The Impact of COVID-19 on Clinical Documentation Integrity: Insights from Fran Jurcak (Part I)

Fran Jurcak, MSN, RN, CCDS, CCDS-O

Chief Clinical Strategist

Iodine Software

Fran Jurcak is an accomplished senior executive with over 30 years of success in healthcare practice, education, consulting, and technology. She is currently the Chief Clinical Strategist at Iodine Software where she has worked for four years and has assisted in bringing artificial intelligence machine learning model technology to CDI and coding workflows. Jurcak currently sits on the ACDIS Advisory Board, serves on several other advisory boards, and received the 2017 ACDIS award for Professional Achievement. Prior to joining Iodine, Jurcak was a healthcare consultant, leveraging her clinical and coding knowledge to support process improvement in the mid-revenue cycle, particularly in the clinical documentation integrity space. These process improvements allowed her clients to successfully minimize mid-cycle leakage and accurately report outcomes of care. Additionally, she is the author of the CCDS Study Guide and has co-authored several papers for ACDIS and AHIMA, both organizations which recognize Jurcak as a national speaker.

Q: What are the greatest challenges faced by CDI teams during the COVID-19 outbreak?

A: Perhaps the biggest challenge has been census fluctuation, and in most cases, a decline in census, which means there are fewer cases for CDI teams to concurrently review. This decrease in census has often resulted in reassignment or furloughing of staff. I also believe the second greatest challenge, specifically for facilities in COVID hotspots, is the limited availability of providers to answer queries. These challenges have caused many CDI teams to change workflow processes to identify the right cases for review, identify appropriate queries, and truly get the answers they need from providers. As a result, many programs are holding records longer than usual before final coding in order to ensure accurate and complete documentation before billing. Increased time to billing increases DNFB and ultimately time before payment is received.

Q: Given the decline in patient volumes, some CDI teams are expanding and adapting their programs. What initiatives do you think should be prioritized?

A: COVID-19 is not just impacting Medicare patients. It is impacting all patients from all payer types, even self pay. Financial reimbursement and quality reporting will continue to depend on the specificity of all conditions requiring accurate and complete documentation in all medical records. This creates a huge opportunity for CDI programs to expand to all payers and ensure that all conditions being monitored and treated during a patient’s encounter are clearly and consistently documented.

Health systems also have the opportunity to expand beyond financially motivated queries to ensure documentation integrity in the entire medical record. To truly capture patient acuity and support the research needed to identify patient patterns that identify at risk populations for COVID-19 and other diseases, CDI teams need to ensure that documentation appropriately captures all of the comorbid conditions that are being monitored and treated during the patient encounter. This means that simply documenting COVID-19 or respiratory failure will not be sufficient; capturing all other comorbidities as well as the specificity of all conditions will be crucial.

At Iodine, we are seeing a mixed bag of initiatives among our clients. For example, some have pulled back on physician-based education because physicians just don’t have additional time as they are busy caring for the influx of COVID-19 patients. Others have spent more time training and educating about COVID-19 and comorbid conditions to ensure they may not have to query as frequently. Census declines have definitely opened the door for CDI programs to reallocate time for additional education and training of their staff – whether it is cross-training to review records in a specialty they are less familiar with, or opening up to other types of inpatient admissions such as pediatrics or obstetrics. Additionally, expanding, supporting, and reinforcing the knowledge base of CDI professionals keeps staff up-to-date during a time of heightened complexity and uncertainty.

Q: In your opinion, can CDI teams stay remote full-time? What do you think the impact will be if remote work continues?

A: There are portions of what has traditionally been seen as CDI workload that I think can be done remotely. Obviously, electronic health records (EHRs) and most of the technology that CDI specialists are using in their workflow can be accessed remotely. However, engaging providers and ensuring accurate, appropriate, and timely responses requires some level of face-to-face interaction. I’ve seen teams accomplish this a variety of ways. Some programs have a portion of their staff conduct record review remotely while additional staff members interact with providers onsite. Other programs have their entire staff working a few days at home and a few days onsite so they can interact with providers themselves. In person communication is important for maintaining not only interpersonal relationships with providers but also to remind them of the relevance of documentation integrity.

I think remote work will increase moving forward, but the need to monitor quality of work will also increase. The challenge is that quality of work often suffers when teams work remotely. Social distancing makes it easier to stay focused on work, but there will be many more distractions once restrictions are lifted. Leveraging additional staff for internal auditing can help ensure query opportunities are not missed, queries remain compliant, and final codes related to queries are accurately captured. Peer audits also promote shared learning and accountability.

Part II will be published later this week.