Clinical Documentation Improvement takes Center Stage in Las Vegas

A Conversation with Steve Robinson, VP Clinical Revenue Integrity, RecordsOne
Twitter: @R1_RecordsOne
Visit them at the exhibitor booths at the ACDIS Annual Conference

Clinical documentation improvement (CDI) programs continue to rise-up in organizational importance and executive focus. The relationship between documentation, revenue and quality reporting has never been clearer—or more important. As the industry’s only association dedicated exclusively to CDI professionals, the Association for Clinical Documentation Improvement Specialists (@ACDIS) holds their 10th Annual Conference next week in Las Vegas.

I had the chance to sit down with a top executive from RecordsOne to discuss the upcoming event and hot topic predictions. Steve Robinson, MS, PA, RN, CDIP, is the vice president of clinical revenue integrity at RecordsOne and a seasoned veteran in clinical documentation improvement (CDI).

Steve, the expansion of CDI services to ambulatory and outpatient settings will be front and center at ACDIS next week and I imagine you’ll get a lot of questions about this growth.

Steve: Yes, nearly one-third of the educational sessions at ACDIS are addressing extension of the traditional inpatient setting documentation reviews into new venues, including in-hospital and out-of-hospital ambulatory and outpatient settings. These include such areas as emergency departments, observation, physician practices, diagnostic clinics, ambulatory surgery centers, etc. Every educational breakout session has a track dedicated to CDI outpatient and ambulatory topics.

These sessions will detail the newest governmental regulations and guidelines. Speakers are focusing on how CDI teams can support the MACRA initiatives, use of risk adjustments, outpatient process applications and more.

The industry is quickly recognizing that confirming outpatient diagnoses are appropriate and supported by clinical documentation is essential to assign correct Hierarchal Condition Codes (HCCs) and ICD-10 codes. Both code sets support an organization’s success under quality programs such as PSIs, HACs and readmissions.

How are vendors at ACDIS addressing the expansion of CDI into outpatient settings?

Steve: CDI education, staffing, consulting, and technology companies have historically focused on CDI programs for inpatient Medicare cases. However, at this year’s conference we’ll see vendors building new service lines, technological capabilities and business partnerships to support the shift to outpatient CDI. We expect that most visitors to our booth will ask about how our technology streamlines outpatient documentation reviews.

What is technology’s role in CDI workflow? And will this topic be discussed at ACDIS?

Steve: Technology serves two main roles for CDI programs and yes – we will talk tech at ACDIS. CDI technology identifies potential documentation gaps requiring further review and clarification by the CDI team. Technology also streamlines communications across all the various CDI touchpoints (coding, CDI, case management, quality, physicians, and even nutritionists and wound therapy as needed). To be effective all CDI stakeholders must be aware of documentation issues and clearly communicate corrective action. Technology facilitates this exchange, ensuring compliance with correct coding and quality reporting requirements.

We’ve often heard about department silos in healthcare and the need for greater collaboration across clinical teams. Are inter-departmental communications a concern for CDI programs?

Steve: Absolutely. Most CDI, HIM and physician leaders are aware of the need for collaboration but continue to fall short. These “primary” stakeholders are charged with building relationships to achieve greater understanding and best practices in effective clinical documentation. Collaboration continues to be a very current and hot topic at the ACDIS conference.

CDI specialists and coders must know their independent responsibilities as well as be confident in their roles. Working in concert with physicians is the objective to achieve a common goal—better clinical documentation. At this year’s conference physician engagement has its own education track.

I’ll also be speaking next week at the American Association of Professional Coders (AAPC) conference on the topic of “CDI / HIM Alignment”. It’s an important topic for both constituents.

Speaking of CDI and coding collaboration, where do you see ACDIS headed in this area?

Steve: Providing a method and practice policy of direct communication between CDI specialists and clinical coders is imperative for an effective CDI program. But territorial issues still exist. For example, I don’t see any sessions addressing CDI-coder relationships at next week’s event. What I do see is ACDIS attempting to bolster coding know-how among their members.

CDI specialists don’t need to know everything about ICD-10 coding, but they do need to understand how gaps in clinical documentation impact quality outcomes, severity, mortality, and payer denials. Sessions focused on knowledge crossover, communication conundrums and understanding coding guidelines are on my schedule! Three ways CDI teams can improve coder collaboration include:

  • CDI specialists should work hand-in-hand with coding experts. We share the same goals and objectives.
  • Leadership oversight is needed to smooth hand-offs between CDI specialists and clinical coders.
  • CDI teams need to know which diagnosis, procedures and coding concepts absolutely require more specific documentation and clearer specificity. A coding and CDI internal audit process can provide that process.

Unity is strength… when there is teamwork and collaboration, wonderful things can be achieved. – Mattie Stepanek

Finally, one of your clients is presenting with RecordsOne next week at ACDIS. What is the topic?

Steve: Educational sessions that feature real-world success stories in CDI are always the most interesting. All ACDIS attendees are welcome to join RecordOne’s Amy Czahor, RHIT, CDIP, CCS and Angela Franceschi, RN, BA/BS from Catholic Health Initiatives on Friday, May 12th at 8:00 AM to discuss how data analytics improves CDI programs. One of the nation’s largest health systems will share how embedded clinical analytics were used to monitor program efficiency, measure query effectiveness and analyze quality data performance. ZDoggMD’s keynote on Thursday, May 11th should also be inspiring and “off the chain”!