3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
Strategies for achieving
medical staff compliance
Trey La Charité, MD
CDI Program Physician Advisor,
Hospitalist, Clinical Assistant Professor
Objectives:
• Learn effective PA techniques for
cultivating medical staff acceptance of and
sustained participation with CDI goals
– Review continuous educational efforts
• “What’s wrong with the way I write in the chart?”
– Promotion of CDI program as team effort
– Generation of effective CDI compliance tools
Physician CDI presentations
• Make each presentation service-line specific
– Orthopods don’t care about “chronic systolic CHF.”
• Make sure they understand why it is important to
learn the rules of “The Game” that CMS
creates:
– The pressures that each treating facility faces
– The pressures that each physician will face
• Introduce more accurate methods and
terminology to appropriately document each
patient’s severity of illness in the medical
record
– How to effectively play CMS’ game
Physician CDI presentations
• Ensure that each physician understands
every reason why participation in CDI
efforts is so crucial for them
• Ensure that each physician understands
that compliance with CDI goals is strictly
their responsibility
– CDI is not a coding issue!
• Ensure that each physician understands
how to be compliant with CDI goals
Why implement CDI?
• To make YOU and their facility look better in the
public perception with quality data reporting
• To make YOU look better to health insurance
companies & CMS for coming P4P initiatives
• To improve YOUR and their facility’s L.O.S.
• To appropriately categorize and justify YOUR
patients’ admission status within hospital system
• To realize all GME educational goals
• To realize all appropriate reimbursements
Medical staff follow-up
• Present CDI updates at quarterly medical
staff meetings
– Show changes in ICD-9 terminology
– Give examples of cases where physicians
either listened to or ignored CDI specialist
queries with consequences of their actions
– Give assurances that we are not asking them
to lie, cheat, steal, mislead, commit fraud, etc.
– Remind them why CDI is so important
– Give CDI improvement tips
Promote CDI as a team effort
• Attend all weekly CDI core team meetings
– Everyone in room has equal status
• All on first name basis with no rank
• All trying to reach same goal
– Review problematic/denied queries with team
– Provide needed clinical education to CDI
team
– Allows quick CDI response for acute issues
– Allows for free generation of new ideas
• CDI specialists much more in touch with what is
happening on their floors than PA
Promote CDI as a team effort
• Give credit where and when credit is due
• Search for ways to make CDS specialists’ work
experience more efficient and effective
– CDS specialists should be on wards, not in the office
• Provide yearly membership in ACDIS
• Send team members to annual ACDIS conference
– All members should have opportunity to attend
• Review insurance/RAC coding denials, assist in appeals,
and provide medical staff education regarding changes
• Participate in coder education
• Keep CDI Program momentum going
Compliance tools
• PA must be creative in order to develop
physician friendly CDI compliance
methods that garner consistent,
sustainable results
• Physicians see themselves as overworked
and extremely busy
– Physicians willing to comply if . . .
• Request does not impact their perceived time
constraints
• It’s believed to be more than just an additional
hassle of dubious reward
CDI pocket cards
• Everybody has one and they all work
great!
• “Universal” or “service-line specific”?
• Advantages of universal CDI card:
– Everyone speaks the same language
– Promote house-wide team building vs.
additional individual physician or group
responsibilities
– Ease of implementing CMS/RAC updates
– Can be facility specific
• No two hospitals alike!
Service-line ‘Blitzes’
• Identify service-line with opportunities for
documentation improvement
• Review every chart on that service in one day
– Leave routine queries as needed
– Sends message that they are being watched
• Take CDI team to lunch in doctors’ lounge
– Occupy prominent table at entrance of lounge
– Display large CDI poster
– Distribute CDI pocket cards as needed
– Answer questions
Inciting ‘SHAME!’
• Show data to medical staff that suggests
to the public they are not good doctors
• Show data to the medical staff that
suggests their local competition is doing a
better job of taking care of patients than
they do
– Physicians are competitive and defensive
about their abilities and skills
– Use physician egos to your advantage!
2006
2009
Inciting ‘SHAME!’
• Save examples where physician(s) ignored or
disagreed with query that would have
resulted in substantial MS-DRG impact
• Present those cases at general medical staff
meeting with all pertinent ramifications . . .
•
•
•
•
What diagnoses they missed
Lack of meeting GM-LOS goal
Loss of reimbursement to hospital
Physician report card impact
• Show them the error of their ways!
Example #1
• 67 yo WM w/ HTN & hyperlipidemia goes
to OSH w/ chest pain & diaphoresis. EKG
shows ST-segment elevations in anterior
leads. Patient transferred to UTMCK &
immediately taken to cath lab. Patient
arrests @ end of procedure and is
intubated and revived during Code 99.
IABP is placed & patient taken to ICU.
Example #1
• What are the diagnoses in example #1?
– HTN
– Hyperlipidemia
– Acute Myocardial Infarction
– Cardiogenic Shock – (MCC)
• IABP was placed
– Acute Respiratory Failure – (MCC)
• This patient was intubated when he arrested.
Example #1
• Despite repeated queries and phone calls
by CDS specialists, no documentation was
ever made in the medical record that this
patient had “cardiogenic shock” or
“acute respiratory failure.”
Example #1:
$31,436.00
4.5950
15.6
If “Acute Respiratory
Failure” or
“Cardiogenic Shock”
had been documented
. . . (MCCs).
Example #2
• 66 yo WM w/ HTN, DM, & PVD goes to
ER w/ 3 days of LLE pain, erythema,
fever, & chills. T=101.9F, HR=113,
WBCs=17K, albumin=1.9, & HbA1c=8.3.
BMI=18.6. A foul smell is noted from LLE.
Patient diagnosed w/ cellulitis & gangrene
and undergoes BKA. Four days later, the
patient unexpectedly arrests and cannot
be revived.
Example #2
• What are the diagnoses in example #2?
– HTN
– PVD
– Diabetes Mellitus – “Type 2” & “uncontrolled”
– Cellulitis and gangrene (CC)
– Sepsis – (MCC)
• Elevated Temp, HR, & WBC’s @ admission met criteria
for SIRS. Source was patient’s LLE cellulitis
– Malnutrition – “severe” – (MCC)
• Admission albumin = 1.9 & BMI < 19
Example #2
• At the time of admission, the physician
only documented “Cellulitis” and did not
mention “Sepsis” or “Severe
Malnutrition” in the medical record.
Note:
The physician
paid attention
to the query
placed on the
patient’s chart
by CDS nurse
& documented
both “Sepsis”
& “Severe
Malnutrition.”
Example #2:
“Sepsis” as principal
diagnosis with “Severe
Malnutrition” as MCC
Amputation for Circulatory
Disorders w/o CC or MCC
with RW = 2.99
GMLOS=7.3
$20,852.56
What about quality ratings?
• Predicted Mortality Rates for some disease
processes in this case:
– Cellulitis w/ gangrene = 15%
– Sepsis = 30%
– Septic shock = 80%
• The patient expired which is never good for any
physician’s report card:
– However, by listening to the CDS nurse, this
physician’s expected mortality bar is much higher
than it would have been for “cellulitis” only.
Problematic service-lines?
• Concentrate CDI training efforts on consultants
and residents to improve documentation
– Both sources of documentation can be coded.
• Treat unanswered queries as incomplete charts
– May require change in medical staff by-laws
• Insert CDI goals into data gathering IS tools
– Do you have EHR or CPOE?
• Insert CDI goals into pre-operative clinics
– Pre-operative clinic H&P can be coded as long as
done 30 days prior to surgery.
Physician interventions?
• Many programs use one-on-one PA
interaction with medical staff to get needed
results.
– Physicians do not like “backseat drivers”
– Potentially places PA in adversarial relationship
with medical staff
• If query is ignored while patient in hospital,
convert to post-discharge query
– Make medical record incomplete until answered
• “Carrot Approach” as opposed to “Sticks.”
Physician advisor results
• Physician Advisor will not be “Silver Bullet” for
your CDI Program
• CDI program success is team effort:
– Must have CDI chart review specialists to reinforce
medical staff education with good, consistent queries
– Must have strong administrative support
– Must have strong coding department support
• Results will not happen overnight!
Questions?