In this podcast episode, we revisit our enlightening conversation with CDI Expert Dr. Christian Zouain. He shares his journey from foreign medical graduate to a Clinical Documentation Improvement (CDI) specialist.

Dr. Zouain reveals how his transition from pursuing a traditional residency path led him to discover CDI. There he found his calling in ensuring accurate medical documentation. This critical aspect of the medical record impacts patient care quality and hospital revenues, which creates excellent opportunities for CDI consultants and medical directors.

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The Daily Life of a CDI Specialist

Working as a CDI specialist involves reviewing patient records, collaborating with physicians, and ensuring accurate documentation for both quality care and appropriate reimbursement.

Dr. Zouain describes the evolution from traditional paper-based systems to modern electronic health records, emphasizing how technology has transformed the way CDI specialists interact with healthcare providers. The role offers regular working hours (typically 8-4 or 9-5) and provides opportunities for both on-site and remote work.

Growing Opportunities in the CDI Field

The CDI field continues to expand, offering various career paths from hospital-based positions to remote consulting roles. Dr. Zouain emphasizes the importance of starting with hands-on hospital experience before transitioning to remote work.

He recommends three helpful steps to consider when pursuing this career:

• joining professional organizations like ACDIS and AHIMA,
• pursuing certifications such as the CCDS (Certified Clinical Documentation Specialist) and CDIP (Certified Documentation Integrity Professional), and,
• networking within the CDI community.

Summary

Whether you're a foreign medical graduate, practicing physician, or healthcare professional looking for a change, CDI provides a promising career alternative that leverages clinical knowledge in a new way.

Want to learn more about CDI? Connect with Dr. Zouain on LinkedIn or check out ACDIS's apprenticeship program. Your journey into healthcare documentation excellence awaits.

Links for today's episode:

• Dr. Christian Zouain's LinkedIn
• ACDIS
• ACDIS Apprenticeship Program
• AHIMA
• Follow This Plan to Establish a Solid Hospital CDI Career
• Why CDI Medical Director Is a Great Nonclinical Job – 224
• PNC Podcast Blast from the Past – No Residency Is No Problem – 211
• Purchase Your All Action Pass Videos and Bonuses from the 2024 Summit (Use Coupon Code 30-OFF)
• The Nonclinical Career Academy

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 378

Become a CDI Expert

- A PNC Classic from 2019 with Dr. Christian Zouain

John: Hello, Dr. Christian Zouain, welcome to the PNC podcast. I'm happy that you're here with us today.

Dr. Christian Zouain: Oh, Dr. Jurica, thanks for having me. I'm a frequent listener, I really appreciate you having me today as a guest.

John: Awesome, one of my three listeners. I'm glad to hear. Hi, mom. No. Kidding. So, no, I really wanted to get you on here. I did listen to a recent podcast where you were a guest and it was really interesting. I personally have this interest in CDI, which we'll explain what that is in a minute, but I thought you'd be a good one because you've had some recent experience in different venues, and I thought, okay, let's get Christian on the podcast.

Dr. Christian Zouain: Great, thanks. Yeah, sure.

John: good, it'll be fun. All right. I'll have recorded a short intro. It gives a little background about you, but why don't you tell us just a little bit, if you want to give us the brief history and a little bit about what you're doing right now?

Dr. Christian Zouain: Yeah, sure. I am a foreign medical graduate, originally from the Dominican Republic. I moved to the United States in 2011 to pursue residency initially, and while I studied for the boards, I worked as a medical assistant, later as a medical scribe, later landed a job in case management, utilization review at a hospital, as a means to get closer to the hospital setting and make connections, meet the doctors and obtain a residency position.

This is when I started doing research and looking into other non-clinical options, which I've never, had never done before. To me, the only path was obviously coming from the Dominican Republic was going into clinical or that's it. I knew a few people that were doing research, but I started exploring the other options. I remember I attended the SEAK non-clinical careers conference in Chicago in 2015, which is the one you've mentioned in your podcast a couple of times already.

John: Let me break in here and clarify that the SEAK non-clinical careers conference is spelled S-E-A-K, and it's not an acronym for anything. There's a reason why it's spelled that way, but it really doesn't relate to the content of the conference. It is still running annually in the Chicago area as far as I know. They just had their most recent annual big non-clinical physicians conference this past October, a few weeks ago, and I believe they will continue to do this annually. It's held not too far from O'Hare airport. They say it's in Chicago.

It's really technically in a hotel at Rosemont, Illinois. Next year will be the 20th event. Most physicians find it really useful because it presents about 20 live lectures over two days, plus access to 40 mentors, more or less during those two days. And they also have, I think, one or two pre-conferences. there's a lot going on. And I thought I would just mention that, and let's get back to our conversation.

Dr. Christian Zouain: And it really helped me realize that I was not alone in my decision to pursue a non-clinical path. then I enrolled in a clinical documentation improvement and ICD-10 coding course at New York University through the advice of a friend. This was actually new because ICD-10 was coming up. It was 2015. It was a big change, October 1st. they were saying that CDI was a growing career that actually needed a lot of healthcare professionals to jump in.

And while taking this course, I learned a lot about the impact that a complete and accurate documentation had in all areas of healthcare. I became really interested in that, and I eventually just decided to jump all in into CDI as a career path. At that point, I also became more involved with the use of social media, LinkedIn. And through there, I was able to land my first position in CDI. right now, yeah.

John: That's great. Let me stop there because I want to check a couple of things with you because some of what you said resonates with me. My recollection when I was working in the hospital setting was, I was involved with UM and CDI both. And at least my recollection was anything having to do with utilization management and the cost of care and even quality, much of it depends on the documentation. it's a natural partner in that whole process of trying to at least improve how things look on paper in terms of the quality. Would you agree with that? Was that part of this thing that led you to the CDI?

Dr. Christian Zouain: Yeah, definitely. Everything, all aspects of that, I would say would fall into place after you would get that true clinical picture of that particular case with the documentation. It's not just about... Initially, I remember I was thinking, okay, it's about reimbursement. And that caught my attention. But then later I started to find that a lot of things besides the reimbursement had a huge say with documentation.

John: I remember when we had projects and we were working on some quality project or some UM project or whatever, we always had the director for, well, it was health information services or whatever it was, but basically it was the coding experts who were at every darn meeting.

Dr. Christian Zouain: Yeah, and that's a huge part of it. In my previous job as a CDI, I was the only CDI, and I was involved particularly with all the administration. I had to report directly to the CFO. And it was a new venture for me because I came from my first experience, which was a department of 12 CDI specialists. We were just there reviewing charts and closing our records, dealing with the coders. But now I would have to go to all these meetings with the administration. I had to interact with the doctors, with case management, with quality management. I would see how it all blended together. I had to be there. I had to be in those meetings. And it's actually also a good opportunity to let them know up front what things need to be done. When they discuss cases, I can just jump in and let them know, this is how we can better document this particular situation for next time, just we don't have to go through the query process. And that way you also work to educate the physicians.

John: Absolutely. The other factor that's heavily dependent on documentation and coding, and we're not talking a lot about it here today, maybe a little bit we're touching on it, but it's the perceived quality of your hospital. The risk-adjusted mortality, complications, and length of stay depend on the accuracy of coding and understanding of inclusion and exclusion criteria and risk adjustment related to preexisting conditions versus those that develop during a hospital stay.

So for all those top 100 hospitals and all those five-star hospitals and forth, they heavily depend on very complete and accurate documentation and coding to demonstrate the quality of care because of those factors I just mentioned. All right. Let's get back to our interview. we're going to go back and go through the detail of how you actually made that transition.

You started to tell us about that, but I want to put a plug in for myself right now, only because I did a podcast early on in one of my, I guess I'd call him a friend, although we don't keep in touch, but we were working together at the hospital I worked at, and that was Cesar Limjoco, who's sort of this icon in a sense of CDI. I think you've probably heard of him, and he's got this massive following on LinkedIn and everything.

Dr. Christian Zouain: Yeah, I do. I do follow him. I haven't been able to, probably this year at this conference, I think he usually presents every year. Probably I'll go ahead and meet up with him. I mean, I know him. I've seen his articles. I follow him on LinkedIn, and he has really good information.

John: Yeah. And the thing that it was, in doing that interview, I mean, I really liked it because he gave like his whole perspective, but the thing is he is unique in the sense that he's been doing this consulting for long, and now there's other companies that are doing it, and really the starting point for someone like you or I back years ago was not what he's doing because he's been doing this for long. So I've been wanting to get a hold of somebody like yourself who has been a more recent entry into this, and again, that's just another reason why I'm happy to have you here on the podcast today, but I will say that was episode number five for anyone that wants to listen to it.

Dr. Christian Zouain: Yeah, I do remember. That was actually, I think, that was the first episode I heard from your podcast when I heard his interview. Yeah, because I was, I really wanted to know more about his journey as well.

John: Well, now we're going to supplement with your journey because you're following in the footsteps.

Dr. Christian Zouain: Thank you.

John: you had been exposed to UM, you became interested in CDI, you actually took the ICD-10 course, but then what are the steps did you take to try and make that leap into basically was essentially a brand new career for you?

Dr. Christian Zouain: Well, I was doing case management and utilization review, and what really caught my attention again was the contribution that Accurate Documentation brought to the process of healthcare. And I mean, I just decided that at that point, clinical medicine wasn't for me. I think that I just saw value and importance of helping the hospitals, helping the physicians in this current profession. that's why I decided eventually to take it on as a career path. I don't know if I'm correctly answering your question. Just let me know.

John: Let me ask you this, and I'll ask you some leading questions. were the hospital, where you're doing the UM, did they have a formal CDI program and did you end up working for them or did you end up going somewhere else?

Dr. Christian Zouain: Oh, no, I ended up going somewhere else. I believe they did later. I would find out later. They have some sort of CDI program that was starting. But I, again, I started doing research. I started being more involved with LinkedIn. So I started following all these hospitals. I was back in New York. And I would follow their HR department and this particular opportunity came up where they said that they were looking for professionals in the healthcare arena to go into CDI.

It was actually a dinner conference. if you had some sort of exposure or knew a little bit about CDI in some formal way, you could attend that meeting. I, at the time I was doing, I was doing the course at NYU. that was my ticket to go, to get into that dinner conference. And that's where I met my future boss. And eventually I was hired as a CDS.

John: now this was part of their recruiting process for people.

Dr. Christian Zouain: Yes.

John: Okay. Where were they promoting that? Where did you see that?

Dr. Christian Zouain: On LinkedIn.

John: On LinkedIn, was it a company that you were following or did they reach out to you?

Dr. Christian Zouain: It was a company that I was following, a health system. And yeah, they posted the human resources recruiter, posted the ad on LinkedIn. And I contacted them, send them all the information. At first they were hesitant because the course at NYU was new. they didn't know, but they wanted to. But I sent them the curriculum and everything and they said, "Okay, you know a bit about CDI. You've been studying for a while on that. you're good to come in." And I remember I was expecting for it to be a big conference or at least a lot of people to join in because I got new at the moment. That's all I would hear about how the CDI profession was growing. I was thinking I don't have the experience.

I was told by a friend initially that you might have to take a pay cut from your case management position because you don't have experiences in CDI. But I was willing to do that because I knew there was a better path for me in CDI. I actually went and it turned out to be the opposite. I didn't end up taking the pay cut. It was actually more. Well, I didn't have the experience, but at that point, there weren't a lot of professionals that had experience.

So I remember I showed up to the dinner meeting conference and we were like five applicants only. we had, there was the health system, each director for CDI of each hospital, which were around five. There were only five people that showed up that were interested. Two of them I remember were also foreign medical graduates, but didn't live close by. And one of them was a nurse who worked on the floor still. I was the only one who, okay, I was already taking the class of CDI and I had good interactions with the other directors.

The little I knew at that time, I was able to discuss during the dinner because they had a presentation, but then we had a moment where we would sit down at the table and meet the other directors. each one of them, I was able to interact with at some point. And one of them actually caught interest in me and decided to interview me and I was in.

John: No, that sounds excellent. That is such a good example of networking, getting in front of somebody who is in a position to make a decision about recruiting and forth. Let me jump in again on this point. LinkedIn is extremely useful. And I would say a necessity if you're looking for a non-clinical job. There is a lot of recruiting and hiring done directly through LinkedIn for many of these non-clinical jobs and some clinical. Many recruiters use it as their number one way to find and contact eligible candidates.

So it behooves you to optimize your LinkedIn profile and understand how to use it. If you're not comfortable setting up your LinkedIn profile and how to use LinkedIn effectively, I recommend you purchase the course called LinkedIn for Physicians by Dr. Heather Fork. Now, this has been out for, I think, at least three years. And she does updates on it every often. It's quite comprehensive.

And you can go find her website at doctorscrossing.com or you can go to my link and check it out at nonclinicalphysicians.com/linkedincourse. That's all one word. nonclinicalphysicians.com/inkedincourse. And I do receive a small payment. If you purchase using my link, the cost is the same either way. But this is an affiliate link. Okay. Now, let's return to the conversation. Now, at that point, were you already a member of any kind of professional society or organization? I mean, is it the ACDIS or there's other organizations? How does that fit into this whole scenario?

Dr. Christian Zouain: No, not yet. At that point, I remember I was still deciding. I was still studying for my boards and et cetera. I wasn't fully in. I haven't decided yet. I was still thinking about CDI as an approach to continue to work with the doctors and acquire experience and make connections.

But then it was that my director at that point, when she was a nurse, but she'd been doing CDI for 15 years. And I remember her telling me, "If you know CDI, if you learn to do CDI well, if you know the basics and acquire experience over time, this experience will take you a long way. You can do a lot of things. You can jump into different areas of healthcare, not necessarily clinical." I think that was the last step for me when I decided, you know what? I think I'm sticking with CDI instead of going into clinical.

So when I made that decision, I started reading more. I started getting more involved with the associations with ACDIS. After two years, I was able to, I got my ACDIS certification and also obtained the one from AHIMA, the CDIP. The one for ACDIS is the CCDS, which you're allowed to obtain two years after, with two years of experience working in the field. at that point, yeah. they have a lot of resources. So I really jumped in. I purchased. They have books, they have guides. that was a good turning point right there because even if when I took the class, I wasn't really sure until you get your hands on in the actual work, you start realizing what it's really about. when you combine that with the resources that are available out there, it makes it much easier. it makes much more sense.

John: let me just clarify for the listeners. the ACDIS is one big organization of people that are involved in CDI are with. Now AHIMA is A-H-I-M-A, right? Is the acronym?

Dr. Christian Zouain: That's correct.

John: Yes. That's more about health information.

Dr. Christian Zouain: Yes, that covers a lot more. That covers HIM, medical records, coding. ACDIS is focused on, exclusively on clinical documentation.

John: Allow me to clarify here a little bit. There are two major organizations that Christian discusses here. The first one is the ACDIS, Association of Clinical Documentation Specialists. You'll hear later in the interview about their apprentice program. But what they're really known for is the CCDS certification, that Certified Clinical Documentation Specialist. And you can find that at acdis.org. So that's the first one. And then the other organization is AHIMA. That's A-H-I-M-A, AHIMA, American Health Information Management Association. And it has at least eight different certification programs. Usually, I think the CDIP is the one most applicable to physicians, which stands for Clinical Documentation Integrity Professional. And that's a CDIP certification, can be found there at ahima.org, A-H-I-M-A.org.

Okay. Now, let's get back to the interview. And I think this is my last interruption. Now here's a question I have because you brought up ICD-10. Which is kind of, that's on the, pretty much the diagnosis codes basically, right?

Dr. Christian Zouain: Correct.

John: How important is that? I mean, that's important in inpatient and outpatient. We're talking mostly inpatient right now in terms of where you were, is that right?

Dr. Christian Zouain: Yes, yes. ICD-10 works, you have on the inpatient side, you have ICD-10, and for clinical codes and for procedures, you have ICD-10 PCS. In the outpatient, for clinical codes, you have ICD-10 and for procedural codes, you have CPT. that's something different right there. there's a lot of, yeah.

John: Now, in my recollection, sort of the coding, the documentation, the risk adjustment was more or less based on the MS-DRGs, but the ICD-10 feeds into the MS-DRGs. Is that how it works?

Dr. Christian Zouain: Yes. It's a bit of a complicated subject, but you have the right path right there. You have ICD-10, which then bundles up the list of diagnosis and then you obtain an MS-DRG, which is then what you use to then bill and what reflects the severity of the patient's condition while he was treated. Or outpatient.

John: there's many different directions we could go, but let's focus on your career at this point. what were you doing in that first job? If I remember, that was a hospital-based job and you're basically helping them better demonstrate the documentation and you can maybe tell us how that day looked like for you and what were the benefits for the hospital as well when you're discussing that? Maybe you can address that.

Dr. Christian Zouain: Sure. my first experience is CDI. we would basically come in CDI, you work Monday through Friday, it's office hours, but it also depends on the hospital and the hospital needs. You might be working with a specific department. It could be surgery. You might want to come in a little bit earlier because surgery is rounding at 7:00 a.m., 6:00 a.m., but our hours were around 8:00 to 4:00, 9:00 to 5:00.

So we would come in, we would have a list of records that we would need to review, particularly at, let's say, at the two-day, three-day mark after the patients were admitted. Not just right away because we wanted to give time to the physicians they could document, we could have enough documentation. It wasn't just like, okay, we just have an HMP, let's go with that. No, we wanted to give the admitting physician and the consultants to take a look at what was going on with the patient and then review.

So we would have a set number of cases that we would do in the morning, my colleagues and I. And in this particular hospital, it was still hybrid. it wasn't completely in... the medical records weren't completely in the electronic medical system. the progress notes were still in paper. we would have to go to the floors and it was a good opportunity as well because there we would see the doctors from time to time they were around or their residents or the physician assistants if we needed to ask them right away.

But we would, this is how the process goes, we review the cases. We would leave a query if we needed clarification on a case. We will leave a paper query inside written document, inside the record. they would see and remember it was a green fluorescent color. they wouldn't miss it. And once they opened that, they would look at the query and they would respond on the next progress note accordingly. And that we will leave there. We would come back the next day and follow up if the cases were not to see if the cases were answered or not. If they didn't, then we would escalate if it had been a couple of days. But particularly most of the time they would ask or we would see them around in the hospital. we would ask them just like I told you earlier, right there and there. And they were either document, agree or disagree. Then we would bring it back, close the cases. And once the case was already sent to billing in this particular hospital, we were involved with coding and we knew at the end what the final DRG was. we were able to make sure to see if we had impact or not on that particular case. we would start with what's called a working DRG, which is the initial DRG that reflected that patient when we first reviewed that case.

Once we obtained the further clarification, the diagnosis with more specificity, then we would change to DRG. we would have a system that would compare both and would tell us the difference that we had achieved on that particular case. I know that that's one of the metrics that we were able to capture with our program and see how good we were doing. We would also get feedback from the coding department. They would receive their denials.

So we would know if a particular case that we had impact had been taken back and it was denied because it didn't meet criteria. we knew what action to take further next time if we needed to change the criteria we were asking the doctors and what to do forth.

John: Yeah, and I want to jump in here and try and for you listeners that are maybe not used to hearing about CDI, I mean, if you work in a hospital, you're pretty much aware of it because you're going to be having these conversations. But the thing is, I mean, it can make such a big difference in both the payment that might because it's DRG based and if you're in a low DRG versus a high DRG, but the quality, that was my big thing when I was chief medical officer is that your risk adjustment's going to look lousy if your documentation's not good and someone who really has renal failure as opposed to, let's say, mild renal injury or something or you name it.

I mean, it becomes important to capture this information and to have basically these consultants like yourself, Christian, walking around helping the physicians. Now, they don't necessarily always want the help. Some do. I guess that's my question for you. Were they already used to having CDI people around and did your relationship with the physicians, was it pretty good there?

Dr. Christian Zouain: Yeah, this particular hospital, it was a big hospital. It was a 900-bed hospital and I know the program had been there for a couple of years already, but being that they were still in some part in paper, it would make it a bit, let's say, annoying for them because now a lot of programs, they use either email or you can send the queries through the actual medical record. in this case, you would have to leave everything, leave something in the medical record.

You don't know if they probably missed it or they didn't really want to answer the query. And in this particular hospital, it was interesting. Some of them were okay because coming also from a clinician's background, being a doctor myself, I know what they go through, what they're going through. So they have tons of other people calling them all the time. They have nurses, they have discharges that they have to do, they have case management, they have people from that administration calling them. with us, if we needed to contact them, we had to page them.

John: Right.

Dr. Christian Zouain: I knew that they were for me when I first started I said, oh my God, but a page that's for emergencies. And sometimes when I would call when I would page them with my number. I would pick up the phone I said I would say, "Good afternoon, CDI clinical documentation. This is Christian." Let's say, is this an emergency? This is not an emergency. I mean, you're paging me. So from that point, it was a bit difficult. Some of the doctors they would just run away. Sometimes we had to be a bit inappropriate because we would see them maybe in the cafeteria or just walking into the hospital. We tried to be as polite as we could they just let them know, "Doc, you have a query in one of your records would you mind taking a look when you have the chance or where can I find you later?"

That's what we don't have to do it right here and there in the cafeteria. Maybe they're taking a break. But yeah, those particular hospitals if it's a big facility and I would say with the inconvenience that this system is not fully automated it could be a bit of a hassle. Later when I was in my second job as CDI where I was the only one, everything was electronic and it was a smaller hospital, but I didn't have a problem there with going meeting with the physicians because it was mostly internal medicine doctors and they were all pretty good. So it depends a lot on the exposure that they have and if you're working with different specialties that could also be something to take in consideration because going from a multi-specialty hospital to internal medicine, basic medicine institution it's a big difference. You're able to handle it better.

John: Let me ask you, Christian. based on those first two experiences. I mean, how were you feeling? Were you pretty happy with the way things were going? Were you pleased that you had made that transition? I just want to understand how you were feeling and whether you feel like it also was a fit like with your personality and what advice you would give to others in that regard?

Dr. Christian Zouain: Yeah. It was tough. At that first one, it was tough because I wanted to let the doctors know that I wasn't there to really bother them again. The majority if we could handle it with the residents or with the PAs up front we would do it. But if it was, say, a surgery attending someone that's really, really busy, sometimes I would think twice on it. Maybe should I go? Should I do it?

I had my ups and downs on that particular job. But I knew that it was different because I've in other places because I would talk to other colleagues. I knew that it could change, that it was just the part that it was starting ICD-10 and in the whole process of documentation on the day until doctors would actually get readjusted. And until they would find update upgrade the system. it would make it easier for them. Because the way it was, it wasn't particularly really convenient for them right now, until later once I started my second job it was particularly way much easier. Now I had control electronically, the doctors could just come in and see my notification there and answer right away. They wouldn't have to be bothered with a call or a page unless they didn't really answer I did have to call them. Yeah, just to answer your question it was, initially I had my ups and downs. But I knew it was going to get better because it was just a particular case of where I was at the time.

John: Okay. Let me ask you this, because this can be a big impact on the way someone in your position is working and feeling. Did you feel like both institutions they had the support of leadership? I mean, here's what I experience is that sometimes the CEO or the COO doesn't want to have that conversation with the medical staff to say hey guys and gals, this is important, and we want to do a good job for you, we want to pair a nurse as well. We want to get paid and the only way we can do it is if you document and we support what we're doing here. We ask you to support it. I mean, did you feel like you had that kind of support at the institutions generally?

Dr. Christian Zouain: Yes, yes, but especially at my second job, because now I was, like I said, I was more involved with the hospital's administration. I was there at every meeting. The doctors already knew me. I remember when I first came in, they actually, they introduced me to the whole staff at one of their monthly meetings, to all of the attending docs. And I felt like I was really important. They really paid attention. And that's a good point you're making when you have the support of your CFO, your CEO when they back you up and they see that importance, they see that it's really necessary.

And especially when you're working in conjunction with the other disciplines again when I worked with case management and quality altogether. Sometimes the case management department would call me, the nurses would call me and will tell me, "I just saw that this particular GRG for this patient it's only giving us three days. Can you take a look at the case?" And sometimes I would say, "Oh." Especially turns out that this case, I had a query for one of the doctors until he answers if he answers, I mean, in the way that I'm expecting, it might change.

So I would tell them, "It might change, it might not. I just have to clarify. Well, I'm thinking of something but I just have to clarify the information with the attending." they would help me, once they had that conversation with the doctor in the floor, they would tell them, "Listen, Christian told me that you had some pending documentation that you need to further clarify. can you please go ahead go down to the floor where he's at and work on that to see if we can move this patient around, if we can keep him or what's going on." at that point, I had good interaction with everyone. we were all working together with a common goal.

John: Excellent. that's good. Yeah, I think that when you're working on a team and you have the support of administration, it's great. maybe that's even something to look at when someone's looking for that second or third job, maybe the first one. Now, I don't want to get bogged down here. you've been involved in a big institution with lots of staff. You've been involved where you're like the solo person, the solo at least the physician CDI person. then you made another change, right? you're doing something different now within CDI. why don't you explain that to us?

Dr. Christian Zouain: yeah, right now I'm working for a company. The company works for, I work remotely. Exclusively remote. I work from home. I know it's a big change. And I decided to make that change because I wanted to experience something different than just being in the hospital. I know there's a lot of these companies out there that they help in some sort of way. They either take over a whole CDI department for a hospital just like they did in the first hospital I used to work, or they help at the back end with physician education, denials management, and CDI. I was looking for that because I saw a trend and that's why I wanted to experience that. And also, I wanted to get to work in an environment with a lot of professionals from different backgrounds. CDI is a field that you're constantly learning new things and you don't know everything. That's why you have to stay updated, continue to read, go to conferences.

I like to be in an environment when I have all these professionals interacting with one another where you can get help in a particular thing to see what can you do in this particular situation? Do you have experience on this? that's also what caught my attention. that's what I'm doing right now.

John: now with that, how does that compare in your mind? Do you feel like this remote CDI activities, do you think that's going to be something that grows? Is it difficult to do when you don't actually have let's say a face-to-face relationship with somebody? What's your opinion on that?

Dr. Christian Zouain: Well, in this particular situation, I feel like the doctors have already, physicians in the hospitals that we work for, they've had some previous experience with CDI in the past couple of years. Every time if I'd contact them through email most of the time. But if they do have any questions or anything, they can just contact me. They can call me. But I haven't seen the need in this particular case to have that face-to-face because I think as time has gone by, they're used to the whole process. they know what CDI is looking for. I rarely get here and there a doctor that's asking me, "Do I have to do this same thing for every case that I have?" And I say, "No." Obviously. But that's one in 100. I mean, I think they're getting used to it and the whole process. I mean, it's still the process that we follow still has their CDI on site, which they can go to. But I mean, they can basically reach out to us via phone or email.

John: Okay. Now, would you say that if you were giving advice to someone who's thinking of moving out of clinical into CDI would it be, is there a better way to go would they try to find one of these companies that are completely remote? Or would it be better to start on the ground with colleagues that you can consult with? What do you think about that?

Dr. Christian Zouain: Yeah. I think it would be better to start in the actual hospital and get familiarized with the whole CDI process as much as you can. See, if you're a practicing physician at the hospital you can visit their CDI department, get to meet everyone and express your interest in CDI. If you can shadow them or they can sit down with you while they review your cases it's even better because these discussions between the CDS and the physician, the treating physician are a great learning experience for both of them and it will save a lot of time in the front and in the future just they don't have to query that much that the doctor knows up front what they need on a particular case.

John: Okay. That makes sense. That's what I assume but no, much is being done remote nowadays. Most people, let's say physicians even practicing telehealth or telemedicine, of course, started with you know live face-to-face patients, but I wonder if there'll come a time when they'll skip that step. But I did want to circle back to something and you went through your process and the fact that when you finished med school and then moved here to the States, but I do want to get your opinion on this because you were able to make this transition.

You did not end up doing a residency and becoming board certified and all that, which is fantastic because I have a lot of listeners who are for whatever reason finished med school whether it's in the US or elsewhere. Didn't do a residency and they're really saying okay, what are my options and there's several things out there. This is the first time that I've talked to anybody that's done that in the CDI realm.

So I just want you to comment on that and maybe what would be the difference if any between someone who maybe did have some clinical experience residency training and they were working for a while versus someone in a similar situation to you. How would the approach be different if it would be in your opinion?

Dr. Christian Zouain: I think that just like I mentioned, if you're already working at a hospital if you have the clinical experience could be easier because you've been already been exposed to CDI. You've had to work with them. The difference would be I would say if you're non-clinical if you're working somewhere else, and if you're interested in CDI you could enroll in a basic coding course of ICD-10. Again, get familiarized with the concepts and the guidelines, get involved with ACDIS. They actually right now they have an apprenticeship program that teaches the principles of CDI.

Which is also a good start if you don't have the experience and it will be valuable to employers later on. ACDIS has local chapters in every state you can look them up on their website. They have meetings every month, some of them maybe more frequent. And just like we said earlier networking is very important they can, both parties, I would say, the ones that have clinical experience and the ones that don't, they can become part of the meetings and go and attend, join ACDIS and the coding classes.

John: Now, you mentioned an apprenticeship. How does one find those or who are those through?

Dr. Christian Zouain: That's in the ACDIS website. I think you can just Google ACDIS apprenticeship program.

John: Okay. I'll definitely put links in the show notes. I'll track down all the URLs for these and listeners can do that, but yeah, another tool, another tactic I guess to really get experience.

Dr. Christian Zouain: Right. Definitely. Yeah, that will help a lot.

John: Any other bits of advice for someone thinking to go into this career that we haven't touched on already?

Dr. Christian Zouain: I would say, don't be discouraged if, this happened to me, if at the beginning you just don't understand right away how all of this works, how the coding side of healthcare works just like we were talking earlier about DRGs and ICD-10 and ESMs and all that. I know for a lot of us, we were not trained in this particular field in school and yet when we start working on it, we feel like we should be able to figure it out right away. But it really takes time to adjust your thought process into the CDI and the coding mindset.

I remember when I started I used to work with a group of nurses that were also CDS's and one of them told me once you have to lower your clinical brain a little bit. You turn down your clinical brain a little bit because as physicians we're taught to look at a case and diagnose, make a diagnosis, make a decision for management. Here we are looking for the wording and how it relates to codes it's different. We might see exactly what the treating physician is trying to portray but we have to be mindful of the coding guidelines and how it's supposed to be written. So that's different and it can take a while to make that transition. for those interested, if you start, and you start feeling like you quite don't get it, believe me, with enough practice and time and studying you'll get there.

John: Well, you're serving almost like a translator in two different languages in a way because the coding language is not meant to be or didn't, I mean it just it's like a legalese in a sense as opposed to what we learn as clinicians, this is what we mean when we say heart failure. But it may not be exactly the same when you're talking in coding language. yeah, you're translating being [inaudible 00:47:40].

Dr. Christian Zouain: Definitely.

John: Well, I think we're getting near the end here. what would be a way to maybe we could reach out to you if somebody just wanted to touch base and maybe follow what you're doing should they go to your LinkedIn page or what do you think?

Dr. Christian Zouain: Sure. Sure. Yeah. LinkedIn, you can send me a message. I have my email there and also my phone number which surprisingly I don't think people realize that because they usually send me messages. But yeah, I mean, if anyone has any further questions...

John: Yeah, I think that's great.

Dr. Christian Zouain: I'm glad to help.

John: And just to have that LinkedIn, it gives them, it's like a little bit of a barrier there. You got to make a little effort you don't get swamped with questions, but I'm not going to put your phone number out on the show notes but it's pretty easy to get through on LinkedIn. And sometimes if there's an issue, sometimes if you're like a third degree connection, you can't always, it won't let you necessarily ask to connect people can go to my LinkedIn page because some of my listeners probably already linked to me and then I could password along or whatever.

Dr. Christian Zouain: Yeah, sure. Definitely.

John: That would work. All right. Well, Christian, anything else you can think of we need to talk about before I let you go?

Dr. Christian Zouain: No, that's it. I think we have covered a lot today. Thanks for having me. Yeah.

John: No, I really appreciate it. And I think those that have even the slightest thought of going into CDI, here's a comment I was going to make earlier, but I guess I'll throw it into my little cynicism is that we have these cottage industries, which are now big industries that have all grown up because CMS has put processes and barriers in the way in a sense whether it's our views for capturing what we do in the clinic or UM there's just tons of rules and now CDI and for what it's worth I think we need physicians like you, Christian, in there serving as experts to translate all those crazy rules for us physicians. So, thanks.

Dr. Christian Zouain: Yeah. Yeah, definitely. There's a huge opportunity for right now just like you're saying, with all these companies developing and they're in great need of good clinicians to work for them and eventually take those things forward.

John: It didn't sound like there's a lot of call involved. that's a good thing.

Dr. Christian Zouain: I'm sorry?

John: It didn't sound like there's a lot of on-call duties involved as many of our non-clinical careers.

Dr. Christian Zouain: Yeah.

John: If you take a slight hit on the income, boy, you're going to make it up in terms of time with your family and free time and giving up the pagers. that's another positive to keep in mind.

Dr. Christian Zouain: Yeah, definitely. Definitely. Absolutely.

John: All right. Well, thanks again for joining us today, and hopefully, I'll get a chance to catch up with you again in the future, Christian.

Dr. Christian Zouain: Okay. Thank you, Dr. Jurica. It's my pleasure.

John: Okay. You're welcome. Bye-bye.

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The post Become a CDI Expert – A PNC Classic from 2019 appeared first on NonClinical Physicians.

Interview with Dr. Christian Zouain – 330

In today's episode, John revisits the hospital CDI career with Dr. Christian Zouain. He was first interviewed in March of 2019.

We explore the fascinating world of Clinical Documentation Integrity (CDI) through the lens of Dr. Zouain, a seasoned professional in the field. Whether you are a seasoned CDI professional or someone considering a career shift, Dr. Zouain's experiences serve as a valuable resource. His journey reflects the changing face of CDI, and the diverse career pathways available within this field.

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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.

Dr. Christian Zouain's Journey into Clinical Documentation Integrity (CDI)

Dr. Christian Zouain reflects on his transition from medical school in the Dominican Republic to his involvement in CDI in the United States. He shares insights into the significance of CDI in healthcare, his initial encounters with physicians, and the evolving role of clinical documentation.

Significance of CDI in Healthcare

Clinical Documentation Improvement (CDI) significantly enhances healthcare quality by ensuring accurate and detailed medical documentation. It thereby improves patient safety, reduces errors, and promotes effective communication among healthcare providers enhancing care coordination.

Evolving Role of Clinical Documentation

In Christian's encounters with physicians, he discovered the evolving role of clinical documentation. What started as expertise needed to optimize payments, later became a critical understanding of how to demonstrate the quality of care. With annual updates published by CMS, the CDI expert must continually update their knowledge base.

From Clinical Documentation Improvement to Denials and Appeals

Dr. Zouain sheds light on the transformation of CDI from Clinical Documentation Improvement to Clinical Documentation Integrity. He explains the crucial role CDI professionals play in ensuring accurate and complete clinical records. Additionally, he explains how his knowledge of CDI enabled his professional growth in the area of denials and appeals.

Summary

Dr. Christian Zouain can be contacted through his LinkedIn profile. For information about job openings and updates, Acuity Healthcare's official website is a valuable resource. Dr. Zouain also recommends following Acuity on LinkedIn for the latest job postings. If you pursue a job, please be sure to mention Dr. Zouain to the recruiter.

If you have additional questions about this career or pursuing your first position, he encourages you to reach out directly to him. 

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

EXCLUSIVE: Get a daily dose of inspiration, information, news, training opportunities, and amusing stories by CLICKING HERE.

Links for Today's Episode:

• Dr. Christian Zouain's LinkedIn profile
• Acuity Healthcare
• Why CDI Medical Director Is a Great Nonclinical Job – 224
• PNC Podcast Blast from the Past: Clinical Documentation Improvement – 206
• Top Reasons to Become a CDI Expert with Dr. Christian Zouain – 077
• NewScr!pt

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 330

Follow This Plan to Establish a Solid Hospital CDI Career

- Interview with Dr. Christian Zouain

John: I wanted to bring back today's guest for several reasons. First of all, his story is very fascinating. Now, he was here in a previous episode in March of 2019. You can learn more about that at that episode, and I'll put a link to that. But he has a really fascinating story about how he became a hospital CDI expert.

I wanted him to come back because I personally think that a CDI specialist is really critical to hospitals functioning. I don't know how any hospital cannot do what they do and get paid appropriately and so forth without using a CDI specialist in some way. And I think it's a position that's often underappreciated and some of you should really consider that. So, welcome back to the show, Dr. Christian Zouain.

Dr. Christian Zouain: Thank you for having me again. It's great to be here.

John: I just remember our session back, those whatever, four or five years ago. I always loved CDI when I was working in the hospital environment, number one. And number two, it was so interesting to hear how you had gotten involved with CDI. And we'll define what CDI is in a minute. Why don't you, for our listeners, just give us the thumbnail sketch about your background and how you first got into the CDI business.

Dr. Christian Zouain: Yeah. The resumed version would be, I graduated from medical school back in the Dominican Republic in 2010. Initially, my plans as every other doctor, especially foreign doctors, who has a vision to come into the US is taking the USMLE. I practiced for a few years while I studied for the boards, and then I moved to New York, and I started getting into roles in the healthcare system. While I studied that way, I could also meet some people, network and all that to get my way through the residency process.

While I did that, I started finding out about these opportunities that were available. And it wasn't after I would say two or three years in that I found out about coding, clinical documentation improvement, the value it brought to healthcare, the importance is has for our health systems, and the well of our whole community.

I said, "You know what? There's something here. This is something that I can see myself doing. This is something that has value and that it will eventually continue to grow." And it's been already eight years. I've been doing this seven, eight years. So it's been great. It's been just as my original mentors had originally told me, listen, if you get into this, if you get the basics, there's so much you can do. There's so many pathways you can take. There's so many ways you can help within the industry to make things better, help the doctors, help the facilities, and eventually help the patients, which is the main reasons why we came into medicine, is to help our patients. That's one of the other good things that we are helping our patients in a good way by doing this work.

John: Yeah, it seems like a lot of these things that we do, whether it's utilization management or informatics or quality or CDI. Ultimately, the bottom line is to get the patient's care taken care of, pay for it, approve it, allow them to stay in the hospital or not stay in the hospital. There's lots of these things that we have to do to make sure they get the care that they need.

Tell us the technical, what does CDI mean now. When I was back in the hospital whatever, nine, 10 years ago is always called clinical documentation improvement. But I think you've kind of evolved that to a different definition now.

Dr. Christian Zouain: Yeah. It has evolved. They changed the last part, which now it's considered, they want to call it clinical documentation integrity, which we just want to make sure that we get the actual most complete accurate picture of that clinical scenario that happened in the hospital for that patient, translated into the record so the hospital, the physicians, and the entire health system gets reimbursed the proper amount of what went on that particular visit.

That's what the basics of CDI is. We're just trying to be of help, be that middleman between the physician and the coding expert, which is something that we don't really learn when we're in school. We tend to learn about this where when you're in residency or you start working in the hospital. Obviously like 10 years ago, I remember when I started something that physicians, they found a bit irritating. Someone's coming up to you, asking you all these, I would say dumb questions.

I even remember taking that as one of my approaches, when going to talk to one of the physicians saying, "Hey, doc. This is a really stupid question that I'm going to ask you, but I need to know this." That way I would be able to get that closeness and that reaction from that physician and I would get the information I needed.

But yeah, it has evolved. Gratefully, a lot of physicians have understood the importance, that this is not something that we're trying to question them or something that we're just trying to mess around. Sometimes I explain to someone that it's not the industry, like it's a game because it's something that it's a process that the insurance has, coding has, and then the hospital has its own process.

We're trying to manage on a day by day basis how to get everyone along. It's like getting all these rules together, getting everyone to understand each other. It's not like something that's going to be clear cut eventually that it's going to be fixed. No, it's something that it's still taking time. It's a process. And rules change every day.

John: I've heard in the past a metaphor where somebody was trying to describe this to me, and they talked about Michael Jordan and basketball or whatever. It could be anybody. But the thing is, games have rules. And you got to know where you can go in terms within the rules and do it right. But even in basketball, should you fouled out, should you not? That's a strategic decision. And you have to know the rules when you're playing a game or you're never going to win at the games. This is another one of those examples.

Now, one of the things that they used to tell me back in the day when we first heard about CDI and the importance of documenting and getting everything down to the last issue in terms of someone's preexisting conditions or president of admission. I don't even know if they call that anymore. But because most of the quality measurement of hospitals is based on billing data, then again, this is another reason why CDI is so important because there's a risk adjustment. And so, tell us about that. Is that still true?

Dr. Christian Zouain: Yeah, absolutely. Every day, again, it still holds true. That was the main reason why the billing process was shifted towards from pay for service, pay for performance. We're paying for the quality of service, the patient experience. How well was that patient treated, not based on the amount of procedures that the patient had. That's why we have the different billing systems, the MS DRG, the APR DRG. We have those in place. And that's the main focus of those. It's shifting that process of payment towards that, because eventually the quality, it's what's going to drive that payment factor.

We just want to make sure that the patient's reflected correctly, that we don't bill for things that happened in the hospital present on admission, of course, that's still something that holds true today. If you came in with something, everything has to be specified as being, okay, did the patient come in with this? Because if the patient had a fall and had a fracture eventually in the hospital, that code by itself can actually shift towards something that increases the bill. And you want to say, okay, if just by shifting that POA code present on admission indicator, shifting it from "yes" to "no" can make a huge difference on the payment.

Something I didn't mention to you earlier, which is now I'm not doing the actual clinical documentation improvement part. I'm working more in the denials and appeals part. I did a lateral shift, and I've been able to see a lot of these things that I would query initially, like coming back. That's one of the main reasons why I wanted to do that, to make that change. Because I wanted to see eventually, okay, is the insurance company really accepting what I'm having these doctors, that document in these records? How are they internalizing it? How are they fighting it back?

I do remember the other day, there was something that I didn't know, it was something about a procedure that the patient had a complication, and they said the doctor clearly said that this was a complication, and it wasn't coded as a complication, and it made a huge difference on the payment. And I said, you know what? They're right. I don't usually agree with what they said, but this is one of those instances where I say, you know what? I didn't know this, but it's interesting how these small factors come into play, the present on admission, quality indicators, anything that happens in the hospital, that make a difference in that payment, how it changes.

John: Yeah. That's why when I think back about my days in the hospital, we probably had at least every two or three years another consulting firm come in. And I don't know that there were these big companies, maybe Acuity was around and some others, but usually just people come in to help us bolster, improve our CDI program. It just amazed me that there were hospitals that still didn't have really even a dedicated nurse or physician even focusing on that. So, it kind of blew my mind. Although I have a question I have for you. Does it seem like the physicians coming out of training, residency and fellowship, do they have a better understanding of this now than they did five or 10 years ago?

Dr. Christian Zouain: Yes, I believe so. Yeah. I definitely think so, especially because just like you said, with let's say the rise of having these consulting companies, like Acuity, the one I work for is something of so much importance because when you have it on site, it is important. You have that person that the doctor can relate to. They know which doctor to go to.

But sometimes even if you're part of a big health system, because I worked in different hospitals, large health systems, small hospitals, and it's hard when you don't have that I would say that support, because you don't know it all. All these rules are very complex. You have the clinical part, but you also are continuing to learn the coding part. So you're trying to do your best.

Now, the doctors, when they see this, it's like, okay, sometimes you might make a mistake or they might think you're a little bit obnoxious. They don't want to really sit down with you and answer to all these nonsense questions. But with these companies now you have these group of professionals that they're all in tune. Even if you're not sure, for example, the model of acuity is you have a physician, which is a medical director position with an expert coder going into the case firsthand reviewing the entire case. So, you have an expert in clinical and an expert in coding reviewing that case.

Next part is they capture the opportunity, they send it over to someone like me, that was my position initially when I started in Acuity, which is the query writer. I would write the query based on the information they provided.

Now, when you have a more effective system, I would say it works better. I think physicians are able to accept it more with more ease. When they have a solid professional asking them questions and explaining to them in the right way, why are they asking the questions? This is the reason why we're doing this. We can show you in the code book. Or you also have administration behind supporting the consulting company.

And they're not just saying we're doing this for the money. No. These are companies like Acuity, and I don't know other consulting companies, but we go on site and we provide education to the physicians on how our process works. And we also give them education on them based on whatever issues we find recurring in their facility, why we are asking these questions, and how it translate into the coding and it translate into the payment and the quality metrics. That's been a huge part in answering your question. I know it's been a little bit lengthy, but yeah, I think that the physicians in these years have adapted more to the role because of the search of these consulting positions definitely.

John: Well, that's a good segue to talk about not so much CDI itself as an entity, as a domain to learn about, but what are the jobs in the CDI? Because I think you've held a number, and I don't remember exactly what you were doing before within CDI, but I know there are remote positions now a lot more probably since the pandemic, but then you have to go on site sometimes. Sometimes you're employed by a hospital system directly. Sometimes you're employed by a company that does the outsourcing. So, what's kind of the range of jobs out there that listeners might say, "Oh, this does sound interesting, this one's got the flexibility I might need?" Maybe give us an overview of that.

Dr. Christian Zouain: Yeah. It all starts with the coding. When I started, again, you have the clinical part and then you need to learn about the coding. And with that, basically, you can go into CDI. Again, I did a lateral move into appeals and denials, but as far as I know, it's coding, CDI, you can do inpatient, you can do outpatient within the realm of CDI. Then you have the different ramifications, which is you can focus more on a specific aspect. You can go more into education. You can be a director in a hospital. You can become a physician advisor. Going by what we have in Acuity, from what I know, just like I said, we have the medical director positions. But then we have educators, we have the people that go on site. We have query closers, we have query writers, we have appeal writers. The coding world is very, very, very, diverse. Just in the inpatient setting, there's a lot of ways you can go.

I remember about three or four years ago, the outpatient, CDI, was coming up and I said, "You know what? I think this is going to be like the future of this because I know a lot of procedures are being done like outpatient, eventually inpatient is going to be." And that was about for a year, two years. That was something that was really booming. But eventually, it has grown, but I've stayed in the inpatient setting. As far as I know, in Acuity we do mostly inpatient. And again, I went into doing appeals now, which I like even more because I get to see, I feel like I am using that knowledge again, and justifying why that service has to be covered or that diagnosis is valid using my knowledge and my expertise in coding in clinical and CDI.

John: Let me ask you this. Talking about specifically your role now in the denials and the appeals and so forth, are they looking at making an alteration in the principle diagnosis? Are they looking at whether the MS-DRG comes in three levels for most diagnoses? Is it that? What are the kind of things that actually get appealed in which you have to provide clarity when you can?

Dr. Christian Zouain: Yeah. In Acuity so far we only do clinical validation and MS-DRG appeals and denials. We receive changes in principal diagnosis, whether it is clinically valid or not. We receive request to change coding based on coding rules. Coding rules, which are sometimes more complex. Like this diagnosis were based on this guideline, it's supposed to be the correct principle diagnosis instead of this one.

And present on admission indicators, but mostly it's clinical validation. Clinical validation denounce is what we get the most. Sepsis. They use a lot of the argument now that sepsis three to one that has to be used, but the facility hasn't placed the rule, the guideline that still used the sepsis two. So we have to argue that okay, although sepsis three was put into place, they don't use that. So, we have to defend it on that end. Or the patient didn't really have an increase in creatinine of more than 0.3 to be considered AKI, but the doctor wrote it consistently throughout the record. Those things are the ones we fight every day mostly. It's mostly that validation of diagnosis that they feel like the diagnosis are not clinically valid.

John: Now, when you say appeals and denials and fighting these things, I have a friend that works at a local hospital. And on the UM side, he's getting on a conference call with an administrative law judge and other people on their side and Medicare side and their people on the hospital side. Is it like that? How do you do these appeals? Who are you appealing to?

Dr. Christian Zouain: No. We received the letters directly from the auditor or the insurance company. We receive letters and the letters have their own rationale. We provide the information, we make a document and we just send it back to the hospital.

John: So, it's a written appeal.

Dr. Christian Zouain: Right. It's a written appeal. We send back to the facility. The facility is in charge. I put my signature on it with Acuity's name, and then they send it over to the corresponding auditor. But then after, we might have several levels, but after it's exhausted how we call it, that's up to the hospital to decide if they want to escalate on their own part. If they want to have a peer-to-peer with their doctor and discuss that at that point. The hospital takes care of that. We are only part of I would say three levels of written appeals. We only do it in writing.

John: Got it. Got it. Yeah. This gets all very confusing because we can throw out a term and say there's always different jobs available, but Acuity does things one way, and there's probably 10 other firms that do other things and the hospital is doing its thing. But just to give us a glimpse in the time you've been doing this, both as in the denials and even before, are these the kind of jobs that are pretty much done remotely? Does it require checking into the office and showing up in person? Is it something you can do on your own time? Is it 9:00 to 05:00? Just give us some of the constraints on these kind of positions in terms of the time and the travel and so forth.

Dr. Christian Zouain: Yeah. When we first did the first interview a few years ago, I had just started with Acuity. And at that time, I do remember that I knew when I found them, I was like, "Wow, this is amazing." Because it was actually the first company I knew that it was 100% remote, and they were hiring foreign medical graduates. Other companies would require you to have an RN license, or some sort of license to work, which I found a bit strange because I was like, really? I'm doing work from home and it's documentation. I'm not really writing a script or anything like that.

But I do believe, especially when COVID hit, when the pandemic hit, a lot of other industries they had to go into fully remote or part-time remote. Then they just basically realized that it was doable.

This work can be done 100% remote. My company Acuity, it's been 100% remote. When I started, the only thing that I had to be present for was the training, which I had to go to the main office in New York to meet with, we had to get all the access and do everything. But during the pandemic that switched. So, the training is now being done just the same way, like any other presentation that's done in the company. It's done via Zoom or Teams. It's done remotely. It's 100% remote.

Now, I do know there are probably other facilities when you have your onsite DDI program, they probably still have it. I know some of them are maybe half and half. You would go several days to the hospital so they can see you and the other days you can work from home because you have access to the electronic health record through your computer at home.

But yeah, eventually I think mostly the ones that are still in the hospital, they are still require some sort of presence. And that's good because I think that's one of the benefits of doing the onsite. I had that I would say that privilege of doing that initially when I started, which it was 100% on site, and the hospital I used to work for was hybrid. They still had part of the records in paper charts.

So, it wasn't something that we could even argue like, "Hey, listen, can we do one day from home?" No, that was out of the question because they were still on paper and we had to go to the floor. But that helps you a lot to build that, to break out of that shell, I would say, to get close to the physicians, have a conversation, get to understand what's really going on with the patient, get their view. And also they learn from you in terms of, "Hey, listen, this is why I'm asking you because this documentation translates into this." Now with being 100% remote, you can't do that. After I started working with Acuity, my contact, when I was writing queries, I would talk to a doctor maybe once every two months. And it was because they would call me, they would see my name on the query, but they weren't really supposed to. They were someone else in a different department who would take care of that. Whereas when I was in the hospital, it was constantly, for every single query I sent, I had to talk to the physicians.

John: Yeah. Interesting. It has evolved quite a bit. I was talking to someone who does UM. He is relatively new, but it was kind of the same thing. He's in a system and they didn't really have a pretty robust UM program. He was assigned and he took a job as a medical director, and there were multiple sites, but he was doing half of it remote because he couldn't drive hundred miles in a day to hit every hospital. He'd do some of it remote, and then sometimes he had to show up and meet the physicians, and he really thought that helped. But I could see him migrating at some point to a 100% remote job with a big company because the lifestyle is so much better.

And so, would you say in general that most physicians are going to be very happy with working in CDI at one of these companies in terms of the lifestyle, the pay and vacation and opportunities for advancement?

Dr. Christian Zouain: Yeah, absolutely. Absolutely. The shift that I've seen and the opportunities just like I've seen in my own work environment, even though I don't interact as much. The company right now from the last town hall, they said we had about 600 employees nationwide. They did implement some sort of activity that we would do. Everyone that lives in the same state or close by, like in the same city, they would get together. I was able to meet a few of the doctors that work for the company as well and other coders. One of them was head of IT education portion of Acuity.

The others, they were directors of coding. There's a lot of opportunities still out there. I think much more that than what I know of, but definitely, again, just like I said, knowing the craft can get you towards getting a lot of opportunities in the field. And I've seen that. I would continue to encourage everyone that likes it and finds the value in it. It's really a good career. And all the companies, just like the one I work for, they're doing a great job and they're growing, expanding, and they're doing a lot of great things.

John: Excellent. That's good to hear. We want to have as many opportunities for our physicians as possible as they decide to transition to something maybe out of clinical that they're doing now or something like that.

We are going to run out of time. We're probably getting close to the end here. Real quickly, if someone is currently in practice, maybe they're doing some inpatient so they have exposure to that part of it, what would you advise them is how to start to look at making that transition? They just start looking up jobs, or is there something they can do in the meantime to set them up to succeed if they decide to apply for a job like this with one of the companies that does the remote CDI activities?

Dr. Christian Zouain: Yeah, I would say it would be the same advice I gave on the first part podcast. Again, you basically have the clinical knowledge part. Just get into knowing more about the coding aspect, how it works. Maybe do a coding course geared toward maybe a certification like a CCS. That's one I would say. For example, there's several coding certifications, but the CCS, it's like the more expert one. But for us physicians, to be honest, it's something that it's not that hard to acquire because we already handle all the terms, all the clinical terms. We just have to know all the coding rules and games, again, like we mentioned earlier.

After that, again, I know that Acuity has that particularly that the medical director position, the doctors they hire, they do have some coding, clinical background, but they don't need to be really like coding experts per se because they're looking more toward the clinical part and having a basic understanding of the coding part. And along with the coding director and with the company itself, you're going to be able to start learning everything and grasping. Because again, every company does everything on their own way.

There's not a specific way. Just like every hospital, CDI program does things a certain way. I know this because since I've worked for different facilities, one might think, "Oh, well, maybe when I go to this next job or this next facility, they might think I don't know how to do it because we did it differently."No, everyone in the industry is very aware that every facility has their own ways of doing things, but the core of everything is knowing the basics of medical coding and how it works. Other than that, it's just a matter of time and experience. Even till this day, I don't know everything, I don't think I'll ever know everything because again, there's a lot out there and everything changes from time to time, but it's a constant process.

There are certain things that are the main focus. There's always opportunities for sepsis, for acute kidney injury. There's diagnoses that are pretty common, for example. There's commonalities on every industry. But that would be my advice. Getting to coding and reach out to other colleagues that are doing the same thing, either in your hospital or through LinkedIn.

Right now, I do remember someone that reached out to me. I think it was who listened to your podcast about a year ago. I do remember she told me. I'm glad she listened to the episode. And a year later she messaged me again, and she told me, I just wanted to let you know that I was just hired in your company. And I didn't know. She actually went on her way. I think she got a coding certification, and she met someone else from the company through LinkedIn. And I think they established a friendship. And she was able to get hired for her first job in CDI 100% remote, which was something that if you would've asked me, probably like five years ago, I would've said no. You have to start maybe on a hospital, that they give you an opportunity on onsite. But now, it's possible. There's a lot of opportunity out there. There's a lot of facilities. You can reach to a lot of people.

John: Plus the power of networking.

Dr. Christian Zouain: Yeah.

John: It's like meeting people, getting advice, getting mentors and talking about their company. Who do I apply to? Is there someone I can talk to? There's so many little tricks you can do too along the way.

First I want to say that you're on LinkedIn, obviously, as you mentioned. Just look Christian Zouain up, or if you want to use the URL, I think it's linkedin.com/in/christianzouain. It's hard to miss you really. There aren't that many other Christian Zouains around. I don't think. I do see though on your LinkedIn frequently you'll post that your company has openings. I could put you on the spot now and say, are there openings there? And if someone has a question about an opening, they can just go ahead and apply, but I suppose it'd be okay to contact you and ask you a little bit more about it.

Dr. Christian Zouain: Yeah, definitely, if anyone is interested. As soon as I see any posts from HR or anything, I would do a repost just so anyone can see. If anyone has any questions, again, just like you mentioned earlier, I want to emphasize just like we did. I know we did on the first podcast interview, like networking that is very important, not just for this industry, for anything that anyone would want to do or pursue. The power of networking, it's very powerful. I would say reach out. Don't be afraid to reach out to anyone for advice. If you don't get a response from someone just move to the next one. There's a bunch of people. Look for someone that works in the company you want to work for and try to establish a connection with them. But if you see me reposting or you can go to Acuity's website, acuityhealthcare.com, or follow them on LinkedIn, they usually post the open positions there. If you have any questions on that, you can reach out to me. Just to throw it in there, we have a referral program. If you want to mention my name, just to put it out there, you can also do so.

But yeah, I'm available for any questions that you might have, any orientation that I can provide. By doing this, what I'm trying to do is be the person that I wish I could have found when I first started, because there was not a lot of people out there. Yesterday I spoke to, there was someone that came to my house. He's a nurse. He works as a nurse in the hospital, but then he's a doctor back in Brazil. And he was telling me. He came in, he did the process of getting his RN license and all of that. I was telling him what I did, and he was impressed because he said, "You know what? I've been doing this. I've been working here 15 years and I've never heard of what you do." And I said, "Really?" And he was like, yeah.

We talked for a while and I said write down my phone number. I send him the presentation I've had that I did back to do the Medical Association to that group of doctors. Because still, sometimes I'm impressed by the fact that these opportunities are really not out there so people can see them. Even if they're in the hospital, if they don't find the right person, some people maybe they keep more to themselves and all that, but whenever I find a colleague and they tell me they're a foreign doctor or a doctor that is trying to do residency, I tell them what I do, because you never know. And also I'm always open to give advice or even not just give advice, also learn, because I can learn from the other person as well.

John: I know there's at least a thousand physicians and other clinicians who eventually will listen to this episode. And so, I'm going to tell you that if you have any linkage whatsoever with a hospital or with documentation, coding, patient care, and if you're actually practicing, of course, you're exposed every day, then this is an opportunity. There's a huge need. It's a good lifestyle, and you're applying your medical background. And so, what could be better?

And the other thing is I don't apologize about maybe having someone mention that you referred them to your employer, because guess what people? I'm talking to my listeners now. All my guests come on for free. They take their time, they share because they're professionals or physicians, most of them, and they want other physicians to prosper and succeed and be happy in their careers, not be miserable doing corporate style healthcare seeing 50 patients a day and working all weekend. The least you can do is if you contact Acuity that you mentioned Dr. Zouain's name just as a little bit of a bonus for taking the time to share his information with us. So I do appreciate that, Christian.

Dr. Christian Zouain: No, thank you. Thank you for allowing me to be on your platform.

John: Basically Christian is agreeing to be your informal mentor. And by the way, if you need a mentor in the future, I always remind my listeners too. A mentor is not someone you're going to sit down for three hours with and take up all their time. A mentor is someone you just go to, you send them a note, or you have a brief conversation, ask them a question, and boom, you just take their advice and move on. And then maybe reconnect again three or six months later. We're not talking about intense coaching here. We're talking about just networking and communicating and getting a little bit of free advice.

Dr. Christian Zouain: Absolutely.

John: All right, Christian. I guess it's time to go. I really appreciate you being here today. It's been fun. I've enjoyed catching up and learning from you, again, more about CDI since I was involved with it over 10 years ago. I'm sure we can reconnect again down the road. Again, thanks for being here today.

Dr. Christian Zouain: Definitely. Thanks a lot, Dr. Jurica.

John: All right. With that, I will say goodbye.

Dr. Christian Zouain: All right. Take care. Bye.

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The post Follow This Plan to Establish a Solid Hospital CDI Career appeared first on NonClinical Physicians.

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.

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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:

1. find a mentor in the field,
2. volunteer for committee work at your hospital,
3. work as part-time CDI physician advisor,
4. join the American Health Information Management Association (AHIMA) and/or the Association of Clinical Documentation Integrity Specialists (ACDIS), and,
5. 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.

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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.

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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.

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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

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Today's PNC Podcast Transcript

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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.

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The post Why CDI Medical Director Is a Great Nonclinical Job – 224 appeared first on NonClinical Physicians.

Today we revisit six jobs in which no residency is no problem. With the right experience and preparation, physicians have successfully landed all of these jobs. And for many, residency and not board certification are not required.

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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.

Why No Residency Is No Problem for These Jobs

Your MD or DO degree is valuable. It enables you to compete for jobs with PhDs and PharmDs. Remember, too, that these jobs are open to residency-trained physicians, often at slightly higher salary levels to start.

1. Medical Writing

For physicians looking for flexibility and home-based work, medical writing is one option. With a range of writing types, from blog articles to technical writing, doctors are sure to find something that fits their needs.

Travel requirements are minimal. But this job requires self-discipline. And, unless your writing is based on interviews, interacting with others is limited. As a result, this may not be the career for the gregarious extrovert.

2. Clinical Documentation Improvement

Medicare regulations have caused an explosion of companies focused on Clinical Documentation Improvement (CDI). As a CDI professional, you will be trained in the intricacies of translating chart information to billing codes. This work is extremely important to hospitals. It determines whether appropriate payments are received and how quality measures are reported.

You can find these jobs in several situations. These include hospitals, large consulting firms, and as independent contractors. For the last one, working on-site or from home is possible. The job requires working on CDI teams, interacting with physicians, and teaching groups of physicians how to document properly. 

3. Medical Communications

Generally, you’ll be working in marketing agencies that serve pharma and device companies. It’s a great role if you enjoy working in a conventional office with a regular schedule. Teamwork and communication skills are important. These ad agencies are found in most large cities in the U.S.

4. Consulting

Consulting is an excellent career choice for physicians without postgraduate training. Firms sometimes prefer doctors without experience. They can train them to their way of doing things, without the need to break old habits. Depending on the position, it may require significant amounts of travel. It can be very lucrative, though, with opportunities for advancement.

There are many companies to consider if you are interested. Here are some of the largest ones:

• McKinsey and Co.
• Boston Consulting Group
• Deloitte
• Bain and Co.
• Huron Consulting Group

5. Medical Monitor

Doctors with experience in research or on pharmacy committees are suited to a career as a  medical monitor. Medical monitors support research studies and ensure that they are medically sound. They track adverse drug reactions. And they serve as liaisons between investigators and the Contract Research Organization or pharmaceutical company.

The job may involve some travel. However, it is usually less than consulting or medical science liaison (MSL) positions. There are hundreds of companies that employ medical monitors. Here are some of the biggest ones:

• IQVIA
• Parexel
• Syneos Health
• Covance
• Icon
• PRA Health Sciences
• PPD
• Medpace

6. Medical Science Liaison

An MSL is a good entry-level job in the pharmaceutical space. Ideal candidates must be familiar with the regulatory landscape. This career involves travel up to three out of five days each week. The MSL Society and MSL Institute are great resources. And the course Introduction to 6 Nonclinical Careers Any Physician Can Pursue will walk you through the process of finding your first MSL position.

Summary of No Residency Is No Problem

There are many jobs in the healthcare industry in which no residency is no problem. Since the original episode aired, additional jobs have been presented on the podcast. In Pharma, there are jobs beyond MSL and medical monitor positions, such as clinical scientist, clinical research associate, or technical medical writer for a CRO.  In Episode 209, Dr. Marsha Caton described the tactics for landing those jobs. And there will be more on that subject in Episode 214 with Dr. Laura McKain.

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

Links for Today's Episode (Online Courses):

• Introduction to 6 Nonclinical Careers Any Physician Can Pursue
• Introduction to Careers as a Medical Writer
• Build a Rewarding Lucrative Career as Medical Science Liaison

Other Resources:

• How to Shine as a Technical Medical Writer – 155
• Top Reasons to Become a CDI Expert with Dr. Christian Zouain – 077
• Why Medical Communications Is the Best Nonclinical Career – 061
• How to Get a Great Job with a CRO with Dr. Christian Urrea – 070
• How to Thrive as a Medical Science Liaison with Dr. Savi Chadha – 050

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

Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 211

PNC Podcast Blast from the Past: No Residency No Problem

As I mentioned a few weeks ago, I decided to bring back some of the classic podcast episodes during this summer of 2021. They are the most popular episodes aired during the first two years of the podcast. And they are inspiring and informative today as they were when I first posted them.

Today, I'm revisiting my solo presentation of six jobs that any physician can pursue, even if you don't have a residency under your belt, or are not board certified. This discussion was first presented in June of 2019, and it was done in response to one of the most common requests I receive via email and in The Physician Nonclinical Career Hunters Facebook group. And that's "How do I get that job if I haven't completed a residency?"

If you're in medical school and you're ambivalent about pursuing a residency, or if you did not match and you want to expand your options, today's episode will be very useful. One of the things you must realize is that your MD or DO degree is very valuable and enables you to compete for jobs with PhDs and Pharm.Ds in many cases.

Here's today's presentation.

Let's get right into the six nonclinical careers that will save discouraged doctors. What do I mean by discouraged doctors? Well, I mean physicians like some of you who are discouraged because you have a medical degree, but you're underemployed because you didn't complete a residency or maybe you're discouraged because you're overworked and burned out.

There are at least six careers that I've found in doing the podcast and working with physicians through career change that are open to just about any physician with pretty much any background, because they depend more on the medical degree than on residency training or clinical experience. But don't get me wrong. These are careers that any physician can pursue. And for some, the clinical experience may provide a competitive advantage, but there are a few examples where actually not having the clinical experience may help. And I'll discuss that later, as I'm talking about particular careers.

Now I'm excluding some of the careers such as doing entrepreneurship or starting your own business. They're kind of a calling, they're not really a career per se, and that can go in hundreds of different directions. So, what I'm talking about is more of a formal career, generally working for an organization that builds upon the medical degree. There are situations where the company needs someone with that medical degree and with or without the additional clinical experience. They're really open to physicians in both categories. Because many of you tell me that you'd like to know what are the options out there for me, if I have limited clinical experience, or maybe I did a partial residency or something like that. So that's why I'm focusing on this group of six careers.

Now I want to keep this to a reasonable length today. So, I'm not going to get into the very nitty gritty details, but I'll describe each of these six careers enough to give you a sense of the pros and cons and the personality you might need to go into that. And also, some of the resources you can pursue. I'll describe each of them and provide the tactics and resources and also be giving you a lot of links. And some of those links are to previous podcast episodes, which address some of these careers.

And one more thing before I do that. Instead of going into the specific tactics that are common to all six of these careers, just let me mention, that you should do the following. The first is to have your LinkedIn profile to be complete. We've talked about that before and LinkedIn is a really vital tool as you're looking at pivoting to a new career. So, make sure you've done that. You must begin to network if you haven't already. And you can use LinkedIn, but you should network with med school classmates and others that you may know in and out of the field. So, keep that in mind. Most of these fields that I'm going to talk about have professional organizations, so you should surely take advantage of those.

And speaking of LinkedIn and networking and so forth, there are many of these that have groups on LinkedIn. They may be groups affiliated with professional organizations, or they may be free-standing groups. So be sure to look at that. And you, of course, need to find a mentor, if at all possible, maybe one or two, and follow the guidelines I've given to that before, which is to keep that a relatively informal relationship and don't put a lot of burden on the mentor. But simply tap into them from time to time to help you not make big mistakes as you're pursuing your career. I'm not going to mention each of those, particularly as we're going through the six careers.

Okay. So here we go. The first career is that of a medical writer. Now, this is actually a vast field in the sense that there's everything in there from writing technical papers and white papers or technical jargon for the FDA and for pharmaceutical companies to writing a book for the lay press and everything in between.

Most of the physician writers I've spoken to have done things like writing articles for online medical journals, write articles or content for CME and or be like a medical journalist, where you're writing for an actual published magazine, something like that. But there's a lot of different types of medical writing. And the ones I would focus on personally, would be the medical writing that you can do where you can get started gradually and work your way into it. You want to find out if you really like medical writing. So, most of us know what it is.

For the type of writing I'm talking about, you'd be pretty self-disciplined because you're either going to be freelancing or are going to be working for a company. But the companies on the plus side allow you to do a lot of the work from home because you don't really need to be in an office to write an article or to write a chapter of a book or something like that, or even to write material for the public. But you certainly have to be able to meet a deadline, which means you have to be consistent in your writing. And this issue of having writer's block really is not anything that you can fall back on because just like a ditch digger, digs a ditch, a writer writes. You need to get up every day and write or whenever you're going to be writing.

That's the type of personality. You can be a bit of an introvert unless you're doing the type of writing that involves doing interviews. You are kind of self-sufficient. You're going to be self-disciplined and you are going to stay on deadlines. There's going to be probably little or no travel unless again, you're going to some kind of conference and doing a summary of the conference. That kind of covers the pros and cons and so forth.

The question is "How do you get started?" There are a lot of tactics you can use to get started. I mean, the thing about writing is, and in anything really to get better at it is to do more of it. If you are practicing, then you can do some writing on the side for a variety of different publications. You can have articles published. Of course, they're not going to necessarily always pay you at first. Kevin MD and Medium and Doximity and others will publish your articles. If you look, you can find many of them at other outlets.

But then at some point you're going to have to try to get paid to do that so that you can phase out a clinical practice or leave the nonclinical job you're already doing. Let's say, if you're doing more of a paramedical job because you don't have board certification or a license.

You can learn more about this by listening to some of the previous podcast episodes. And those include my interview with Mandy Armitage, which is episode 22, my interview with Emma Nichols, that's 56. My conversation with Heidi Moawad, episode 63. And then two episodes with part one and part two with Andrew Wilner. Mostly we talked about his writing in the first part of the interview, which is episode 75.

Now the thing is, if you question how good your writing is, you should sign up for a writing course, perhaps through a local community college or something like that. There is a place where you can get some specific instruction on how to not only write better but do medical writing better and even create a business. And that's through Emma Nichols, again, who I interviewed in episode 56, because she has a course. She usually introduces a course through a free webinar, which can generally be found at sixweekcourse.com. And by the way, I don't have an affiliate relationship with her. I just have talked to multiple physicians that have gone through the course and they really enjoyed it. It teaches you how to do the business side of it, as well as the writing side to some extent. And she even has the ability to hire you for some of her business if you're a good writer. So, I would definitely check that out at sixweekcourse.com or just look her up by going to the podcast episode I mentioned.

The other resource I would provide for that in addition to her course is the American Medical Writers Association, which can be found at amwa.org. And as it sounds, there's a lot of resources there for medical writers. So, that would be something to check out. I guess that's what I'll say about medical writing at this point. You can look at those resources and get more into it if it's something that you think you might do. If you're really thinking of doing it, you might want to actually sit down over a period of a week or so, and write three or four articles. The same advice I give to bloggers and podcasters is to create some content before you decide that that's what you want to do and see how difficult it is. And if you enjoy it and if you love it, and if you get motivated by it, then you know you're on the right track.

Okay, let's go to career number two, a career in clinical documentation improvement. I love CDI - Clinical Documentation Improvement. It's something I enjoy digging into. I like learning the rules of the game and sticking to the rules and using the rules to help improve an outcome in a game. So that's kind of what it is. I've always found it interesting that we've had these industries grow out of nowhere in the last 10, 20, 30 years because of the regulations that Medicare and CMS have created.

Clinical documentation has never been a big deal until it was tied very closely to how the hospital or a medical group gets paid. And when I was working as a CMO, I was just intrigued by it because the outcomes that are now publicly published for hospitals and health systems and nursing homes and hospices now all depends how things are coded, because we don't have a great way for actually measuring quality without going into the medical record and the billing record as a primary source of the information. So, these arbitrary rules were created and we found that we needed experts to figure them out. And the CDI world has grown enormously.

It's a world where a physician becomes trained in the intricacies of translating the documentation, let's say in a hospital chart to the actual coding, such as the coding reflects the risk adjustment as needed to get paid properly or not to be dinged or when you're measured on your quality outcomes. Your risk-adjusted mortality and morbidity and things like length of stay and readmission rates, it all depends on coding. So, you have this huge business that's developed and you need someone to talk to the physicians and explain things. And there's a certain subset of those that need to be physicians themselves. It's the kind of job that involves working with others, talking with others. But you have to dig in and understand the rules of CDIs. There is some learning, but there's nowhere to get this kind of training except by doing it.

And so, this is a career that's grown up for a lot of physicians. The opportunities are to be employed by the hospital you're working at as a CDI, but you can also work for a company that does offsite reviews and helps interact with physicians or a company that places you into a hospital. So, there are different options here.

But it's something that can be quite interesting. And there's a great upside, because not only are you improving the apparent quality provided by the hospital that's using your services, but it also improves the bottom line most of the time, because the risk adjustment allows you to bill at a higher level of DRG. So, there's no real school you can go to learn this, but you can learn from an organization known as the Association for Clinical Documentation Improvements Specialists, ACDIS. So that would be a place to learn more, to sign up. It includes a lot of non-physicians in the group. And it also has courses that you can learn and you can become certified.

In terms of resources for my podcast, I had a couple of them. One of my early interviews was with Cesar Limjoco and that was episode number five. And by the way, he has a vast LinkedIn following. He has more than, I don't know, 10,000 - 20,000 followers on LinkedIn. It's crazy. You can find him there, but also you can listen to that podcast episode.

And then a more recent one with Christian Zouain who is someone who has the medical degree, but not board certification. He definitely has successfully transitioned into the CDI role and that's episode number 77. That's what I would do. I would access those resources and look into it. It's one of those things that if you have any previous exposure to the hospital environment, it would be helpful. I think Christian kind of came in through the UM side. He was working as a UM specialist, not a physician, let's say medical director, but kind of similar to a nursing role. But by virtue of that, he was able to get into CDI and has been really able to develop a nice career.

Let's move to career number three, medical communications. Now, this is one where you can actually see that it's open to both types of physicians, whether just the medical degree or also the clinical experience. And it becomes apparent as you're looking for jobs where you'll see that associate medical director roles are given to those who simply have the MD or DO degree or equivalent. And the medical director role is for those that are board-certified and have some clinical experience. But what is it? The ones I'm talking about are related to pharmaceutical companies in the sense that you're working for an advertising agency, which does the promotional materials and the supporting materials and sometimes the educational materials for the drugs of a pharmaceutical company, probably also for a device company, a similar type of situation. It's just a totally different environment. In a way, it's kind of like medical writing, but this is a very specific and specialized area that is open again to both.

You're going to be working on teams here. You may want to be a little more extroverted. You're not going to be holed up at home and working on these things. You're going to work together. You're going to be in an office environment, but there's a great opportunity for advancement. Basically, that's the way it goes. It's kind of a 09:00 to 05:00 job more or less, although sometimes you have to go to different meetings or you might have to go onsite to a pharmaceutical company to pitch something, or to explain a whole marketing campaign. You may be working on materials that are audio-visual. It's really quite advanced these days. It's pretty exciting and fun.

And one of the resources you could look at would be my conversation with Dana Carpenter in episode number 61. Now she relayed that the way she got the job was she had left clinical medicine and had started doing some writing and some consulting, and she had a pretty heavy presence on LinkedIn and out of the blue, one of these companies found her and asked her if she might be interested in joining their team. So, it does get back to the issues I was discussing earlier.

You don't necessarily have to be super creative because they actually have people in these ad agencies that do that part, but you're there as a medical expert. And you should focus perhaps on one type of area that's related to a particular drug or therapeutic class. Your medical degree is there basically so that you can learn new medical areas to expand into. So, you don't have to be an expert, let's say in women's health. You might start out in another area and eventually get that under your wings, so to speak. But you just have to have that experience that you can read and understand and take the information from the pharmaceutical company on the drug and its complications and its indications and so forth and so on, its uses. And then translate that into a way that people can understand.

And then also you're there to make sure that the creative people don't overstep what they're saying about the drug. So that keeps it real, keeps it honest. Dana said it was really such a wonderful type of job. She really loved it. She enjoyed it. And it's one of those that I've found people typically don't leave.

There is a resource that I have, I'll put a link here. It's a visual that I included in the original podcast show notes. And it basically shows the relationships or the parent organizations and the offspring ad agencies that focus on different drugs, different therapeutic classes or different areas of the country. The graphic has over 100 companies.

So, I would recommend if you're interested in looking at medical communications, which combines this scientific background along with writing and creativity and working with a team, then grab that, print it up, look at it, start looking up some of the companies you might look at geographically with something that's within your reach. It is possible to work remotely, but it's not the majority of the way that this works. But it does provide that as an option in some cases.Let's see, resources. That really would be that download. And I would look at those companies. They almost all have job listings or career sections on their website. So, you can just start there and start looking. And again, don't forget about networking, LinkedIn and finding a mentor.

The fourth area I want to talk about is consulting. Now I'm not talking about consulting from the standpoint of starting your own consulting business. And I've talked to people that have done that very successfully, but I'm talking about consulting as a job for a big company. And this is the one area where a consultant, a physician consultant, told me that they sometimes are looking for someone without clinical experience. I think partly it's because they can pay you less perhaps, but they want somebody with that MD degree. Basically, you are kind of similar to the PhDs they would sign up. But also, because they want to brainwash you, I guess, in a positive way. They want to teach you their way of doing things. They don't want you to come in with a lot of preformed ideas and ways of doing things. You know how some of us physicians are when we were practicing for 20, 30 years, how we get. And we want somebody who's going to be a little more flexible. So that's the one place where there may be an advantage to having less experience.

This type of job requires more travel. It depends on the company and where you're located. A lot of these companies are international and in some of them, it might be international travel, but certainly, a lot of it will be domestic as long as you're signing up for a domestic position. But it can be very interesting, it can be extremely lucrative. Let me just give you a list of some of the companies that I'm aware of. And I think these are all referred to as healthcare consulting firms. They're usually more than healthcare consulting firms. So, they have healthcare divisions within them. At least the ones I'm going to describe now. And these are the big ones.

If I were me, I would focus on finding out as much as I could about the first one and finding out what I would need to do to apply for a job. And that would be with McKinsey & Company. It's really considered to be one of the best, and I have no direct relationship with them. I get no compensation for recruiting for them.

McKinsey is headquartered in New York, but it's really around the world and it's an accounting and management firm. It's got a diverse array of healthcare consulting types of subsidiaries and probably employees, hundreds, maybe thousands of doctors around the world, at least. So, I would definitely look them up. There'll be a link to McKinsey in the show notes.

The Boston Consulting Group is another one. It's been around a long time. And it has a healthcare section that does kind of the same thing. There's just so much consulting going on for things like the CDI that I mentioned earlier for utilization management, for bringing on new service lines in hospitals for population health.

The third is Deloitte. I've been aware of them for many, many years. We had many consultations at my hospital from Deloitte. And then Bain & Company is another one. And finally, Huron Consulting Group, which I think bought the Advisory Board and has a bunch of other subsections that address healthcare consulting. But that's just a sampling. I mean, there are literally hundreds. And you can get into little boutique consulting firms.

Again, I actually don't have a podcast episode on this. The resource would be to just look at those companies, look at the career boards, look at what they're looking for and see if it's something that would fit with your needs.

The fifth one would be a medical monitor. This is another one more direct in pharma. The last two involve working for a pharmaceutical company directly or indirectly. A medical monitor is a person that helps to monitor research studies, making sure that the protocols are followed, answering questions, keeping the researchers on track.

It involves some travel. You're probably stationed more at the business and maybe even working from home a little bit and less traveled than let's say a consultant or an MSL would do, which we're going to talk about in a minute.

Usually, the medical monitor has some kind of science background in addition to the MD. So, anything that you have undergrad, or if you have a master's degree in the scientific area, or if you've had any exposure to working with patients or even a committee like the formulary committee or the P&T committee (pharmacy and therapeutics committee) in a hospital. Anything that exposes you to medications and in working with patients and or research would help get a job in this setting.

Now, most medical monitors work for what's called a CRO, a Contract Research Organization, which are the organizations at the pharmaceutical companies. They outsource their medical monitoring too, generally. There are LinkedIn groups related to this. There's no organization that I could identify.

In terms of podcast episodes, there was a conversation with Christian Urrea in episode number 70. Unlike medical writing, you do have to get out there, work with people. You have to work one-on-one with the researchers and their teams. You have to take that information back, to answer questions, you have to be educational and you have to be attuned to regulatory requirements. Maybe if you know a little bit about IRBs or Institutional Review Boards and the strict guidelines they require, that would be very helpful.

Just as a way of providing some resources, there are basically 10 or 15 primary CROs, big ones that hire many of the medical monitors, but you might want to look at these and to get more information to understand what the job description would look like. And the list would include the following. There's one called IQVIA. And then there's one called Parexel, Syneos Health. Company called Covance is a CRO and it's actually owned by Labcorp. ICON PRA Health Sciences and PPD, which is Pharmaceutical Product Development. And Medpace. So, that's eight. I'll stop there. I'll put links to all of those. And like I said, they all should have links to career boards for them.

Again, it's something where if you are interested in research and have had exposure to it in the past, you like working with people, that would be a definite option.

The sixth career would be that of a medical science liaison. Another career in pharma, kind of an entry-level or an introduction to pharmaceutical careers. You can go elsewhere once you've done the MSL job, but the MSL job is open to both board certified and non-board certified physicians.

What is it? Basically, you're interacting with key opinion leaders and influencers. They go by different terms to help educate them and take back information from them to the company about drugs or a therapeutic class of drugs. You are strictly on the education side, you're not promotional, although your activities may result in increased utilization of the drug, but it's more from an educational standpoint.

You have to understand the regulatory requirements, some of the things from the pharma code and the FDA. Personality-wise, if you don't mind traveling if you like getting out and working with people and communicating with people if you can be a little bit extroverted that helps. You're going to be doing more travel than the average job. I would say probably at least 50%, maybe more. So, it wouldn't be common for an MSL to travel let's say three days a week, and spend a day a week at home working, maybe two. And occasionally traveling to the parent company for your employer.

Again, you may not work directly for the pharmaceutical company. You may be working for a third party, kind of like the CRO, but it's a company that would hire MSLs and use them with different pharmaceutical companies. But anyway, yeah, it can be up to two or three days of travel. Now, some of the travel could be local. If you're in a very dense area, you can travel by car. If you're not in such a dense area and you are covering multiple states, you're going to have to travel by air. So, keep that in mind.

I happened to have interviewed many MSLs, so you can hear more from my guest Savi Chadha, it was episode 50, Linda Ho in episode 51. A review of MSL jobs in episode 66 and in an interview with Swati Shah in episode 89. I think you'll find those interesting.

There definitely is a Medical Science Liaison Society, which would be worth looking up as well. And something called the MSL Institute, which is really an online resource. It has been out there for, I don't know, roughly 10 years. And it just has dozens and dozens of articles, many of which are addressing how to seek the MSL career.

I think I'm going to stop there. Those are six careers that are open to any physician really. I could go on, but that is a starting place for those of you who feel frustrated and don't know where you should go. You can start with those six.

As you can see, we've addressed these issues in prior interviews. I've tried to add some value here, so you can understand these six careers and that you have these options. And there's many more out there. I'm learning as we go just as you are.

I hope you enjoy today's episode. Since that one aired, I have had additional conversations with experts in pharma, and there are jobs to be had beyond the MSL and medical monitor positions. You can search for positions as a clinical scientist or clinical research associate or technical medical writer for a CRO using the tactics discussed in episode 209 with Dr. Marsha Caton. I'll have more on that subject coming up in episode 214 with Dr. Laura McCain.

You can find my show notes for today's episode at nonclinicalphysicians.com/noresidencynoproblem.

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The post PNC Podcast Blast from the Past – No Residency Is No Problem – 211 appeared first on NonClinical Physicians.

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.

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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.

Summary

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 dr_cesar_limjoco@me.com. 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.

Links for Today's Episode:

• Dr. Cesar Limjoco's LinkedIn Page
• ACDIS Website
• AHIMA Website
• National Association of Physician Advisors Website
• Dr. Limjoco's email address: dr_cesar_limjoco@me.com
• Top Reasons to Become a CDI Expert with Dr. Christian Zouain – 077
• Nonclinical Careers That Will Save Discouraged Doctors – 095

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

Today's PNC Podcast Transcript

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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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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. 

The post PNC Podcast Blast from the Past: Clinical Documentation Improvement – 206 appeared first on NonClinical Physicians.

Dr. Christian Zouain is a foreign medical graduate who used networking to land his first job as a CDI expert.

He graduated from medical school in the Dominican Repubic. He worked first as a medical assistant and a medical scribe because he had not completed residency and was not licensed.

Christian realized that he was not alone in his decision to pursue a non-clinical path after attending the SEAK NonClinical Careers Conference. He was inspired not to give up on his quest.

He looked for his next opportunity and landed a job doing hospital case management and utilization review. That enabled him to build a network of medical colleagues. And he began to consider non-clinical career options.

He discovered that clinical documentation improvement (CDI) was a growing field that needed healthcare professionals. He enrolled in a clinical documentation improvement (CDI) and ICD-10 coding course. The course addressed how complete and accurate documentation impacts all areas of health care.

Once he decided on the CDI career path, Christian started to get involved with professional associations, such as the ACDIS. That led him to educational courses addressing CDI.

Our Sponsor

This podcast is made possible by the University of Tennessee Physician Executive MBA Program offered by the Haslam College of Business. You’ll remember that I interviewed Dr. Kate Atchley, the Executive Director of the program, in Episode #25 of this podcast.

The UT PEMBA is the longest running, and most highly respected physician-only MBA in the country, with over 650 graduates. Unlike most other ranked programs, which typically have a duration of 18 to 24 months, this program only takes a year to complete. And, it’s offered by the business school that was recently ranked #1 in the world for the Most Relevant Executive MBA program, by Economist magazine.

University of Tennessee PEMBA students bring exceptional value to their organizations by contributing at the highest level while earning their degree. The curriculum includes a number of major assignments and a company project, both of which are structured to immediately apply to each student’s organization.

Graduates have taken leadership positions at major healthcare organizations and have become entrepreneurs and business owners. If you want to acquire the business and management skills needed to advance your nonclinical career, contact Dr. Kate Atchley’s office by calling (865) 974-6526 or going to vitalpe.net/physicianmba.

Networking Using LinkedIn

To make this career change, and become a CDI expert, Christian did the following:

• took advantage of what he was learning, and of the ACDIS, and completed a certifying program in ICD-10 and clinical documentation;
• used LinkedIn to follow hospitals’ human resources (HR) departments and connect with CDI professionals;
• attended a recruitment meeting for physicians which led to his first job as a CDI expert.

He's an excellent example of how effective networking is.

Typical Day

Christian works regular office hours Monday through Friday. He and his colleagues split up the cases to review each morning. Then they contact physicians and other practitioners. And they suggest changes to the medical record that will better reflect each patient's clinical picture.

When he started in CDI, his hospital was still using paper charts, which slowed the querying process down. Now that electronic medical records have been universally adopted, it's much easier to communicate with physicians. That has streamelined Christian's job as a CDI expert immensely.

Physicians Prefer Physician CDI Experts

Christian now works much more collegially with physicians. He knows that they appreciate his help with documentation. Physicians believe that he understands the pressures they work under better than a nurse or medical records clerk.

He thoroughly enjoys his work. The physicians appreciate the help with the arcane documentation rules. And the organization benefits with better payments, and improved risk adjusted quality measures.

He also enjoys the support of the CEO and CFO at his hospital. And that support makes his job easier and more fulfilling.

Optimizing Opportunities

For those interested in a career as a CDI expert, Christian recommends you join the ACDIS and enroll in an ICD-10 coding course. This will familiarize you with useful concepts and guidelines. As Christian can attest, networking is very important, too.

Click here to download the TRANSCRIPT

CDI is a field that involves continuous learning. You have to stay updated, continue to read, go to conferences, and learn from others CDI experts.

And new types of CDI jobs are developing each day. There are now opportunities as a CDI physician advisor in:

• hospital systems,
• outpatient clinics,
• large consulting firms that serve hospitals, and,
• small CDI start-ups.

Links for today's episode:

Dr. Christian Zouain
International Statistical Classification of Diseases
World Health Organization
John's Interview with Dr. Cesar Limjoco – 005
Dr. Cesar Limjoco on LinkedIn
ACDIS
ACDIS Apprenticeship Program
AHIMA
CDIP
CCDS

Thanks to our sponsor…

Thanks to the UT Physician Executive MBA program for sponsoring the show. It’s an outstanding, highly rated, MBA program designed for working physicians. It might be just what you need to prepare for that joyful, well-paying career. You can find out more at vitalpe.net/physicianmba.

I hope to see you next time on the PNC Podcast.

If you enjoyed today’s episode, share it on Twitter and Facebook, and leave a review on iTunes.

Podcast Editing & Production Services are provided by Oscar Hamilton.

Disclaimers:

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. 

Many of the links that I refer you to, and that you’ll find in the show notes, 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, that I have personally used or am very familiar with.

The information presented on this blog and related podcast is for entertainment and/or informational purposes only. It should not be construed as 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 counsellor, or other professional before making any major decisions about your career. 

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The post Top Reasons to Become a CDI Expert with Dr. Christian Zouain – 077 appeared first on NonClinical Physicians.

But first, a story…

Ten years into my career as a full-time family physician, I began to consider moving in another direction. For the most part, I enjoyed my practice, and my patients liked me. My two partners and I had busy schedules and a waiting list for appointments.

And we had a good reputation in the community.

But I wanted something more. I enjoyed working on hospital committees. I relished collaborating with nurses, pharmacists and other professionals, to create new protocols that improved patient care. And I enjoyed assessing learning needs and planning CME activities for my colleagues.

When the first wave of managed care plans began to show up in our community, I found it invigorating to work with eleven of my colleagues to help develop an independent physician association. The goal of the IPA was to contract with insurers, develop our own patient panels, and manage our utilization.

Photo by Samuel Zeller on Unsplash

I began to think that I might pursue a career in hospital management.

Self-Limiting Fears

But I had so many fears and insecurities that surfaced with each small step I took in that direction:

How would I explain this to my partners? We shared everything equally in the practice. How could I find time to still cover all of the call responsibilities and ease into a management position?

I’m a family physician. Sure, it’s a noble calling. But surgeons, cardiologists, gynecologists, and other specialists really don’t respect our opinions. We’re treated like the proverbial “red-headed stepchild.” And our hospital had never had a physician executive, so I was sure my peers would be very skeptical of the idea.

I thought, if I move into management, I’ll need to interact with other physicians, and even lead them. What makes me think I can be a leader? I’m not charismatic. I’m an introvert. I don’t have a booming voice or any “gravitas.” For goodness sake, I’m only 5 feet 3 inches tall!

And, I could hear my brothers and sisters, maybe even my parents, saying: “What do you mean, you won’t be seeing patients any more? Why would you give up being a doctor? Why waste your medical education?”

This is just a sampling of the self-limiting beliefs I had to overcome. And with the encouragement of my close friends, and wonderful mentors and supporters, including the CEO that first hired me as VP for Medical Affairs, I slowly faced those fears.

Fears Unfounded

And I discovered that those fears were unfounded. I learned that having a good reputation in the community was important. Being meticulous in my work and committed to improving patient outcomes was appreciated. And serving my colleagues by facilitating a dialogue between hospital executives or board members and the medical staff was what mattered.

As I present a plan today for you to follow, I want to acknowledge that you’ll likely face similar self-doubts and limiting beliefs. But don’t let those stop you.

Your clinical experience is the platform upon which you can build a rewarding career. You just need to add a bit of additional expertise and nonclinical experience.

You’ll likely be helping more patients in your new career. And you’ll be supporting your community and advancing your profession.

Three Awesome Nonclinical Careers

I’m going to briefly outline the steps that will take you from practicing physician to Physician Advisor for Utilization Review, Medical Informaticist, or Physician Advisor for Clinical Documentation Improvement.

Click above to download free guide.

These awesome nonclinical careers are ideal for many hospital-based physicians, including hospitalists, anesthesiologists, infectious disease specialists, and pulmonologists.

Each of these can be started part-time, if you like. But they will readily become a full-time career. They can also serve as a stepping stone to more highly paid positions as medical director, CMIO, or CMO.

Much of the information I’m going to share can be found in a free guide titled 5 Nonclinical Careers You Can Pursue Today. This guide can be downloaded for free by going to vitalpe.net/freeguide and signing up for my newsletter.

For the rest of this episode, you might want to have pen and paper handy. I’m going to provide many resources for you to access.

Utilization Management

This field is also sometimes called case management or care management. A physician advisor for UM will help determine the appropriate care status (outpatient vs. inpatient) in the hospital. As a PA for UM, you may be asked to determine appropriateness for observation care. You will work with other team members to determine if continued stay is warranted.

You’ll also help physicians understand CMS and other payer rules with respect to appropriateness of testing and performing invasive procedures. As a UM advisor, you’ll help your colleagues appropriately document their thought processes so that their patients can get the care that they need.

Finally, your work will be critical to the financial viability and the reported quality outcomes of your organization, by helping to reduce risk adjusted length of stay and unnecessary readmissions.

To begin to seek this career, you generally must be residency trained, and board certified, with 3 or more years of clinical experience. It is easiest to begin this transition if you’re currently a medical staff member at a medium to large hospital with an existing Utilization Management Department.

Typical Job Listing Looks Like This

“Candidate will have a strong clinical background with excellent communication skills and leadership abilities. The role of the Physician Advisor of Case Management Services requires the review of other physicians' cases, their plan of care and resource utilization. Case study can be necessary for various reasons including patient outliers (extended stays), utilization review issues, reimbursement issues or quality concerns. The Physician Advisor will work with hospital administration and clinical committees as requested to develop processes and guidelines to improve quality of care and value.”

Get Started

Here are some actions you can take to begin this career journey. They don’t necessarily need to be taken in the following order.

• Purchase and read: The Hospital Guide to Contemporary Utilization Review, by Stefani Daniels and Ronald Hirsch, and Physician Advisor Handbook, by Pooja Nagpal and Ven Mothkur.
• Meet with the Director for Utilization (or Case) Management and identify the most active physicians and the committees where the work is generally done.
• Then join your hospital utilization or case management committee. Get involved with denials management, including appeals.
• Identify a mentor that is currently working in utilization review, possibly the current Medical Director or a Physician Advisor for UM or case management. Establish a relationship and a dialogue about pursuing a similar career.
• Create a complete LinkedIn profile with a focus on experience in quality and length of stay, and on clinical experiences with hospital care.
• Consider joining the American College of Physician Advisors (acpadvisors.org) or the National Association of Physician Advisors (physicianadvisors.org). Check out their websites and see which one resonates most with you.
• You might consider attending the Annual SEAK Nonclinical Careers Conference held in Chicago, Illinois each October. There is usually at least one presentation devoted to this role.
• You should look into the costs and time commitment needed to achieve certification in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, the ABQAURP (abqaurp.org)
• Finally, to learn more, listen to my interview with Dr. Timothy Owolabi in Episode # 12 of this podcast by going to My Interview with Dr. Timothy Owolabi.

Before proceeding, I want to spend a minute talking about the American Association for Physician Leadership. I’m not an affiliate and receive no compensation for this endorsement. But I’ve been a proud member of the AAPL for about 25 years, because it’s an outstanding organization.

It helps to support and promote physicians as managers, executives and leaders. The AAPL provides live conferences, online education, books, coaching, mentoring, career services and nonclinical job postings. It also provides physician executive certification, the CPE, that demonstrates expertise and skills as a physician leader.

I’ve mentioned the AAPL in numerous podcast episodes and interviewed the Director of Career Services, Dian Ginsberg, in Episode 24.

It truly is the world’s leading organization of emerging and established physician leaders. The cost of annual membership is a little less than $300.00 per year, which is a ridiculously low price. I strongly recommend you consider joining. Check It out using this link – vitalpe.net/aapl – to find out more.

Medical Informatics

Physicians in this position will need to learn about information technology and informatics. Medical informatics is the study of the design, development, adoption and application of IT-based innovations in healthcare services delivery, management and planning.

As a physician informaticist, you will be the bridge between information technology and practicing physicians. You will be involved in converting clinical protocols for use in an EHR. And you will develop procedures for effective use of technology in health delivery. This is probably the fastest growing of these awesome nonclinical careers.

To pursue this career, you should generally be residency trained and board certified, with 5 or more years of clinical experience.

Typical Job Listing Looks Like This

“The primary purpose of the Physician Informaticist is to develop EMR application training in one on one and group settings for physicians, based on workflow analysis and evaluation. The Physician Informaticist will develop and deliver learning solutions that improve efficiency and promote business objectives. As a member of the Clinical Informatics team, this person will provide ongoing support of EMR products and will work with the team in the maintenance and enhancement of EMR software. He/she will help implement requests for system changes on all assigned modules and participate in the development of operational workflow.”

Get Started

Here are some steps you can take to begin this career journey.

• Purchase and read: Health Informatics: Practical Guide for Healthcare and Information Technology Professionals by Robert E. Hoyt (Editor).
• Meet with the Director or VP for Informatics and identify the most active physicians and the committees.
• Participate in IT or EHR committees in your hospital.
• Identify a non-physician mentor that’s currently working in the Medical Informatics Department, or a medical informaticist or the Chief Medical Informatics Officer, if one exists. Meet with them and learn more about seeking a career in informatics.
• Create a complete LinkedIn profile with a focus on experience in EMR implementation, application, protocol development, etc.
• You should check out the following organizations: The American Medical Informatics Association is devoted to informatics and has a substantial physician component; The American Health Information Management Association addresses coding, privacy, security, data analytics, and CDI, in addition to informatics. It has a smaller focus on physician members.
• You should subscribe to the Health Data Management Online Journal at healthdatamanagement.com for news related to healthcare information technology.
• Join the Healthcare Information and Management Systems Society or HIMSS. And then check out the Physician Community within HIMSS at himss.org/physician.
• You can learn even more about this career choice by listening to my interview with Brian Young in Episode #14 by going to My Interview with Dr. Brian Young.

Clinical Documentation Improvement

Physicians in this position will need to learn appropriate coding and documentation guidelines and teach other physicians about coding. You will likely need to interact with them on specific cases to make appropriate changes to coding when needed.

As coding guidelines have become more specific, the need for an expert in this field continues to grow. As a CDI expert, you will help to ensure that the severity of illness of hospitalized patients is fully demonstrated.

This is critical to proper risk adjustment and quality outcomes published by CMS and other quality reporting organizations (Truven Top 100 and HealthGrades, for example).

Photo by rawpixel on Unsplash

Like the Physician Advisor for Utilization Management, your work will be critical to the financial viability your organization. You accomplish this by helping to optimize payments, reduce CMS-imposed penalties and demonstrate the quality of care to your stakeholders.

You’ll need to be residency trained, and board certified, with 3 to 5 or more years of clinical experience.

Typical Job Listing Looks Like This

“As the CDI physician advisor, you will act as a liaison between other CDI professionals, the Health Information Management Department, and the hospital’s medical staff. The PA will facilitate accurate and complete documentation for coding and abstracting of clinical data, in order to capture severity, acuity and risk of mortality, in addition to DRG assignment.”

Get Started

Here are some of the steps you can take, not necessarily in this order:

• You can read manuals such as Understanding Hospital Billing and Coding, 3rd Edition or DRG Expert – 2015.
• Better yet, you can go to the CMS page with DRG data at CMS Website and download the most recent DRG dataset in Excel format and sort by volume to see the most common DRGs being used nationally. Then you can look up the definitions of individual high-volume MS-DRGs at this link on the CMS website
• Meet with the Director or VP for Health Information Management and the Director of Clinical Documentation and identify the most active physicians and the committees.
• If possible, join the CDI team and attend CDI committee meetings. Spend time with the coding specialists in the Hospital Information Management Department.
• Identify a mentor that is currently working in hospital clinical documentation improvement.
• Create a complete LinkedIn profile with a focus on documentation and coding experience.
• Consider joining the Association of Clinical Documentation Specialists. It has a significant physician membership.
• The American Academy of Professional Coders may also have some useful educational and networking opportunities.
• The American College of Physician Advisors and the National Association of Physician Advisors might be useful to you. AHIMA may be more helpful for the CDI specialist than for the physician advisor for utilization management.
• And you can learn even more about this career choice by listening to my interview with Cesar Limjoco in Episode #5 by going to My Interview with Dr. Cesar Limjoco.

Closing

Well, there you go. I tried to provide actionable information and inspiration for three very important and popular nonclinical careers.

Let's close with this quote:

If you have any questions about what has been presented, please email me directly at johnjurica@nonclinical.buzzmybrand.net.

You can get the written overview of these three careers and two others by signing up for my newsletter at vitalpe.net/freeguide.

Resources

The resources mentioned in this episode are all linked below.

[table id=25 /]

Right click here and “Save As” to download this podcast episode to your computer.

The easiest ways to listen:  vitalpe.net/itunes or vitalpe.net/stitcher

If you'd like to listen to the premier episode and show notes, you can find it here: Getting Acquainted with Physician NonClinical Careers Podcast – 001

The post Three Awesome Nonclinical Careers You Can Embark on Today – 034 appeared first on NonClinical Physicians.