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We often overlook the human component of metrics within our profession.

I recently received some feedback on an article I wrote about the metrics used to measure clinical documentation improvement (CDI) performance. It reminded me that we often overlook the human component of metrics within our profession, especially when CDI professionals have a clinical background. Coders are used to having the volume and accuracy of their work being measured, bedside nurses, not so much. As the demand for new coding and CDI professionals continues to increase due to a variety of factors, many organizations, especially those in smaller cities or rural areas, are transitioning existing clinical staff into the CDI role. This is not an easy transition.

Because CDI professionals must have a couple of years of prior clinical or coding experience, being a new CDI specialist (CDIS) is not exactly the same as being a new coder or new nurse; however, it does require a completely different skill set than what has been developed as a bedside nurse. Essentially, the new CDIS with a clinical background is a new coder, and the new CDIS with a coding background is a new nurse. I don’t say that to downplay the skills of nurses or coders, I say that to emphasize that new CDI professionals are learning a completely new skill set. In many ways, it is like starting a new career. 

When I managed a CDI department at an academic medical center, I was lucky to grow my CDI team and double the number of staff we had during my tenure. I wasn’t able to find experienced CDI professionals, so I hired from within. Even though my health information management (HIM) director (who oversaw the CDI department) was a nurse, she expected the new CDI staff to be proficient within six weeks. Nurses transferring from one unit to the next, say from medical/surgical to the ICU, usually only received about a 4-6-week orientation, so she thought the same would apply to CDI.

I think this perception of how long it takes to “become” a CDI professional has persisted, because when I was the Educational Director for ACDIS, we often had new CDI professionals with a clinical background attend the CDI boot camp at various stages of their orientation, from “just started” to “working in the field for almost a year.” Those who were just starting were often deer in headlights, too new to know what questions to ask. Not only can it take up to a year to learn how to be a CDI professional, regardless of your background, there is also always more to learn. After all these years in the business, I am still learning new things every day. Maybe that is why I love the CDI profession so much. And although I was an advocate of giving new CDI professionals the time to develop their skills, I now realize that I have not been a good advocate of protecting their well-being, thanks to the feedback I received. 

I have been guilty of overlooking the mental toll of transitioning from a role in which you are task-oriented (e.g., following orders, making assessments, caring for a patient, etc.) to a role in which your worth is measured by how many records you review; whether your working DRG was accurate; how many of those had a query; whether the provider agreed with the query; and most of all, what the financial impact of your work was. During my career I often have heard from CDI managers and staff alike asking about how to “get credit” for their work. I was lucky that as a CDI manager, I didn’t have to measure every CDI query to identify financial impact that could be solely attributable to the CDI staff, because we looked at more global indicators like overall trends, but I do know of many programs for which that is a requirement. Even though I eliminated that metric, my veteran staff often kept their own tallies of their financial impact, because that was how they were trained, and that was what they felt validated their work. 

The reason I’m not an advocate for directly measuring query financial impact is that I don’t think it tells the whole story – that is, the whole value of CDI efforts. In my opinion, it misses our educational efforts. Yes, queries can be used as education, but they can also be a crutch for some providers, especially when we send the same types of queries to the same providers year after year. Is that really how we want to measure success? Consider this: changing a provider’s documentation behavior could improve hundreds of records, compared to the query process, which impacts one record at a time. Yes, it is a little harder to measure the impact of CDI education, but it isn’t impossible – yet that is a topic for another day.  

It is important to balance the number of reviews CDISs complete with the desired outcome. In other words, does the volume of CDI reviews really matter if the review has no impact? Of course, it all depends on how you define “impact,” but there are fewer and fewer records with documentation opportunities, so it really is like finding a needle in a haystack to identify those records for which there is an “impactful” query opportunity (especially if you don’t leverage technology to help prioritize records). As I’ve discussed in my prior articles, it is getting harder and harder to move diagnosis-related groups (DRGs) and case mix index (CMI) through queries, because the prevalence of experienced CDI departments has already resulted in overall improvement of provider documentation, so we’ve harvested most of the low-hanging fruit. In fact, a recent U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report found that “the number of inpatient stays at the highest severity level increased almost 20 percent from 2014 to 2019, and accounted for nearly half of all Medicare spending on inpatient hospital visits.”  

Why do we even conduct CDI reviews of the record? The record will still be final-coded. Isn’t the goal of CDI reviews to change provider behavior, e.g., improve provider documentation, so it can be accurately reflected through ICD-10-CM/PCS codes on the billed claim? And if that is our goal, is a one-record-at-a-time approach really the best approach? It doesn’t seem very efficient, when we consider how many records you have to review before you even find a record with an impactful query. Is it really that important to know that one query had a financial impact, and the value of that financial impact? What about when the query doesn’t initially have an impact on the DRG assignment, because it adds an additional complication or comorbidity (CC) or major CC (MCC), but that same claim later has a denial, so the queried condition ultimately did become impactful? The bottom line is that the act of performing CDI record reviews and queries is important, but there is a lot of inefficiency in our current processes, and we do a lot of work that doesn’t appear to “yield an impact” because it is either not easily measured, or the impact can be delayed.  

So, consider the new CDI professional, when it can take a year or more to become a “strong” CDIS. Remember, it can be very discouraging for the new CDI professional, who may not initially have the assignment that provides “juicy records” (or the skills to find those), challenging query opportunities, resulting in financial impact on the record. Let’s remember that CDI professionals are more than the dollars they capture through queries, especially with the shifting focus to documentation integrity and an emphasis on supporting risk-adjustment efforts. I hope that the financial burden of COVID on our healthcare institutions does not negatively impact the progress we have made as an industry towards documentation integrity. In the meantime, as an industry, let’s find ways to help transition the new CDI with bedside experience into a less task-oriented world, where you have productivity and accuracy measurements – and, in some cases, must demonstrate a return on investment, each and every day.

Maybe taking a positive reinforcement approach of what is accomplished through CDI reviews, even when it does not move the DRG, will help the industry arrive at metrics that better reflect our efforts, align with our skills, and promote our well-being and values.


Cheryl Ericson, RN, MS, CCDS, CDIP

Cheryl is the Director of CDI and UM/CM with Brundage Group. She is an experienced revenue cycle expert and is known internationally for her work as a CDI professional. Cheryl has helped establish industry guidance through contributions to ACDIS white papers and several AHIMA Practice Briefs in the areas of CDI, Denials, Quality, Querying and HIM Technology.

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