How to Engage and Motivate Your CDI Staff Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS‐CP Manager of CDI Children’s National Medical Center Washington, DC

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Polling Question • Does your facility have multiple tiers for CDI  specialists? – – – –

Yes, we have tiers based on years of experience Yes, we have tiers based on certifications Yes, we have tiers based on role/responsibilities No, we do not have any tiers/levels beyond staff specialist  and CDI director/manager

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Learning Objectives • At the completion of this educational activity, the  learner will be able to: – Identify three mechanisms for CDI specialist professional  advancement – Detail at least 4 specific CDI specialist roles  – Describe 3 or more challenges CDI specialists and their  managers face

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CDI Specialist Landscape

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CDI Specialist Landscape • Clinical experience – The traditional CDI specialist role is increasingly a clinical‐ adjunct role  – Clinical bedside experience is still not required for the CDI  specialist role, though it offers many advantages – Credentialed and experienced coders are able to work as CDI  specialists, but they face a higher threshold of acceptance – Many hospitals and other organizations only seek those with  clinical experience as CDI apprentices

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CDI Specialist Landscape • Education – Most hospitals require a bachelor’s degree to fill the role of  CDI specialist – Nursing Magnet® hospitals require at least a BSN and for CDI  staff to be registered nurses or credentialed physicians – Those hospitals that have HIM professionals filling the CDI  role frequently require at least a bachelor’s degree and an  RHIT/RHIA in addition to a recognized coding credential

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CDI Specialist Landscape • CDI experience – Applicants with prior coding experience in demand – Applicants with BOTH hospital and clinic experience are  highly sought after – Applicants with CDI experience of any type are able to  switch jobs or demand increased salary based on experience – In a crowded healthcare market (like DC/Baltimore),  experienced applicants have the upper hand

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CDI Specialist Challenges

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CDI Specialist Challenges • Over‐reliance on metrics – – – – –

Who establishes the metrics? Are the metrics fair? Are the measures objective? Have the measures been validated? Do the measures promote strife?

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CDI Specialist Challenges • CDI reviewer rut – Do you concentrate on reviewing records? – Is it most important to be the person with the most records  reviewed? – Are you bored? – Are you by yourself? (Or does it feel like you are?)

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CDI Specialist Challenges • The query fanatic – Is placing queries the most important task? – Is your performance measured in part on how many queries  you place? – What is your query rate? – Are your queries validated? – Do you place queries that have little to no impact?

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CDI Specialist Challenges • Novice CDI specialist plateau – – – –

How long until you feel comfortable in your role? Do you have regular feedback sessions with your manager? Do you have an identified mentor? Are you able to try new roles and shadow more experienced  staff? I am trapped here! – Are you able to participate in  shared decision‐making?

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CDI Specialist Challenges • Physician’s handmaiden/valet? – Are physicians relying on you to teach them the EMR? – Do you have to send the same queries over and over again?  (physician using the CDI specialist to cover lazy documenting  habits) – Do you feel like you are taken advantage of?

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CDI Specialist Challenges • Lack of focus – Do you receive regular  feedback? – Do you have scheduled and  structured time with your  manager? – Are you able to check your own  metrics/performance? – If you did not come to work,  would the hospital notice?  (outside of your department) – Do you feel like you make a  difference? 15 2018 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

CDI Role Specialization

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CDI Role Specialization • QA (quality assurance/assessment) – – – – –

Serves as second‐level chart reviewer Regularly reviews others’ queries Interfaces with coding staff Performs internal “audits” Can serve as team lead

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CDI Role Specialization • Physician educator – Takes lead in creating/presenting education for physicians  and other providers – May also serve on EMR optimization committee – Involves CDI specialist assigned to clinical area – Responsible for all physician‐facing communication  (newsletters, emails, special events, posters)

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CDI Role Specialization • CDI team educator – Creates educational content for  CDI team – Solicits team for knowledge and  practice deficits – Provides CDI and clinical education  to coding staff – Provides regular case review for  other CDI specialists

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CDI Role Specialization • Preceptor – Experienced CDI staff member  • 2 or more years as a CDI specialist • 1 or more years at facility – Serves as ongoing mentor to new staff – Creates educational plan for each new staff member based  on that person’s experience and skill level – Can serve as team lead

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CDI Role Specialization • Post‐discharge CDI reviewer – Pre‐coding review – Experienced CDI staff member • 2+ years experience as CDI specialist • Ideally with some formal coding education  – Serves as post discharge case reconciliation – Reviews all cases discharged without CDI review – Reviews all cases discharged with low SOI, ROM, sign and  symptom DRGs, no CC/MCC

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CDI Role Specialization • Mortality reviewer – Pre‐coding review – Experienced CDI staff member • 2+ years experience as CDI specialist • Broad CDI experience – Reviews all cases with discharge status “expired” – Strong APR‐DRG skills

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CDI Role Specialization • Denials/appeals – Experienced CDI staff member • 2+ years experience as CDI specialist • Broad CDI experience – Does not review for “charges” – Strictly a clinical review to ensure diagnoses are appropriate  – Case manager/utilization reviewer experience helpful

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CDI Role Specialization • Quality collaborator – Experienced CDI staff member • 2+ years experience as CDI specialist – Strong interest in quality initiatives – Participates in quality department activities – Education in value‐based purchasing and other pay‐for‐ performance reimbursement schemes – Strong understanding of risk‐adjustment mechanisms 

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CDI Role Specialization • Utilization review collaborator – Experienced CDI specialist – Reviews all case management notes and compares with CDI  working DRGs – Accesses and understands MCG/Interqual criteria – Collaborates with UR to ensure that patient’s UR criteria  match what will be coded out – Provides ongoing CDI education to case managers, utilization  reviewers, and physician advisors – Serves as subject matter expert for all diagnostic and  procedural code questions 25 2018 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

CDI Role Specialization • Data analyst – Experienced CDI specialist – Formal coding education – Received advance training in data extraction, data analysis,  and reporting – May be combined with other role

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CDI Career Ladder

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CDI Career Ladder • CDI Specialist I – – – –

May or may not have CDI experience Checklist and task responsibility based Minimum education: Bachelor’s level Requirements to move up: • Completion of formal CDI training program • Experience

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CDI Career Ladder • CDI Specialist II – Must have two years or more CDI experience • 1 year for CDI member with prior experience  OR • 2 years for apprentice CDI specialist AND • Certification AND/OR • Role specialization  – Minimum required to work partially or fully remote 29 2018 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

CDI Career Ladder • CDI Team Lead – Must have three years or more CDI experience • 3 years for CDI member with prior experience  OR • 4 years for internal candidate AND • Certification AND • Formal coding education – Operational responsibility (i.e., team lead) • Inpatient • Hospital‐based outpatient • Clinic 30 2018 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

Future State CDI Engagement

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Future State CDI Engagement • Pay for performance – – – – – –

The movement AWAY from DRG payment mechanisms Payment based on quality measures Incentive + Physician profiling on steroids EMR measurement Observed to expected ratios • Mortality • Readmissions • Complications • Etc. 32

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Future State CDI Engagement • Integrated networks – Hospitals and providers are one – Payers and providers are one – New frontiers • UHC + Optum + Hospitals • Kaiser + Providers + Hospitals + Clinics

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Future State CDI Engagement • Outpatient (ambulatory) CDI + provider‐oriented CDI – – – – –

Provider‐based billing (E&M) Alignment of professional diagnoses and hospital diagnoses Hierarchical (and other) Condition Categories Cost and profit sharing  Telemedicine pre‐visit review

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Future State CDI Engagement • On behalf of payers – Forcing change upon physicians and hospitals – Analysis for holes in technology – Steering patients to payer owned or managed providers and  hospitals – Quality and outcomes 

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Future State CDI Engagement • CDI (and coding) technology – – – – –

Disruptive technology Threats to CDI profession Threats to coding profession EMR embedded documentation tools Computer‐assisted coding

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Thank you. Questions? [email protected] In order to receive your continuing education certificate(s) for this program,  you must complete the online evaluation. The link can be found in the  continuing education section at the front of the program guide. 

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