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Strategy: Consider the benefits of a CDI specialist in the ED

CDI Strategies, June 12, 2008

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The benefit of employing a dedicated CDI specialist in the ED is worth far more than the cost of his or her salary, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, an independent consultant located in Maryville, TN. A dedicated CDI specialist can capture additional ED documentation necessary to support diagnoses, outpatient diagnostic workups, procedures, and admissions to the hospital.

Many physicians use the T-System® to capture documentation to bill their professional services in the ED, Krauss says. However, physicians neglect to use a free-flow text box on the form, he adds. Physicians should use this space on the form to document relevant clinical findings and other pertinent clinical concerns that might support an inpatient stay or provide additional medical necessity to support an outpatient CT scan of the head, for example.

A case manager or dedicated CDI specialist reviewing the ED documentation concurrently could solve that problem by noting the deficiency and reminding physicians through positive reinforcement to document appropriately.

For example, a physician admits a possible myocardial infarction (MI) patient. The physician documents the results of mildly elevated troponins, but he or she doesn’t link the abnormal lab values to any provisional diagnosis or concern for possible diagnoses, including relevant patient risk factors. The physician also does not document his or her concern for the abnormal lab values and what the plans are for further workup of the patient’s condition.

This admission wouldn’t hold up under a Recovery Audit Contractor (RAC) review unless the physician links the lab values to the possible MI, Krauss says. This small added step also helps to explain why the patient would be better served as an admit instead of being sent home or admitted to observation.

This is where the CDI specialist comes in.
 
“I, as a documentation specialist, can say, ‘Knowing the patient’s troponins are mildly elevated, were you concerned about the MI and the risk for sending the patient home with the noted patient risk factors for a MI? Would you mind documenting your concerns with the abnormal tests and establish a relationship to the reason for the admission?’” Krauss says. “That explains the physician’s thought processes to support the admission. A few sentences can go a long way.”
 
Note: Stay tuned for more benefits of CDI specialists in the ED in an upcoming issue of CDI Journal.

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