Interview with Dr. Cesar Limjoco

Nonclinical Nation, it has been a long time since we have heard about clinical documentation improvement as a nonclinical career. And I thought it was time to revisit this topic.

With over 200 episodes under our belt, the PNC Podcast has covered a lot of territory. And it can be very easy for new listeners to miss the classic interviews on important nonclinical careers. Not everyone goes back to early episodes.

So, I decided to bring back some of the classic episodes during this summer season of 2021. We'll post several of these in the coming months, interspersed with new episodes. In that way, we will revisit some really popular nonclinical jobs discussed with awesome guests. Many are my most popular episodes and are as inspiring and informative today as they were when I first posted them.

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Clinical Documentation Improvement

Today I am revisiting my wonderful conversation with Dr. Cesar Limjoco, a nationally recognized expert on Clinical Documentation Improvement. This conversation is from Episode #5.

Cesar has a massive following on LinkedIn because of his reputation in the CDI industry. When I was CMO, our CDI program was essential for getting paid properly and demonstrating our quality of care.

It's not just about parameters; it's not just about protocols; it's not about coding. But it's really about the clinical truth. – Dr. Cesar Limjoco

If you have any interest in this area, it is a great entry into hospital management. And it provides opportunities for employment by a hospital or a consulting firm. It also makes for a nice consulting business once you’ve mastered the basics.

Getting Your First CDI Job

I enjoyed revisiting my conversation with Dr. Limjoco. He is very passionate about what he does. We really got into the core principles of CDI. And Cesar outlined the basic steps for pursuing such a career. Here they are:

  1. Get involved at your hospital on a voluntary basis with the appropriate committees and offer to help with CDI projects
  2. Join professional organizations such as the Association of Clinical Documentation Improvement Specialists, the American Health Information Management Association, and the National Association of Physician Advisors.
  3. Take on a paid part-time position as CDI Physician Advisor as you continue your learning process.
  4. Expand your responsibilities to full-time if that’s your goal.


Working as a physician advisor or medical director in CDI is a challenging and rewarding job. And it can lead to advancement in the hospital to chief medical officer or chief quality officer.

You can contact Dr. Limjoco by email at His LinkedIn profile is very complete and includes resources such as articles he has written. He is also on Twitter: @cesarlimjocomd.

NOTE: Look below for a transcript of today's episode.

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Transcription PNC Episode 206

Blast from the Past: Clinical Documentation Improvement

Interview with Dr. Cesar Limjoco

John: Hello, Dr. Limjoco. It's great to have you here.

Dr. Cesar Limjoco: Thank you. Thank you, John. It's so nice to be here.

John: I guess my first question for you is how did you get into doing this work with clinical documentation and coding?

Dr. Cesar Limjoco: Well, I guess I'm a little bit ahead of my time. We're talking about a lot of burnouts and physicians nowadays. Well, way back when more than 25, 30 years ago, I kind of saw it coming already. And I thought, you know what? This is something that maybe isn't for me. Direct patient care. And I was looking for something out there that would still utilize my knowledge and be able to contribute to bettering health care out there.

So, I just stumbled upon this thing. And it was all about coding at that point back in the eighties. I just started asking questions from the coding department at the hospital and learned to be cognizant of the issues between coding and documentation. That turned out and it evolved into sort of a working relationship as a liaison to the medical staff. And I did that willingly. And at that point, of course, I wasn't being paid for it, but I was just interested and I was able to help up both camps, both the coding department and also the medical staff to kind of be the go-between the two areas.

Coding is about portraying what is documented clinically in the chart. But also at the same time, these two areas are talking different languages, which is weird because it's supposed to be a mirror, a representation of the actual clinical reality. But that really gave me some good viewpoints, perspectives as to how to tackle issues.

John: Interesting. Now I might have my history wrong, but correct me if I'm wrong. Back before the mid-eighties and the adoption of DRGs, there really wasn't probably a big need for this. But once we got into the DRGs, it started getting more and more complicated and we were trying to use billing information or codes to not only get paid, but as time went on, it affected quality and measurement and so forth. So, I'm assuming over the last 20 years or so, it's changed a little bit.

Dr. Cesar Limjoco: Which is interesting. I would like to bring up a point. When you speak to providers, most of the time when the subject of coding comes into mind, still their perspective is more that coding is about the pro fee billing, E&M codes and all of that. That's really their main concern because that is what's nearest and closest to them but it really goes beyond that. It's about capturing severity of illness, the diagnosis is going to have a major impact on clinical coding, inpatient hospital coding.

By the way, it also impacts back on through the ENM levels because it impacts the medical decision-making part of the E&M code. It's actually a very important part of figuring out the E&M levels, because depending on the severity of illness, your medical decision-making will be impacted. And also, therefore the way you take your history and physical examination, what sorts of information you're getting from the patient? What kind of examination you're going to do and what kind of workup you're going to go into, it's going to be really directed and led by the medical decision making. And that's one thing that I think many physicians do not really realize.

So, a lot of times, it's a matter of checking the boxes. Yes, I did this H&P, I did this physical examination, I did this review of systems, this history, blah, blah, blah. But it's not just about collecting points. You have to justify it by why is it needed? Why do you need to get social history? Why do you need to get this family history? Does it have anything to do with your medical decision making?

John: Absolutely. And it's interesting because I think it takes a very certain type of person to be interested in this. I remember at my hospital and we should let the listeners know that we know each other, because when I was chief medical officer for the local hospital, you would come and you would be our consultant, talk to our medical staff, train our nursing staff, there were documentation specialists.

But there was a certain type of physician on the medical staff who would look at this and say "This is not really a game, but it's a system. And if you don't know the rules, you're going to be in trouble". And like you said, not only from the coding for your own professional services, but then the hospital itself, of course, could suffer greatly depending either financially or even based on the quality or safety length of stay and so forth, because there's a lot of risk adjustment that depends on the coding, from what I recall.

Dr. Cesar Limjoco: That's very true.

John: Speaking of that, what are you up to now? What kind of hospitals are you working with currently?

Dr. Cesar Limjoco: I'm working with this hospital in Norfolk, Virginia. It's a medium sized hospital and I go there every month for a week and train the physicians, do in-service for the coders and also train their clinical documentation specialists. So, it's challenging. It's rewarding. It's about making a culture change and that's really what's most important. It's not something that you go into for a week or two weeks or even a month and everything will change just like that. No, it doesn't work like that.

Culture change is something that happens slowly. At the beginning, there's a lot of resistance and it slowly moves and finally it gains momentum. And that's when you know that it's working. So, it takes some time for this thing to grow. And it really gives me great satisfaction when I see that coming, when I see that "aha" moment. And it's not just individually, but as a group. It's amazing.

John: Yeah. I'm sure you see shifts in the way things are being recorded, documented, the coding improves and then some of the metrics improve. So, when you're working at the facility that you're at now, I'm thinking there's probably some local medical staff members who become more involved or do they take a formal role for the hospital in terms of the coding and documentation initiative?

Dr. Cesar Limjoco: It's interesting, but there've been others that have field plural in the past. And so, it's still evolving. Some have left the role. Some are filling in the role. And hopefully after I leave someone else would go in and do the full-time position. So that's where it's at.

John: Because I remember that we had physicians on staff who would serve as a resource if one of the nurses had a question about the documentation or needed some face-to-face time with the doctor to kind of get something changed in real time. And I don't know if you're available to do that for your clients, or again, if that's something that you teach maybe one or two interested physicians to deal with on a daily basis. But I recall that we had someone like that.

Dr. Cesar Limjoco: Yes. That's part of the process, training a physician advisor or a physician champion to be the go-to person when I'm not there or when I'm not there anymore. So yes, that definitely provides continuity and sustainability of the program.

John: Now, do you remain available after the fact for, let's say the physicians that are doing that locally to consult with you or do you do any kind of ongoing training for the people that serve in that role?

Dr. Cesar Limjoco: It depends on what the needs are. The people at the facility can also gauge that and they will sense that, "You know what? We need to get him back or we need to do our consult" or something like that. Otherwise, if it's working well, probably follow-up assessments quarterly or semi-annually or annually deal.

John: So now if you've got somebody that's maybe stepped into that role part time, and they probably initially got most of the training from you, are there other resources that someone who's interested in this could access?

Dr. Cesar Limjoco: Definitely. The biggest resource that they can tap into would be ACDIS, which is the Association for Clinical Documentation Improvement Specialists. They're a good resource. As part of the association, we have annual conferences. I actually speak, present at the conference. Before the main conference there's the two-day pre-conference, where there's actually kind of like a bootcamp for physician advisors. So, that's a great starting point right there. Plug in to that ACDIS boot camp for physician advisors.

John: Okay, good. I'll put some links in the show notes here so that if any of the listeners are interested, they can look up those things.

Dr. Cesar Limjoco: There's also one more association, the National Association for Physician Advisors. You can Google it and it will come up. That's another thing you can plug into.

John: So, if our listeners are interested, they will definitely be able to check that out. Again, I'll put all that in the show notes.

Dr. Cesar Limjoco: One thing I wanted to add is for any physician who's interested in, maybe looking into this area is maybe to follow the same trail that I left out there. And that is first of all, be interested, plug into the coding department, the CDI department, and offer your services to be a resource, a champion. And that's how you get to learn because they will refer cases to you and you discuss them and you understand all the intimate underpinnings of what's going on in the nuances of the case. And that's how you learn.

John: Well, absolutely. I remember some of the nursing staff, and I guess they were in the medical records department or health information department that were doing the actual coding. They were pretty well trained, but really looking at a chart, they didn't really understand completely what was going on, particularly with a complex patient. So, they definitely liked having one or two physicians that they could go to, to help clarify those issues. And it's vitally important to the hospital. The hospital, again, the quality ratings and the amount of payment they're going to get, it just completely depends on how accurate this coding is now and it reflects the actual severity of illness. I think it's still to this day.

Dr. Cesar Limjoco: One of the main things that I do when I enter a facility is I want to make sure that everyone is on a level playing field and everyone is doing the right thing. And the way to ensure that is to help the facility and all the players, and all the stakeholders understand what's the real objective for this program or the CDI thing? And it's very important because if it's all about the money, people do really, really bad things just because of that. Then you start to see people looking for loopholes or maybe we can slide and get away with this because of this and that, and that.

It's really important that all of those rules and regulations that you alluded to, all those coding guidelines, and even clinical parameters, protocols and practice guidelines are directed towards one big thing. And that's actually the clinical truth. If you will have that as your north star, that will guide you to do the right thing. If you don't have that as the north star, you'll do weird things. And just to justify whatever your goal is, if it's maximum reimbursement or what have you. And people get in trouble with that. They may get away at it in the front, but at the back end, it will come and bite you.

John: Absolutely. Let me put it this way. The CFO looks at a program like this and says, "This is great. We're going to try and optimize our payments and we're going to document all this stuff". And again, if the staff don't understand exactly what's going on with a patient, that might happen, but that's why I think it's extremely important to have that physician involved to say, "Look, we're going to optimize and we're going to be complete here, but at the same time, it has to link really to what happened with the patient". And that way that person can stand up and say "Clinically, no, it does not justify shifting into that DRG or that diagnosis". And so, I think it's a really good point that you got to keep that in mind. I think that's just an awesome role for a physician to be in because they're the ones that have really the most clinical expertise.

Dr. Cesar Limjoco: Can I share you a little story that I like to share for the folks out there? And it's about a story about sepsis. I remember as a rookie physician in training. As a first-year resident or a second year resident, when you do your H&P assessments, we used to write them back in the middle ages where I come from.

John: Yeah, me too.

Dr. Cesar Limjoco: And when the resident comes in and the attending comes in, they kind of like to write a scratch off what you wrote and put down, no, this is something else. And they amend things that you write down. And it's a great thing, but also it shows you that, "Oops, I made a mistake". Anyway, it becomes like a thing. The goal as a rookie is to make sure that you get everything done correctly so that nothing gets changed or amended.

So, there was this one patient I examined and I did the initial workup and I was on the ball. I really thought I did a great job getting the history, physical examination and assessment of the initial laboratory workup. And I said, "Oh, this patient, all the classical pictures of a patient with pneumonia, and blah, blah, blah. Oh, by the way, the patient also has a creeping creatinine. So, the patient has acute failure, blah, blah, blah. Or the patient was also hypotensive, blah, blah, blah. And all of this comorbid could they have.

But anyway, I was so happy that I wrote it really nicely. I said, I bet you they won't be able to do anything with this. So, anyway, that attending goes on and he was one of the revered attendings. He was smart as a tack. He was really, really a great diagnostician. When he came on, I asked the senior resident, so what did he say? And he said, "Oh, sepsis". I said what? I said, "What? How can he say sepsis? He doesn't even have a blood culture".

John: Yep. But you described all the symptoms and signs, correct?

Dr. Cesar Limjoco: Yes. Yes. And the seniors said to me, well when you get to that level of the practice, you will be able to sniff out diagnosis, and be fully dependent on the workup lab. And I was thinking to myself, when could I ever get to that point that I'll be able to diagnose sepsis without the possible blood culture? Actually, this patient actually died 48 hours after. And you know what was in my head? I was still looking for the blood culture that was so ingrained in me that I have to have septicemia in order to call it sepsis.

But anyway, it's a great story to tell because in 1992 when the first serious criteria came out and you have two out of four criteria on mixed sepsis, and blah, blah, blah, people got kind of distracted. They are kind of misdirected. And they started doing stuff and everybody is now having sepsis. Every patient that comes through the doors of the hospital with leukocytosis are now called sepsis. We're missing the point. The pendulum has gone and swung to the other side that now everybody has sepsis in contrast to before that we were so dependent on blood cultures to make sepsis.

But really, it's something in between. And it is really possible blood culture does not make sepsis. You will have possible blood clots and pyelonephritis and pneumonia and even other infections, but the patient may not be septic. So, this is a great story to tell about how you get to the clinical truth. And it's not just about parameters, it's not just about protocols, it's not about coding, but it's really about the clinical truth. What does the patient really have?

John: Right. And the devil is in the details, and it's easy to just lump things and go on your way. So, it takes a level of sophistication, absolutely. Let me ask you something that you did mention. You did mention residents, of course, when you were in training, but I was wondering if you see that the people that are coming out now, medical school, residency, fellowships, and so forth, do they seem to have a better handle on this whole issue of documentation and coding?

Dr. Cesar Limjoco: Yes and no. The yes part is because they are getting the message about this thing, about documentation, about getting the specific diagnosis is important because of coding and so forth. But they are also held back by the same things that many are held back for, which is on the two other four criteria about the definitions and failing to see the big picture. And some folks actually on the extreme side are coming out and say, "Well, if I can't call it sepsis based on two of the four criteria, which I was taught in med school and in residency, how am I going to call it sepsis?" I get that kind of response. And I said, "Wait a minute. I was just supposed to be a doctor".

John: What's interesting is we are taught certain clinical things in med school and residency, but I would advise the residents and fellows to pick up the regulations or the descriptions of a DRG. Most of them were at MD-DRGs, right? There are usually three categories for each illness. And you have to somehow marry that system to what we're trained clinically and make some sense out of it. And it's not easy.

Dr. Cesar Limjoco: I have something to share with you about the DRGs. The reason why clinicians, physicians in general don't understand DRGs is this thing about the selection of the principal diagnosis, which one is the principal diagnosis. It's a very important question to them. And it's really a way of the industry figuring out why the patient needs to be in the hospital. That's really what it comes down to. Why does this patient need to be in acute inpatient care? It's not that every patient needs to be in acute inpatient care. If the patient has abdominal pain, the patient can be seen in the office or in the emergency room, urgent care, and be sent home. Not every patient with pneumonia needs to be in acute inpatient care. So, you need to figure out what it is that needs inpatient care in this patient.

This patient with pneumonia may have other comorbid conditions that make you think I got to get this patient in or else this patient will have higher risk of sepsis or other organ failures and so forth and so on because of the patient's circumstances and the comorbid conditions that the patient bring to the table.

So, the patient may come into the emergency room and say, I'm having abdominal pain. And once the physician examines the patient and does the initial workup and finds out that it's not abdominal pain that the patient needs to be in the hospital for. That this patient needs to be in the hospital because the patient is septic from a source or what have you. That is what the principal diagnosis is. That is why the patient needs to be in the hospital. Not because of the abdominal pain, which may or may not be related to this thing that is important that needs hospitalization.

John: It's a very complex situation. It's good for someone who's very meticulous, who likes to sort through problems and solve mysteries to some extent.

Dr. Cesar Limjoco: It's very House-like. You remember that TV show. And it's investigative medicine. It's really being into diagnostics and being a good diagnostician and that's what it's about.

John: Do you see any changes coming in CDI in this whole field in the next few years?

Dr. Cesar Limjoco: Yes, definitely. When the CDI thing for scanning took play, it was the way that people were able to sell it to the C suite is, hey, you know what? If you're not capturing specificity in documentation, you're leaving a lot of money on the table. So, it was all about the money at that point.

But the industry has to evolve because it's all about the money, a lot of things that are being done are because of the money. Every patient with infection is not sepsis. So, now the industry is getting to learn that's not the way also because now the payers, Medicare, Medicaid, and all the commercial payers are going to bite back and say, "Well, that's not really sepsis. Prove to me that it is sepsis". So now you have a lot of things that have been over-documented probably, or that now the payers are wanting to get it back. And now the hospitals are getting inundated, overwhelmed by a lot of claims denials.

And hospitals are using a lot of resources to answer those denials. So, it's just inundation. It's overwhelming. It's really going to affect their finances. So, the idea is if you do it right in the first place, that is, if your north star is the clinical truth, then it will take care of itself. Yes, there will still be denials. I'm not going to say that there's not going to be denials because the payers are still going to try and get some money back. But if your documentation is based on clinical truth, it will withstand scrutiny. You can go all the way to the Supreme court and you will win. But if your basis is on shaky ground, no.

John: Let's go back before we close here and talk just again about the process that someone who is interested in this might want to follow. You mentioned about if you're interested, get involved at your hospital, maybe work with the coding and documentation department, if they have one. Now sometimes how are those usually structured? Are they usually separate or part of health information? What do you usually see?

Dr. Cesar Limjoco: Both. They can be with H&N or they can be with quality. When I see that it's working under H&N, they kind of work together better. They're more collaborative when they're together. Whereas if it's not, you know how hospitals operate in silos. And that's what I try to do is break down silos. And if you can have them work more collaboratively instead of being territorial about stuff, that's how you get the most bang.

John: So physicians are getting involved at a certain level, maybe on a volunteer basis, and then would seek out the organizations that you mentioned earlier and see what kind of courses they might be able to take or meetings they could attend. Does that make sense?

Dr. Cesar Limjoco: Yes, definitely.

John: Okay. And then tell their CEO to hire Dr. Limjoco to come in and train them.

Dr. Cesar Limjoco: I think that's the message.

John: That's the way to go. At least to get started, right? And then once they've got that locked in, then maybe they can back off. Now, it would be conceivable that a medical adviser for coding and documentation could end up at just an average sized hospital spending maybe 25% of their time or more doing this, I would think.

Dr. Cesar Limjoco: It can zoom up after that because he or she can be dealing with a lot of denial appeals, a lot of issues that are coming up with the coders or the clinical documentation nurses. Being the liaison, with individual physicians or with groups of physicians or specialties, education, all of that stuff. So, it can wrap up quite a bit after that.

John: So, ultimately, especially for a larger hospital I suppose they could end up being in a full-time position.

Dr. Cesar Limjoco: Yes, yes. Just like their advisors for utilization management. Same thing. Or you can actually marry the two together. It depends on the facility.

John: Do you have any sense of what hospitals are paying physician advisors, whether it's part-time or full-time?

Dr. Cesar Limjoco: If you look at Glassdoor, they have their own data. It's something low, what they mentioned as the entry level of physician advisors. They're looking at about maybe 150, 160. It can go up. And actually, in reality, I know that it is up. We're looking at about maybe anywhere from 180 to 200.

John: You are talking about annual salary.

Dr. Cesar Limjoco: Yes, yes. And depending on how much time in the position. And then in a hospital you go from adviser to medical director to CMOs. So, you know that the salary levels that are involved from a medical director to a CMO would be different also.

John: It's definitely conserved as a stepping stone for physicians who are seeking more, let's say, advanced or executive level as opposed to just getting out of clinical medicine. But someone who's happy doing the clinical documentation could do that for a long time and probably easily at least replace their clinical payment unless they were a subspecialist or something, I would think.

Dr. Cesar Limjoco: And then if you're a consultant, then of course, you'll have a higher return on investment.

John: Once you become the expert to the people that are learning like yourself. Definitely, it's a whole different ball game. Well, I think we can wrap it up here, but I need to find out how our listeners can get a hold of you if you'd like them to, or their organizations could. That would be very useful.

Dr. Cesar Limjoco: I think the best way to contact me is through my email address. Plus, also you can connect with me on LinkedIn and I can get messages through LinkedIn. It's got a wonderful profile there with lots of information, articles, published articles and so forth.

John: Well, any last words of encouragement or thoughts that you'd like to leave us with today?

Dr. Cesar Limjoco: What I want to leave with you is the thing about the clinical truth. If only everyone had that foremost in their minds, the better things will be, the better information will feed into improving healthcare. And that's really what's important because patient care is what's really all about.

John: Absolutely. Excellent words of wisdom there from a very experienced physician and documentation specialist.


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