CDIP Virtual Exam Prep:

Domain 4
CDI Metrics & Statistics
Objectives
• Track and trend the query process
• Learn how to do internal and external
benchmarking
• Interpret data to improve processes
Domain 4 Overview
• Domain 4: CDI Metrics & Statistics
– 13 subsections in this domain
– 14-18% of exam
– Approximately 25 questions of the total 140

3
Domain 4 Topics
1. Track denials and documentation practices to
avoid future denials
2. Trend and track physician query responses
3. Track working DRG and coder final DRG
4. Perform quality audits of CDI content to
ensure compliance with institutional policies
& procedures or national guidelines
Domain 4 Topics (continued)
5. Trend and track physician query content
6. Trend and track physician and query provider
7. Trend and track physician query volume
8. Measure the success of the CDI program
through dashboard metrics
9. Track data for physician benchmarking and
trending
Domain 4 Topics (continued)
10. Compare institution with external
institutional benchmarks
11. Track data for CDI benchmarking and
trending
12. Track data for specialty benchmarking and
trending
13. Use CDI data to adjust departmental
workflow
Topic 1

TRACK DENIALS AND DOCUMENTATION

PRACTICES TO AVOID FUTURE DENIALS
Track Denials
• Hospitals write off up to • Denials management
4% of net revenue due • Coding Supervisor/HIM
to denials (up to $14 Director
million in lost revenue) • Perform reviews of
• Lack of a denials denied charts
process can be
financially devastating
– CDI Specialist
• Discuss with CDI
Specialists and Coders
• Financial Services
Where are the Denials Coming From?
• Medicare Administrative Contractors (MAC)
• Recovery Audit Program
• Insurance Companies
Tracking Denials
• Medical Necessity
• Missing Documentation
• Missing Clinical Evidence
60

• Incorrect Coding 50

40

30

20

10

0
January February March April May June
Denial Rate
Number of claims or line items denied
Number of claims or line items submitted
Additional Learning Activity
• Look at your facility’s denial rate
Topic 2

TREND AND TRACK PHYSICIAN

QUERY RESPONSES
Query Responses
• Definition of Query Response Rate
• Establish Query Response Rate parameters
– Concurrent query response expectations
– Retrospective query response expectations

Formula:
Number of Query Responses
Number of Queries Sent
Query Response Rate
• Track the Query Response Rate (QRR)
– Calculation of the QRR
• Based on responses only
• Based on completion within established
timeframe
Query Response Rate

Dr. Know

Dr. Jones
No response
Answered
Dr. Smith Total Queries

Dr. Howard

0 5 10 15 20 25 30
Escalation Policy
• Do you have an escalation policy in place?
• Example:
– CDI makes 3 contacts with physician
– Case is then escalated to manager to contact
physician
– Still no response after being contacted by
manager/director, case is escalated to Physician
Champion
Topic 3

TRACK WORKING DRG AND FINAL

DRG
Working DRG vs. Final DRG
• CDI professional- “Working DRG”
• Coding professional- “Final DRG”
• Benefit of tracking information
• Coding professional/CDI professional
interaction
Working
DRG

Final
DRG
Topic 4

PERFORM QUALITY AUDITS OF CDI

CONTENT TO ENSURE COMPLIANCE
WITH INSTITUTIONAL POLICIES &
PROCEDURES OR NATIONAL
GUIDELINES
Quality Audits
• Institutional policies for queries
– When should queries be generated
– Who should generate queries
– Types of queries
– Who should answer the query
– Other considerations
Quality Impact
• Severity of Illness (SOI)
• Risk of Mortality (ROM)
• Patient Safety Indicators
(PSI)
• Hospital Acquired
Conditions
• Readmissions
Policies & Procedures
• Health record review process
• Compliant query policies
• Institutional policies for auditing queries
• Acceptable methods for query responses
• Escalation policies
– No response queries
– DRG reconciliation
Additional Learning Activity
– Review the AHIMA Practice Brief “Guidelines for
Achieving a Compliant Query Practice (2016
Update)” at
http://library.ahima.org/PB/QueryCompliance#.W
NGefU3rvmQ
Topic 5

TREND AND TRACK PHYSICIAN

QUERY CONTENT
Physician Query Content
• What queries are being written?
• How to maintain consistency with queries
Topic 6

TREND AND TRACK PHYSICIAN AND

QUERY PROVIDER
Tracking Providers
• Track which providers are receiving queries
• Track who is writing the queries
Topic 7

TREND AND TRACK PHYSICIAN

QUERY VOLUME
Physician Query Volume
• Track which physicians are receiving queries
• Track what types of queries
Topic 8

MEASURE THE SUCCESS OF THE CDI

PROGRAM THROUGH DASHBOARD
METRICS
Program Success
• Dashboard metrics:
– Number of queries placed
– Query response rate
– Number concurrent patient reviews
– Number of patients eligible for CDI review
– Percentage of patients reviewed and target
Leadership Metrics

Review
CMI Trend Rate

Reimbursement
Impact

Query Rate Response Rate

Top Queries Top Responders
Quality
Impact
MCC & CC Capture Rate
for Top DRGs
Financial Impact
CMI Tracking
1.85

1.8

1.75

1.7 2011
2012
1.65 2013
2014
1.6

1.55

1.5
Qu1 Qu2 Qu3 Qu4
Presentations
• High level Example
• Clear
Chart Title
• Concise
471

• Use Tables & 500 446

450
400
Graphs 350
300
250
200
150
100 20
15 10
50
0
Agreed Disagreed Unable to No Response Total
Determine Responses

Series1
Team Performance Metrics
• Case Mix Index (CMI) • Quality Impact
• Review Rate • DRG Match Rate
• Query Rate • Audit Scores
– Percentage of Query
types
• Response Rate
• Reimbursement
Impact
Topic 9

TRACK DATA FOR PHYSICIAN

BENCHMARKING AND TRENDING
Physician Benchmarking
• Query response rate
• Diagnoses being queried
• Repetitive queries for same topics
Physician Compare
• Primary & Secondary Services
• Quality Ratings
• Medical School Education
• Group Profile
• Hospital affiliation
Additional Learning Activity
• Example of Benchmarking: Physician Compare
https://www.medicare.gov/physiciancompare/search.html
Topic 10

COMPARE INSTITUTION WITH

EXTERNAL INSTITUTIONAL
BENCHMARKS
Institution Benchmarking
• Know your institutional benchmarks
• Compare to national standards and other
facilities
Leapfrog Hospital Survey
• Computerized Physician Order Entry (CPOE)
• Evidence-Based Hospital Referral (EBHR)
• Maternity Care
• ICU Physician Staffing (IPS)
• Safe Practice Score (SPS)
• Managing Serious Errors
• Bar Code Medication Administration
• Resource Use for Common Acute Conditions
Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)
• Patient Experience
• Included in Value Based Incentive Payment
• Random sample of adult admission 48 hours
and 6 weeks after discharge
Healthgrades
• Compare physician and hospitals
• By location
• By specialty
• Quality rating
• Patient experience
Hospital Compare
• Timely and effective care
• Complications
• Readmissions and deaths
• Use of medical imaging
• Patient experience
• Payment and value of care
Additional Learning Activity
• Example of Benchmarking: Hospital Compare
www.hospitalcompare.hhs.gov
Topic 11

TRACK DATA FOR CDI

BENCHMARKING AND TRENDING
CDI Benchmarking
• Number of queries per month
• Diagnoses being queried
• Agree/Disagree
• Number charts reviewed by CDI
• Percentage of eligible charts reviewed by CDI
Topic 12

TRACK DATA FOR SPECIALTY

BENCHMARKING AND TRENDING
Specialty Benchmarking
• What specialties are being queried?
• What documentation specificity is being
asked?
Monthy CHF Queries
April 2017

10

0
Intensivists Hospitalists Cardiology Nephrology
Topic 13

USE CDI DATA TO ADJUST

DEPARTMENT WORKFLOW
Workflow
• Streamlining workflow for CDI specialist
• What can be changed for reviews
• What can be changed for the query process
• Physician education
• CDI and Coder interaction
Summary
• Track denials and documentation
• Track physician query response
• Track working DRG and coder final DRG
• Perform quality audits
Summary
• Trend and track query content
• Trend and track physician and query provider
• Trend and track physician query volume
• Measure the success of CDI
Summary
• Track data for physicians benchmarking
• Compare institution and external institution
benchmarking
• Track data for CDI
• Track data for specialty benchmarking
• Use CDI data to adjust workflow
AHIMA CDIP Exam Prep Resources
• Hess, Pamela. Clinical Documentation
Improvement: Principles and Practice.
AHIMA Press: 2015.
https://my.ahima.org/store/product?i
d=62223
• Online CDIP Practice Exam in ICD-10.
(84 questions)
https://my.ahima.org/store/product?i
d=62474