Comprehensive yet pertinent documentation is critical within the medical record. Far beyond coherent communication of data and insight between medical providers caring for a patient, good documentation also allows for accurate representation of patient severity in quality data, and appropriate coding, billing, and reimbursement.
Clinical Documentation Improvement (CDI) queries are a critical tool in optimizing the medical record by ensuring every aspect of the patient’s clinical condition is captured. But, identifying and creating appropriate queries is only half of the process. Without provider involvement, the efforts can simply die on the vine.
Shortly after I entered my as physician advisor, I learned that one of the challenges the CDI team faced was provider engagement with queries. Queries were kept open for up to 10 business days following patient discharge, which, when added to the timeframe allowed for coding queries, often lead to delay in billing of well over three weeks. This delay not only increased the risk of claim audits, but also, overt denials. Additionally, it was apparent that many of the providers within the health system were concerned about altering the medical record post-discharge, and there was not a clear understanding of what CDI queries were for, nor how impactful their completion could be.
After reviewing the data, we determined that anywhere from 20 – 25 CDI queries went completely unanswered every quarter. Knowing that the majority of the queries were directed toward our system’s hospitalist team, which primarily works a seven-on/seven-off schedule, we decided on an eight business day model so even if a query was received on the final day a provider was on service, they would have time to answer it when they returned. These eight days started from the time the query was initially sent, not from the time the patient was discharged. This required education for all providers that the CDI query clock starts immediately upon receipt of a query, and does not stop ticking when away from the office, on vacation, or otherwise off-service.
Next, we devised a step-wise timeframe of reminders to the providers that a CDI query remained open and required attention. Two days after the initial query is routed to the provider within our electronic medical record by the clinical documentation specialist, another message is routed to the provider in addition to a call to the office or a text page. If the query remains unanswered on days four, six, and the morning of day eight, the clinical documentation specialist informs me via e-mail. I then send a communication to the provider about the unanswered query via fax to the office, electronic medical record message, or via secure e-mail. Within my communication is identifying patient information, the date the query was originally sent, the date of discharge, and the diagnosis which is being queried, in addition to the time and day the query will permanently close. There is also generalized information regarding the purpose and importance of CDI queries, and directions on how documentation can be amended in the electronic medical record following patient discharge.
Over the first three months of this new process, our unanswered CDI query rate dropped by 55%. Two quarters later, it dropped by 73% of our baseline. While a significant amount of additional effort is being put into this process, our work has clearly made a difference. Along with the electronic and paper reminders putting the work front-and-center in the minds of our providers, the process has also prompted thoughtful questions about what is needed and why. Almost two years later, I continue to field questions from new and established providers after they receive a message from me, further strengthening the educational aspect of this process.
I encourage you to reassess your CDI query processes, consider trying these methods, and fortify engagement between yourself as physician advisor and your CDI team. You may find that a little more interaction will greatly improve your results!
About the Author
Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade and she was also medical director of pediatric hospital medicine and vice-chair of pediatrics in northern Illinois before transitioning into her current role. She is a member of the Board of Directors for the American College of Physician Advisors, the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA,) and a member of the RACMonitor editorial board.
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