CDI Specialists: The Unsung Heroes of the Healthcare Industry

The Centers for Medicare and Medicaid Services diagnosis-related groups (CMS-DRG) classification system was introduced in October 2007. In accordance with this system, an International Statistical Classification of Disease and Related Health Problems (ICD) code is given to each inpatient diagnosis. Hospital reimbursement is then based on the relative value of the DRG.

Hospital administrators shortly learned that documentation of major and minor comorbidities, as well as shifting the primary diagnosis to a higher intensity, could be used to increase DRGs and increase reimbursements. This meant hospitals could maximize DRG-related reimbursements through accurate documentation under this new system of categorizing inpatient discharges and payment modification. And to reflect a more accurate medical record, the severity of illness and risk of mortality (SOI/ROM) indicators could be changed.

But to do this required consistent, focused work on accurate documentation and effective coding. Without prompt, accurate clinical documentation, hospitals risk reputational damage in addition to losing out on significant reimbursements.

So who would take on this liability? The CDI specialist (CDIS).

Or as we like to call them, CDI superheroes.

The Role of the CDIS in a Value-based Care Ecosystem

The Revenue Generator

To remain competitive in the value-based care ecosystem, hospitals depend on the CDIS.

To support reimbursements, payers rely on clinical documentation and precise coding. Additionally, a lack of information or assigning DRGs with a lower relative weight may cause hospitals to lose out on reimbursements and face value-based penalties. There have been cases where healthcare providers missed out on incentive payments due to a lack of achievement documentation to show payers.

Hospitals can prevent such mishaps by leveraging a skilled CDI team. According to a 2016 Black Book Market Research survey, almost 90% of hospitals that employed a strong CDI program with skilled specialists earned at least $1.5 million more through reimbursements and healthcare revenue. Most of the additional revenue came from improving key performance indicators (KPIs) such as the Case Mix Index (CMI) through CDI.

A CDIS is responsible for accurate reporting of hospital-acquired conditions, in addition to proper SOI/ROM documentation (HACs). Due to their growing importance in generating healthcare revenue, quality care and desirable patient outcomes become the foundation of the revenue models used among healthcare organizations. Patient safety indicators (PSIs) and mortality outcomes, both of which define quality measures that have an impact on the hospital's bottom line, are also documented and monitored by CDI professionals.

Improving Brand Positivity

In the era of healthcare consumerism, the public disclosure of hospital quality ratings puts the institutions' reputations in a fiercely competitive position. The rankings of hospitals are influenced by several different variables. However, a sizable portion of these variables is linked to quality-based performance indicators, including promising clinical outcomes, patient safety, and care quality. These are all direct functions of documentation, so their effectiveness depends on the CDIS.

Hospitals frequently deal with Medicare-contracted Recovery Audit Contractors (RACs) due to Medicare's ongoing efforts to ensure payment accuracy and improve the quality of care for patients. A CDIS can support hospitals in preparing for RACs as the entire responsibility of documenting successful patient outcomes falls on their shoulders. A robust audit report results in favorable ratings from grading organizations and government bodies in charge of assessing hospitals for the public. Thus, thorough and accurate documentation can raise public perceptions of the hospital.