More than half of CDI programs employ physician advisors, but those that do typically find their efforts ineffectual, according to the 2011 Physician Advisor Benchmarking Survey. More than 300 people responded to the survey, with nearly 60% indicating that their CDI program employed a physician advisor. Of those, 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts and 54% described their advisor as either moderately effective or ineffective.
“It looks like physician advisors really are not part of the process right now,” says ACDIS Advisory Board member Trey La Charité, MD, physician advisor for CDI at the University of Tennessee at Knoxville.
Juggling responsibilities La Charité serves as physician advisor for CDI and coding, a trend followed by only 25% of respondents. Most physician advisors also serve as advisors for the case management (51%) or utilization review (47%) departments. Others indicated that their physician advisor also works on claim audits and denials, and a few indicated that their physician advisor also serves as the chief medical officer.
Facilities frequently hire physician advisors to work with case management, La Charité says, because there is a clear and consistent financial return on investment associated with matching conditions to their geometric mean length of stay. “Facilities still make money based on volume—the ‘get ‘em in and get ‘em out’ mentality,” says La Charité. “As the pendulum swings to a quality of care payment model you’ll see more emphasis on core measure and quality reporting” and potentially more focus on physician advisor roles in CDI.
That’s the situation at Lehigh (PA) Valley Health Network, says John Pettine, MD, FACP, CCDS, director of the CDI program there. Lehigh primarily employs physicians and physician assistants as CDI specialists. It has one fulltime RN and 30 part-time physician advisors on a large campus with 900 beds over two sites. The physician advisors concurrently review records, and coders perform retrospective reviews and queries.
“I just don’t know how much success you can possibly have in a CDI program without a dedicated, trained physician advisor,” says Pettine. “If you only allow one to five hours [for the physician advisor to spend on CDI efforts], that is just not enough time.”
When Pettine first took on CDI duties, he dedicated one day per week to the task. That one day quickly turned into 50% of his time. Now he estimates that he spends roughly 80% of his efforts on CDI.
“I am able to engage more people, and teach more people, and provide more data on DRG performance, and explain face-to-face what physicians need to know,” says Pettine.
“More organizations find justification for physician advisors in utilization review and case management. As time goes by, however, they will see an increasing role for them in CDI programs,” agrees Mark Michelman, MD, MBA, medical director of case management at Morton Plant Mease Health Care System in Clearwater, FL.
Michelman serves as advisor to CDI staff as well as case management and utilization review, “but I’ve been working as a physician advisor for more than 20 years now,” he says. “The typical physician advisor does not have the experience in CDI and cannot perform all these different roles.”
Further, the survey illustrates how little training and support most facilities provide to physician advisors. Only 40% indicated that their physician advisor received CDI- specific training, and only 12% indicated they received specific coding training.
La Charité came to his facility’s CDI program from case management. He then received an afternoon’s worth of one-on-one CDI training from a CDI consulting firm. Although the facility did not provide coding training, La Charité sought additional education on his own and took a semester-long course at a local community college. “It was a lot of work but it really helped me learn the lingo,” he says.
Pettine also educated himself on CDI via various ACDIS offerings. “It is a great resource for self-education,” he says. But obtaining ACDIS membership is not an activity mirrored by most.
Respondents indicated that only 7% of their physician advisors were members. While Pettine definitely encourages his staff to join ACDIS (he told a potential new hire that obtaining CCDS certification is an expectation of the job), he does not believe that physician advisors should be solely responsible for their own CDI training.
“If they don’t even have CDI training, how are they going to be successful? Whoever hired the physician advisor for the role should be the one to make sure that the physician advisor gets the CDI training he [or she] needs,” says Pettine.
With so little time and support afforded to them in their CDI role, it didn’t surprise Pettine to find that a majority of respondents dubbed their physician advisors as either ineffective or only moderately effective in their duties.
And what do those duties entail? According to the survey, everything from providing pre-/post-bill clinical documentation support (22%) to assisting with Recovery Audit Contractor (RAC) appeals and drafting appeals letters (33%) to reviewing charts for medical necessity of inpatient admissions (33%).
Many of the tasks listed in the survey should be “critical” responsibilities, Michelman says, wishing more respondents indicated that their physician advisor helped to close queries (42%), draft queries (16%), and even query other physicians themselves (17%).
“It is critical for physician advisors to help in drafting queries along with the coders, also. This helps ensure the queries include the most accurate clinical and coding information, which is the whole purpose of the CDI program after all,” he says.
However, the majority of respondents indicated they refer less than 5% of their total cases to their physician advisor for review. The physician advisor role is “different from just going to another physician and trying to put out a fire,” says Pettine. “When educated properly, physicians will want to learn this stuff. [CDI] requires a multifaceted approach with the end goal of teaching the physician and changing their behavior.”
Yet only 26% of respondents listed providing documentation/clinical education to CDI and coding staff as part of their physician advisor’s duties, and 50% listed presenting CDI education to physicians.
“If the physician advisor doesn’t have any education in CDI themselves, then how are they supposed to educate other physicians?” asks Michelman.
“Are the physician advisors just there to get the non-responding physicians on board? If so, that’s pretty disappointing,” says Pettine, who attends division meetings and provides analysis regarding how physician documentation affects patient outcomes and provider report cards.
Queries alone won’t change a physician’s documentation behavior, says La Charité, who also found the results of the survey disheartening. “If you don’t preach the gospel to them, if you don’t show them the error of their ways, you don’t educate them,” he says.
Analyzing physician advisor efforts
Don’t give up on potential physician advisor involvement, says Michelman. Programs that consider their physician advisor ineffectual should go back and reevaluate their contracts, roles, and responsibilities.
Ideally, a CDI physician advisor should not have to juggle responsibilities for case management and utilization review as well, says Pettine. “Although we indirectly touch all these other areas, we need to keep our focus,” he says.
Clearly describing expectations within the contractual agreement can help, but the CDI program needs to understand how a physician advisor can best help them, too. (If you don’t have these expectations in place, consider adopting the roles and expectations outlined in the “Physician liaison contract and sample job description” and the “Physician advisor job description” located in the ACDIS Forms & Tools Library.) on the website www.acdis.org
“You need to log what you are currently using the physician advisor for and you need to track how successful your physician advisor is for those uses,” Michelman says.
For example, if your CDI program only uses the physician advisor to help with CC/MCC capture rate, then how will the rest of the medical staff appreciate the larger role of the CDI staff and its effect on their performance and financial statistics, asks Michelman.
“You need to have the physician advisor focus on the improvement of the clinical picture and have that individual working toward educating the physicians about how their documentation affects that picture,” he says.
It is that type of clinical documentation connection that won Pettine’s support for the program when he made the career move to CDI effort back in 2007.
“I feel really badly for physicians that are not getting credit for taking care of very sick patients because they simply do not know the right words to use. I don’t think that’s right. So I try to help. In the beginning, I had no idea what this role was all about; I had no idea that I would really like doing this, but I do. I just think that if you are going to teach and educate physicians you have a better chance if you are a physician yourself,” Pettine says.
This article first appeared in the January 2012 edition of the CDI Journal.
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