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Prove return on investment to reap CDI rewards

Association of Clinical Documentation Improvement Specialists, February 5, 2009

Implementing a clinical documentation improvement (CDI) program can have long-lasting benefits if you can prove that the initial investment is a worthwhile endeavor.

Medical Records Briefing spoke with two HIM directors to learn how they managed to prove return on investment (ROI) for two thriving CDI programs and how they continuously monitor each program’s success.

University of Minnesota Medical Center, Fairview

When the University of Minnesota Medical Center, Fairview in Minneapolis began its CDI journey in 2001, it knew that proving ROI was an essential step toward getting the program approved. At the time, the hospital had also embarked on a larger care management initiative that included a review of care coordination, utilization management, and discharge planning.

To help establish the need for a separate CDI program, the medical center had an outside consulting firm conduct a baseline analysis. The consultants reviewed 200 charts to determine the potential effect more detailed documentation would have on case-mix index and reimbursement.

“It was helpful to have an outside vendor provide an objective view of potential areas of opportunity,” says Pat Gastonguay, MBA, RHIA, director of HIM at the medical center.

The need for a CDI program was obvious once the medical center established its baseline, says Gastonguay, adding that it decided to place the CDI program under the auspices of the HIM department.

“We were concerned that, given our size, if the CDI program was part of the new care management initiative, it would probably get lost, given that the case managers had so many other things to do,” she says. “The steering committee thought the HIM department would take this and run with it, especially because it’s so important to the coding function.”

The CDI team at the University of Minnesota Medical Center consists of 4.7 FTEs, including a mix of nurses and HIM professionals who all report to Gastonguay. The combination of nurses and coders has worked to the program’s advantage because they complement each other, she says.

Although CDI specialists conduct concurrent queries, coders maintain responsibility for retrospective queries. “We found that there were still some opportunities for the coders to catch and that they shouldn’t rely on the documentation specialists to catch everything,” she says.

Gastonguay uses the following steps to track the program’s success and ROI throughout the year:

1. CDI specialists engage physicians in dialogue to educate them about more specific documentation.

2. When conversations with physicians result in a positive outcome (i.e., additional documentation and more accurate coding), CDI specialists flag the account with a homegrown system.

3. Coders look for flagged accounts and then distinguish between working and final DRGs. Unlike many hospitals, the University of Minnesota Medical Center decided to charge coders with determining the working DRG. It felt that their coding backgrounds equipped them—rather than the CDI specialists—to do the job.

4. Gastonguay tracks dollar amounts for accounts that resulted in a higher DRG due to more specific documentation. She uses Excel® to track dollar amounts of the accounts for which the final DRG resulted in higher reimbursement than the working DRG.

Gastonguay also tracks the case-mix index. The facility’s case-mix index rose in 2001, when the program went live, and in 2005, when the center hired a physician consultant to reinvigorate the program with additional education for the CDI specialists, coders, and physicians. “The consultant helped increase the clinical knowledge of the CDI specialists and the coders,” she says.

The consultant also met with physician groups and trained four physicians to work as part-time clinical advisors. In this role, the physicians review charts, follow up with other physicians, provide advice regarding the need for queries, and assist with physician and resident education.

There was never a time when the CDI program wasn’t successful, and by now, physicians are accustomed to the efforts, says Gastonguay. “The physicians are used to it. They know what it’s about, and they’re more cooperative than they were in the beginning. That takes time,” she says.

Kindred Healthcare

CDI and physician education go hand in hand, says Wendy DeVreugd, RN, BSN, PHN, FNP, senior director of case management for the West Group of Kindred Healthcare, Hospital Division, in Westminster, CA. Her facility implemented a CDI program more than three years ago.

“We started the CDI efforts to increase the quality of documentation by educating physicians on specificity and terms,” says DeVreugd, who helped implement the program in several long-term acute care settings throughout the health system and currently oversees three additional pilot programs.

Before implementing the program and devoting resources to the CDI effort, DeVreugd needed to prove ROI.

“While we need to be excellent at CDI work flow and processes, we have to balance cost efficiency with measuring the potential impact of adding any extra tiers of employees and services, such as CDI specialists,” she says.

Like the University of Minnesota Medical Center, Kindred used an outside vendor to establish a baseline that answered the following questions:

  • Which information and diagnoses don’t physicians typically document?
  • How does this lack of documentation affect coding?
  • How does coding affect patient severity and acuity in outcomes data?

Hospitals could do a similar analysis internally, even if they don’t want to hire a vendor, says DeVreugd. A baseline is essential because it establishes where opportunities lie, as well as the costs and benefits of the program. It also provides a comparative base for measurement of future successes, she says.

After completing its baseline analysis, Kindred decided to embed its CDI function in the case manager/RN position, where it encompasses one-third of the individual’s responsibilities. This model was also more efficient for the hospital because nurses and case managers had already established a rapport with physicians, says DeVreugd.

As part of her ongoing monitoring, DeVreugd performs a monthly DRG operational analysis for each of the 42 hospitals she oversees. She examines the tiered DRGs that could have potentially migrated to the top level (i.e., with a major complication and comorbidity) but didn’t due to lack of physician documentation of a secondary diagnosis. When documentation is insufficient, DeVreugd reviews these cases with her case management leaders. She also reviews revenue per patient day and case-mix index.

By far, the most important indicator of CDI success is a comparison of actual and predicted mortality rates, says DeVreugd. For example, if the predicted mortality rate is 40%, but the actual mortality rate is 17%, the hospital may have a favorable profile. A predicted mortality rate of 40% with an actual mortality rate of 35% is less than ideal. CDI programs that boast a wide gap between the two have more than proven their ROI, she says.

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