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A Physician-First Approach to Clinical Documentation Improvement

July 16, 2013
by Rajiv Leventhal
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M.D.-licensed CDI specialists have helped lead to better documentation at Baptist Health
The CDI team at Baptist Health South Florida, a play off of CBS' "CSI Miami" television series

In today’s healthcare, clinical documentation improvement (CDI) has become a strategic imperative at hospitals and health systems across the country. Documentation is critical for patient care, as it validates the care that was provided, reduces the re-work of claims processing, and thus impacts coding, billing, and reimbursement.

Documentation improvement programs were formed in an effort to work with care providers to appropriately reflect the quality of patient care while increasing accuracy in coding and reporting. Health information management (HIM) and clinical staff form the core of CDI programs working within a multidisciplinary team to provide guidance on documentation challenges.


One health system in Coral Gables, Fla., Baptist Health South Florida, demonstrates that a CDI implementation is not a “one-size-fits-all” scenario. Baptist Health South Florida is the region’s largest not-for-profit healthcare organization, with more than 13,000 employees working across six hospital campuses and multiple satellite locations. Baptist Health has deployed a unique approach to CDI, using a physician-first technique at the point of care to help providers ensure financial integrity, reduce risk, and improve patient outcomes.

When Lorena Chicoye, M.D., corporate medical director of managed care, network development and medical management at Baptist Health, joined the health system a few years ago, she noticed that its documentation and utilization benchmarks needed improvement. Having past experience with Nuance, a Burlington, Mass.-based vendor at her previous position in a health system in central Florida, she recommended the introduction of a comprehensive CDI program.

“In Florida, what’s unique is that the state has a large number of international medical graduates that are licensed to work as physicians under the supervision of already [established] licensed physicians,” says Chicoye. “We found that several of these international physicians were working in our hospitals looking for growth and opportunity, so we decided to recruit them for our CDI specialist roles.”

The origin behind this unique approach, says Chicoye, was that physicians were less likely to bump heads with other physicians, especially ones who they knew or have worked with in the past. “Applications began to stream in and the majority of them were from our international physicians,” says Mauricio Palma, M.D., director of CDI at Baptist Health. “While this is a different approach, we found that hiring international physicians as documentation specialists was a perfect fit for us.”

The physicians are from all over the world, with many coming from Egypt, Peru, Columbia, Nicaragua, and the Dominican Republic. All of them have Educational Commission for Foreign Medical Graduates (ECFMG) Certification, and Baptist Health has given them the understanding that if in fact they continue to look for residency and find a job, they are encouraged to take it, says Chicoye. “We don’t want to hold them in these positions when they can become licensed physicians in the U.S. We had that happen with one person here already, and part of the reason he got the job was because of his experience here as a CDI specialist.”

Currently, with 15 full-time documentation specialists (one critical care nurse and the rest international medical graduates), Baptist Health South Florida’s CDI program is structured in a way that meets the cultural and institutional needs of this health system. “In our system, most of our CDI specialists have an M.D. badge, as well as a CDI badge. Physicians look at the M.D. badge, and it’s instant credibility,” notes Palma.

And while most systems face some degree of physician resistance to CDI, Baptist Health has received accolades both privately and in public forum for the work the specialists have done for the hospitals and the physicians, says Chicoye. “We find this type of acceptance very unique. The physicians and CEOs of our hospitals always make a point to applaud the CDI specialists for the hard work that they are doing.”


As far as results go, Chicoye says the health system has “cleaned up.” The quality of the documentation in the medical records has significantly increased, making it a much better record and less likely to be pulled by the search,” she says. “The charts that our people our touching, we’re making a difference on.”

While M.D.-licensed CDI specialists have a strong medical knowledge and are used to working collaboratively with physicians, a lot of organizations have not wanted to use other physicians as CDI specialists, Chicoye says.  “One reason for this is that, to be honest, physicians trained in the U.S. have huge egos. That is something that has grown and fostered. When physicians communicate with other physicians, there is a tendency to play doctor rather than deal with the issue at hand, which is the documentation piece. That’s my understanding as to why a lot of systems have preferred to use nurses or coders in those roles as opposed to physicians. So for us, it wasn’t all sunny and roses in the beginning, but the few physicians that did complain are the same people who wouldn’t want to listen to anyone.”

Baptist Health’s CDI program is only gaining momentum as the ICD-10 transition nears. At Baptist Hospital of Miami, specifically, the baseline Medicare Case Mix Index (CMI) prior to implementation was 1.56, and the current Medicare FY 2013 CMI now stands at 1.74, according to Nuance.

The CDI team works to improve accuracy on an ongoing basis. For example, it reviews charts that were flagged by Medicare RAC (recovery audit contractor) auditors for medical necessity. “We review those charts and assess if we touched the patient, and ultimately want to know if we could have done something additional to avoid the RAC audit,” says Palma.

And as ICD-10 comes bearing down, Chicoye says Baptist Health is ramping up its preparations. “We have a separate vendor that trains our CDI specialists, and assists with the coordination of all the various moving pieces within our hospital system for ICD-10, including IT, which is obviously a huge component. We’re also doing dual coding for ICD-10 as we speak. Around the country, some smaller hospitals don’t have the ability to pay for outside sourcing when it comes to these types of things, but when ICD-10 comes crashing in, we think we’ll be riding the wave pretty easily.”

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