Health Information Management

Q&A: How to get surgeons on board with your CDI program

CDI Strategies, March 27, 2014

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Q: I am new to the CDI role and looking for suggestions as to how to work with our surgeons to help them beef up their documentation. Do you have any suggestions?

A: I smiled when I read your question; this challenge is not particular with you. Surgeons offer us a number of challenges.

One of the reasons is that surgeons are reimbursed differently than other providers. When the primary care physician rounds on inpatient acute care patients they document their notes to assist with their E/M (evaluation and management) charges in mind.

Depending on the extent of their assessment, the patient’s condition, and the amount of time the physician spends with their patient, the physician can submit a bill for the visit based on four levels. They will submit charges for every time they round on the patient. When CDI professionals work with the primary care providers to improve their documentation it often can have a direct impact on their E/M levels as well.

When we talk about how their documentation improvement efforts support their own billing as well as the hospital’s they can be more open to CDI efforts. Surgeons are reimbursed differently.

For example, a surgeon performs a total hip replacement. He will be reimbursed one global fee which covers the pre-operative, peri-operative and post-operative care. Their documentation within the post-operative period does not directly affect their payment. Surgeons therefore don’t have a tangible motivation to write a thorough post-operative note.

Now, I don’t want to put all surgeons in this category, as I have met many that offer excellent documentation starting with the pre-op history and physical. When I find a surgeon who documents well I will hold them up as a top performer and use examples from his documentation for others to see. Sometimes, a little peer pressure works wonders.

Another more tangible motivator is to discuss severity of illness/risk of mortality (SOI/ROM). These measures are determined based on their documentation. Then discuss quality ratings and how patients, organizations, and even commercial payer contracts with providers are based on quality measures pulled from SOI/ROM data. No surgeon wants bad ratings for everyone to view on the internet.

Explain that your efforts as a CDI not only will improve reimbursement for the organization (which consequently buys new operating room equipment and pays for qualified staff to care for his patients) but also can effectively assist in increasing the SOI/ROM of his patients. So if his patients develop complications or die due to underlying comorbidities, their level of SOI will demonstrate a patient who was at risk for such complications. There is much information on physician quality ratings on the internet to assist you in these discussions.

Talk to your medical staff leadership to determine if your organization produces a physician quality report card and if there are specific quality measure your surgeons must demonstrate to maintain their privileges. You can use this data to identify areas where the CDI program may be able to help. You can also talk to the chief medical officer or other leaders to identify CDI metrics to add to the list of measures physicians need to meet to maintain their privileges.

My last piece of advice is to make yourself available to the surgeons. Be visible when they are rounding. Ask them questions about their patients, and be open to let them teach you. Most physicians love to teach. This will help them learn to trust you and perhaps work with you. Once they begin to understand what you are doing they are more apt to cooperate as well. Keep your head up and celebrate each win…no matter how small! With persistence you will have much to celebrate.

Editor’s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is a CDI Education Specialist, at HCPro, in Danvers, Mass. Contact her at She originally answered this question on the ACDIS Blog.

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