Three Top Focus Areas for a Second-Level Clinical Documentation Integrity (CDI) Review Team
- It’s no secret that third-party auditors have turned their attention to clinical validation from the retrospective point of view (that which occurs post billing). Knowing that a CDI professional plays a large role in clinical validation with every review leaves an opportunity for a second-level review between the times the CDI professional last reviews the record and the third-party retrospective review.
A few of the reasons for second-level review opportunities could be:
- timing of the CDI professional’s review (due to scheduling and priorities, whether the review stops at discharge or continues after discharge)
- scope of coverage (weekend, all payers, all patient units, etc.)
- number and/or type of queries that can be developed (per the facility process)
- lower than usual staffing numbers (vacations, conferences, attrition, etc.)
While these are valid reasons for the opportunities, the fact that the opportunities exist points to the need for a second-level review team to be the safety net for capturing documentation of clinical validation for the most vulnerable diagnoses. The diagnoses deemed vulnerable are at the discretion of the facility based on its case mix, but typically include base diagnoses such as sepsis, encephalopathy, malnutrition, pneumonia, and respiratory failure, and expands to specificity as the medical record indicates.
Having a second-level review team in situ to support the current CDI team is invaluable to a facility’s quality profile as well as its financial health through the denial management process.
- A query is developed to reconcile a gap between the medical record documentation and the guidelines that apply to that particular environment and scenario. There is no argument that query development is the most important task a CDI professional performs. A query is also the task that is visible to both internal and external stakeholders, which places priority on query compliance.
There are two main areas of a query that are integral in compliance. The first area is the clinical indicators. Per the industry standard practice brief, Guidelines for Achieving a Compliant Query Practice (2019 Update), co-produced by the American Health Information Management Association (AHIMA), and the Association of Clinical Documentation Improvement Specialists (ACDIS), all clinical indicators that are relevant to the specific identified gap must be included in the query.
The second essential area of focus in terms of compliance (but by no means limited to only these two) is that every option in a multiple choice query must be clinically significant and reasonable.
A second-level review team can ensure ongoing query compliance by auditing the clinical indicators and options in terms of relevance and significance.
- Ongoing education for both providers and CDI professionals is the reality due to ever-changing guidelines. Self-education and one-on-one education with providers is mostly impromptu as the CDI professional performs their work, therefore, it is imperative that time be set aside to conduct formal education sessions. Having a second-level review team who can attend department meetings and develop regular education to groups of providers can be valuable as an adjunct to the one-on-one education between the CDI professional and the provider. A second-level review team can also present regular formal education to the CDI team to reap the benefits of group education.
Quarterly coding clinic education, guideline education, regulatory and quality measures education, and education on the latest CDI and medical best practice are some of the regular education events that are instrumental to the health of your CDI program.
With access to high-quality CDI professionals, we can assist with all of your second-level review team needs to take your CDI program to the next level.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-0
MRC CDI Content Manager