Health Information Management

Q&A: Reinforcing the importance of a physician advisor

CDI Strategies, February 3, 2011

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Q: Our small hospital has decided at this time that they no longer need the services of a Physician Advisor (PA). He will only be here another sixty days. Can you tell me from your perspective why a hospital should have a PA?

A: From a CDI standpoint, the absence of a PA can break your program. The PA’s typical CDI responsibilities include:
  • Continuing medical staff education
  • Supporting CDI efforts among the medical staff
  • Assisting with finalizing/closing queries by contacting the physician and discussing the case
  • Providing second-level review of problematic cases, i.e., serving as the clinical expert for assessing whether the clinical condition/circumstances of admission will support ICD-9 diagnosis and procedure codes (pre-bill expertise, denial prevention, etc.)
  • Serving as clinical advisor to the CDI specialists and coders
Here is a case-in-point: Your CDI staff have queried the physician about an excisional debridement case and received no response. You are sure that this was an excisional debridement (clinically) but the documentation is not specific enough to code 86.22 (surgical procedure) versus the default 86.28 (non-surgical procedure). 
 
Without a response the case groups to DRG 194 (simple pneumonia with a CC) based on the documented principal diagnosis, secondary conditions and procedure. But an affirmative physician response as to the type of debridement would allow the case to group to DRG 167 (Other respiratory system OR procedures with CC). 
 
The difference in the average MS-DRG reimbursement is approximately $5,379—this can be measured as lost revenue for your facility. This is just one example. At times, the impact of losing this procedure due to insufficient documentation can be more than $10,000 per case.
 
At my previous facility, we paid our physician advisor $150 per hour and contracted for no more than 20 hours per month for a total cost of $3,000 per month. So, that would be quite the return on investment if he or she could help the CDI team resolve those unanswered queries and further support the mission of improvement documentation for quality of care with the rest of the medical staff team.
 
For my facility it was a no-brainer. Nothing can take the place of peer-to-peer interaction, not even the best CDI specialist.
 
There are some Physician Advisor job descriptions on the ACDIS website in the Forms & Tools Library. Writing the job description in such a way as to highlight the benefits of your advisor can help, too. Even for a small hospital, where do you go for this type of clinical expertise and support if you don’t have a PA? There are a couple past conference presentations talking about the impact of a PA on the ACDIS website as well.
 
In addition, ACDIS is sponsoring a one-day conference event, “The Physician Advisor’s Role in CDI: A Collaborative Approach to Success,” on April 6, 2011 in Orlando, FL   . The event takes place the day before the 2011 4th Annual ACDIS Conference.
 
Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, CDI Education Director for HCPro, Inc., in Danvers, MA, answered this question. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership and program development. She co-authored the Physician Queries Handbook: Guide to Compliant and Effective Communication, is a member of the CCDS exam committee, and teaches the ACDIS-sponsored CDI Boot Camp.



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