Supporting CDI with Physician Advisors

Eight steps to create a physician advisor system.

The physician advisor (PA) role has become more commonplace over the last decade, with an increasing number of hospitals and health systems turning to PAs to assist with a variety of issues, such as supporting clinical documentation integrity (CDI), ensuring compliance with increasingly complex regulatory requirements, creating innovative ways to provide high-value care, and developing and implementing utilization management (UM) and care management (CM) strategies. 

The organization of an advisor system will vary based on the size and location of the institution, and careful thought and advanced planning is necessary. The accomplishments of an advisor system are dependent not only on the advisors themselves, but also the training, vision, and infrastructure provided to enable its success. This article presents our experiences in creating an advisor system at an academic tertiary care center.

Step 1: Physician Advisor and Support

When first determining the need for a PA, consider the strategic priorities of the institution. Ask yourself the following questions: Why create the program? Why create the program now? What is the need for the hospital? Who would be your ideal physician advisors? Proceduralists, rehabilitation physicians, hospital medicine physicians, emergency medicine physicians, or perhaps a blend for a multi-specialty approach? Also, in preparation and prior to implementing the advisor program, consider several variables that may influence the overall vision: a) what is the type of institution (academic versus community)? b) what is the location (urban versus rural)? c) what is the patient population? And d) what is the payer mix for your institution? Lastly, determine the amount of time and/or stipend to dedicate to the PAs and the administrative support they will need to be successful in their role.

Step 2: Physician Advisor Orientation  

We recommend a day-long orientation, as successful on-boarding of the PA is necessary to create a solid foundation for an effective system. Key agenda items for this orientation include: a) background of the advisor role and how it has evolved to current day; b) duties and expectations; c) how success will be measured; d) current and ideal states of UM, CM, and CDI of the institution; and e) an initial basic primer on Medicare coverage rules, as well as the two-midnight rule (including understanding of the condition code 44 and provider liable processes, plus CDI basics and second-level reviews).

These agenda items will be key starting blocks for success. Equally important to a PA’s success is an understanding of the strategic priorities for the advisor system – knowledge of the overarching vision of the hospital and/or hospital system can better help physicians prioritize tasks and create strategies to achieve these specific aims.

Step 3: Organize the Second-Level Review and Peer-to-Peer Process  

Second-level reviews, primarily related to Medicare fee-for-service (FFS) patients and peer-to-peer reviews with managed Medicare plans and commercial payers, are a foundation for a PA’s role; therefore, identifying a process to complete these in an effective and efficient manner is essential. At our institution, for every 10 percent of an advisor’s dedicated time, we expect them to be available one-half day to complete second-level reviews and peer-to-peers. We recommend having PAs identify consistent days of the week they will be available to provide coverage and that they release a monthly schedule. We have created a template that the UM nurses fill out and email to the advisor on call, which includes relevant information needed for our review, such as date of admission, current patient class/status, location from which the patient was hospitalized, brief hospital course, and the reason for the second-level review. For more time-sensitive requests, we ask the UM nurses to page advisors to expedite the review.

Step 4: Facilitate Partnerships 

Hold meet-and-greets among inpatient medical directors, care management leadership, administrative leadership, and physician advisors to collaborate and discuss areas of focus. This will help build relationships among different leadership teams, foster teamwork, and help strategize regarding how to best achieve specific outcomes.

Step 5: Divide and Conquer the Meetings

Understanding the strategic priorities for the advisor system can help identify what meetings and committees would be most fruitful for PAs to attend. For most academic institutions, this will include the utilization management steering committee meeting, complex care (or discharge) meeting, clearinghouse meeting ,system multidisciplinary meeting (including revenue cycle, denials, compliance, UM, etc.), relevant steering committee charged to oversee processes involving outside hospital transfers meeting, inpatient medical directors meeting, CDI-specific meetings with internal and external stakeholders, and a monthly meeting with the chief medical officer (CMO).

We recommend that advisors align themselves with a specific area (UM or CM, for example) to identify what meetings they should attend, but emphasize that all advisors have the ability to step in to various meetings should the need arise.

Step 6: Schedule In-Person Monthly Physician Advisor Meetings

These meetings are critical, as they provide the opportunity for advisors to discuss ongoing projects, update the group on agenda items of the meetings they attend, and to troubleshoot any barriers together. We recommend creating a punch list of ongoing projects, divided into UM, CM, and CDI categories, to keep track of initiatives and to clearly identify action items for the next meeting. These meetings also provide the opportunity to discuss major hospital-wide initiatives, upcoming changes to Centers for Medicare & Medicaid Services (CMS) regulations, and the facilitation of advisor cross-coverage in different areas (CDI, UM, or CM).

Step 7: Ensure Continuing Education

We recommend this be a priority, as CMS regulations continue to increase in complexity and frequently change. We have created a website for easy access to key online links and resources, such as Medicare local and national coverage determinations. We send our advisors to the annual ACPA (American College of Physician Advisors) conference, not only for continuing education purposes, but also for them to network with and learn from other physician advisors; we do the same for the Association of Clinical Documentation Improvement Specialists (ACDIS) annual conference. We hold biannual physician advisor education symposiums, during which we receive training on high-yield topics by an invited speaker with that area of expertise (CDI, observation, two-midnight rule, etc.). Lastly, we have found the best method of learning is through collaboration, and we as an advisor group regularly share information we have learned, tips for meetings or approaching difficult scenarios, and resources that we find helpful.

Step 8: Growth and Success

There has been little dissemination of information regarding the work and impact that PAs have on the healthcare system. Dedicated time to focus on scholarly work will more strongly demonstrate this, while also disseminating strategies regarding how to tackle common problems faced by hospital systems, such as length of stay, improving high-value care, and managing high-capacity scenarios, to name a few examples. Publishing scholarly work also has the added benefit of improving PA job experience and retainment, as it provides a venue for creativity and an opportunity to demonstrate key accomplishments while also assisting with promotion.

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