a casemix; or less experienced interns may not understand the importance of thorough, insightful reporting during handovers – just to name a few situations. A CDI and CDS will identify these gaps.
For example, Ballarat Health Service (BHS) Dietetics Unit put together a business case for increased resources to assess and treat malnutrition with inpatients. They chose 60 episodes of care separated during April 2017. The CDS dual-coded these episodes – first without the dietitian’s documentation, then using their notes. The result was an increase in revenue of $87,000 for 19 episodes identified as lacking details. This exercise subsequently afforded them more resources.
Inconsistent abbreviations, non-standard terminology, and missing casemix data can all impact the services of other professionals tending to a patient. This includes everyone from the administration staff through to technical teams and allied health professionals.
With a CDI program overseen by an experienced CDS, terminology becomes standardised, appropriate to the Diagnostic Related Group/s (DRG) and thorough. The CDS also instigates code education/understanding across all hospital-cohorts and, because they work alongside of patient care, the CDS is easily contactable for further explanation (either from clinicians or coders).
Poor documentation leads to adverse events with patients – particularly during patient handovers. Missing or misinterpreted information can cause mistakes in care, higher readmission rates, lack of follow-up after discharge, increased costs, medication errors and a tarnished hospital reputation.
Disease identification and tracking
One of the lesser identified benefits of implementing a CDI is the long-term data collection and monitoring of communicable diseases. This can consequently inform policy decisions (of the hospital and government bodies), and enable surveillance for epidemiological purposes.
For non-communicable diseases, CDI provides accurate data for hospitals and regulatory authorities to track numbers, forecast community trends and develop procedural policy.
How software can facilitate the implementation and operation of CDI
Coding/Auditing software can facilitate the implementation and operation of a CDI program enormously.
With Code Focus’ real-time audit and management tool, you’ll have a wealth of support across all departments – allowing you to obtain the highest degree of quality assurance with documentation and achieve the maximum financial and clinical benefits that a CDI and CDS have to offer.
How? The software is streamlined for every step of the coding / auditing / reporting process – and it’s accessible to every member of the team that needs case information and data. Key benefits include:
- Fully integrated episodes for coder/auditor interactions
- ‘First time right’ approach to avoid costly and problematic reworks
- Educational feedback loop to assist all levels of coding awareness
- Immediate updates and explanations to classification changes
- Full transparency of casemixe data for all users
- Fully configurable for easy access to the user’s most relevant data
- Management status tracking
- Reporting insights and historic explanation for easier investigations
- Unparallel, ongoing product support and advancements