Focused Review for Clinical Documentation Specialists

Applied correctly and consistently, these can solve the problem of missing query opportunities.

With each passing year, it seems that clinical documentation improvement (CDI) branches out into new territory. In addition to performing everyday CDI tasks, it is now becoming more important than ever for CDI specialists (CDISs) to understand how they can directly impact several areas of their facility. 

For example:

Clinical Validation: Under the False Claims Act, it is prohibited to bill for a diagnosis that is not clinically valid. Therefore, the CDIS must perform a “clinical validation” review on their cases to assist with accurate billing.

Quality Measures: Working with quality specialists is a must in CDI. Identification of what constitutes a healthcare-acquired condition (HAC) and a careful review of the case when the documentation triggers a patient safety indicator (PSI), along with mortality review, have become very important tasks for CDI. 

Case Management:  CDI directly impacts the average length of stay/geometric mean length of stay (ALOS/GMLOS) through the DRG assignment for each case.   

Provider Education: This is a very important role of clinical documentation, as the CDIS is considered the “expert” in understanding documentation requirements, reporting mandates, coding and billing rules, and best practices for capturing an accurate clinical picture, which affects acuity level and resource consumption.

Data Analysis: Trends are an important part of CDI, which drives metrics such as the case mix index (CMI) and provider quality scores.

What is the most important task of the CDI?

 The “CDI review” is the one tool that clinical documentation improvement specialists use on every case they look at, and it impacts all of the categories listed above. Overlooking this important area can have dramatic effects on the success of any CDI program.

Diagram 1.a- Effects of CDI Review/Queries on other areas of the facility

In 2017, I performed a survey involving 50 CDISs, and I asked the following question: “which CDI task takes you the longest to perform, out of all your duties in CDI?” 

Every single CDIS answered that “query writing” was that task. Every CDIS also stated that this is the most difficult task they perform in CDI.   

Query writing, when applied correctly, can have a far-reaching impact on any provider’s overall CDI program. How well queries are written impacts many important areas in CDI, such as how well providers understand what is being asked, which in turn impacts provider response and acceptance of the CDI program, denial rates, quality scores, length-of-stay measures, acuity levels of the patients being treated, and so on.

What is the solution for this?

The “focused CDI review,” if applied correctly and consistently, can solve the problem of missing query opportunities to clarify the medical record, as well as increase the quality of each query, thus helping prevent the reporting of inaccurate acuity levels, resource consumption, quality measures, length-of-stay measures, provider quality scores, and more. 

Steps to achieve comprehensive focused review:

1. The very first thing that the CDIS must know is the clinical indicators for the most commonly billed diagnoses. Until they get used to the process, I suggest starting with the most impactful diagnoses, as these are target audit areas that involve complications and comorbidities (CCs), major CCs (MCCs), and hierarchical condition categories (HCCs), because they shift the DRG and affect risk assessment.
   1. They can also include any “target diagnoses” that a department has identified. Once these items are correctly identified, the CDIS can branch out into other commonly billed diagnoses that are non-CCs, MCCs, and HCCs.
2. The CDI review should illustrate why the patient presented, and then it should contain the clinical indicators (whether normal or abnormal) listed in the medical record for the most commonly billed diagnoses. This will aid in identifying gaps in documentation.
3. If the CDI review is done correctly, all clinical indicators that would be needed for any query are already captured and can be easily copied and pasted into the query format.

The goal of the “focused CDI review” is to be able to write a query from the CDI review without repeating the step of going back to the record to identify the clinical indicators for the query.

This type of review not only speeds up the writing of the query, but it also captures more query opportunities in the medical record that are commonly overlooked, such as when a diagnosis is not documented, but rather described, or when there is conflicting documentation on a diagnosis often seen when the hospitalist changes in the middle of an inpatient stay, or a consult is done.

Too often, clinical documentation specialists are concerned about meeting their monthly metrics, and not on the actual query identification process. Although metrics are an important part of CDI, quality often gets overlooked due to the CDIS’s focus on the “production” metrics. If the CDIS can focus on capturing “clinical indicators” for widely seen diagnoses within their facilities, they can easily identify gaps in the documentation. 

This leads to meeting all metrics, because upon re-review of the record, they have captured the quality information in prior reviews that enables them to quickly and accurately analyze the review of the documentation. The goal thus shifts from “metric-based reviews” to “quality reviews,” allowing for the CDIS to write more effective queries in a timely manner, leaving more time for quality CDI reviews.

When I teach CDISs how to perform the “focused CDI review,” whether in my facility or when I am lecturing at conferences, I often hear that they can write their queries from what they captured in their review, thus killing two birds with one stone. I also often hear that they used to capture a few lines in their CDI reviews because this is how they were taught, and they then had to spend more time returning to the medical record to “data mine” for clinical indicators for a query, which took even more time, meaning they often struggled with meeting their overall metric goals.

The focused review concept allows for increased query opportunities to be identified, because you have a more accurate look at the record through the CDI review, which leaves all the non-pertinent details behind. I have applied this process judiciously over the years as a concurrent CDIS: a clinical educator who performs numerous CDI reviews on difficult cases, and as a CDI manager performing CDI audits. It works if applied correctly, and you will soon see CDI metrics increasing, with a higher quality of queries, which yields an increase in provider responses. If applied correctly, the focused review concept can have far-reaching effects on multiple areas of your facility, and can enhance the overall success of any CDI program.