A few weeks ago, ACDIS put out a call for members to nominate a colleague to be featured on the ACDIS Blog. We received a number of responses, but this one stood out. Kristi Repetto, RN, BSN, CCDS, director of CDI at Lee Health in Fort Meyers, Florida, nominated her colleague, Christi Drum, RN, BSN, CCDS, and had this to say:
“[Christi] is the ‘rock’ of our department. She has held a team lead role in the past and is extremely knowledgeable. She works collaboratively with our coding department to make sure both coding and CDI receive the same information regarding new updates, education, or query work flow. Christi is amazing!”
Drum began her career in CDI three years ago and, before that, worked as a nurse in the inpatient setting. She is currently a Florida ACDIS chapter member. Drum and her husband have two sons, ages 17 and 15, and one daughter, age six.
ACDIS Blog: Why did you get into this line of work?
Drum: I was looking for a career change away from bedside nursing that would benefit from my inquisitive nature, attention to detail, and readiness to learn new things, but would also benefit from my years of experience in critical care nursing.
ACDIS Blog: What has been your biggest challenge?
Drum: To accept that little in the realm of CDI is black and white. Chart reviews can be very subjective based on personal clinical experience and interpretation, not only for CDI specialist but for coding as well. Learning to adjust to this as a new CDI staff member was certainly a challenge for me.
ACDIS Blog: What has been your biggest reward?
Drum: My transition to the CDI educator role. I thoroughly enjoy training and orienting new staff members on all things CDI. I’m quite passionate about CDI and love to cultivate that in others. It is a very rewarding job to see others learn and become successful as CDI specialists.
ACDIS Blog: How has the field changed since you began working in CDI?
Drum: I think the biggest change for us has been the buy-in from the physicians. They were initially very resistant and reluctant to work with and learn from the CDI team. We have seen physicians begin to engage, increase compliance, and seek out CDI staff members for new education and learning opportunities.
ACDIS Blog: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on CDI Talk or through ACDIS?
Drum: ACDIS is a wealth of information and a crucial resource in this job. From sample queries and networking opportunities, to physician education and keeping abreast on current news topics, ACDIS offers it all.
ACDIS Blog: What piece of advice would you offer to a new CDS?
Drum: Be patient with yourself! CDI is very different from bedside nursing. It takes time and exposure to learn and remember the many different facets, rules, regulations, requirements, guidelines, Coding Clinics, etc. Also, never stop asking questions. So much in this industry changes so frequently. It is normal and beneficial to seek the help and advice of others in your field.
ACDIS Blog: If you could have any other job, what would it be?
Drum: Something that allowed and paid for international travel and sightseeing.
ACDIS Blog: What was your first job (what you did while in high school)?
Drum: I started working at the age of 14 at Chick-fil-A and worked there for two years. To this day, I still enjoy eating there.
ACDIS Blog: Tell us about a few of your favorite things:
- Vacation spots: Maui
- Hobby: Relaxing at the beach and kayaking
- Non-alcoholic beverage: Unsweetened tea with a little Stevia or flavored sparkling water
- Foods: Anything gluten free, but I particularly like the sweet treats
- Activity: Traveling to new places
Editor’s note: The ACDIS Blog occasionally introduces an ACDIS member to the larger CDI community. If you would like to be featured or know someone who would, please email Associate Editorial Director, Melissa Varnavas, at firstname.lastname@example.org.
Note: This post is part four of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.
by James S. Kennedy, MD, CCS, CDIP
In earlier posts, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS’s SEP-1 core measure), and ICD-10-CM coding compliance.
We emphasized that the February 2016 definition of sepsis (Sepsis-3) as a “life-threatening organ dysfunction caused by a dysregulated host response to infection,” differed from the terminology of sepsis and severe sepsis that has been embraced by many clinicians, CMS, and ICD-10-CM. We also discussed how provider documentation using the Sepsis-3 terminology eliminates the term “severe sepsis,” and discussed that the definition change affected ICD-10-CM code assignment and compliance.
(Definitions and clinical indicators in Sepsis-2 are available here, and definitions for Sepsis-3 are available here. CMS’s definition of sepsis and severe sepsis for the SEP-1 core measure is available here. Please familiarize yourselves with these differing definitions.)
Coding Clinic update
Effective September 23, the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS published advice concerning the documentation and coding of sepsis in light of Sepsis-3. In Coding Clinic, Third Quarter 2016, p. 8, they stated “coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis).”
Coding Clinic went on to write (emphasis mine):
The coding guidelines are based on the classification as it exists today. Therefore, continue to code sepsis, severe sepsis, and septic shock using the most current version of the ICD-10-CM classification and the ICD-10-CM Official Guidelines for Coding and Reporting, not clinical criteria.
In my opinion, this means that if the diagnosis is incorporated by the documenting physician, Coding Clinic is saying ICD-10-CM still embraces the coding of:
- infections without sepsis
- with sepsis but without organ dysfunction
- with sepsis resulting in organ dysfunctions (otherwise known as severe sepsis)
The AHA further stated that if a physician arrives at a diagnosis of sepsis or severe sepsis using whatever criteria he or she wishes, and then documents these terms in the medical record, the coder is to code it, period, end of story.
Alternatively, while Sepsis-3 states that the word “sepsis” requires the presence of acute organ dysfunction, Coding Clinic states that ICD-10-CM does not recognize this clinical concept. Unless the provider documents “severe sepsis” or associates an acute organ dysfunction to sepsis, a code reflecting this concept, R65.20 (severe sepsis), cannot be assigned. Furthermore, if a provider wishes to diagnose and document the term “sepsis” (without organ dysfunction) using Sepsis-2 or other reasonable criteria, the coder is obligated to code it as such in ICD-10-CM.
Coding Clinic, Fourth Quarter 2016
As we discussed in previous ACDIS Blog posts, the fiscal year 2017 ICD-10-CM Official Guidelines were amended to state (emphasis mine):
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.
In explaining this new guideline, Coding Clinic, Fourth Quarter 2016, pp. 147-149 stated (emphasis mine):
While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same—as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded.
Coding Clinic went on to highlight that this concept applies only to coding, not the clinical validation that occurs prior to coding. Coding Clinic emphasized that clinical validation is a separate function from the coding process and the clinical skill embraced by CMS and cited in the AHIMA practice brief Clinical Validation: The Next Level of CDI.
Coding Clinic then went on to say that (emphasis mine):
“a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.”
While I agree that facilities should standardize clinical definitions for clinical and coding validation purposes, note how Coding Clinic gave tremendous power to a payer to define any clinical term any way they want to. This may differ from that of a duly-licensed physician charged with direct face-to-face patient care responsibilities using the definitions of clinical terms he or she learned in medical school or read in their literature.
As such, while our facilities may implement clinical validation prior to ICD-10-CM code assignment, a payer that is not licensed to practice medicine and has no responsibilities for direct patient care, can require a provider or facility to use a completely different clinical definition that serves only one purpose in my mind, and that is to reduce or eliminate payment for care that was properly rendered, diagnosed, documented, and coded.
I’m sure that legal battles will ensue, given this caveat written by Coding Clinic.
Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version. Kennedy is the president of CDIMD-Physician Champions, a Nashville-based group of physicians, coders, and clinicians engaged nationwide as CDI physician advisors, ICD-10 medical informaticists, and DRG and HCC compliance advocates. His opinions do not necessarily reflect those of ACDIS or its Advisory Board. Contact him at email@example.com.
The ACDIS advisory board recently announced a new timeline for applications and elections to serve on the board. Beginning in 2017, the application period will open in mid-January. Candidates will have three weeks to complete their application. A committee will review applications and narrow the pool of applicants down to a group of finalists, who will be selected by a popular vote of the membership in mid-March. The results of the election will be announced in early April and our new board members will be introduced at that time.
Each year four new board members are voted on and four rotate off.
In 2017, ACDIS will open up the application period on Monday, January 9, and it will run through Monday, January 30.
Why should you run for the ACDIS advisory board? ACDIS advisory board members are engaged in the CDI profession. They are forward thinkers, with a positive vision of evolution of the CDI profession. They must be ACDIS national members in good standing and possess the CCDS certification.
ACDIS advisory board members learn from each other and the ACDIS membership, whom they serve. They are content experts who provide insight on our quarterly membership calls, contribute to our position and white papers, and speak on panel sessions at the ACDIS conference.
Above all they care about the CDI profession and want to make a difference in healthcare.
If the above sounds like you and something you want to be a part of, we encourage you to apply.
You can view the complete list of qualifications here, as well as the nomination and election process and frequently asked questions: http://www.acdis.org/membership/boards#advisory.
You will also find a list of presently serving ACDIS advisory board members and their email addresses; they are happy to answer any questions you may have about the requirements, time commitment, and benefits of board service.
We look forward to your application! Please keep an eye out for the official opening of the application period on January 9.
Three different regions in New York started CDI networking outreach in the last month—Westchester (County), Central (regional near Syracuse), and Champlain Valley (connecting CDI professionals on both side of the great lake in Vermont and New York).
In the Champlain Valley their hope is to “start with quarterly telephonic (GoToMeetings) sessions as a means of getting acquainted, exploring CDI educational needs/desires, and networking,” says Kellie B. Halsted, MSN/MHA, RN, CCM, CDI specialist at the University of Vermont Medical Center. (Contact her at firstname.lastname@example.org.)
In Central New York, the group’s first successful meeting took place in Syracuse with great attendance both on site and via conference call, according to Dawn Burr, RN, BSN, CCDS, CDI specialist at Crouse Hospital (contact her at DawnBurr@crouse.org). Burr says the open discussions were “both informative and timely considering the importance of CDI and coder collaboration,” and that they illustrated an opportunity for the group to continue to share tips and invite both team members to the subsequent meetings tentatively slated for April 2017.
In Westchester, more than two dozen CDI professionals joined at Northern Westchester Hospital in Mount Kisco, for a roundtable discussion of CDI productivity/metrics, types of reviews, types of units covered and staffing, use of query templates, and issues as pertaining to query response and varying escalation policies from site to site. The group plans to meet again in January/February. For more information, contact Kerry Seekircher at email@example.com.
- The next Maine ACDIS Chapter meeting is scheduled for Thursday, December 8, from noon-4 p.m., at St. Mary’s in Lewiston. For information, email Valerie Parent, at firstname.lastname@example.org.
- The next St. Louis Missouri ACDIS Chapter meeting takes place Wednesday, January 18, 6:30- 8 p.m., at DePaul Health Center. Kay Piper, inpatient coding educator and member of the AHA Coding Clinic for ICD-10-CM/PCS advisory board will present. For information, contact email@example.com.
- The Massachusetts ACDIS Chapter meets Wednesday, January 25, 11 a.m. to 2 p.m., at Beth Israel Deaconess Medical Center in Boston. The agenda includes Litsa Georgakilas, RD, LDN, CNSC Clinical Dietician II, who will discuss malnutrition risk and assessment tools and Maureen Lira, RN, BSN, CWCN, CHI, who will discuss pressure ulcer staging and progression. Pizza/soda will be provided, however, RSVPs required to Faustino@bmc.org as space is limited.
CMS will hold a MLN Connects® National Provider Call on Monday, December 12, 1:30-3 p.m., Eastern, regarding the 2016 hospital appeals settlement update, which became available to providers with outstanding claims denials as of December 1.
On November 3, 2016, CMS provided details on the process to allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. Details on the settlement process are posted on the Hospital Appeals Settlement Process 2016 website.
To register or for more information, visit MLN Connects Event Registration. Space may be limited, register early.
ACDIS is excited to announce that it is accepting applications for poster presenters at its 10th Annual Conference, to be held May 9-12, 2017, at the MGM Grand Hotel in Las Vegas.
This is a great opportunity for hospitals and other CDI professionals to promote their CDI programs and share them with a national audience. Posters may describe an innovative program process or department expansion, a CDI success story, or an obstacle your team overcame. Posters may not promote a product or service.
If you are interested in presenting a poster, click this link to submit your idea: http://app.keysurvey.com/f/1084930/5a39/
The deadline to apply is December 15, 2016.
Here are some key details you need to know:
- We have room for 40 posters.
- The 2017 Conference Committee will review all applications and select those chosen for presentation. All applicants will be notified of the Committee’s decision by the first week in January.
- Presenters will be given a $200 discount off their conference registrations. If the poster is presented by a team the discount will apply to one member.
- Presenters must be able to spend one hour with their poster during a dedicated poster viewing time. Presenters who do not particulate in the session hour will be billed for the $200 discount. The date and time of the presentation session will be announced at a later date.
- We will approve one application per facility (unless space permits additional posters).
- Maximum poster size requirements have CHANGED. Posters may be NO WIDER than 36 inches and NO HIGHER than 48 inches. Posters exceeding these limits will be turned away and the presenter will be billed for the $200 discount.
We look forward to hearing from you with your poster idea!
Note: This post is part three of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.
by James S. Kennedy, MD, CCS, CDIP
For those who have been reading along with my columns regarding sepsis documentation and coding challenges, allow me to suggest the following strategies to assure a balance of compliance :
- Standardize the definition and documentation of severe sepsis first. Recovery Auditors (RAs) will be looking for records with sepsis codes that do not have R65.20 or R65.21 as a secondary diagnosis as to deny these codes and DRGs. So CDI specialists should work with medical staff to establish standardized definitions; this could incorporate any or all of the following three criteria:
- Change in SOFA score of 2 or more, which means that a new PaO2 of <60 on room air, or a Glasgow Coma Scale of 13 could, by themselves, generate the two points needed to qualify for an acute organ dysfunction. The physician would have to document what the organ dysfunction is, which may not necessarily be an organ failure, given that ICD-10-CM uses the word “dysfunction” rather than “failure” in justifying R65.20, severe sepsis. I suggest this be part of a standardized emergency department assessment template or admission order involving an infection, which means we must reprogram our electronic health record (Epic, Cerner, Meditech, McKesson) to systematize their capture.
- A lactate level of 2 mEq/L or more due to an infection. If the coder requires an organ dysfunction to go with R65.20, the physician would have to document tissue hypoperfusion for which no ICD-10-CM code is in the index to diseases. I suggest coding I99.8, other disorder of circulatory system.
- Any of the criteria described in SEP-1 (which can include a lactate level of 4 mEq/L or more to define septic shock). Note that SEP-1 documentation or order templates must be reviewed in light of what is needed for ICD-10-CM, given that these are signed by a provider, they may be used for coding purposes.
No matter what criteria you use, be sure to coordinate it with your quality and CDI/coding staff so if a physician documents “severe sepsis” or “septic shock,” the SEP-1 algorithm can be implemented. Also, be sure that physicians explicitly link organ dysfunctions to sepsis or preferably use the word “severe sepsis” so R65.20 is not inadvertently missed by the coders. As mentioned above, coders and CDI specialists should work closely with quality to ascertain if any of these organ dysfunctions in the setting of sepsis represent severe sepsis prior to claim submission. Here are my suggestions as to how to handle the current situation:
- Develop a facility-wide definition for sepsis without organ dysfunction. As you see above, many physicians in the United States do not believe that organ dysfunction is required to diagnose a patient with sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, you must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding purposes so that when it is documented by a provider, this statement can be used to disprove the RA’s denials. These will be handy if you are appealing beyond the first level.
- Remind the RA that the ICD-10-CM guidelines is part of HIPAA and that coding is based on provider documentation, not the RA’s interpretation. I’m sure that all of our contracts with private-payers state that we will comply with federal law, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign ICD-10-CM codes based on provider documentation and that Coding Clinic, First Quarter 2014, pp. 16-17, states that “the official guidelines are part of the HIPAA code set standards.” We don’t want RAs to violate HIPAA or our contracts with payers, do we? This may require that a hospital attorney or compliance officer weigh in, given that RAs have been known to deny codes based on provider documentation.
- Be on the lookout for Coding Clinic advice clarifying this issue. Coding Clinic for ICD-10-CM/PCS addressed some aspects of this in its fall 2016 publications for the third and fourth quarter. In addition to this advice, you may wish to submit your own cases to Coding Clinic advisors to see how they comment.
Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version.
A couple of weeks ago, the 3,500th person to hold the CCDS certification passed the exam. We are delighted to introduce you to Jaime Brown, BSN, RN, CCDS, a CDI specialist at Ochsner Health System at Jefferson Parish, Louisiana. Please join us in congratulating her on this tremendous accomplishment!
Before becoming a nurse, Brown had a career as a commercial loan underwriter for a major financial institution before obtaining her bachelor of science in nursing. She worked in oncology for seven years and has been in CDI for three years.
“CDI has been an awesome professional opportunity,” says Brown. “I have had the opportunity to increase my clinical knowledge, learn the financial side of healthcare, and be a part of the formative years of this unique profession all while having the flexibility to be there for my children when they need me.”
Brown has two children—daughter, Kaitlyn, age nine, and son Cody, age seven. She enjoys her free time trying new restaurants and catching up with family and friends.
ACDIS: Why did you get into this line of work?
Brown: I was looking for a change and saw the job posting. It peaked my curiosity because it was the “business” side of nursing.
ACDIS: What has been your biggest challenge?
Brown: The biggest challenge for me is that there is usually not a straight answer to a question. Each admission is different and no two clinical scenarios are the same.
ACDIS: What has been your biggest reward?
Brown: The biggest reward has been seeing the financial and quality impact I can have through my chart reviews. It’s always nice to query for the only MCC on a record or clarify something with a provider so that their record is accurate. Although I am not at the bedside, I can still make a difference. I also feel like I have learned more from a clinical aspect in the last three years in CDI than I did in my seven years at the bedside.
ACDIS: How has the field changed since you began working in CDI?
Brown: When I started in CDI, we were still in ICD-9. Most people had not heard about CDI. We worked strictly with inpatient records. Today, we code in ICD-10. Other medical professionals have heard about our role and providers are looking to expand our role. My employer now has an additional program specifically for reviewing ambulatory records. (Click here to learn more about that program.) I can only imagine where CDI will be in another three years.
ACDIS: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on CDI Talk or through ACDIS?
Brown: One of our primary responsibilities as CDI professionals is to educate providers. When I started, I often wondered if we would ever educate them enough to the extent that we would be out of a job. I have learned rather quickly that CDI will always be in demand because the rules are so complex and there are always new providers to train. If you miss a query opportunity, it is a learning opportunity.
ACDIS: What piece of advice would you offer to a new CDI specialist?
Brown: There is a learning curve in this job like none other. Just when you think you understand the concepts, you will be faced with a situation that makes you question your new found understanding. Confidence and understanding come with time. Be patient.
ACDIS: If you could have any other job, what would it be?
Brown: I would love to be a personal financial advisor, managing everyday household finances. I love a spreadsheet and have serious organizational skills. I make a spreadsheet for just about everything, including vacations!
ACDIS: What was your first job (what you did while in high school)?
Brown: I was a store clerk at Afterthoughts Boutique in high school. I pierced ears and sold jewelry and hair accessories.
ACDIS: Can you tell us about a few of your favorite things:
- Vacation spots: Chicago and Florida beaches
- Hobby: Dining at new restaurants–there are always new places to try in New Orleans
- Non-alcoholic beverage: Diet Coke
- Foods: Boiled crawfish and steak
- Activity: Hanging out with my kids and friends
I was looking through old drafts of blog posts and came upon some notes from ACDIS blogger Linda Renee Brown. She wrote that sometimes CDI professionals look for expert advice and that once they identify it, they follow it to the letter. But “What’s an expert?” she asked, and went on to quote an old teacher who broke the term down into its component parts stating that a “ex is a has-been and a spurt is a drip under pressure.” Clearly the teacher (and Brown) meant that anyone can self-describe as an expert but its up to us as individuals to do the extra research and ensure that the advice provided is actually sound.
In clinical documentation, as in any professional field, there exist any number of possible expert resources from which to draw advice and information. Programs instituted on the advice of a consulting firm may have benefited from its initial education and training. Those with extensive electronic health records and eQuery systems no doubt learn from the expertise of its designers and staff as well as the technological tools and resources available within the system.
All types of other experts also exist. The person who hired you, perhaps. The co-worker who offered you a kind word and simple advice which resonates even today. The coder who continues to lend you an ear as you try to decipher the latest recommendations from Coding Clinic.
Yes, even various publications can provide a certain amount of expertise. Coding Clinic of course serves in this role, as the AHA represents one of the four cooperating parties governing code assignment. So, too, does AHIMA and it’s publications, similarly due to its participation on that four-corporation governing body as well as its more than 75 year legacy representing the health information management field.
And, of course, we believe that ACDIS provides expert advice as well. It is the only association totally focused on the daily activities of those working to ensure the complete integrity of the medical record. That’s not why I believe ACDIS’ advice equals sound advice, however. Actually, I believe the strength of the education, insight, interpretation, and analysis provided to its members comes directly from the collaborative nature of the association itself. We depend on the input and opinions of our members. We bring those thoughts and ideas forward in a number of ways, through the Journal, ACDIS Radio, our quarterly conference calls, and more. We encourage your feedback and suggestions on those items and we continue to grow and reassess the state of the profession through your eyes.
As Brown wrote in her notes, “if you’ve been working in CDI for any length of time and you’ve allowed yourself—and have been allowed—to think for yourself and act for yourself and make judgments based on what you know in your core to be right, you don’t need an expert. You are headed in the right direction.”
Whether you’re looking for advice on a particular topic or have an opinion, thought, or CDI success story reach out to your peers here or via the ACDIS Forum. By sharing our expertise we all benefit.
As we prepare for the Thanksgiving holiday with family and friends and give thanks for all of our blessings, it is important to be ready with appropriate codes to accurately document any holiday mishaps.
Here’s a short list to help you quickly and efficiently communicate the information required to file a complaint claim:
For incidents with a fresh (live, not saucy) turkey:
- W61.42 Struck by turkey
- W61.43 Pecked by turkey
- W61.49 Other contact with turkey
For general kitchen and meal prep actions:
- Y93.G1 Activity, food prep and cleanup
- Y21.2 Undetermined event involving hot water
- Y93.G3 Activity, cooking and baking
For dealing with obnoxious Uncle Leo who insisted on pushing his way to the dessert table:
- Y04.2 Assault by strike against or bumped into by another person
For your mother-in-law’s criticism of the lumpy gravy (which we know was not lumpy):
- Z63.1 Problems in relationship with in-laws
For activities post-meal to work off effects of R63.2 Polyphagia (overeating):
- W21.01 Struck by football
For Friday morning:
- W72.820 Sleep deprivation
Editor’s note: The ACDIS office will be closed for the Thanksgiving holiday and will reopen on November 28. Please send along your most common documentation improvement opportunities either in the comment section or via email to firstname.lastname@example.org.