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Strategy: Focus on emergent cases

CDI Strategies, February 7, 2008

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If you're an overworked clinical documentation improvement (CDI) specialist with too many cases to review, focus on those patients who are admitted through the emergency department. These cases require the CDI specialist to solidify principal and secondary diagnoses, and provide the most "bang for the buck," since they have the greatest potential for DRG change, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, an independent consultant located in Maryville, TN.

"I don't want to say that they're [scheduled patients] not important, but if you have 30 records to review in a day, focus on emergent cases," says Krauss. "That's where you have the opportunity to solidify a principal diagnosis and look for secondary diagnoses, seeking clarification when clinically appropriate " Krauss says.

In contrast, scheduled patients typically have their primary diagnosis and their procedure already well documented. Even though a CDI specialist can sometimes further specify the diagnosis, the procedure drives the final DRG assignment, Krauss notes.
 
For example, an elderly hip replacement patient has osteoarthritis as a primary diagnosis. Although a CDI specialist might uncover secondary diagnoses such as atrial fibrillation, stable chronic obstructive pulmonary disease, chronic blood loss anemia, pernicious anemia, diabetes, hypertension, and seizure disorder for acuity reporting purposes, the chance of finding MS-DRG-changing complications/comorbidities is considerably less than in a sick patient admitted over the weekend.

Deborah Mange, RN, BSN, DRG-DOC specialist in the documentation program of EMH Regional Medical Center in Elyria, OH, says that CDI specialists should also focus on patients with:

• pneumonia and urinary tract infections, to determine whether there are signs of sepsis
• pneumonia patients, to look for underlying causes
• vague reasons for admission (e.g., back pain, chest pain)

"You should identify whether the real reason for admission is documented correctly," she says.

The ultimate goal is to ensure that the record accurately reflects explicit physician medical record documentation of all medical conditions, acute as well as chronic, that affected the physician's medical decision-making and contributed to consumption of healthcare resources while the patient was in the hospital, says Krauss.

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