When Should an Initial CDI Review Occur?

Having worked in clinical documentation integrity (CDI) in a variety of roles, I have heard a lot of advice when it comes to the timing of the initial CDI review. In the days of paper records, we waited at least a day or longer for provider notes to be available within the health record. Consequently, the earliest that CDI reviews could occur was the second hospital day but transitioning to electronic medical records has removed that barrier.

Although the mechanics of what CDI professionals do is similar across hospitals, the specifics of how they perform their duties should fit the needs of the organization. Therefore, the best time to perform an initial CDI review will vary across healthcare facilities.

Some may find it advantageous to perform an initial review on the day of admission (or within 24 hours of admission), assuming all relevant documents are available, while others may defer the initial review until the second day of the admission or even later.

Some organizations want a working Medicare Severity Diagnosis-Related Group (MS-DRG) as quickly as possible to guide discharge planning using the associated geometric mean length of stay (GMLOS). This approach can be sound if the CDI team is appropriately staffed to perform subsequent reviews as needed.

Advantages of performing an initial review on day one includes the following:

• Establishing a working MS-DRG, which also provides an associated GMLOS.
• Greater likelihood of query resolution prior to discharge.
• The opportunity for documentation clarified by query to be included in subsequent provider documents.
• Shorter initial review times, which may allow more reviews to be completed.

Performing initial CDI reviews as quickly as possible may work for some hospitals, but there can also be drawbacks. These include among the following:

• Inability to establish the principal diagnosis.
• Insufficient clinical data to identify potential missing diagnosis query opportunities.
• Query hesitancy – the belief that it is leading or improper to query a provider before they have had the opportunity to complete the workup, which can result in additional reviews to determine if a query remains necessary.
• A lack of staffing, processes, or accountability to ensure subsequent CDI reviews are completed when appropriate.
• Too much emphasis on initial reviews and the establishment of a working MS-DRG rather than reviewing the record for incomplete, vague, or missing documentation.

Although many CDI managers strive for continuity within the CDI review process, one-size-fits-all may not be the best approach across hospitals within the same health system or even CDIs within the same department. I would encourage CDI leadership to avoid requiring all initial CDI reviews to be completed within the same period depending on how reviews are assigned.

Many of the variables that I will be discussing in this article are also applicable when reviews are distributed by service line.

Far too often, CDI workflows are determined by arbitrary or external factors rather than the specific needs of the organization. Important considerations when determining the timing of initial CDI reviews are the quality of the history and physical (H&P). It is my experience that completing a CDI review on day one is less beneficial in organizations with nocturnists or academic medical centers. Why? Because there are often discrepancies between initial provider notes and those of the attending, especially when the patient has an infectious process. The clearest illustration of this phenomenon is the patient who is initially diagnosed with sepsis only to have the antibiotics changed and sepsis documentation falls off the chart when the attending takes over the patient’s care. In these situations, it is better to delay the initial review until both initial assessments are complete.

As inferred earlier, surgical patients, especially those admitted for elective surgery often have a definitive principal diagnosis. If the priority is establishment of a working MS-DRG, CDIs can have high confidence in their initial MS-DRG. Subsequent reviews should only be necessary if the patient’s actual length of stay (LOS) reaches the working GMLOS unless there is a discharge issue.

Ideally, hospitals should have a process that identifies patients with placement issues or other non-medical issues delaying their discharge to avoid unnecessary subsequent CDI reviews. This process can be used for any patient population with a definitive principal diagnosis, not just surgical patients. The only caveat to this approach is if a query is issued based upon the initial review, in which case, daily reviews may be necessary to determine if a query response occurred if the hospital does not have an automated query process.

Not only can CDIs have high confidence in the principal diagnosis but many surgical MS-DRGs require a major complication/comorbidity (MCC) for movement, which are unlikely to be present in an elective surgery patient. However, if the surgical patient experiences a complication, their LOS is likely to extend beyond the working GMLOS, and a subsequent review should occur to update the working MS-DRG.

If the organization does not prioritize working MS-DRGs, I would recommend conducting initial reviews on surgical patients following completion of the surgery. This strategy is more likely to limit the number of times these charts will need to be reviewed because if there are any issues during or following surgery, they should already be reflected within the health record when the initial review occurs. During periods of low staffing, surgical reviews can often be delayed beyond the second day as long as supported by the average LOS for the procedure. For example, the initial review for coronary artery bypass surgery (CABG) patients could be the third or fourth day of the admission.

Taking a closer look at LOS, hospitals that have a short average LOS may consider postponing their initial review until day-two. It may seem backwards, but hospitals with a high volume of brief inpatient stays often do not have the resources to perform multiple reviews on each patient. Because medical patients often have an incomplete clinical picture on presentation, delaying reviews until the second day, when there is likely to be more documentation, may prevent unnecessary subsequent reviews. If the patient is discharged within the expected GMLOS, no additional review should be required if the principal diagnosis is not a symptom. If the working principal diagnosis is a symptom, the CDI and/or coding professional should query for a diagnosis associated with the presenting symptoms. Otherwise, the next CDI review should occur when the actual length of stay (LOS) reaches the GMLOS.

CDI is a limited resource and likely to become scarcer as nurses are pulled back to the bedside and the demand for inpatient coders continues to grow. CDI workflows need to be efficient and effective. Arbitrarily reviewing a record either every day, every two days, or any other fixed number of days contributes to unnecessary reviews. Strong leaders understand the clinical revenue cycle and how to incorporate key elements like GMLOS and hospital metrics into the workflow.