At the Margins

Focus on quality to protect your revenue: The evolving role of CDI

It’s a common theme in my discussions with CFOs and CEOs across the country: health care is moving from fee-for-service, volume-based reimbursement to quality-based reimbursement. The days of higher volumes equating to more revenue will soon be fully in our rear-view mirror.

This change may already be having a huge impact on your reimbursement. And if it hasn’t yet, it likely will soon: 75% of hospitals polled in a recent Advisory Board study expect to have shared savings contracts in place by 2017.

Why documentation improvement starts with a look in the mirror

Health care executives across the country often ask me: How can I ensure that quality-based reimbursement doesn’t send my hospital’s finances down the drain? My answer: expand the role of clinical documentation improvement (CDI) to review records for documentation that impacts quality measures. By doing this, you’ll make sure that you get paid the right amount for the high-quality care your hospital provides and not get dinged for quality scores that don’t reflect reality.

But that’s easier said than done. CDI programs are often already understaffed and struggling to achieve benchmark chart coverage rates and query rates without adding quality to the mix. Here’s how to expand your CDI team’s focus while maintaining everyone’s sanity.

Shift your outlook

Most CDI programs have largely focused on boosting DRG payments, particularly by securing documentation to support complications and comorbidities. That is understandable since CDI programs need to show a tangible return on investment in staffing and technology. Attuning your CDI program to quality metrics requires a shift in your outlook. 

Best-in-Class Clinical Documentation Improvement Programs

At the same time, though, you need to make sure what you’re asking your CDI specialists to take on related to quality is actually doable on top of their current responsibilities. The main focus of CDI must remain on concurrent reviews to ensure your program can still maintain that demonstrable ROI—just with a quality twist.

Join forces with your colleagues

This doesn’t mean you should try to turn CDI into Quality. Ultimately, it’s your Quality team that is responsible for assuring high-quality care. Of course, being a compassionate human being, you care that your patients are getting great care. But it’s not your job to police that.

Instead, you should be joining forces to make quality metrics an organization-wide priority. Convene a cross-functional team regularly that includes representatives from CDI, Quality, and Finance to roll out the expanded scope for CDI and assess its impact. Gather baseline performance data and create a system to track the impact of CDI on driving documentation to accurately reflect quality of care.

Find your highest-impact quality indicators

There are many quality indicators out there, and CDI specialists need to have a clearly defined scope of work. Your cross-functional team needs to identify where quality penalties are currently reducing revenue or will likely reduce it in the future. Focusing on improving documentation for those quality metrics first will decrease the added burden on CDI staff and ensure the biggest bang for your buck.

Give your staff the information they need

Your CDI specialists, physicians, and other clinical staff need to understand your expanded focus and your goals. Partner with Quality to educate clinicians on the basics: what PSIs are, how they are calculated, and the role providers play in ensuring the level of care they provide is reflected in your hospital—and their own—quality scores.

Once they know the "why," turn to the "how." Partner with your quality and strategic marketing teams to educate clinicians (outside of concurrent CDI reviews) on how to document for the highest-impact quality metrics. Sharing performance data with providers may be the right strategy to jump-start change.

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Monitor your progress and adjust course

Assess your progress against quality metrics regularly. Not moving the dial on documentation? Have your cross-functional team brainstorm why. Are one or two providers still not "getting it?" Consider one-on-one mentorship with a physician advisor.

Finally, keep in mind that the new world of quality reimbursement is still somewhat unknown. So set realistic goals and timelines for your organization and celebrate successes along the way.

Want more?

If you’re struggling with CDI program effectiveness, or if you need help in figuring out where you are losing reimbursement from quality measures, our team of experts can help. Feel free to contact me at

About the author

Samantha HaugerSamantha Hauger

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