The Director of Coding and CDI Services for UC Davis Health chats with Healthleaders about its leap of faith in discontinuing its reconciliation process.
At the heart of the revenue cycle are the CDI and coding teams, which is why revenue cycle leaders tend to focus here first when looking to rework processes, improve productivity, and increase the bottom line.
When it comes to streamlining the middle revenue cycle, one area leaders look to is the CDI reconciliation process.
Traditionally, a CDI and coding reconciliation process consists of a CDI specialist reviewing a chart, assigning a working diagnosis-related group (DRG), and occasionally determining a set of diagnosis and procedure codes proactively to help create queries, quality reviews, and more—all before the patient has even left the building.
Once that patient gets discharged, the coding teams report the case based on the documentation in the medical record. And, if the MS-DRGs and/or codes don't match what the CDI team chose, the chart could be passed back to the CDI team to identify the mismatch.
While some leaders believe this reconciliation process is an important step in proper documentation and denials management, other leaders have said the time spent reviewing the mismatches is not only bad for productivity, but team moral as well.
To discuss this further, HealthLeaders caught up with Tami McMasters Gomez, the director of coding and CDI services for UC Davis Health, about how she recently did away with her entire CDI and coding reconciliation process and found positive results from doing so.
This is part one of a two-part series.
HealthLeaders: We spoke earlier this year about the technology that UC Davis has been implementing in the middle revenue cycle. And at the time you mentioned to me about your organization's discontinued CDI reconciliation process. Since it seems to be the opposite of what a lot of revenue cycle leaders look to do, I was so eager to chat with you about it.
Revenue cycle leaders obviously know every aspect of the revenue cycle, but depending on an organization’s size, they may not be as in the weeds with CDI and coding as their directors are. So, we are chatting about this topic today because this change that you made in your department increased productivity by 33% and that can have a huge impact on the revenue cycle.
To start us off, can you give revenue cycle leaders a brief overview of what your CDI and coding reconciliation process looked like?
McMasters Gomez: Before discontinuation, if the teams’ DRGs didn’t match, there was a process where the coder would pass it back to the CDI specialist in a work-cue-type environment and say, “my DRG doesn't match yours, let's figure out why.” The CDI team would then spend sometimes 30 or 40 minutes trying to figure out why their DRG didn't match the coders.
In most cases, the CDI team does not consist of seasoned coders: they're clinical reviewers. And the mismatch could have been from an obscure coding guideline or a seventh character in a procedure code that the CDI specialist just wasn't aware of. It just didn't feel like it was very productive to have this process in place.
This process also created a low team moral. There was this back and forth between the teams and they were questioning me and asking, “why are we doing this?” It really felt like there could be a better way at UC Davis.
That's kind of what set this in motion for me. I needed to figure out how we could make the process more efficient and why this process was creating more problems in the unit and less team engagement.
Tami McMasters Gomez, director of coding and CDI services for UC Davis Health. Photo courtesy of HealthLeaders.
HL: What happened to make you see that discontinuing this entire process was the right move? And what was your process in implementing this change?
McMasters Gomez: As I mentioned, my wheels started turning about why this process was so adversarial and why the teams were going back and forth. I also began wondering why I was holding the CDI team to a coding standard when they're not coders.
We actually had two external audits done back-to-back in 2019 and 2020 to gauge our coding accuracy rates. I already knew we had a strong coding team, but the third-party auditors determined that we have a 99.9% coding accuracy rate.
I knew there was one benefit to having this reconciliation process, and that was the education the teams received from investigating or learning about why their DRGs didn't match when we have such high coding accuracy rates. And then I thought, well, “What can I do to take this process outside of these teams so that they could spend time doing what they do, coding and clinical reviews?”
That’s when I created a back-end process where I have clinical reviewers that get a daily report that shows all of the DRG mismatches. That review, which is done by both a high-level coding analyst/auditor with CDI credentials and a CDI lead, do the reviews and provide individual feedback to either the coder or the CDI specialist on why there was a difference in the DRG.
That review is done retrospectively prebill, and the individual feedback is provided to the team in real time prior to completing the case with the supporting documentation on why there was a DRG mismatch.
We also look for trends. If everybody's missing the boat on this one area, then we provide a much broader education or scope. But we really did a lot of looking at data and leveraging reports. And when there are coding errors or missed opportunities discovered, there's direct feedback daily to the coders so they're still getting that education.
We found that after implementing this change, CDI productivity increased more than it did the coders by anywhere between 25% to 33%. This new process really lets the coders be coders and the CDI specialists have more time to perform those clinical reviews and touch more cases.
And another added benefit was team morale. It really did just completely change the morale regarding the interaction between the coders and the CDI.
“My wheels started turning about why this process was so adversarial and why the teams were going back and forth. I also began wondering why I was holding the CDI team to a coding standard when they're not coders.”
Amanda Norris is the Revenue Cycle Editor for HealthLeaders.