The State of CDI

Analysis of AHIMA’s New Clinical Documentation Improvement Industry Survey

By Tammy Combs, RN, MSN, CCS, CDIP, CCDS

The AHIMA Clinical Documentation Improvement Practice Council (CDIPC) is a group of clinical documentation improvement (CDI) experts that meet once a month to discuss the hot topics that are impacting the CDI industry. From that discussion, action plans are made to develop and update CDI products to support the needs of the CDI industry. One need identified by this group is information on the various program structures that are being utilized by the CDI industry. To obtain this data, the 2018 AHIMA CDI Industry Survey was created by the CDIPC, who developed and analyzed the survey questions in the hope of identifying typical CDI practices in the industry.

This article will discuss some of the key takeaways from the survey. Full survey results can be found online in AHIMA’s HIM Body of Knowledge. This article will focus on results that detail the types of organizations where the respondents work, the departments under which CDI teams are managed, professional backgrounds for CDI professionals, CDI credentials that are seen in the CDI industry, location and type of CDI reviews, and the training methods of CDI professionals.

The survey featured 40 questions that brought a wealth of information forward regarding the structure of CDI programs. There were a total of 157 respondents, with 39.72 percent identifying as working in a leadership role and 57.45 percent identifying as working in non-leadership roles.

Type of Organization

The survey began by asking participants to state the type of organization they work for, which found 78.98 percent of the respondents were hospital-based (see Table 1 below). This is an important element of information for healthcare leaders who are thinking about starting a CDI program and are trying to decide on the healthcare setting in which to initiate the program. Most CDI programs begin in a hospital setting, but programs are not limited to this setting. The survey also featured responses from staff in other healthcare settings that fell into the inclusion criteria for this survey (21.02 percent), showing CDI programs are branching beyond the traditional hospital arena. These non-hospital locations included critical access hospitals, post-acute long-term care, rehab, and physician clinics. There was an “other” option for this question, and these organizations were identified via comments as vendor services, insurance plans, staffing agencies, educators, software developers, behavioral health, and auditors.

For further clarity on the non-acute participants, the survey asked those respondents who reported working in a physician clinic about the size of the clinic by physician number. All respondents worked for clinics with more than nine physicians. This reflects that CDI programs are gaining the interest of larger clinics.

Of all the participants who responded to the survey, 90 percent work for organizations that have a CDI program. It is important to note that some of the participants work in a non-traditional CDI organization identified as “other,” who would likely work with CDI programs but would not necessarily have a CDI program within their organization (such as a vendor).

Reporting Structure of CDI Programs

The majority of the respondents indicated their CDI programs reported to the health information management (HIM) department (see Table 2 below). HIM departments are responsible for managing the information within a healthcare organization, and since CDI is responsible for the accuracy of the clinical information, it makes sense that this would be the department seen most often in the reporting structure of a CDI program.

Other departments that were identified included case management, finance, nursing, quality, and compliance. There was also an “other” section, which respondents identified in the comments as CDI reporting to coding, data quality, education, and corporate administration departments.

Most of the respondents have more than 10 CDI professionals on their CDI teams. They indicated that 71.63 percent of them have a physician advisor for their program. Most of the respondents begin their health record reviews within 24 to 48 hours of an inpatient hospital admission or after an encounter for outpatient reviews. Of those reviewing inpatient records, 82.27 percent follow concurrent queries after discharge.

Another question that is brought up frequently in the CDI industry pertains to the professional backgrounds of CDI professionals. Concerns have been brought to the CDIPC that some CDI programs only hire nurses and physicians to fill the roles of CDI professionals. It has also been voiced on the CDIPC that some programs take a hybrid approach by hiring CDI professionals that come from both clinical and HIM backgrounds. By following this structure, CDI programs have staff who can bring in both perspectives to the program. CDI is seen as the bridge between physician and coding languages. For this reason, it is seen as beneficial to have staff who understand physician language, such as nurses, and staff that understand coding language, such as HIM/coding professionals.

This idea brought up the next survey question, which was asked to determine how many CDI programs hire HIM/certified coding professionals. The majority of the respondents, 58.87 percent, do hire these professionals, which supports the desire to include HIM/coding professionals in CDI positions (see Table 3 below).

Comments were provided regarding the reason why some programs do not hire HIM/coding professionals. The reasons were mostly related to the desire to have staff with clinical knowledge. This is an interesting reason, since coding knowledge is equally important in the identification of high-quality clinical documentation. It is also important to note that HIM professionals are required to take clinically-focused classes like anatomy in their prospective educational programs. Nurses and physicians have experience in applying clinical knowledge in direct patient care and HIM/coding professionals have experience in applying clinical knowledge in the accurate representation of diagnosis and procedural codes. Both of these areas of clinical knowledge are crucial in the accurate representation of patients through clinical documentation.

Preferred CDI Credentials and Education Level

There are several credentials seen in the world of CDI. To determine the most frequently seen CDI credentials, a survey question was asked regarding the credentials the respondents hold. The most frequently required credentials are RN and CCS, according to the survey. The highest preferred credentials are the CDIP and the CCDS. The required and preferred educational levels were also assessed. The majority of the respondents indicated that an associate degree is the most required level and the bachelor’s degree is the most preferred level of education.

Location and Type of CDI Reviews

The next topic for discussion is the location and type of CDI reviews. The CDIPC has been discussing the possibility of remote CDI positions. There has also been some concern discussed regarding maintaining physician engagement in remote CDI programs, so this question was asked to determine how many CDI programs are taking the step toward remote positions. The hybrid approach, which has a mixture of onsite and remote days, captured the highest number of responses (see Table 4 below). Programs that are strictly onsite came in second. There were some programs that report a completely remote CDI program.

For the programs that reported a hybrid approach, the majority of them allowed CDI professionals to work remotely two days per week.

The type of health records being reviewed by CDI programs was also questioned in the survey. Inpatient records accounted for the majority of the health records reviewed (see Table 5 below). The second-highest review was a combination of inpatient, outpatient, and professional records. This supports the industry’s beginning shift toward CDI reviews of outpatient health records.

CDI Training Methods

Organizations sometimes struggle to identify the best training methods for their CDI professionals. In this survey, the majority of respondents reported providing onsite training for their CDI staff (see Table 6 above). From the comments regarding training, greater detail in this training can be recognized. Many respondents report having a classroom type training, either by vendor or onsite personnel upon hire—then the CDI professional is transitioned to peer-to-peer training with current CDI s taff or a CDI educator. These professionals continue working with this peer until they obtain a pre-determined percentage of accuracy on review and query quality audits. The survey comments also reflect that programs provide ongoing training for their CDI staff through educational sessions. Training time ranged from six weeks to three months. The following training topics were identified in the comments:

• Chart review
• Coding guidelines
• Medicare Severity-Diagnosis Related Groups (MS-DRGs)
• Major Diagnostic Categories (MDCs)
• All Patient Refined Diagnosis Related Groups (APR-DRGs)
• Hierarchical Condition Categories (HCCs)
• Documentation standards
• Query process
• Compliance and ethics
• Knowledge of federal, state, and private payer regulations
• Organizational policies and procedures
• Quality improvement theory and reporting structures

More Results Available Online

This article has discussed some of the key takeaways from the CDI Industry Survey. To find greater details on the program structures of CDI programs, visit the AHIMA Body of Knowledge to access the full survey.

Tammy Combs (tammy.combs@ahima.org) is director of HIM practice excellence, CDI/nurse planner, at AHIMA, an AHIMA-Approved ICD-10-CM/PCS Trainer, and an AHIMA-Approved CDI Trainer.