And How to Pursue It
Today we discuss CDI Medical Director. It's a popular hospital-based job that can be a stepping stone to the C-suite.
CDI was originally the acronym for clinical documentation improvement. More commonly today, it refers to clinical documentation integrity.
I have interviewed two CDI specialists in the past. One worked primarily as an independent CDI consultant. The second worked as a physician advisor for a large consulting firm.
[See below for a special message about joining NewScript.]
Our Sponsor
We're proud to have the University of Tennessee Physician Executive MBA Program, offered by the Haslam College of Business, as the sponsor of this podcast.
The UT PEMBA is the longest-running, and most highly respected physician-only MBA in the country. It has over 700 graduates. And, the program only takes one year to complete.
By joining the UT Physician Executive MBA, you will develop the business and management skills you need to find a career that you love. To find out more, contact Dr. Kate Atchley’s office at (865) 974-6526 or go to nonclinicalphysicians.com/physicianmba.
What is CDI?
Clinical Documentation Integrity is critical to a hospital's success. It is the lynchpin for demonstrating the quality and safety of care. It is also integral to receiving appropriate payment and avoiding performance penalties from Medicare.
A good CDI program will improve internal and external quality reporting. External reports dependent on CDI include HealthGrades, HospitalCompare, Watson Top 100, and LeapFrog Rankings.
CDI Medical Director
Most physician experts start out as hospital Physician Advisor for CDI. If the organization is large enough, CDI Medical Director is the next step up. Revenue cycle consulting firms also employ physicians in these roles to work on-site or remotely.
In the hospital setting, the CDI Medical Director position can lead to a senior level position as Department Director, Vice President, or Chief Medical Officer.
Preparing for the CDI Position
To prepare, interested physicians can take the following steps:
- find a mentor in the field,
- volunteer for committee work at your hospital,
- work as part-time CDI physician advisor,
- join the American Health Information Management Association (AHIMA) and/or the Association of Clinical Documentation Integrity Specialists (ACDIS), and,
- advance to medical director or director.
Summary
A hospital CDI job is excellent in its own right. But it is also a good way to position yourself for other jobs. These include revenue cycle physician advisor at a healthcare consulting company or a more lucrative leadership position in hospital management. The lifestyle and pay are good. Both home-based and on-site work are available. And opportunities for advancement are excellent.
Special Announcement: the NewScript Community is open and accepting new members!
You have an opportunity, for a very brief period after this episode is released, to get in on the ground floor of a brand-new one-of-a-kind online community. It is called NewScript because it enables you to write a new script for your career and life.
It is a community of healthcare clinicians dedicated to helping each other to overcome burnout, marginalization, and disrespect common in today’s corporatized health system. And it is more than a community. It is an app, a membership program, a forum, and an online repository of audio files, written resources, mentorship, courses, and live-streamed events all in one place.
But unlike social media sites, it is private, uncensored, and ad-free.
We are launching NewScript the day after this episode is released. And the first 200 registrants will receive a lifetime membership to the NewScript Community at no charge. After that, there will be a modest fee to join. And as the community gets larger, that monthly fee will increase.
There are already hundreds of hours of education, training, and mentorship on the app. I am joined by consultant and telemedicine expert Dr. Tom Davis, as my partner in this venture.
And the greatest asset you may find in the NewScript Community is each other! Tom and I have found in working with hundreds of you, those in the thick of it, searching, experimenting, preparing, and making progress on your journies are excellent mentors for one another.
This truly is a rare opportunity to be a founding member of NewScript. We expect to enroll the first 200 of you very quickly.
How to Join NewScript
So, take a minute to go to the Apple App Store or GooglePlay and download NewScript and sign up now.
If it’s more convenient, or if you’d like to read a little bit more before signing up, check out this website: newscript.app.
And one more request: When you sign up for the app, you will be invited to join the NewScript email list. I urge you to do so and receive a series of welcome emails that will help you get the most from the Community.
For those listening days or weeks later, you will find that we’ve instituted a small monthly membership fee to support the Community. But it will be well worth it because by then we’ll have hundreds, if not thousands, of members, dozens of expert mentors, and everything you’ll need to embark on the new script for your life. Click here to learn more.
NOTE: Look below for a transcript of today's episode.
Links for Today's Episode:
- Top Reasons to Become a CDI Expert with Dr. Christian Zouain – 077
- Three Awesome Nonclinical Careers You Can Embark on Today – 034
- Clinical Documentation Improvement – Interview with Dr. Cesar Limjoco – 005
- American Health Information Management Association
- Association of Clinical Documentation Integrity Specialists
- HealthGrades Hospital Ratings
- Watson Top 100 Hospitals
- Leapfrog Group
- NewScript Community
Download This Episode:
Right Click Here and “Save As” to download this podcast episode to your computer.
Podcast Editing & Production Services are provided by Oscar Hamilton
Transcription PNC Podcast Episode 224
Why CDI Medical Director Is a Great Nonclinical Job
John: I'm going to talk to you today about a popular hospital-based job that can also serve as a good segue to the C-suite. It's the position of CDI medical director. CDI is the acronym for Clinical Documentation Improvement or more commonly today, Clinical Documentation Integrity.
I've previously interviewed two CDI specialists. One worked primarily as an independent CDI consultant, and the other worked as a physician advisor at a large consulting firm. But today I want to provide my take on hospital-based CDI professionals. And I will explain why working in CDI is so attractive, what the employed hospital-based CDI expert does and how that position can be leveraged for career advancement.
Let's start by defining what it is. CDI, as I said, it's Clinical Documentation Integrity, and the way I'm using it today mostly applies to the hospital setting. Now there obviously is clinical documentation in the outpatient setting, and that does fall under the CDI situation, but I'm talking about hospital-based CDI medical directors, physician advice, and so forth today. And I'll talk a little bit about how they overlap with the other situation.
A person that works in CDI has to understand how documentation in the medical record, in the EMR relates to payment and communicating what happened during the hospital stay, for example, with other entities, particularly with insurance companies including CMS - Center for Medicare & Medicaid Innovation.In fact, this whole industry grew out of the development of DRGs primarily also ICD-10 or ICD-9, which we had before. Because again, we're trying to use clinical data to do billing, to monitor quality, to just keep track of what happened in the hospital setting. And we normally don't go directly into the medical record every time we need some information that will tell us how much to pay or what we're charging, if we're on the hospital side, as opposed to the insurance side.
The reason for calling it clinical documentation integrity, and again, I was not involved in this, but there was a feeling that it was focused more on getting paid more. But really the bottom line, if you talk to CDI professionals, is that they want the medical record to reflect exactly what the patient's condition was, the services that were offered, what happened while they were in the hospital. And so, that is reflected in the quality measures and in the way that institution is being paid. Because obviously if it's a more complex situation, it usually has a longer length of stay, usually uses more resources. And so, they want the payment to correlate with those factors.
As I said, this all grew out of the development originally of DRGs, which was really in the early 80s. Actually, I think it was released while I was still in medical school. Prior to that, hospitals were being paid on basically what they build or on customary charges. But since around 1986, hospitals have been paid on DRGs - Diagnosis Related Groups, and the principal diagnosis and other things that happened while they're in the hospital, including surgeries, complications, and so forth.
It became a little more sophisticated a few years ago when they developed ways to identify presents on admission, which is basically an easy or simple way of saying that if someone came into the hospital with a preexisting condition, it had a different effect on the payment and was not considered a complication.
Now there are over 700 specific DRGs for hospital care. Most physicians only use a small number of those depending on their specialty. And the DRGs, for the most part, are broken down to three levels for each individual DRG. Let's say triplet. It's for the least complicated, the moderately complicated, and the highly complicated cases. I'm not going to get into the DRG system, but suffice it to say, what I'm trying to explain is that this whole idea of having experts in CDI grew out of the fact that over the last 30 years or so, coding and documentation have become more and more complex.
It is very similar to the office space, coding, and documentation, which many of you are more aware of because you realize that when you document in your record, either under the old or the new system for outpatients, you have to document the right things and then you have to choose the right diagnosis based on what is supported in the record. Well, it's the same thing on the hospital side, but we're talking about a lot of money and other effects, including a more direct effect on the reporting of quality. Although that also applies in the outpatient setting. And again, everything I'll say today about CDI in the hospital is pretty much applied to the outpatient setting as well. It's just that those areas don't have the need for consultants as much or for physician advisors and medical directors. Although you will see that in the outpatient side as well. But let's face it, the hospital and health system environment accounts for about a quarter of all healthcare costs in the country in any given year. And a lot of hospitals spend a lot of money trying to optimize their coding and documentation and maintain their integrity.
Now, the other reason why it's so important is that it has now been used extensively to help also to reflect the quality. Because we have these systems that measure quality or track quality and report quality in the hospital setting. And they don't go into the medical record in search of what was done. It's too complex. We don't have the systems in place yet for that, although they are developing. If you look at Hospital Compare, if you look at Health Grades, if you look at Watson Top 100, it used to be Truvin.
Anyway, when you look at those, they are using medical record data to identify the risk of the patient when they come in the hospital, what happens during the hospital and deciding whether the outcomes are as expected.
The CDI specialist, whether it's a nursing specialist or a paraprofessional or a physician medical director or physician advisor, have become very, very important. There are just simple things that I can give you as an example, but for many of these quality metrics, if your patient dies, of course, that is a mortality and it goes into your numbers generally.
However, when I was working back in the hospital, it wasn't uncommon for us to find that there were patients who were really comfort-care-only, basically a palliative care or hospice type of patient, although they may not have been on the formal hospice service. And if they died during their stay, if you didn't code appropriately and make sure that you used that suffix at the end of your coding to indicate that they were comfort care only, it would really hurt your numbers.
If you excluded all the people, which is how these measures are usually designed, as you exclude those that are comfort care only, then your mortality rates look much better. Similarly, for other factors that go into complication rates and length of stay, even which most people really consider a type of quality measure. And when you look at the Watson Top 100, for example, a lot of these factors are important. It's the outcomes for specific diagnoses, the overall mortality rate, the overall complication rate from surgery and from medical care, the length of stay, readmissions are now included, and other factors, many of which relate to the clinical documentation.
And I was looking at LeapFrog. This is probably the other big quality tool or system that people look at. It's obviously an external entity that tracks the quality based on its own metrics. And some of those are also affected by the clinical documentation.
Because we have this big system of tracking these things and reporting these things, remember, some of this reporting is internal. I was doing reports to my board every quarter, and we had tools that we instituted inside. We didn't have to share those with anyone, but we needed a way to monitor risk-adjusted outcomes.
And so, we used these tools, which evolved over time and are much more sophisticated now. And I reported that to my board and we had to have those and we had to understand how those systems work and what they were looking at in terms of monitoring and reporting quality. That's what we did. But it's become even more important now with Health Grades and Hospital Compare and others. There's Nursing Home Compare and Hospice Compare and others that the public is going to look at your outcomes. They're going to make decisions about where they want to have their care. And so, it becomes more important than ever. That all rolls down to the bottom line of the hospital. So, it's extremely important.
Now, what jobs are there? Most of these jobs fall into two or three categories. There's definitely a physician advisor for CDI, just as there is a physician advisor for utilization management or case management. There's usually potentially a physician advisor for quality improvement in some hospitals. There are often physician advisors, which might also be called informaticist physicians or medical informaticists do the same kind of thing, only on the information side, mostly for the EMR.
Physician advisors can be part-time or full-time. And so, it's a job that is kind of an entry-level position, helping hospitals. Now there are third-party consulting firms that also provide offsite support in the form of physician advisors since the EMR is now usually available online. It's always online internally, but it can be accessed from outside the hospital. And therefore, we now have many companies that hire many physicians doing remote PA work for CDI.
But I'm talking again in the hospital. In the hospital, you've got the physician advisors, and then you also have the medical director. Now, a medical director. I'll talk about their roles, but that's the next level up. And then sometimes you'll get into an actual director's role because often a large hospital will have a clinical documentation integrity department. It might be part of health information services. It might be under finance. It might be under medical affairs, which was the area that I had.
I always had CDI under me. I was never a PA for CDI directly, but I did a lot of clinical documentation improvement work in my role as VP for medical affairs and then as chief medical officer. Again, a physician can end up running this area where there would be the medical director and the actual department director. And then, eventually, this can help you move into other leadership positions. I'll talk more about why that is in a minute.
But the thing is, remember, the areas that this impacts include revenue cycle, of course, how their hospital is being paid, and Medicare compliance. There are a lot of issues that have to be addressed and met, and the documentation is key to that because that's really what CMS looks at. Occasionally you end up having to explain yourself personally, or to an administrative law judge let's say for utilization management or something like that. And maybe CDI would be involved, but usually, it's just based on what's documented in the record and supported by the record.
Let's look at the individual roles and what a CDI expert does. We're talking about a physician at this point, although I would say for those non-physicians listening, there are certainly many jobs. In fact, the majority of jobs in CDI in hospitals are nursing jobs, because nurses are the clinical documentation specialists. Obviously, they would be more of the front line in terms of reviewing the records. Lots of communication with the health information systems people so-called the medical records to make sure things are clear. But then the nurses will oftentimes interact with physicians and will engage the physician advisor or the medical director when they need some help. And some of the experts in CDI across the country are physicians because it's such an important part of what we do.
The day-to-day for a physician advisor is to advise physicians and nurses through queries and direct conversations and tell them whether they need to improve their record or ask them about something to clarify an issue, to see if it does need to be changed or updated. It's not that physicians don't know how to document. Most of us get that training. In fact, I'll say that since most of the frontline hospital work is done by the emergency medicine physicians and the hospitalists, those two groups really generally know how to document pretty well.
And during their residencies, these topics will be discussed. What is a DRG? What are the levels of a DRG? What goes into the final diagnosis? What are the complications? What's present on admission? What are the exclusion and inclusion criteria in certain circumstances? If you're a nephrologist, you're going to know the renal diagnosis codes and DRGs extremely well. If you're a cardiologist, you're going to know all of the cardiac diagnosis codes and different codes for different types of heart failure and different levels of heart failure on the DRG system. And so, most of you'll have exposure to this through your residency. But what we're talking about is getting even more sophisticated.
And one minor change in a code suffix or what we call a modifier can make all the difference, whether something is paid or not paid and how it's paid. And so, the physician advisors will be asking physicians sometimes directly or in a written query. It looks like the patient is on this kind of medication, yet you didn't mention that diagnosis and that can be a "present-on-admission." So, could you document that? Or why are you not documenting that?
That's one way that the nurse and physician advisors look through the record to see if there are medications being used that are not fully justified in the medical record, not from a medico-legal standpoint, although that's important, but to say, "Oh, this patient has a condition that you're not reflecting, but we're kind of get the hint of that because of the medication that they're taking".
They might be doing reviews of charts after discharge, but before billing. And they're going to be making recommendations, but they're kind of the front line. And so, the physicians are working with the nurses and they're all working with the attending staff or the consultants on a case, just to try to clarify things. They also do some education and one-on-one training and maybe even presentations to larger groups as part of an educational process.
Now, usually when you move into a medical director role, that's a little bit more management, more leadership, let's say. You might be doing more common presentations to the board of a hospital or to a group of physicians to try and get them up to speed on changes. Every year there are dozens of changes to the DRG system. And the way things are communicated, new codes are added. Old codes are dropped, as our principal diagnoses, as our DRGs.
The medical director, of course, would probably be supervising the physician advisors and training them if they need training. And then they may be more likely to interact with the quality improvement committee. They may sit down to some of those committee meetings or certain projects, utilization management committee meetings. They might be working directly with health information systems to solve problems about why things aren't being documented and how the health information system can be used to maybe do the queries better or to automate some of those functions. And even with the informatics department, again, because the informaticists are teaching the physicians how to document in the EMR generally, and they're helping to create little tools and maybe order sets, things like that, which if they're designed properly, could actually help with the documentation.
Definitely more management, more leadership. I'll give you an example. Let's say that you decide you're at a hospital that you want to really shoot for the Watson Top 100 designation. That's a multi-departmental issue because it includes finance, documentation and coding, quality, utilization management. If you have any other sub-teams on avoiding readmissions or things like that, then you're going to have this large group that's multidisciplinary, that's going to work together to strive towards and measure progress towards being a top 100 hospital. And you can engage Top 100 to teach you how to do that. But it definitely involves all of those different departments. Well, as a medical director, you might run that team, that project team, that oversight team that's keeping everybody on track and monitoring the overall scores internally that mirror the scores that end up being published externally. And so, again, that's something the medical director might do, or a director, as I mentioned earlier, who's director of the department, or even a vice president level.
Basically, you're working with larger groups of people and you're managing more projects and more committees than you would as a physician advisor, which can be very minimal time and minimal expertise needed.
How does one get the training and experience to do this? Well, simple. The things we've talked about before. Number one, find a mentor. If you can have a mentor who's a medical director for CDI, they're going to be a great resource. They're going to point you in some of the directions I'm going to point you to today, but they're also going to answer direct questions about how to do this job and how to work towards maybe going from part-time to full-time to more of an advanced position. Mentors are always important.
The other thing is to get involved at committee and departmental levels at the hospital, most of which is volunteer, but usually, if you're on staff at a hospital, you need to spend some time working on different committees and departments. Maybe it's QI, maybe it's documentation, maybe it's utilization committee, it might be the Credentials, Committee, but you're going to have to do that anyway. If you can focus your efforts on those that relate directly to health information systems and clinical documentation, then you're going to start to get some education, start to learn what that's all about. You'll start hearing a lot of the keywords and you'll hear about really specific issues related to meeting health grades, five-stars versus three-stars versus one star, or how documentation can help with LeapFrog and that kind of thing.
And then the next obvious step is to just sign on as a part-time physician advisor. Depending on the size of your hospital, there might be one or two positions or there might be dozens. Some of the hospitals are going to use offsite physicians through a company like Optum360 where they have offsite physicians, and sometimes, they place physicians onsite.
Sometimes that is another job option later in this process is to work for a company like that. But in any event, even if you have offsite services supporting you, you'll usually probably have maybe one or two part-time people that can interact directly or give lectures and presentations. That's obviously one step.
If you find that you like what you're doing in that process, then you want to maybe get more education. I looked at the AAPL website and they don't seem to have anything directly that applies to clinical documentation improvement. They have a lot about quality, obviously, which interfaces with that. But number one, there's the American Health Information Management Association - AHIMA. You'll hear that talked about a lot. That's usually what we used to call the medical records department or health information services, which is a more global moniker, so to speak.
And that organization does have physicians and does have education and information about CDI. Although it's probably overshadowed somewhat in that arena by the Association of Clinical Documentation Integrity Specialists known as ACDIS, they have a lot of information and a lot of support for nurses, physicians, and others to learn about what CDI is, new trends. And actually, when I was on the website recently, I saw they have a lot of education. They have certifications that will demonstrate and that you do have a base amount of knowledge about DRGs and applying CDI principles. I think the certification only basically requires being in the job for two years and then taking the exam. But it's a fairly comprehensive exam and it gets into pretty great detail.
Now I will say they also have a podcast. I listened to an episode or two of that, which was quite interesting and really gets into the nitty gritty of different types of documentation improvement scenarios. It'd be very useful if you're a PA or trying to be a PA for CDI at your hospital, and even blogs, a lot of written articles, and that sort of thing. The ACDIS is a must-join organization if you're serious about getting into clinical documentation improvement. AHIMA might provide some assistance as well.
Now, as far as getting your first job, I've already alluded to that. Of course, you would carve out time, if the position is available, to become a part-time physician advisor. You could do it in the mornings. The way people document, depending on their rounding patterns and so forth, it's now kind of something that could be useful to do all during the day in little spurts of time, from what I know. Do some chart reviews and interact with the nurses, the nurse clinical documentation specialist at lunchtime, or maybe shortly before closing, because you want to catch people before the patient gets discharged, if at all possible, for at least the concurrent reviews. There are actually post-discharge reviews, of course, as well. And maybe you could focus on those.
But you want to spend an hour or two a day just like in the old situation where you would do that kind of thing as well. And there are some physician advisors who do both of those because it does involve looking at the record anyway.
And then, over time, if it's something you like, then you increase your hours. And basically, you're carving out from the clinical. If you're in a big capitalist group, for example, a lot of times the group itself would like to have someone involved with that because your performance as a group will depend on things like the risk-adjusted length of stay, risk-adjusted complications, and mortality rate. And so, it's to the group's advantage to have an expert in those areas that can help the rest of the group with it.
And then you just gradually increase your hours as the need occurs. If you're at a hospital that has, let's say, three, four or five part-time people, well, maybe you go half-time or almost full-time while cutting down on the part-time people. And to the hospital, the budget's the same but you're increasing your hours and you're getting away from the drudgery of the call and the long hours and so forth that comes with clinical medicine and the highs and the lows and the urgency that occurs. Whereas CDI is a more constant type of job where it's a move and you get time off.
Anyway, you do that and then eventually just build yourself up to be the medical director at that institution. Or after you've been doing PA work for a while, and if you feel like you're willing to make a change, you could move to one of these offsite consulting firms that provide services. So, then you can be working remotely reviewing records and talking to physicians and nurses remotely, or you could move up to that director level at another institution. And then again, similarly, you can do a lateral move to maybe get a CMO job, or stay at your own institution if a position opens or in your system if you're part of a multi-hospital system. I think if you get involved heavily in health information, informatics, quality, and utilization management, while you're working in the CDI realm because again, there's a lot of overlap and coordination, then that really will position you well for a position as a chief medical officer.
Just to mention the salaries briefly. Probably if you're swapping your time out as a PA one or two hours a day, it's going to be the equivalent of $150,000 to $180,000 per year. In other words, if you were full-time. I don't know what that amounts to, I think that would be maybe $70 to $100 per hour. But basically, what you want to do is say, "Look, I'm going to cut back by a quarter-time in my clinical, and I'm going to replace it with this". The dollars will probably be pretty close to what you would get clinically.
Then if you move up to medical director, the typical medical director will earn usually between $180,000 to $230,000 per year in an equivalent full-time position. You can move to be a PA or a medical director at a revenue cycle company like I mentioned earlier that offers these services and the pay I think is about the same. And they'll either place you in someplace or they'll just do the remote.
And once you get to the position of a VP or chief medical officer, you're basically going to be making $300,000 or more. Depending on seniority and the size of your system, you could make well over that with bonuses and seniority. That's why it's such a good job. It's a good entree. It's a good part-time job that can morph into a full-time job, which can morph into more management and more leadership. The salaries on the hospital side are pretty darn good.
I think that's basically what I wanted to cover today. Hopefully, I've given you a good idea of what clinical documentation integrity is, what a physician advisor for CDI and a medical director for CDI would be doing, how that can segue into a position as a VP or a chief medical officer. And if it's something that you might be interested in, I advise you to look at those resources I mentioned today. Check it out and let me know how it goes.
Sign up to receive email reminders, news, and free stuff every week!
Enter your name and email address below and I'll send you reminders each podcast episode, notices about nonclinical jobs, information about free and paid courses, and other curated information just for you.
Transcription PNC Podcast Episode 224
Why CDI Medical Director Is a Great Nonclinical Job
John: I'm going to talk to you today about a popular hospital-based job that can also serve as a good segue to the C-suite. It's the position of CDI medical director. CDI is the acronym for Clinical Documentation Improvement or more commonly today, Clinical Documentation Integrity.
I've previously interviewed two CDI specialists. One worked primarily as an independent CDI consultant, and the other worked as a physician advisor at a large consulting firm. But today I want to provide my take on hospital-based CDI professionals. And I will explain why working in CDI is so attractive, what the employed hospital-based CDI expert does and how that position can be leveraged for career advancement.
Let's start by defining what it is. CDI, as I said, it's Clinical Documentation Integrity, and the way I'm using it today mostly applies to the hospital setting. Now there obviously is clinical documentation in the outpatient setting, and that does fall under the CDI situation, but I'm talking about hospital-based CDI medical directors, physician advice, and so forth today. And I'll talk a little bit about how they overlap with the other situation.
A person that works in CDI has to understand how documentation in the medical record, in the EMR relates to payment and communicating what happened during the hospital stay, for example, with other entities, particularly with insurance companies including CMS - Center for Medicare & Medicaid Innovation.In fact, this whole industry grew out of the development of DRGs primarily also ICD-10 or ICD-9, which we had before. Because again, we're trying to use clinical data to do billing, to monitor quality, to just keep track of what happened in the hospital setting. And we normally don't go directly into the medical record every time we need some information that will tell us how much to pay or what we're charging, if we're on the hospital side, as opposed to the insurance side.
The reason for calling it clinical documentation integrity, and again, I was not involved in this, but there was a feeling that it was focused more on getting paid more. But really the bottom line, if you talk to CDI professionals, is that they want the medical record to reflect exactly what the patient's condition was, the services that were offered, what happened while they were in the hospital. And so, that is reflected in the quality measures and in the way that institution is being paid. Because obviously if it's a more complex situation, it usually has a longer length of stay, usually uses more resources. And so, they want the payment to correlate with those factors.
As I said, this all grew out of the development originally of DRGs, which was really in the early 80s. Actually, I think it was released while I was still in medical school. Prior to that, hospitals were being paid on basically what they build or on customary charges. But since around 1986, hospitals have been paid on DRGs - Diagnosis Related Groups, and the principal diagnosis and other things that happened while they're in the hospital, including surgeries, complications, and so forth.
It became a little more sophisticated a few years ago when they developed ways to identify presents on admission, which is basically an easy or simple way of saying that if someone came into the hospital with a preexisting condition, it had a different effect on the payment and was not considered a complication.
Now there are over 700 specific DRGs for hospital care. Most physicians only use a small number of those depending on their specialty. And the DRGs, for the most part, are broken down to three levels for each individual DRG. Let's say triplet. It's for the least complicated, the moderately complicated, and the highly complicated cases. I'm not going to get into the DRG system, but suffice it to say, what I'm trying to explain is that this whole idea of having experts in CDI grew out of the fact that over the last 30 years or so, coding and documentation have become more and more complex.
It is very similar to the office space, coding, and documentation, which many of you are more aware of because you realize that when you document in your record, either under the old or the new system for outpatients, you have to document the right things and then you have to choose the right diagnosis based on what is supported in the record. Well, it's the same thing on the hospital side, but we're talking about a lot of money and other effects, including a more direct effect on the reporting of quality. Although that also applies in the outpatient setting. And again, everything I'll say today about CDI in the hospital is pretty much applied to the outpatient setting as well. It's just that those areas don't have the need for consultants as much or for physician advisors and medical directors. Although you will see that in the outpatient side as well. But let's face it, the hospital and health system environment accounts for about a quarter of all healthcare costs in the country in any given year. And a lot of hospitals spend a lot of money trying to optimize their coding and documentation and maintain their integrity.
Now, the other reason why it's so important is that it has now been used extensively to help also to reflect the quality. Because we have these systems that measure quality or track quality and report quality in the hospital setting. And they don't go into the medical record in search of what was done. It's too complex. We don't have the systems in place yet for that, although they are developing. If you look at Hospital Compare, if you look at Health Grades, if you look at Watson Top 100, it used to be Truvin.
Anyway, when you look at those, they are using medical record data to identify the risk of the patient when they come in the hospital, what happens during the hospital and deciding whether the outcomes are as expected.
The CDI specialist, whether it's a nursing specialist or a paraprofessional or a physician medical director or physician advisor, have become very, very important. There are just simple things that I can give you as an example, but for many of these quality metrics, if your patient dies, of course, that is a mortality and it goes into your numbers generally.
However, when I was working back in the hospital, it wasn't uncommon for us to find that there were patients who were really comfort-care-only, basically a palliative care or hospice type of patient, although they may not have been on the formal hospice service. And if they died during their stay, if you didn't code appropriately and make sure that you used that suffix at the end of your coding to indicate that they were comfort care only, it would really hurt your numbers.
If you excluded all the people, which is how these measures are usually designed, as you exclude those that are comfort care only, then your mortality rates look much better. Similarly, for other factors that go into complication rates and length of stay, even which most people really consider a type of quality measure. And when you look at the Watson Top 100, for example, a lot of these factors are important. It's the outcomes for specific diagnoses, the overall mortality rate, the overall complication rate from surgery and from medical care, the length of stay, readmissions are now included, and other factors, many of which relate to the clinical documentation.
And I was looking at LeapFrog. This is probably the other big quality tool or system that people look at. It's obviously an external entity that tracks the quality based on its own metrics. And some of those are also affected by the clinical documentation.
Because we have this big system of tracking these things and reporting these things, remember, some of this reporting is internal. I was doing reports to my board every quarter, and we had tools that we instituted inside. We didn't have to share those with anyone, but we needed a way to monitor risk-adjusted outcomes.
And so, we used these tools, which evolved over time and are much more sophisticated now. And I reported that to my board and we had to have those and we had to understand how those systems work and what they were looking at in terms of monitoring and reporting quality. That's what we did. But it's become even more important now with Health Grades and Hospital Compare and others. There's Nursing Home Compare and Hospice Compare and others that the public is going to look at your outcomes. They're going to make decisions about where they want to have their care. And so, it becomes more important than ever. That all rolls down to the bottom line of the hospital. So, it's extremely important.
Now, what jobs are there? Most of these jobs fall into two or three categories. There's definitely a physician advisor for CDI, just as there is a physician advisor for utilization management or case management. There's usually potentially a physician advisor for quality improvement in some hospitals. There are often physician advisors, which might also be called informaticist physicians or medical informaticists do the same kind of thing, only on the information side, mostly for the EMR.
Physician advisors can be part-time or full-time. And so, it's a job that is kind of an entry-level position, helping hospitals. Now there are third-party consulting firms that also provide offsite support in the form of physician advisors since the EMR is now usually available online. It's always online internally, but it can be accessed from outside the hospital. And therefore, we now have many companies that hire many physicians doing remote PA work for CDI.
But I'm talking again in the hospital. In the hospital, you've got the physician advisors, and then you also have the medical director. Now, a medical director. I'll talk about their roles, but that's the next level up. And then sometimes you'll get into an actual director's role because often a large hospital will have a clinical documentation integrity department. It might be part of health information services. It might be under finance. It might be under medical affairs, which was the area that I had.
I always had CDI under me. I was never a PA for CDI directly, but I did a lot of clinical documentation improvement work in my role as VP for medical affairs and then as chief medical officer. Again, a physician can end up running this area where there would be the medical director and the actual department director. And then, eventually, this can help you move into other leadership positions. I'll talk more about why that is in a minute.
But the thing is, remember, the areas that this impacts include revenue cycle, of course, how their hospital is being paid, and Medicare compliance. There are a lot of issues that have to be addressed and met, and the documentation is key to that because that's really what CMS looks at. Occasionally you end up having to explain yourself personally, or to an administrative law judge let's say for utilization management or something like that. And maybe CDI would be involved, but usually, it's just based on what's documented in the record and supported by the record.
Let's look at the individual roles and what a CDI expert does. We're talking about a physician at this point, although I would say for those non-physicians listening, there are certainly many jobs. In fact, the majority of jobs in CDI in hospitals are nursing jobs, because nurses are the clinical documentation specialists. Obviously, they would be more of the front line in terms of reviewing the records. Lots of communication with the health information systems people so-called the medical records to make sure things are clear. But then the nurses will oftentimes interact with physicians and will engage the physician advisor or the medical director when they need some help. And some of the experts in CDI across the country are physicians because it's such an important part of what we do.
The day-to-day for a physician advisor is to advise physicians and nurses through queries and direct conversations and tell them whether they need to improve their record or ask them about something to clarify an issue, to see if it does need to be changed or updated. It's not that physicians don't know how to document. Most of us get that training. In fact, I'll say that since most of the frontline hospital work is done by the emergency medicine physicians and the hospitalists, those two groups really generally know how to document pretty well.
And during their residencies, these topics will be discussed. What is a DRG? What are the levels of a DRG? What goes into the final diagnosis? What are the complications? What's present on admission? What are the exclusion and inclusion criteria in certain circumstances? If you're a nephrologist, you're going to know the renal diagnosis codes and DRGs extremely well. If you're a cardiologist, you're going to know all of the cardiac diagnosis codes and different codes for different types of heart failure and different levels of heart failure on the DRG system. And so, most of you'll have exposure to this through your residency. But what we're talking about is getting even more sophisticated.
And one minor change in a code suffix or what we call a modifier can make all the difference, whether something is paid or not paid and how it's paid. And so, the physician advisors will be asking physicians sometimes directly or in a written query. It looks like the patient is on this kind of medication, yet you didn't mention that diagnosis and that can be a "present-on-admission." So, could you document that? Or why are you not documenting that?
That's one way that the nurse and physician advisors look through the record to see if there are medications being used that are not fully justified in the medical record, not from a medico-legal standpoint, although that's important, but to say, "Oh, this patient has a condition that you're not reflecting, but we're kind of get the hint of that because of the medication that they're taking".
They might be doing reviews of charts after discharge, but before billing. And they're going to be making recommendations, but they're kind of the front line. And so, the physicians are working with the nurses and they're all working with the attending staff or the consultants on a case, just to try to clarify things. They also do some education and one-on-one training and maybe even presentations to larger groups as part of an educational process.
Now, usually when you move into a medical director role, that's a little bit more management, more leadership, let's say. You might be doing more common presentations to the board of a hospital or to a group of physicians to try and get them up to speed on changes. Every year there are dozens of changes to the DRG system. And the way things are communicated, new codes are added. Old codes are dropped, as our principal diagnoses, as our DRGs.
The medical director, of course, would probably be supervising the physician advisors and training them if they need training. And then they may be more likely to interact with the quality improvement committee. They may sit down to some of those committee meetings or certain projects, utilization management committee meetings. They might be working directly with health information systems to solve problems about why things aren't being documented and how the health information system can be used to maybe do the queries better or to automate some of those functions. And even with the informatics department, again, because the informaticists are teaching the physicians how to document in the EMR generally, and they're helping to create little tools and maybe order sets, things like that, which if they're designed properly, could actually help with the documentation.
Definitely more management, more leadership. I'll give you an example. Let's say that you decide you're at a hospital that you want to really shoot for the Watson Top 100 designation. That's a multi-departmental issue because it includes finance, documentation and coding, quality, utilization management. If you have any other sub-teams on avoiding readmissions or things like that, then you're going to have this large group that's multidisciplinary, that's going to work together to strive towards and measure progress towards being a top 100 hospital. And you can engage Top 100 to teach you how to do that. But it definitely involves all of those different departments. Well, as a medical director, you might run that team, that project team, that oversight team that's keeping everybody on track and monitoring the overall scores internally that mirror the scores that end up being published externally. And so, again, that's something the medical director might do, or a director, as I mentioned earlier, who's director of the department, or even a vice president level.
Basically, you're working with larger groups of people and you're managing more projects and more committees than you would as a physician advisor, which can be very minimal time and minimal expertise needed.
How does one get the training and experience to do this? Well, simple. The things we've talked about before. Number one, find a mentor. If you can have a mentor who's a medical director for CDI, they're going to be a great resource. They're going to point you in some of the directions I'm going to point you to today, but they're also going to answer direct questions about how to do this job and how to work towards maybe going from part-time to full-time to more of an advanced position. Mentors are always important.
The other thing is to get involved at committee and departmental levels at the hospital, most of which is volunteer, but usually, if you're on staff at a hospital, you need to spend some time working on different committees and departments. Maybe it's QI, maybe it's documentation, maybe it's utilization committee, it might be the Credentials, Committee, but you're going to have to do that anyway. If you can focus your efforts on those that relate directly to health information systems and clinical documentation, then you're going to start to get some education, start to learn what that's all about. You'll start hearing a lot of the keywords and you'll hear about really specific issues related to meeting health grades, five-stars versus three-stars versus one star, or how documentation can help with LeapFrog and that kind of thing.
And then the next obvious step is to just sign on as a part-time physician advisor. Depending on the size of your hospital, there might be one or two positions or there might be dozens. Some of the hospitals are going to use offsite physicians through a company like Optum360 where they have offsite physicians, and sometimes, they place physicians onsite.
Sometimes that is another job option later in this process is to work for a company like that. But in any event, even if you have offsite services supporting you, you'll usually probably have maybe one or two part-time people that can interact directly or give lectures and presentations. That's obviously one step.
If you find that you like what you're doing in that process, then you want to maybe get more education. I looked at the AAPL website and they don't seem to have anything directly that applies to clinical documentation improvement. They have a lot about quality, obviously, which interfaces with that. But number one, there's the American Health Information Management Association - AHIMA. You'll hear that talked about a lot. That's usually what we used to call the medical records department or health information services, which is a more global moniker, so to speak.
And that organization does have physicians and does have education and information about CDI. Although it's probably overshadowed somewhat in that arena by the Association of Clinical Documentation Integrity Specialists known as ACDIS, they have a lot of information and a lot of support for nurses, physicians, and others to learn about what CDI is, new trends. And actually, when I was on the website recently, I saw they have a lot of education. They have certifications that will demonstrate and that you do have a base amount of knowledge about DRGs and applying CDI principles. I think the certification only basically requires being in the job for two years and then taking the exam. But it's a fairly comprehensive exam and it gets into pretty great detail.
Now I will say they also have a podcast. I listened to an episode or two of that, which was quite interesting and really gets into the nitty gritty of different types of documentation improvement scenarios. It'd be very useful if you're a PA or trying to be a PA for CDI at your hospital, and even blogs, a lot of written articles, and that sort of thing. The ACDIS is a must-join organization if you're serious about getting into clinical documentation improvement. AHIMA might provide some assistance as well.
Now, as far as getting your first job, I've already alluded to that. Of course, you would carve out time, if the position is available, to become a part-time physician advisor. You could do it in the mornings. The way people document, depending on their rounding patterns and so forth, it's now kind of something that could be useful to do all during the day in little spurts of time, from what I know. Do some chart reviews and interact with the nurses, the nurse clinical documentation specialist at lunchtime, or maybe shortly before closing, because you want to catch people before the patient gets discharged, if at all possible, for at least the concurrent reviews. There are actually post-discharge reviews, of course, as well. And maybe you could focus on those.
But you want to spend an hour or two a day just like in the old situation where you would do that kind of thing as well. And there are some physician advisors who do both of those because it does involve looking at the record anyway.
And then, over time, if it's something you like, then you increase your hours. And basically, you're carving out from the clinical. If you're in a big capitalist group, for example, a lot of times the group itself would like to have someone involved with that because your performance as a group will depend on things like the risk-adjusted length of stay, risk-adjusted complications, and mortality rate. And so, it's to the group's advantage to have an expert in those areas that can help the rest of the group with it.
And then you just gradually increase your hours as the need occurs. If you're at a hospital that has, let's say, three, four or five part-time people, well, maybe you go half-time or almost full-time while cutting down on the part-time people. And to the hospital, the budget's the same but you're increasing your hours and you're getting away from the drudgery of the call and the long hours and so forth that comes with clinical medicine and the highs and the lows and the urgency that occurs. Whereas CDI is a more constant type of job where it's a move and you get time off.
Anyway, you do that and then eventually just build yourself up to be the medical director at that institution. Or after you've been doing PA work for a while, and if you feel like you're willing to make a change, you could move to one of these offsite consulting firms that provide services. So, then you can be working remotely reviewing records and talking to physicians and nurses remotely, or you could move up to that director level at another institution. And then again, similarly, you can do a lateral move to maybe get a CMO job, or stay at your own institution if a position opens or in your system if you're part of a multi-hospital system. I think if you get involved heavily in health information, informatics, quality, and utilization management, while you're working in the CDI realm because again, there's a lot of overlap and coordination, then that really will position you well for a position as a chief medical officer.
Just to mention the salaries briefly. Probably if you're swapping your time out as a PA one or two hours a day, it's going to be the equivalent of $150,000 to $180,000 per year. In other words, if you were full-time. I don't know what that amounts to, I think that would be maybe $70 to $100 per hour. But basically, what you want to do is say, "Look, I'm going to cut back by a quarter-time in my clinical, and I'm going to replace it with this". The dollars will probably be pretty close to what you would get clinically.
Then if you move up to medical director, the typical medical director will earn usually between $180,000 to $230,000 per year in an equivalent full-time position. You can move to be a PA or a medical director at a revenue cycle company like I mentioned earlier that offers these services and the pay I think is about the same. And they'll either place you in someplace or they'll just do the remote.
And once you get to the position of a VP or chief medical officer, you're basically going to be making $300,000 or more. Depending on seniority and the size of your system, you could make well over that with bonuses and seniority. That's why it's such a good job. It's a good entree. It's a good part-time job that can morph into a full-time job, which can morph into more management and more leadership. The salaries on the hospital side are pretty darn good.
I think that's basically what I wanted to cover today. Hopefully, I've given you a good idea of what clinical documentation integrity is, what a physician advisor for CDI and a medical director for CDI would be doing, how that can segue into a position as a VP or a chief medical officer. And if it's something that you might be interested in, I advise you to look at those resources I mentioned today. Check it out and let me know how it goes.
Sign up to receive email reminders, news, and free stuff every week!
Enter your name and email address below and I'll send you reminders each podcast episode, notices about nonclinical jobs, information about free and paid courses, and other curated information just for you.
Disclaimers:
Many of the links that I refer you to are affiliate links. That means that I receive a payment from the seller if you purchase the affiliate item using my link. Doing so has no effect on the price you are charged. And I only promote products and services that I believe are of high quality and will be useful to you.
The opinions expressed here are mine and my guest’s. While the information provided on the podcast is true and accurate to the best of my knowledge, there is no express or implied guarantee that using the methods discussed here will lead to success in your career, life, or business.
The information presented on this blog and related podcast is for entertainment and/or informational purposes only. I do not provide medical, legal, tax, or emotional advice. If you take action on the information provided on the blog or podcast, it is at your own risk. Always consult an attorney, accountant, career counselor, or other professional before making any major decisions about your career.
Leave A Comment
You must be logged in to post a comment.