UR and CDI - They Go Together

by Stefani Daniels
Published on Jul 14, 2015

Should CDI and UR continue to be separate roles when both are reviewing the very same documentation? As hospitals are looking for ways to improve efficiencies, it may be time to consider an integrated role.

According to a position paper from ACDIS, the clinical documentation improvement (CDI) specialist has "a specialized skill set and a high level of clinical knowledge and training. Many CDI specialists are registered nurses with 15–20 years or more of bedside nursing experience, and/or advanced chart review and inpatient coding experience as health information management (HIM) professionals specially trained with expert knowledge about the nuances of documentation to support medical necessity."   According to recently published The Hospital Guide to Contemporary Utilization Review, the UR specialist must "accurately screen medical documentation for acute care medical necessity and recommend a level of care to the physician based on the set of guidelines being used. In addition, the specialist must critcially review the completeness of the physician's documentation so it will withstand the scrutiny of oversight agencies and payers."   

Because hospitals are scrambling to reduce costs and achieve greater efficiencies in work flow, operational processes and patient progression of care, the question must be asked:  "Are these two roles overlapping and if so, what can be done?" Based on the definition of both roles, it appears that the roles certainly overlap.  Both roles are reviewing the very same documentation to evaluate the completeness and accuracy of the documentation to support medical necessity.  The UR specialist primarily uses a set of nationally recognized guidelines to confirm the patient's need for an acute care hospitalization.  If the documentation is incomplete or inadequately paints a full picture of the patient's condition , the reviewer will offer documentation information to the physician or may offer alternative level of care options.  The CDI specialists are intent on improving the quality of the medical documentation and through their knowledge of coding concepts,  documentation guidelines, and clinical terminology, they will query the physician to ensure accurate reporting and the greatest level of specificity of all diagnoses and procedures required for accurate representation of severity of illness, expected risk of mortality and complexity of care.

The answer to the second part of the question is the evidence found in the literature that the merger of these two roles is slowly occurring.  JATA, a leading vendor of CDI program resources, promotes a CDMP Point of Entry product that combines the two roles into a Clinical Integraton Specialist.  They began with a focus at access into the hospital system knowing as we do, that the best way to avoid back end rework is to get full and accurate documentation at the beginning of the patient's progression of care. AR Systems, a coding compliance and audit vendor, promotes an integrated CDI program.  Similarly, PhoenixMed.net  promotes the integrated role as part of its Breakthrough Transformation of the hospital's care management program to distinguish the practice of care management for selected high risk patients from the organization's statutory and contractual obligations for a robust UR function applicable to all patients.