Building the Bridge Between UR and CDI

Dr. Erica Remer and I had the pleasure of co-presenting at the Healthcare Financial Management Association (HFMA) Region 6 Conference this past week in Columbus, Ohio. Our topic was the intersection of utilization review (UR) and clinical documentation improvement (CDI), examining the current state of these disciplines and offering predictions about their future directions.

Our presentation aimed to provide clinical relevance to a healthcare financial and revenue cycle audience.

In previous articles, I have explored why these two disciplines have historically been separate. Key reasons include differences in technology and the distinct roles UR and CDI play; UR traditionally aligns with case management, and CDI with coding. However, the landscape is evolving. Technology firms such as Iodine are making significant strides in bridging UR and CDI, enhancing transparency and efficiency in collaborative learning.

Other technology platforms are also recognizing the importance of uniting these two areas to form a cohesive clinical revenue cycle.

While the partnership between case management and utilization review remains essential, the increasing focus on the social determinants of health (SDoH) and transitional care across the care continuum is continuing to shift case management’s role. It is becoming more integrated with population health, creating new opportunities for collaboration with outpatient services.

To foster greater collaboration between UR and CDI, and to improve efficiency, I recommend the following steps for consideration today:

1. Incorporate Collective Learning: Include both UR and CDI teams in shared educational sessions. For example, webinars aimed at CDI should also include UR staff, and vice versa.
2. Build Unified Dashboards: Develop dashboards that provide a comprehensive view of both UR and CDI activities. For example, patient status conversions affect CDI review times, and short-stay conversions to inpatient status influence CDI’s capture rate of chronic conditions (and ultimately impact case mix index) – putting both groups at risk for denials, either for medical necessity or DRG downgrades.
3. Expand Outpatient CDI: Consider having your CDI specialists review observation cases to identify opportunities for capturing Hierarchical Condition Categories (HCCs) or even help with queries to support improved documentation, which may create greater defensibility for inpatient conversion.
4. Align Physician Communication: Ensure that documentation improvement efforts convey unified messages from both UR and CDI. This can reduce confusion and reinforce the importance of thorough documentation for multiple areas, including quality, level of care, denial management, and coding.
5. Integrate CDI into UR Reviews: Explore how the UR team can incorporate CDI initial reviews into their concurrent review process for payers. Greater transparency to see what the CDI specialists are querying may help the UR team see potential risks in the continued stay.

The convergence of UR and CDI is essential as we move towards a more integrated healthcare model. Technology is playing a pivotal role in bringing these traditionally separate disciplines together, allowing for better communication, efficiency, and financial outcomes. By fostering collaboration through shared learning, data transparency, and unified communication efforts, healthcare organizations can enhance their clinical revenue cycle while delivering high-quality patient care.

The future of UR and CDI lies in breaking down silos and working cohesively to adapt to the rapidly changing demands of healthcare.

Programming note:

Listen to senior healthcare executive Tiffany Ferguson report this story live today during Talk Ten Tuesday with Chuck Buck at 10 Eastern.