What is Clinical Documentation Improvement?

The compliance and coding worlds are filled with acronyms – and we’ve got another one for you: CDI. That stands for Clinical Documentation Improvement, and it’s a crucial piece of the healthcare puzzle.

We invited Joanne Spethman, a Coding, CDI, and HIM Consultant, to share insights from her 30+ year career in inpatient and professional coding, CDI and HCC auditing on our latest episode of Compliance Conversations.

Tune in to our conversation to learn more about:

  • Some of the biggest challenges with overlap between clinical and coding teams (and what to do about it)
  • How to break down silos between coders and CDI professionals
  • Career paths and opportunities for clinical staff to transition to a CDI role

 Listen Now >>

Joanne also discusses her career, certifications, and opportunities to advance CDI efforts in your organization. By developing deeper cross-functional relationships and solid internal processes, CDI teams can maximize their positive impact and showcase their value to the organization.

Clinical Documentation Improvement – What is it and Why is it so Important? - Podcast


Episode Transcript


CJ Wolf: Welcome everybody to another episode of Compliance Conversations. I am CJ Wolf with Healthicity and we are excited to have another episode and today our guest is Joanne Spethman and we are so excited to have you, Joanne, welcome.  

Joanne Spethman: Thank you. I'm happy to be here.  

CJ: And Joanne, you know one thing we love to have our guests do is just tell us a little bit about how you ended up where you are, what you're doing, maybe a little bit about kind of your experience in kind of this coding, compliance, documentation world that we're going to talk about today.  

Joanne: Sounds great. So, I've been in healthcare for 30 years, so I had to kind of sum it up in my head with all the twists and turns. I've worked for health systems and coding, I've been a traveling coder. I've worked in software development and then I eventually got into consulting, and I've been in the consulting role for the last eight years, but my experience has been in in-patient pro-fee, HEC coding, auditing, and now CDI. I decided to take the CDIP, the AHIMA credential for CDI, about four and a half, five years ago, and then I was lucky enough to get the opportunity to be in a role as you know, learning CDI and providing coding support for a CDI as well. So, I got to do both and I got to see that world up close because I had always been interested in knowing more, but just hadn't pursued it. So, that opportunity helped me realize where our differences are, where our similarities are, and all kinds of helpful information for sure. I'm currently working for MRA as an inpatient coding auditor and DRG validator. I also consult on some other projects and am a member of the AAPC compliance committee.  

CJ: Cool! You are busy!  

Joanne: Yeah. Oh, yeah!  

CJ: That's a good way to live life, though.  

Joanne: Right. Never a dull moment!  

CJ: Well, and Joanne, just to kind of give some of our listeners might not be as familiar with CDI, correct me if I'm wrong, clinical documentation improvement, right? 

Joanne: correct! 

CJ: Awesome. So, tell us a little bit about that. What are the CDI coding roles? Tell us like in the day-to-day of an organization or hospital, what does CDI do?  

Joanne: Okay. CDI, just kind of as an overview, reviews the record to make sure the documentation accurately reflects the care being given to the patient. They review everything clinical just to make sure that the documentation; say a patient lost a significant amount of blood they were transfused, it was monitored and either anemia was documented, but not the specificity, or it wasn't documented at all, that CDI would query the provider to get specificity for that documentation, or lack thereof.  

CJ: So, you're reaching out to clinicians after and reviewing the medical record at an in-patient basis, right? 

Joanne: And they're also doing it concurrently while the patients are in house. So, they work off of lists of, you know and each facility has their own method of how those lists are distributed and run, and that CDI is responsible for monitoring that patient for I don't know how many days, you know it's specific to each facility and they can get the documentation that's necessary for the most specific or accurate code, for the code.  

CJ: Yeah, exactly. And this is important, both from a reimbursement and a compliance standpoint, right? because you want to make sure it's as accurate as possible so that you capture the complexities so you get reimbursed appropriately if it's a complex patient, but from a compliance standpoint, you also don't want to go overboard and receive reimbursement you shouldn't be because that could be a compliance issue, right?  

Joanne: Exactly! And an example of that might be, you know, a patient has low blood pressure requiring medications, and fluids but not reaching the level of shock, you wouldn't want to say the patient had shock if it wasn't at that level if it didn't meet clinical criteria. And sometimes if our insurance companies don't feel that that diagnosis is met, you know, a denial could happen based on that diagnosis, and then a clinical validation rebuttal would might be necessary, or if they in fact did have it. So yes, the clinical aspects are very important to the coding.  

CJ: So we have some listeners who are compliance officers, they might not be, as versed in the details of this, but and you correct me if I'm wrong, but basically on the inpatient side and this is a high-level summary, the hospitals get reimbursed off that diagnosis, right? that ICD code which maps to a DRG which maps to a payment, and that may be a little different than a lot of folks thinking like, "Okay, for my doctor, the reimbursement level is more or less determined by like the CPT or professional procedure code. ICD coding is still important for like, LCDs and that sort of thing, but the reimbursement level is driven by that procedure code" So, that's a little different from like how hospitals are reimbursed from like a professional, right?  

Joanne: One difference for sure and for PCS, so some DRGs will be procedure driven and others won't and that's a very big difference for sure. Because certain procedures can impact coding more than you realize.  

CJ: Gotcha, on the inpatient side. So, PCS stands for procedure coding system, is that right?  

Joanne: Yes! 

CJ: I just wanted to give a little bit of that background, you know, to our compliance folks who may, we have a lot of coding folks that are listening to, but some might not as know all those details. And then before we kind of go on to some of the other questions I wanted to ask you, you mentioned a CDIP, which is a certification from AHIMA. Can you tell us about other certifications and tell us about that one as well? in this space.  

Joanne: The clinical documentation improvement practitioner is what the CDIP is and I took that. I am certified with two other certifications from AHIMA, so I didn't have to join another organization, at least not right away! Their study guide is amazing and I mean it was a tough test I'm not going to lie. 

CJ: Well, that's fine we can cut there. So, that's really interesting. And my guess is that you know, you have people that are in these roles, have to know some really clinical information, right? So, do some people come into this role from a clinical background? Are people learning the clinical, you know in these trainings and certifications? 

Joanne: Yes, nursing is the biggest group, I guess that goes to the CDI role. I do know people with RHIA's, like myself, and coding backgrounds that have gone in that direction, but it's mostly for nursing and believe me, I got to find out why, because it's extremely clinical, it's extremely clinical. I learned about things I never thought I would know, which is great and it made me realize how completely necessary both groups are and how necessary the relationship is.  

CJ: Yeah, I was just going to say that because you know, and medicine is always advancing, right? And so, you know, you're getting the specifics, my assumption here is that you've got some clinicians that when you query them, they're pretty good at explaining things and you probably learn a lot, and then some that might not be so good at that communication.  

Joanne: Yes, yes! Some don't want to hear from you as often and others are okay with it, but I think like any role, coding is the process of taking the clinical documentation and assigning diagnosis and procedure codes so the data is standardized for reimbursement and it's just important to remember the goal is for a complete and accurate record and that's where our common goal is, that's what we want. And we want an accurate reflection.  

So, clinically, learning about the CDI rule, open my eyes, and it sort of widened my lens because as a coder I was very sort of black and white I guess where I was like, "Well it's not written, the clinical side isn't my part, so I'm just going to do what's here." And while that has been acceptable in the past, I think things have shifted since CDI came into the picture and I don't know that our processes have shifted with it enough because being a consultant I've seen a lot and seen where there's a communication breakdown, there's, you know, there's a thing called a mismatch, where coding and CDI come up with two different scenarios and they need a third-party reviewer in-house to look at those and make decisions, and so it can get tricky.  

CJ: Yeah, I can imagine. So, it's sounding like too that there may be some challenges on the overlapping of roles; coding, CDI, clinicians, I don't know if there are other roles involved, what, you've kind of already mentioned some of those challenges. Are there any additional challenges that you can think of?  

Joanne: Oh, yes.  

CJ: You've read them.  

Joanne: But I do feel like some places handle them better than others. And we can talk about that too, the circumstances that can impact these challenges. But I see where both teams, so both teams are querying the provider and it's important to have boundaries on you're querying on this, we're querying on this, kind of thing. And if there's a clinical question that it does go to CDI or it goes for verification with CDI, so they can help address you know those issues with the provider. The other overlaps, so when CDI does their job, they do what's called a working DRG. So, they're coding basically and then the mismatch can happen because of coding differences, the coder feels something else should have been coded or it was coded incorrectly and I would say, and then procedure codes, some CDIs will do them, some won't. Some places will say, "just skip that part and let the coder do it because that's coding." So, that creates a little more work for the coder, but at the same time, if it's not their specialty, it's good they're letting it go, you know, letting coding do it.  

The principal diagnosis seems to be one of the biggest challenges in the overlap area because that decision is difficult because the documentation may reflect a different principal diagnosis, like on the discharge summary and wherever and as a coder, we don't usually challenge that, as a CDI you're looking at a bigger picture, you're looking at the entire stay. You're not just looking at what he wrote and what he wrote wasn't, he doesn't ever say this should be first. This is the reason, you know, and there's just, I just learned, "I guess there's more to the story," is what comes to my head for this scenario. So, it’s definitely widened my lens to what's going on.  

CJ: Yeah, I can imagine it like you said it, there's more to the story, and we're going to get more to the story here with Joni in a second, we're going to take a short break and then we'll be right back.  

Welcome back everyone from the break. We're talking today about CDI and its important role in coding and compliance and Joanne is our guest. Joanne, anything else that you want to share kind of on, we were talking about challenges overlapping the roles, and one of the things that I'm wondering in that context of roles; are there always CDI people? Are they, sometimes are the coders the CDI people? It sounds like there may be three, you know, three points to this triangle, but is that the case in every organization that you work with?  

Joanne: Yeah, there's a coding department and there's a CDI department. So, one of the things that can impact a challenge is what department the teams report to. I noticed at different facilities they report to different people. Some will report to revenue cycle, and some will report to HIM, quality, care management. But what's important is regardless of where they're reporting, you know leadership needs to support them as a team because they really do work together. And when you put them in silos, it creates sort of another gap, you know, because it's just important for both parties to really understand where the other ones coming from. 

CJ: So, to avoid those silos, are there things you've seen that have helped, like, I don't know, are there committees or they're working groups that, you know, maybe meet on a regular basis so that those relationships get formed so you're not in these silos, what have you seen that works well?  

Joanne I've seen where they're pairing coders with CDIs. They'll pair one with another and that scored well, I've seen like where they do information and education shares, where like if they get audited by an outside auditor that they're sharing results with both departments. So, coders will share their results, and CDI will share theirs. They're inviting each other into their meetings when findings are being discussed so that they can learn and that seems to work very well.  

CJ: You know one thing I've wondered, you know, because I come from a medical background and work a lot with docs, some docs you know might be employed by the system and so they might have an interest in making sure that the hospital and the system are reimbursed appropriately and correctly, but what if they're just like a community Doc who has privileges at the hospital but it's like no skin off their back, if the hospital doesn't get the right coding and reimbursement, you know, do you see that sometimes with those different, maybe incentives in the docs?  

Joanne: I guess I don't ever focus on like necessarily, I focus on specialty more than I focus on that type of role because you can have a disinterested physician that's you know, well connected so...  

CJ: Yeah, exactly.  

Joanne: So, it's really about how can you get them engaged, how can you keep them engaged and not query them to death, you definitely don't want to do that because they'll run away from that.  

CJ: Yeah, exactly. It's like they don't want to be contacted every five minutes. I mean, what is the general, I know there's probably not a firm rule, but what is too much is it like I'm not in this space, so I don't know, are people querying every day? Is it every week? Is it like, what are you generally... 

Joanne: I mean, they're getting probably more than they should be. It just depends, I can't give a solid answer because of, there are some physicians that get queried more than others and think about the services they're providing too. Whereas we know how much sicker patients are, so those cases are going to be more complicated, they're going to need more clarification or specificity, so queries I'm sure have gone up since COVID.  

CJ: Yeah, exactly. And do queries take place, I'm assuming it's like an e-mail or a message inside the medical record and they get an alert or is it you're picking the phone or all of these off? 

Joanne: So yeah, they have an EMR, EMRs usually have something in place for them. I know 3M does, where it's in the system for them to respond to and that's where the CDI leaves the query for them to answer and it notifies the physician.  

CJ: Yeah, interesting. I have a doc colleague that who was retiring kind of from the medical field, from practicing and he still wanted a career and he got into CDI, do you see that happening very much? you mentioned nurses.  

Joanne: Oh, yes. Yeah, there are a lot of physicians getting into CDI for sure. And like I said, they'll have second-level reviews, they call them or a physician liaison that handles, you know when there's mismatches and things like that. So, they have actual roles like that for providers. 

CJ: You mentioned specialties before, are some specialties like, is it usually like one CDI expert dealing with all specialties or you can you specialize in CDI like in critical care or in neurosurgery? Do you know what I'm saying? Cause it would seem like there would be some benefit to having people work in the same general areas.  

Joanne: I haven't seen it. The only area I've seen that maybe they specialize in or they would have to, or really want to, is pediatrics, where they'd want a pediatric nurse. I mean, it's not that they couldn't train, but other than that, you know, they look at everything.  

CJ: OK. And that makes sense with pediatrics, you know because all sorts of things are different with kids, right?  

Joanne: Yes. Oh yeah! 

CJ: Vitals different... 
Joanne: coding... 
CJ: Different normal, different normal values, different abnormal values. So, if we go into it with a child thinking, "Oh, this is the heart rate or respiratory rate, it just, Oh well, that might be normal for a kid!"  

Joanne: And there are a lot of coding differences as well.  

CJ: Yeah, absolutely. One other thing I was thinking of and I don't know if you know much about, but it's like we're talking about in the hospital processes, do insurance companies have their own CDI? what happens if they feel it's different than what you guys feel, if that makes?  

Joanne: Yes, it does. And believe me, that happens more than it should. Yeah, they have probably what are called nurse reviewers. Not necessarily CDI that review for clinical reasons and to make sure that it's they're doing their own clinical validation and they're the ones that would probably be part of the denial of you know this doesn't meet criteria to be reporting this or wasn't treated or addressed or whatever.  But yeah, they probably have physician reviewers too, they have physicians that also work on denials and or on that end, on their end. 

CJ: Gotcha. I know on the inpatient side, I don't know if this is still the case, just with the coding piece like the AHA's coding clinic, like the coding clinic is like a foundational resource, right? like in on regs and how it should be done? Are there definitive guidelines like that in the CDI world or does it also come from like a coding clinic type of publication?  

Joanne: It actually comes straight from that. So, the coding guidance like hierarchy is the coding conventions, the official guidelines, and then coding clinic and they'll use coding clinic, you know as well. But they use all, and that's where the biggest overlap is, they really are working in coding because to do a working DRG you have to have that understanding so that you're following guidelines that you are aware of coding clinics surrounding certain diagnoses and so that's where it can get kind of tricky.  

CJ: You shared some examples of, you know, things you might come across. Are there any common examples? So like, you know, if our compliance officers are listening and they're like, "Oh, we want to just make sure that things are working well." Are there two or three things that you see over and over again that are problems?  

Joanne: As far as problems...  

CJ: Like far as the documentation, you're noticing that code, CDI folks are constantly going back to the doctor saying, "Okay, in this scenario you know we need to know the difference between this or this," like you were mentioning shock before...  

Joanne: Shock would be...  

CJ: I just kind of, Shock is one.  

Joanne: Shock would be, I mean that would be fairly common to have to query about. Sepsis is always been an issue. There are COVID-related diagnoses that we usually have to see if they come back or if they come in with pneumonia. Is it COVID pneumonia? You know, did they have to, you know, link things?  

CJ: Right.  

Joanne: I'm trying to think.  

CJ: Let me ask you about this one. Like I've seen it, because I come from a compliance background and so sometimes, I'm looking at cases that hit the news of like, this hospital had to settle because they up-coded their DRGs. Yeah, I know this was a couple of years back, but like the whole issue with undernutrition and crusty old core and all those types of things, are those still out there that you see?  

Joanne: Yes, I, but I feel like because of that issue that it has forced hospitals to really look at that and have a better process in place because where they're being, they're having nutrition consults done and getting the appropriate information to make sure that the appropriate criteria are met because I think what was happening was, you know, the patient can look malnourished or not be eating, but you know, doesn't make them severely malnourished?  

CJ: Right.  

CJ: Where do you get your education? Like, you know, we all go to conferences and things. Are there certain conferences? My guess is there may be certain tracks at conferences, like coding conferences that deal with CDI. Any thoughts on just kind of continuing education in this space?  

Joanne: AHIMA is always good. AAPC is always good. MRA actually provides free CEUs and excellent education and they have a really good blog as well. And then ACDIS also has a conference and great information. I feel like there's some really good information out there and ACDIS and AHIMA had recently come out with the query writing, it was the practice brief on querying, and that collaboration is very positive and I hope to see more of a collaboration to encourage coding and CDI to sort of come together more.  

CJ: Yeah, yeah, that makes a lot of sense. And you've talked a lot about just kind of the collaboration and how important that is and I can completely see why that is essential and try to avoid those silos, as you mentioned.  

Joanne: Yeah, yeah.  

CJ: Yeah. Joanne, we're getting a little bit towards the end, but I want to want you to think if there's anything I didn't ask you or if there's anything, you know, think of our listeners, we've got some coders, we've got some compliance people. Anything else that you think is important on this topic? I think we could talk about it all day.  

Joanne: Yeah, definitely! I think just, you know, each organization can try and work on solutions to improve communication and like some are even putting concurrent coders on the front lines with CDI and just really brainstorm on how they can kind of meet in the middle.  

CJ: I love that. You know, when you work shoulder to shoulder with somebody, those walls tend to come down a little bit, right? and you start to collaborate more than, like, fight about it.  

Joanne: Yes, yes, definitely.  

CJ: It's so good, Joanne it has been a pleasure talking to you about this. 

Joanne: Thank you! You too.  

CJ: We really appreciate your expertise, over 30 years in healthcare and you obviously know a lot about this topic.  

Joanne: Well, I've learned a lot for sure and will continue to.  

CJ: Exactly, right? It's lifelong learning I think in the field. Well, thanks again, and everyone that's listening, thank you for listening to another episode. If you like these episodes, please hit the like button and share it with friends. That's how we get the word out and we'd love for you to share it if you enjoy it. So that we can share this information, and if you have suggestions for other guests, we'd love to hear that as well. Until our next episode, thanks, everybody. Have a great day. 

Joanne: Thank you!

Questions or Comments?