There has been growing interest in the intersection of utilization review (UR) and clinical documentation integrity (CDI). With greater recent changes, such as more UR and CDI staff going remote and case management being left in the hospital, I can’t tell you how often Dr. Erica Remer and I are asked to speak about the partnership between CDI and UR – and together we have really learned a lot about how closely these two professions align.
Recently, ACDIS responded to a public question about the potential for greater collaboration with utilization management, and even cross-training of team members. The question confirms the growing interest, but I must admit that the responses seemed to leave me wanting more. So here is the response I would give: absolutely, it is time for UR and CDI to look at further collaboration and intersection, and for a multitude of growing reasons. The top one is that they have long been specialists on the quest to both support clinical documentation and medical necessity for accurate revenue capture.
They also often collaborate with physician advisor(s) (PAs), which are often expected to cover both areas in their role, depending on hospital size. Greater alignment would benefit the PA as well.
From a physician standpoint, there is often confusion over the role both groups play, as they are often seen as people who bug physicians about their documentation. Greater coordination is needed in education and discussions with the physicians, which would eliminate multiple intrusions.
From a denial perspective, it can already be a pass-the-baton approach between UR and CDI as to what caused a denial: medical necessity or a DRG downgrade. The payers even sometimes use both reasons of clinical validation and medical necessity in their justification to deny, leaving the siloed CDI and UR specialist confused as who is expected to “write the letter.”
Technology is already working to integrate the two disciplines. Without mentioning names, the same techniques for UR and CDI are being configured and rolled out for efficiency across lines. The machine learning and algorithms being built to pull documentation or identify areas of opportunity from abnormal lab values have been proven to be of great benefit to the CDIS and the URS.
With greater movement of a remote workforce and the increasing requirements for the social determinants of health (SDoH) and health equity, case management (CM) is being pulled in a different direction. Although I know the importance of case management – to move the progression of care and understand resource over-utilization (utilization management) – the requirements CM specialists face are pushing them across the continuum and away from the traditional dyad and triad models.
Finally, these disciplines need each other. How often does the CDIS review a record and provide a primary diagnosis, maybe even a query, to the physician only for it to be downgraded to observation services after a UR review process? Or how about the denial that comes through for a short-stay hospitalization – despite the clear and concise documentation by the physician, thanks to the great efforts of the CDIS and coder, the case does not present the relevant medical necessity to even pass the Two-Midnight Rule. Finally, how often does the UR team scour the record to find justification for a continued hospitalization to provide criteria and clinical documentation to the payer, when the CDIS has already completed a beautiful review that is sometimes not even visible to the URS in the record.
So, when the question is asked regarding greater collaboration between CDI and UR, the unequivocal answer is yes.
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Photo courtesy of: ICD10 Monitor
Originally Published On: ICD10 Monitor
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