UASI CDI/UR Services

UASI CDI/UR Services

uasisolutions.com | 1

UASI CDI/UR Service Line Stats

▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement

• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs

• CONSULTANTS average 8 years in CDI and/or UR and 22 years in clinical nursing

• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing

UASI Lunch and Learn: CDI Management Series

“CDI Audit: Understanding the Keys to a Successful Process”

Staci Josten, BSN, RN, CCDSDirector, UASI CDI/UR [email protected]

mailto:[email protected]


YOU ARE GETTING AUDITED!

Desired Outcomes

Describe the keys to a successful CDI Audit

Recognize the value of completing a CDI Audit

Understand the process for creating an effective CDI Audit


Polling Question

Does your CDI Program currently perform CDI Audits

on the CDI staff?

1. Yes, one of our CDI program leaders performs routine internal CDI Audits

2. Yes, an outside vendor performs routine CDI Audits

3. Yes, we do peer to peer CDI Audits

4. No, we do not perform CDI Audits

5. Other


Keys to a Successful CDI Audit Process


Plan and Prepare

Communicate

Analyze ResultsProvide Feedback

Deliver Education

Why?

• Why perform a CDI audit on your team?

Who?

• Who will complete the audit?

When?

• When is the best time to complete?

What?

• What is reviewed?

How?

• How are records selected?

• How many reviews per CDS?


Know the answer to these questions:

Plan and Prepare

Plan and Prepare

Why Perform a CDI Audit on your Team?

Advance CDI program to the next level

Assist in outlining CDI staff educational needs

Confirm CDI processes are followed

Evaluate compliance with standard query

language

Identify CDI Program opportunities

Validate documentation of care

and treatment is accurately reflected in

medical record

Assess quality of CDI Specialist performance

Identify potential shifts for risk of mortality

(ROM) and/or severity of illness scores (SOI)

uasisolutions.com | 8Plan and Prepare

Internal

Pros:

• Part of the CDI Team

• Insider knowledge of team members

• Familiar with facility policies

Cons:

• May not be objective

• Audit may not be a priority

• Can cause hard feelings

• Don’t know what they don’t know

External

Pros:

• Objective 3rd person

• Experience from other organizations

• Fresh pair of eyes

Cons

• Cost

• Will need orientation on internal policies

Who Will Complete the CDI Audit?


UASI CDI Quality Review (Audit) ROI

ROI:

Positive reimbursement of $1,157,980

Over $263 on average per record

UASI evaluated and provided feedback on over 4400 health

records.

Approximately 60% of potential DRG changes were realized

based on follow up queries and documented coding changes.

UASI CDI Reviewers evaluated health records and provided

feedback on key CDI performance elements such as

query compliance, query validity, additional query

opportunities, DRG changes, SOI/ROM changes, as well as

quality elements.


When is the best time to complete?

Considerations for time of audit

▪ When time allows for evaluation and action on results

▪ Last time an audit was completed, ▪ minimally yearly, best is twice a year or ongoing

Avoid these times:

▪ Upcoming big projects (IT conversions or process changes)

▪ When selecting record reviews, avoid holidays or high PTO time (e.g. Christmas time)


What is Reviewed in the Audit?

Consider and focus on your current areas of struggle


Process

• Timing of initial reviews and subsequent reviews

• Reconciliation accuracy

General Understanding

• Correct working DRG and Final DRG

• CDI and Coder Mismatch

Clinical Concepts

• Missing query opportunities

• Other areas of program focus (e.g. SOI/ROM, PSI, HAC’s, Vizient, etc.)

Query Compliance

• Query validity

• Query compliance

Audit Tool Example


Process CDI Understanding Query Compliance CDI Concepts Process

Name

Date Initial

Review

Date

Subsequent

Review

Discharge

Date

Working

DRGFinal DRG

Working

DRG ValidQuery Left

Query

Valid

Query

Compliant

Missed

Query

Missing Query

Opportunity Topic

Location of

information

Reconciliation

Completed

Accurately

Plan and Prepare

Record Selection Suggestions

▪ Narrow down criteria

▪ Random, but targeted

▪ LOS: > 3 days, < 7 days

▪ Discharged within the past 90 days, final coded

▪ Patients outside of GMLOS without CC/MCC

▪ Focus on troublesome DRGs for your team

▪ DRGs with high denial rates

▪ Similar number per CDS

▪ Minimally between 20-25 records per CDS twice a year

DRG Suggestions

Record Selection and DRG Suggestions


MS DRGs Descriptions

189 Respiratory Failure

193, 194, 195 Pneumonia

290, 291 CHF

313 Chest Pain

330, 331 Major small and large bowel resection

640, 641 Misc. Disorders of Nutrition, Metab, Fluids/electrolytes

690 UTI

Polling Question

Approximately, how many record audits are

performed on your CDI staff each year?

1. Zero, not currently auditing

2. 1-36 records/year (1-3 reviews /per month)

3. 37-60 records/year (4-5 reviews/per month)

4. Greater than 50 records/year (>6 reviews/per month)


Communicate before the audit starts

Share the why

Excite the staff

Convey anticipated timeline

Ease concerns

Convey how results will be used


Communicate

Keys to Successful Communication to the CDI Team

Communicate

Additional Tip:It’s important to provide clear communication to the team, but it’s also imperative the auditors are clear on the objective of the audit as well.



Analyze Results

What does the data show?

Are the results surprising?

What are the trends?

What are the opportunities?

Results are in, now what? Ask yourself these questions.

Analyze Results

What Does the Data Show?

uasisolutions.com | 19Analyze Results

Total cases reviewed 800

Cases with query opportunities 401

Total potential query opportunities 420

Potential MS-DRG changes 100

Potential SOI changes 301

Potential ROM changes 401

Client A Scenario: CDI Overall Review Results

Total cases reviewed 820

Cases with query opportunities 119

Total potential query opportunities 130

Potential MS-DRG changes 75

Potential SOI changes 57

Potential ROM changes 53

Client B Scenario: CDI Overall Review Results

Are the Results Surprising?

uasisolutions.com | 20Analyze Results

Query Compliance Findings Count

Total Query Compliance Evaluated 606

Query Compliant 250

Query Enhancement Recommended 95

Query Non-Compliant 201

Query Non-Valid 60

Query Compliance Findings Count

Total Query Compliance Evaluated 606

Query Compliant 475

Query Enhancement Recommended 110

Query Non-Compliant 11

Query Non-Valid 10

Category Description

Query Enhancement

An educational opportunity to further strengthen query

language

Query Non-Compliance

Not adhering to the AHIMA “Guidelines for Achieving a Compliant Query Practice

(Update)"

Query Non-ValidNot meaningful; to ensure there is no “over-querying”

Client C Scenario: CDI Query Compliance Findings

Client D Scenario: CDI Query Compliance Findings

What are the Trends?


Comparison of Insufficient Follow-up

Q1 90

Q2 40

Q3 2

Q4 10

Comparison of Non-Compliant Queries

Q1 48

Q2 28

Q3 5

Q4 0

Analyze Results

Client E Scenario: CDI Findings

Client F Scenario: CDI Findings


CHF14%

Blood Disorders

11%

Clinical Validation

11%

Encephalopathy11%

Renal11%

CVA Related7%

Complication7%

Respiratory7%

Sepsis7%

Other14%

Abn. Lab Value3%

Blood Disorders

7%CHF5%

Clinical Validation

20%

Complication11%Conflicting Documentation

9%

Encephalopathy9%

Malnutrition2%

Other9%

Pneumonia2%

Renal3%

Respiratory16%

Sepsis4%

Client H ScenarioBreakdown of Query Opportunities

Analyze Results

What are the Opportunities?Client I Scenario

Breakdown of Query Opportunities

❑ Be thoughtful and prepared

❑ Give overall program feedback (no names identified) and then individual feedback

❑Provide information for review prior to meeting

❑ Celebrate the positives

❑ Anticipate constructive feedback will be challenging

❑ Consider “sandwich feedback”

❑Start with what they are doing well, provide areas of improvement and end meeting with more positive feedback

❑ Give specific examples

❑ Ask for response and recommendations on how to help them improve

❑ Expect defensiveness

❑ Remain calm

❑ Be clear on expectations

❑ Restate any action items, consider writing out

❑ Remember to follow up


Provide Feedback

Keys to Successful Feedback

Provide Feedback

CDI Performance Feedback ExamplePerformance Review ResultTotal Cases Reviewed 16

Total Query Opportunity Missed

Breakdown:

Query Opportunity:

Complication

Query Opportunity: Sepsis

2

1

1

% Missed Query Opportunity 13%

CDS/Coder Mismatch 3


Query Review ResultsTotal Queries Reviewed 13

Total Query Compliant 13

% Query Compliant 100%

Query Enhancement

Opportunity

4

Total Query Non-Compliant 0

% Query Non-Compliant 0%

Total Query Non-Valid 0

% Query Non-Valid 0%

Strengths:CDS is an effective reviewer and demonstrates a strong knowledge of CDI core principles along with a good foundation of coding knowledge with proper selection of Pdx. CDS is proactive and aggressively searches for potential impacting query opportunities. CDS looks for treatment or continued monitoring before submitting a query, complying with UHDDS standards for secondary diagnoses. Overall CDS demonstrates a solid foundation of core CDI principles, leaving valid, compliant queries on a variety of query topics which include ABLA, Malnutrition, CHF specificity, Hyponatremia, Shock specificity, Wound clarification, and rule in/rule out diagnoses.

Areas of Opportunities:1. Query Opportunity:Expand clinical knowledge and review all laboratory values, radiology reports, vital signs, MAR summary and PMH for clinical indicators that would support querying for additional diagnoses such as: Sepsis and Catheter Associated Urinary Tract Infection (CAUTI).2. Query Enhancement:Add additional clinical indicators, treatment & monitoring, and risk & related conditions to queries. Doing so helps support why a diagnosis is a reportable condition and helps establish the presence of the condition.3. Complications and Sequencing:Noted was one potential Query Opportunity and two CDS/Coder Mismatches related to complications. Be alert for complications of previous conditions/surgeries or condition(s) that occur while in the hospital to determine if the condition(s) was/were inherent to a procedure/condition, or outside the norm. If complication is already documented this could affect sequencing and DRG assignment, if not then a query may be needed for clarification.

Per Official Coding Guidelines Section 1.B.16 Documentation of Complication of Care:Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise

instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.

Become acquainted and refer to the Alphabetic Index regarding instructional notes for code sequencing of complications as this could affect DRG assignment. Also note any exclusion notes as these are fairly extensive in Chapter 33 and often will direct to elsewhere.

Provide Feedback

CDS Trends Example


0

1

2

3

4

5

6

7

8

Occ

urr

en

ce

CDS Trend Report Example

Q1

Q2

Q3

Q1 Q2 Q3

DRG Change 4 1 0

Insufficient Follow Up Review 1 7 0

Late Initial Review 3 5 3

Query Non Compliant 0 0 4

Query Enhancement 1 0 0

Query Opportunity 3 1 0

Query Opportunity: Abnormal Lab

Values1 0 0

Query Opportunity: Blood Disorders 3 0 0

Query Opportunity: CHF 2 0 0

Query Opportunity: Clinical Validation 1 2 0

Query Opportunity: Respiratory Failure 1 1 0

Query Opportunity: Complication 0 4 0

Query Opportunity: Malnutrition 0 1 0

Query Opportunity: Renal 0 1 0

ROM Change- Query Opportunity 4 3 0

SOI Change- Query Opportunity 3 4 0

Provide Feedback

CDI Score Card Example

NameCases

ReviewedQuery Left

Case Count

Query Opportunities

Missed

%Missed Query

Opportunities

Query Accuracy

PointsQuery

Accuracy Points

Query Valid

%Valid Query

PointsQuery

Compliant %Compliant

QueryPoints

Total Points

Excellence Award Status

CDS A 27 22 0 0% 100% 3 6 22 100% 3 22 100% 3 12 Yes

CDS B 27 12 0 0% 100% 3 6 12 100% 3 12 100% 3 12 Yes

CDS C 36 36 0 0% 100% 3 6 36 100% 3 36 100% 3 12 Yes

CDS D 28 16 2 7% 93% 1 2 16 100% 3 16 100% 3 8

uasisolutions.com | 26Provide Feedback

Legend Excellent (3 points)

% Query Valid (needed) 100%

% Query Compliant 100%

Excellent (6 points)

% Query Accuracy >97

❑Education is imperative to ongoing improvement

❑Complete education prior to next audit to realize results

❑Keep education actionable

❑Share specific examples in audit findings


Provide Education

Keys to CDI Education Success

Deliver Education


Questions


Staci JostenBSN, RN, CCDS

Director, CDI/UR Services, [email protected]

Join us for the next UASI CDI Management Series Lunch and Learn:

Creating and Maintaining the Best CDI Teamon December 9, 2020 at 1:00 EST

email: [email protected] for invite


mailto:[email protected]

UASI CDI/UR Services


UASI CDI/UR Services Stats

▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement

• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs

• CONSULTANTS average 8 years in CDI and/or UR and 22 years in clinical nursing

• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing

UASI at a Glance


Headquarters:

Founded:

Clients:

Team:

Charts handled annually:

Solutions:

Experience

• Management: 22 years of HIM experience;

11 in CDI

• Coding staff: 8+ years

Quality

• 97% accuracy in coding

• 100% target for accuracy, certification and

meeting industry standards

Reliability

• 32+ years in business

• 40 clients in US News & World Report best

regional and honor roll hospitals

Culture

• People-centric, team-driven culture

• High employee satisfaction

• 20% new hires referred from current employee

• Industry-leading average employee tenure

Cincinnati, Ohio

1986

200+ hospitals/health systems nationwide

450+ employees, including AHIMA/AAPC-certified

coders, HIM and clinical documentation specialists

3.75 million coded; 200,000 audited

Coding Services, Coding Reviews, Clinical

Documentation Improvement, Revenue Integrity,

HIM Solutions, Strategic Consulting

UASI CDI/UR Services

Documents