In an era of declining reimbursement, expanding Medicare regulations, and ICD-10 implementation, a growing number of hospitals have enlisted the services of physician advisors. The physician advisor is a physician, typically with a broad base of clinical experiences, who assists certain hospital departments by ensuring compliance with regulatory issues, advises physicians on medical necessity and documentation needs, and helps the leadership team reach overall goals for efficient utilization of health care.
Physician advisors primarily support the clinical documentation and coding improvement (CDI or CDCI), utilization review/case management, audit and appeals, and quality departments. They come from a variety of specialties, but hospitalists and internists are an excellent fit.
Such advisors were often called physician champions when they were unpaid volunteers, but today, CDI programs typically have one or more physician advisors, often paid full-time by the hospital. They go by a variety of titles, including physician advisor, clinical or medical director, or vice president. According to salary.com, the average Physician Advisor salary in the U.S. was $130,634 as of Dec. 28, 2020, with a typical range between $102,130 and $168,088.
Responsibilities may include the following.
Applying authoritative diagnostic standards. Many authoritative, evidence-based consensus definitions and guidelines are available for the most current diagnostic standards and criteria. Where consensus guidelines do not exist (e.g., respiratory failure, rhabdomyolysis, acute tubular necrosis), the diagnostic standards that are widely accepted in the medical community can be gleaned from peer-reviewed, evidence-based medical literature. The CDI program is responsible for helping clinicians apply these diagnostic standards, and the physician advisor plays a pivotal role.
Identifying proper documentation terminology for correct code assignment. Another major challenge for busy clinicians is using diagnostic terminology that will result in the correct code, describing the patient's true condition and severity of illness. The coding rules and guidelines often require specific terminology unfamiliar to clinicians, creating a disconnect between common diagnostic descriptions and the proper code (e.g., renal insufficiency vs. renal failure, respiratory distress or insufficiency vs. respiratory failure, HIV-positive vs. AIDS, bacteremia vs. sepsis).
Ensuring clinical validity. Pursuant to a modern interpretation of the False Claims Act of 1863, CMS billing and payment regulations and policy prohibit the assignment of codes for a condition that isn't clinically substantiated by findings in the medical record. Doing so can expose the hospital and the clinician to unpleasant regulatory entanglements or worse. It's the responsibility of the CDI program—coders, documentation specialists, and physician advisors working together—to ensure compliance with this imperative.
Conducting peer-to-peer conversations. CDI programs regularly encounter some obstacles from physicians, such as unresponsiveness to queries, particular diagnostic dilemmas (e.g., where the clinician insists the patient does not have a particular condition but authoritative diagnostic criteria are evident in the medical record), or a consistent pattern of diagnostic misconceptions (e.g., documentation of acute kidney injury or respiratory failure when not present).
A physician advisor must be good at communicating, building interpersonal relationships, and collaborating, as well as willing to engage peers in conversations about their diagnostic and documentation challenges. It also requires someone who is respected by peers, has the necessary core knowledge and a broad range of clinical experience, and is well-versed in hospital processes. To be effective, the physician advisor must be kind, patient, sympathetic, and tolerant—a humble mentor.
Providing CDI education. Physician advisors provide clinical diagnostic education for coders and documentation specialists and keep abreast of new information as it unfolds over the years. They also offer both group and individual physician CDI education. Total expertise is not required, but it's highly beneficial to have a working knowledge of ICD-10 and diagnosis-related group methodology, ICD-10 coding guidelines, and CMS regulations and payer policies.
Handling audit recovery appeals. Physician advisors are often called upon to support and advise the hospital's recovery audit appeals processes and represent the hospital's interests in peer-to-peer conversations with the payers' audit physicians. Again, detailed knowledge of the authoritative and evidence-based diagnostic standards is crucial for fulfilling this responsibility.
Many strategies have been employed to engage physicians in CDI and to overcome objections such as its purported lack of relevance to patient care or interference with workflows. These are some of the tactics that physicians in CDI programs have used to convince reluctant colleagues:
- Making five- to 10-minute CDI presentations regularly at medical staff department and section meetings
- Emphasizing the importance of precise documentation for communication, quality measurement, and research
- Getting assistance of medical staff leadership
- Conducting in-house CDI promotion, such as posters, articles in medical staff newsletters, flyers in mailboxes, and monthly “Best Documenter” awards.
In summary, the physician advisor role is a rewarding career path. The American College of Physician Advisors is a good source of additional information.