CDI to CDI · – To improve physician quality score ... • Strong focus on relationships, trust, and mutual ... • Coders able to view CDI coding and clarifications • Coding

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CDI Success: Keys to Healthy CDI and Medical Provider Relationships

John Houskamp, MD

CDI Physician Lead, Hospitalist

Gundersen Health System

La Crosse, Wisconsin

Jennifer Conroy, RN, BSN

Clinical Documentation Nurse Specialist


La Crosse, Wisconsin

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify strategies to engage medical providers

– Recognize effective educational opportunities and techniques for medical providers

– Initiate effective feedback and recognition opportunities for medical providers

– Articulate the benefits of collegial relationships with medical providers


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• A comprehensive healthcare network including one of the nation’s largest multispecialty group medical practices, regional community clinics, and hospitals

• Tertiary referral center

• Physician‐led, not‐for‐profit healthcare system

• Located throughout Western Wisconsin, Northeastern Iowa, and Southeastern Minnesota caring for patients in 19 counties

• 2014 – became first hospital “off the grid”

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Gundersen’s CDI Goals

• Accurately represent Gundersen Health System in administrative databases

• Capture the true “severity” of illness

• Demonstrate medical necessity and patient complexity

• Document quality of care given

– To improve physician quality score

– To optimize reimbursement

• Prepare for value‐based purchasing


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Gundersen’s CDI Scope

• Patient types– Inpatient adult

• Excluding OB, psych, and rehab

– Inpatient pediatrics

• Excluding newborn

• Payers– DRG payers

• Medicare and Medicare Advantage

• Medicaid

• Commercial

– Gundersen Health Plan

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Gundersen’s CDI 2014 Outcomes

• 7,031 CDI scope charts reviewed – 91% review rate

• 2,188 clarifications sent

• 30% of cases with a clarification

• 98% provider response rate

• 89% positive response rate

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Gundersen’s CDI 2014 Impact

• 604 Medicare FFS charts had a DRG change based on clarification

• 20.83 monthly average DRG relative weight change for Medicare FFS

• $137,246 monthly average financial impact for Medicare FFS


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Key Factors Overview

• Leadership support

– Sponsored by medical staff executive committee

– Support from director of medical education

• Physician leader and physician champions

• Onboarding process for new providers and residents

• Strong focus on relationships, trust, and mutual respect

• CDI staff and coding specialists aligned with common director

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• Team assignments

• Clarification process through EMR

• CDI software application accessible to coding specialists

• Feedback and recognition to medical providers

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• Rounding

• Ongoing education

• Ongoing work to customize our EMR to reduce the documentation burden

• Lead role in ICD‐10 provider education


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Our Physician Support

• Lead physician 0.1 position (4 hours a week)

• Two general surgery physician champions

• Additional hospitalist physician

• Designated physician resources in specialty areas:

– Metabolic support services

– Cardiology

– Pediatrics

– Orthopedics

– Infectious disease

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Physician Responsibilities

• Serve as a resource for clinical questions

• Collaborate with colleagues to establish clinical definitions

• Facilitate discussions in peer groups and help mediate opposing views

• Provide medical provider orientation and education

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Building the Foundation

• Initial teaching to hospital providers 2010–2012

• New medical providers are oriented during their onboarding process

• Resident orientation

– General medicine and transitional residents

– General surgery and podiatry residents


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Provider Education

• Tailored to the providers’ specialty

• Basic coding terminology

• Stressing the importance of quality documentation showing true picture

• Case examples

• Documentation tips

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Visual Perspective

• Documentation– Respiratory insufficiency, hypoxia

– Infiltrate

– Low hemoglobin

– CHF

– Fever, tachycardia, low BP

– Cachexia

Providers see: Reviewers see:

• Documentation– Acute hypoxic respiratory failure

– Aspiration pneumonia

– Expected acute blood loss anemia

– Acute Diastolic CHF

– Sepsis due aspiration pneumonia

– Severe protein‐calorie malnutrition

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SOI ROM

Principal diagnosis

1 1

SOI ROM

Principal diagnosis

2 1

Severe sepsis

PneumoniaAcute respiratory

failure

Chronicdiastolic HF

AKIAtrial fib

HTN

Sleep apnea

Acute on chronic respiratory failure

HTN

Pneumonia

COPD

Chronic diastolic HF

All diagnoses

3 3

All diagnoses

3 2

Importance of Secondary Diagnoses


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Case Example

• 91‐year‐old admitted with acute diastolic heart failure

• Secondary diagnoses:

– HTN.

– CKD 3.

• Documented in medical record:

– BMI 41.7.

– “91‐year‐old female who comes in with respiratory distress, noted to have low sats in the 70s, placed on high‐flow oxygen. She is normally on home oxygen.”

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Case Example

• 91‐year‐old admitted with acute diastolic heart failure

• Secondary diagnoses:

– HTN.

– CKD 3.

• Documented in medical record:

– BMI 41.7.

– “91‐year‐old female who comes in with respiratory distress, noted to have low sats in the 70s, placed on high‐flow oxygen. She is normally on home oxygen.”

– Clarification sent for morbid obesity and acute on chronic respiratory failure.

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Results of Clarification

Before clarification After clarification

Severity of illness 2 3

Risk of mortality 2 3

Relative weight 1.2285 1.2285

Reimbursement $8,596.53 $8,596.53

GMLOS 3.9 3.9


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Documentation Tips

• Common themes to avoid a query or a clarification

• Common complications and comorbidities and major complications and comorbidities

• Department‐specific education

– Neurosurgery – midline shift vs. cerebral edema or brain compression

– General surgery – PVD vs. atherosclerosis

• Using the problem list

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Providing the Tools

• Resource guide given out at orientations

– Created with assistance from specialty departments

– CDI staff contact information provided

• Electronic version available

– Epic resources

– Hospital coding website

– Links in resident handbook

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RN Team Assignments

• Assigned to specific medical and surgical teams

• Provides consistency for providers

• Better prepares RNs for rounding with providers

• Creates deeper knowledge of disease processes for our assigned teams


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Strengthening the Relationship

• Providers know who we are – putting a face to the name

• Residents spend a month on a medical service

– Interact regularly with us

• We are considered part of the team

• Invited to round with them

• Helps us learn providers’ nuances

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Rounding

• Resident teams

– Goal of two times/week

– Two general medicine teams

– Cardiology

– Pulmonary

• Hospitalist teams

– Four adult teams

– One pediatric

– As‐needed basis

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Rounding

• Goals– Learn more about patients when they are presented

– Give more education to providers regarding clarifications

– Review problem list

• Process– Walking & sit down

• Bring our laptops, which double as tablets

• Results– Providers think of documentation due to CDI presence

– Witness providers teaching each other

– Immediate feedback and improved documentation


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Surgical Teams

• Rounding with provider teams

• Attending department meetings

• Discussing how their quality definitions differ from coding definitions

• Encouraging them to see the “whole person”

– Documenting all the problems being managed

• Morbid obesity

• Malnutrition

– Looking beyond the surgery

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Clarification/Query Process

• CDI clarifications sent through Epic in basket

• “Urgent documentation question”

• Standard templates used

• Sent to attending and associate staff/resident

• Response required

• Follow‐up process

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Acute Respiratory Failure TemplateDear ***,

According to the progress notes, the diagnosis of "***" with "***" has been documented.

If one of the following choices accurately describes the condition being treated and/or monitored, please indicate by selecting the appropriate diagnosis and adding it to the problem list.

Acute respiratory failure

Chronic respiratory failure

Acute on chronic respiratory failure

Acute respiratory distress

Acute respiratory insufficiency

Unable to determine

Other

Acute respiratory failure guidelines

Present if any of the following criteria met:

o Respiratory distress AND

o pO2 < 60 (pulse ox 88% on room air) – hypoxemic

o pCO2 > with pH < 7.35 – hypercapnic

Chronic respiratory failure guidelines

o On continuous home oxygen

o Indicate if hypoxic or hypercapnic

Please use the REPLY ALL button to indicate if you agree or disagree with the clarification. This will inform all parties that the clarification has been addressed.

Thank you,

XXX, RN, CDI specialist


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CDI and Coding Working Together

• Coders able to view CDI coding and clarifications

• Coding query

– Check CDI application prior to sending

– Use standard templates

– Use CDI staff as clinical resource

– CDI RNs assist with query response delays

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CDI and Coding Working Together

• Aligned under common director

• CDI and coding monthly meetings

• Regular team building sessions

– Physician perspective

– CDI perspective

– Coding feedback

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Benefits – Reduction in Queries

• 43% reduction in post‐discharge coding queries

1821

1645

1032

2012 2013 2014

YEAR

Coding queries sent


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Utilizing the EMR (Epic)

• Strong relationship with our Epic physician leads

• Preference lists

• Problem list calculator

• CDI RNs are very proficient in Epic

• Templates

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Templates

© 2015 Epic Systems Corporation. Used with permission.

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Relationships and Trust

• Attend meetings that are important to them

– General surgery morbidity and mortality

– Noon conferences

• Reach out to the providers for education

• Learn what quality measures they value

– American College of Surgeons National Surgical Quality Improvement Program (NSQIP)

– Society of Thoracic Surgeons National Database (STS)

– Surgical Care Improvement Project (SCIP)

• Go to department meetings with education


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Relationships and Trust

• CDI staff seen as a resource

– Providers feel comfortable asking questions

– Providers will call CDI RNs with documentation questions

– Asked to review pediatric charts

– Asked to assist with an audit of rehab patients

• CDI staff treated with respect

– Providers open to feedback

• CDI staff respect physician frustrations

– Different languages in medicine

– Everyone is busy

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Ongoing Education for Residents

• Completed in the spring

• Types of topics covered:

– Diagnoses with high‐volume clarifications

– New guidelines

– What they have done well

– Documentation tips

– Input from chief residents on topics they request

• Reinforces expectation that graduates are competent in clinical documentation

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Benefits – Reduction in Clarifications

• Resident clarifications July 2013 to June 2014

0

20

40

60

80

100

120

140

160


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Ongoing Education

• Monthly education topics for hospitalists

– CDI staff prepare short topic

– Presented by hospitalist

• Medical and associate staff newsletters

– Significant updates

• Individual attention as needed

– CDI nurses

– Peer to peer if ongoing

• Friendly email

• Occasional talk with provider

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ICD‐10 Education

• Lead role in ICD‐10 education 2014

– Significant input into education

– CDI staff present during education

• Ongoing provider education since delay

– Focus on specificity

– Topics found with dual coding

• 2015 update pending

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Provider Recognition

• Treats

– Mainly given to residents

– Given at big education sessions

– Tailored to the requests of the residents

• Emails

• Electronic “high fives”

– Internal reward system

– Email sent with message to person and their manager

– Receive a pin


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Provider Feedback – Physician Detail Reports

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CDI Feedback – Graduating Residents

“At my new hospital, I frequently need to update my problem list because I know it needs to be more specific.”

“I felt very prepared for my fellowship and my current position. My peers do not seem to focus on the specificity of diagnoses such as acute on chronic combined systolic and diastolic CHF.”

“There was no one in your position to provide feedback to residents, fellows, or staff. I believe you do assist us with capturing more, and painting a more clear picture of the complexity of the

patients we care for.”

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CDI Feedback

Hospitalists

“The coders had never seen this kind of documentation before.”

“They were hoping I would help start a program at my new

hospital.”

Current residents

“Thank you for teaching me so much about documentation.”

“Thank you for bringing those clinical indicators to my

attention.”


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Next Steps

• Medical provider shadow day

• Resident champion

• Associate staff champion

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Conclusion

• Strong executive leadership support

• Initial and ongoing physician involvement

• Initial and ongoing education

• EMR templates, tools, and practices

• Provider recognition and feedback

• Fostering CDI relationships

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Thank you. Questions?

[email protected]@gundersenhealth.org

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

Documents

CDI to CDI · – To improve physician quality score ... • Strong focus on relationships, trust, and mutual ... • Coders able to view CDI coding and clarifications • Coding