A day in the life of a
Clinical Documentation Improvement Specialist
What Killed
Was it urosepsis?
A urinary tract infection?
or
 Sepsis resulting from the decomposition
of extravasated urine?

Was it pneumonia?
Pneumonia, unspecified?
or
 Pneumonia related to aspiration?

Was it an appendicitis?
Appendicitis, unspecified?
or
 Appendicitis with rupture & peritonitis?

These are just a few
questions a
Clinical Documentation
Improvement Specialist
may ask
Why do we ask and
why does it matter?
Let’s investigate…..
Coders must rely on physician
documentation
They cannot assume or interpret what is in
the medical record
Physician
Documentation
Code
Assignment
Sometimes there is a “broken link”
between the clinical and “codeable” documentation
Any time documentation in the
medical record is:

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
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ambiguous
conflicting
incomplete or missing
lacks specificity
unclear whether a condition was present on
admission
Clarification is necessary to ensure accurate assignment of
codes, severity of illness & risk of mortality scores, length of
stay targets, and appropriate reimbursement for utilization of
resources
One solution…..
A Clinical Documentation
Improvement Program
aka – Master Detective Agency
Clinical Documentation
Improvement Program (CDIP)
What is a CDIP? –
An initiative which focuses on improving
the documentation concurrently or at the
point of service to the patient.
A 2007 HCPro survey found
that 50% of US hospitals have a
CDIP

CDIP Models:

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HIM
CM
Quality
Finance
Why have a CDIP? –
Effect on Quality of Care
•Identifying a condition by your thoughts
permits others who follow to know what you’re
thinking •What is the patient’s clinical picture during
your assessment
•What work-up has been done so far
•What were the results
•What treatment has been started
•What is the plan of care
Why have a CDIP? –
Effect on Legal Risk Reduction
•The better the documentation reflects the
complexity and the risks, the easier it is to
explain morbidity and mortality – and the
likelihood of frivolous liability claims is
reduced.
• If it’s not documented – it didn’t happen
including excellent patient care!
Why have a CDIP? –
Effect on Public Quality Measures
•Results in better physician and hospital
outcomes on consumer-oriented health
care websites such as:
• Health Grades
• US News & World Report
• Consumer Reports
According to a 2009
PricewaterhouseCoopers consumer survey,
48% of consumers said they use health
websites to find information to make
decisions about their healthcare.
Why have a CDIP? –
Impact on Mortality Risk Adjustment
•Provides a more accurate illustration of patient
acuity and the care provided.
•Impacts Severity of Illness (SOI) and Risk of
Mortality (ROM) statistics.
•Severity adjusted expected mortality rate
depends on ICD-9 codes being assigned that
demonstrate SOI & ROM
Two of the most common metrics used for
mortality risk adjustment:
• Severity of Illness
• How sick is the patient?
• Risk of Mortality
• What is the likelihood of death?
• The four levels of SOI & ROM are:
•
•
•
•
1 = minor
2 = moderate
3 = major
4 = extreme
Why have a CDIP? –
Contributes to appropriate and timely
reimbursement for utilization of
resources


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More appropriate payment for the hospital
and physicians.
Accurate severity-adjusted Case Mix Index
(CMI)
Reduces number of retrospective queries
which negatively impacts the revenue cycle.
How are questions communicated?
Either verbally on the patient care floors,
or written via a Physician Documentation
Query Form.
To maintain a paper trail for verbal
queries, the CDIS will document
a brief synopsis of the discussion on
a concurrent query form.
Where will the query forms be
found? - When appropriate, a query
form is placed in the progress notes.
Where should physician
document response? -Query
response may be documented in the
progress, consultation, or procedure
notes, and/or the discharge summary.
Responses then become a
permanent part of the medical record.
Who may respond to query? Any physician (or physician extender) who
provides “face to face” care.
What happens if the concurrent query is
not addressed while the patient is
in-house?
A retrospective or
post-discharge
electronic query
is sent to the
Attending Physician
Disadvantages of a
Post-Discharge Query
Since the Post-Discharge query is sent a week or
more after the patient is discharged:
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The details of the patient’s condition are not as clear
The record is scanned so the physician must access
the electronic record
For physicians who rotate, they may be out of town
or even out of the country
Negatively impacts the DNFB (Discharged Not Final Billed)
Query Guidelines for Concurrent &
Post-Discharge Queries
The query should not:
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Sound presumptive, directing, prodding,
probing, or as though the physician is being
led to make an assumption
Give only choices that increase the
reimbursement
Indicate the financial impact of the response
to the query
Be designed so that all that is required is a
physician signature
Physician Documentation Education
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One-on-one
Small groups – on the nursing units
Large groups – Departmental Grand Rounds
New Housestaff Orientation
Pocket cards
What Killed
Mr. Boddy, a 64-year-old male was
found on his living room floor. On
arrival to the ED 
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Altered mental status
RLQ abdominal pain
Elevated temperature
Hypotensive
Tachypnea & tachycardia
Positive UA & BC – e coli
Chest x-ray revealed bilateral lower lobe
infiltrates
Mr. Boddy was taken to the OR
and underwent an appendectomy.
Thick, purulent pelvic fluid was
encountered. He was kept in the
SICU for eight days where he
received IV antibiotics and
Vasopressin.
Unfortunately, he did not survive.
Physician documented cause
of death as:
Urosepsis
 Pneumonia
 Appendicitis s/p appendectomy

Urosepsis…

To a coder, this = UTI

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GMLOS=3.5 days
SOI=1
ROM=1
Reimbursement=$5,883

To a physician, this =
sepsis from a urinary
source

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GMLOS=4.6 days
SOI=1
ROM=1
Reimbursement=$8,514
Pneumonia…

Pneumonia,
unspecified =

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GMLOS=3.3 days
SOI=1
ROM=1
Reimbursement=$5,415

Pneumonia due to
aspiration =
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GMLOS=4.3 days
SOI=1
ROM=2
Reimbursement=$7,700
Appendicitis (with appendectomy)

Appendicitis,
unspecified =

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GMLOS=1.7 days
SOI=1
ROM=1
Reimbursement=$7,144

Appendicitis with
rupture & peritonitis =
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GMLOS=3.4 days
SOI=2
ROM=1
Reimbursement=$9,310
Without the investigative services
(concurrent query) of the CDIS (aka –
Master Detective) it would appear that
Mr. Boddy died from a simple urinary tract
infection, pneumonia, and an appendicitis.
GMLOS = 5.1 days
 SOI = 2 (moderate)
 ROM = 1 (minor)
 Reimbursement = $ 16,875

After receiving clarification from the
physician in response to a concurrent query, it
was determined that Mr. Boddy died from
septic shock related to a urinary tract
infection and aspiration pneumonia. In
addition, he had a ruptured appendix with
peritonitis.
GMLOS = 12.5 days
 SOI = 4 (extreme)
 ROM = 4 (extreme)
 Reimbursement = $41,938

Impact of CDI Investigation
and intervention
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Greater specificity of existing conditions
Appropriate severity of illness score

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Appropriate risk of mortality score

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The patient was extremely ill
The patient died – his ROM should be extreme
Increased length of stay allowance
Appropriate reimbursement for utilization of
resources
Questions
Donna Fisher, CCS, CCDS
Lead Clinical Documentation Improvement Specialist
Shands at the University of Florida
fishdl@shands.ufl.edu
352-265-0680 extension 48769
aka – Master Detective