Who Should CDI Report To?
As the CDI industry continues to grow and take a more prominent position in a healthcare organization’s goals and mission, I think that it’s important to take a closer look at the reporting structure of the CDI function. I believe this can be an all-important step to take, especially if one wants to be a truly effective CDI function that achieves and surpasses its goals. Based on my experience, I have seen varying forms of CDI reporting relationships and organizational structures. This is a blanket statement, but I do believe most organizations need to reassess the reporting structure for CDI. If you truly want to make a long-term difference in the quality of the documentation and the culture around documentation at your organization, the most common structure, outlined below, will not bolster those goals.
Historically, the CDI program has reported directly up to HIM along with Coding, and/or Finance/revenue cycle. I can appreciate this model, as not only should we acknowledge the concept of “no margin, no mission,” CDI professionals also work closely with the HIM/Coding world to ensure accurate coding and reporting. I think this has been the default reporting mechanism because CDI historically has been an initiative that ensures accurate reimbursement through accurate coding, inevitably looping back to recouping dollars that could have potentially be left on the table, hence reporting to Finance. Below I will outline the following:
- Why I believe reporting up through Finance is typically not optimal for CDI
- What I believe is the most effective reporting relationship for CDI
Why I believe Finance is not the most effective reporting relationship for CDI
If we ask ourselves the obvious, which is, what is the source of the clinical documentation that the CDI function focuses on? Physicians at the bedside is the answer. The physician at the bedside is at a disadvantage when it comes to CDI rules and guidelines, as this is not routinely a part of their medical training. Hence, the CDI program exists to bridge that gap, on behalf of the physician. It is imperative that a CDI professional have some sort of sound clinical acumen, to avoid queries that do not make any clinical sense to a practicing clinician. Note that I didn’t say that the CDI professional MUST have clinical credentials, as I have met many individuals without nursing credentials who have been dealing with clinical documentation for so many years and are extremely competent in the generation of clinically relevant and complaint queries. The reason I bring this up, is because, for the most part, finance has no understanding of the clinical decision-making process, or its true potential for improvement. This too is a generalization, but as I mentioned, for the most part, I believe this is the case. If you want to ensure clinical documentation integrity, as opposed to only looking at the dollars, reporting to finance won’t cut it. I have run into too many revenue cycle professionals and CFO’s, who just don’t understand what CDI really is about, other than achieving an ROI or improving the accuracy of CMI. This not only results in poor management of the program through poor decisions and expectations, but also poor physician engagement and accountability as well.
What I believe is the most effective reporting mechanism for CDI
The following is what I believe the reporting structure of an effective CDI program should look like for most organizations:
The Physician Advisor and Clinical Documentation Manager jointly run the program, each bringing their unique value and expertise to the table, and report directly to the Chief Medical Officer who represents the program at the C-suite level. For this model to work though, it is imperative that the Physician Advisor and CDI Manager have a firm understanding of the program’s goals, objectives, metrics and associated plan for success. As true leaders, they should be held accountable for poor performance of the program, which can include factors like compliance, physician engagement, query rates, query compliance and query response rates. In addition, and not unique to CDI, the CMO must have the business skills and acumen to represent the program and its accomplishments at the C-suite level. The CMO, being ultimately responsible for the program, is motivated to fully understand and support the components that ensure success of the program.
This model is probably not being implemented very often across the industry, mostly because it requires a paradigm shift in thinking with regards to how an organization approaches and perceives the value of CDI. We all know how change is received, especially in healthcare.
CDI is a clinical initiative that achieves and maintains the integrity of an organization’s clinical information and resulting coded data, and the stakeholders responsible for success should be reflected in the organizational structure. This ideal structure holds those essential to the quality and performance of the program--physicians and documentation specialists--accountable. The physicians being queried should be considered a part of the program, and not as a separate entity, which I believe, is one of the contributing factors to poor physician engagement. Ideally, this reporting model should be distributed very early in the physician’s tenure at your organization, or at the inception of this change in organizational structure allowing you to set expectations upfront.
Clinical leads should be responsible for the documentation integrity at your organization, and them being held accountable for its success will be crucial for overall progress.
“Organizational structures of today demand too much from a few, and not much from everyone else”