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Guest Post: CDI Reporting Structure

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Cara Belnap, MS, RN, CCDS

As I embark on the start-up of a new CDI program for my health system, I face a number of operational decisions that have to be made. One of which is reporting structure.

According to the CDI Week Industry Survey, 45.5% of respondents report to HIM/coding, followed by case management (23.5%) and finance/revenue cycle (17.9%). I would propose a new reporting structure—our own. Hospitals whose budgets only allow for combining CDI duties with other functions then it may make sense for the CDI to report to that department, and true enough that many of our duties and functions cross over into many departments within the health system.

Do CDI programs report through to HIM/coding, because that’s the best fit or are we traditionally house CDI staff in that department for fear of conflict if we don’t.  In the book, Using Conflict in Organizations, authors C. DeDreu & E. Van de Vliert propose that “conflict is a way of confronting reality and creating new solutions to tough problems. Conflict, when well-managed, breathes life and energy into our relationships and strengthens our interdependence and makes us much more innovative and productive.”

CDI staff do work very closely with HIM and coding staff and lean very heavily on each other for support, functions, staff and provider training/education, workflows, and policies/procedures. That would still be the case if we were two separate but equal departments. Collaboration and communication is an essential skill set for any CDI specialist. Perhaps if CDI specialists, whether coder or nurse by background, were housed in their own department, we would lessen some of the ongoing debates about roles and functionality. We would simply be CDI specialists.

The ideal reporting structure, in my opinion, is a CDI director/manager who reports to a chief medical officer (CMO) or chief financial officer (CFO). This allows the CDI department to set its own goals, mission, and vision, all while collaborating alongside their health system counterparts of HIM/coding, case management/utilization review, quality, revenue cycle, nursing, ancillary departments, non-physician providers, and physicians.

I know this can be a controversial topic, so I’d love to hear what you have to think.

Editor’s Note: Cara Belnap, MS, RN, CCDS, Regional Operations Manager, CDI for Samaritan Health Services contributed to this post. 

News: CMS’ first round of end-to-end testing a success

news blocksAdd another nail in the “delay ICD-10 because the industry isn’t ready” coffin.

CMS declared its end-to-end testing week from January 26 through February 3 a success. A total of 661 volunteers submitted 14,929 test claims, with CMS accepting 81% (12,149 claims).

CMS rejected 13% of the claims for reasons not related to ICD-10, such as:

  • Incorrect National Provider Identifier
  • Dates of service outside the range valid for testing
  • Invalid HCPCS codes
  • Invalid place of service

Three percent of claims contained an invalid ICD-10-CM and 3% had an invalid ICD-10-PCS codes, leading CMS to reject the claims.

More than half (56%) of the claims fell under professional services and 38% were institutional claims. Suppliers submitted 6% of the claims.

CMS identified zero issues related to professional and supplier claims and stated that none of the claims were rejected because of front-end submission problems.

CMS did find one system issue related to institutional claims, but it affected fewer than 10 total claims. It will fix the problem before the next end-to-end testing week April 26-May 1.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog.

Book Excerpt: Open-ended queries

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The Physician Queries Handbook

The following is one example of a possible open-ended query:

“Dear Dr. Phil,

The patient’s sodium (Na) was 129, the progress notes indicate low serum sodium level, ‘¯Na.’ An order was written to place the patient on .9NS. Please clarify the associated diagnosis being treated.”

In this scenario, the physician is highly likely to respond and document “hyponatremia.”

The 2013 ACDIS/AHIMA query practice brief describes an obtruded patient with a history of vomiting treated for pneumonia. The open-ended query asks the type/etiology of the pneumonia, which, in that example, most likely result in a response of “aspiration pneumonia.”

Sometimes an open-ended pneumonia query can be problematic, however. For example,

“Dear Dr. Oz,

The patient’s progress note indicates he is being treated for pneumonia with vancomycin. Please clarify the type of pneumonia being treated.”

Although the wording of this query does a great job of not leading, it may not result in the most clinically appropriate answer (methicillin-resistant Staphylococcus aureus pneumonia). In many cases, the physician will respond “bacterial pneumonia,” which will still lack the specificity needed for coding purposes. Other physicians may respond “complex” or severe pneumonia.

In such situations, the CDI specialist would have to use a second query in an attempt to further clarify the issue. The use of open-ended queries works best when the potential answers are limited, involve commonly used terminology, and when physicians essentially understand the type of documentation required.

 Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

Reminder: New CEU requirements for CCDS recertification

I'll never wear this pin but tomorrow I'll walk through the testing process.

The number of CEUs required for recertification will go up to 30 on March 1.

With February coming to a close, we wanted to take a minute to remind everyone about some upcoming changes with the CCDS certification.

Effective March 1, the price of a non-member CCDS exam will go up to $355. There is a new application on our website under the “How to Apply” tab.  The number of CEUs required for recertification will go up from 20 to 30. There is a new application and a new version of the CCDS Candidate Handbook on the website.

There are several ways to obtain CEUs towards your CCDS recertification, including our CDI Journal quiz, participation in ACDIS quarterly conference calls, ACDIS local chapter meetings and conferences, and HCPro CDI Bootcamps.

Those whose CCDS expiration dates fall close to March 1, 2015 change in requirements may need additional assistance. Rest assured we will work with you to manage the change.

ACDIS sends reminder notices 90, 60, and 30 days prior to your CCDS expiration. To ensure you receive these notices make sure to communicate any email or mailing address changes to us. You may do this via the Contact Us link on the ACDIS web site. It’s your responsibility to notify ACDIS of any address changes and ultimately, your responsibility to know when your certification expires.

If you have questions or concerns, please contact Penny Richards.

TBT: Documentation for the physician and the hospital

Take a look at your emergency room records to ensure that E/M efforts are appropriately captured

We need to make the physicians allies of our CDI programs.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, we’re looking at an article from our July 2013 “CDI Journal” titled “CDI goal: Documentation for the physician and the hospital”, originally published in July 2013, in which Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS discusses the goal of the CDI program and why we need to stop feeding the ‘EHR reimbursement beast.’

What is the goal of a CDI program? Most of the ones I see still focus on DRG optimization. Unfortunately, they are not preparing for ICD-10 and not supporting the physician with his or her professional billing. Very rarely do I hear about programs that help with the core question, “What’s in it for the physician?” And that’s our biggest problem. We need to make the physicians allies of our CDI programs, and right now they are not. Instead, they are often targets of our queries.

So how do you make the transition? By changing physician behavior one encounter at a time and letting them see that additional documentation helps with their professional billing.

Recently I spoke with a surgeon missing some important documentation from his consult notes. I provided him information about history of present illness (HPI) and why it was important to his evaluation and management (E/M) billing. He thanked me, but his words were more telling than his gratitude: “This is great information. I’ll do better next time so I can continue to successfully feed the EHR reimbursement beast.”

Think about it: Isn’t that what we’re really doing when we’re asking for CC/ MCCs, “feeding the EHR reimbursement beast” with a diagnosis? To change this paradigm, we need to ask about the context, not just the diagnosis.

When reviewing the charts, consider asking:

  • What is the clinical context in the chart supporting the diagnosis of record?
  • Does the HPI in the history and physical (H&P) support the diagnostic assessment of the physician, corroborated by nursing documentation and chosen plan of care?
  • Is the physician’s clinical rationale, judgment, and medical decision-making in arriving at the diagnosis using available diagnostic information clearly depicted in the chart? Or is it instead implied through sporadic bits and pieces of documentation in the EHR?

Unfortunately, EHRs and its “point and click” and “cut and paste” features often detract from the accurate capture of the physician’s clinical judgment, thought processes, and medical decision-making—all of which validate the physician’s clinical diagnosis.

Interpretation of diagnostic test results and their clinical significance plays a key role in the establishment of medical necessity for any patient encounter. The physician needs to mention the diagnostic test results in his or her assessment, interpret them, and make a statement about how the abnormal values relate to the diagnosis or diagnoses that appear in the daily progress notes.

Here’s an example for a sepsis patient: “Temperature trending down to 101, white blood cell count 15, bands are 12, patient still a bit confused but showing marked improvement from admission, respiratory rate now 19, slowly responding to the IV antibiotic regimen recommended by infectious disease. Anticipate discharge when chest x-ray improves and white count comes down a bit.”

Do these clinical indicators and picture paint a picture of a patient recovering from a bout of sepsis? Yes, they do, and they also lend credibility to the hospital and physician reporting a sepsis code.

A chest x-ray might show atelectasis, but the doctor needs to acknowledge it and make a notation. When the physician does acknowledge it, that’s one point on his or her E/M level. For example: “Atelectasis, chest-x-ray still shows increased chest haziness, patient encouraged to use incentive spirometry.”

You don’t need 20 sentences, just a statement of fact of how the doctor came up with the conclusion of atelectasis.

Isn’t this what we as CDI specialists really should be doing? Our goal is to solidify the documentation for medical necessity and the physician’s work. We need to demonstrate efficient and effective treatment measures, which we’ll need under value-based purchasing. It’s not just about feeding the “reimbursement EHR beast,” which is unfortunately a perceived byproduct of our CDI efforts by a growing number of clinicians.

Ultimately, we should strive to show an accurate clinical picture of the patient’s presentation and response to treatment to complement the documented clinical diagnoses. Describing the patient’s true clinical picture as opposed to generalized diagnostic statements is the key to establishing medical necessity for admission as well as the patient’s continued stay.

Q&A: Principal diagnosis assignment for UTI versus encephalopathy?

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Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?

A: Assigning the UTI as the principal diagnosis makes the claim more vulnerable to denial than the encephalopathy does. If you look at the big picture, a UTI does not support inpatient care. Additionally, there is no coding rule that requires the UTI to be coded as the principal diagnosis because it is not part of an etiology/manifestation pair. According to the Uniform Hospital Discharge Data Set (UHDDS) definition of the principal diagnosis, it is the condition (after study) that occasioned the admission.

The inclusion of the term “after study” is often what throws off accurate principal diagnosis assignments, because people don’t look at the totality of the coding guidelines. At times symptoms present at the time of admission require further “study” in order for the physician to find a definitive diagnosis.

Symptoms may be reported when no other definitive diagnosis can be identified, but this this leads to assignment of lower weighted MS-DRG, less specificity in assignment, and vague medical record overall. So, the preference is to avoid reporting symptoms as a principal diagnosis.

For example, the provider often describes encephalopathy instead of diagnosing it; documenting the patient as having altered mental status. If the patient has encephalopathy, they usually need inpatient care, not just supportive care, because the goal is to stop the progression of the encephalopathy by finding and treating the cause.

When looking at the record, think about the patient’s continuum of care. Ask yourself, at what point is the patient safe for discharge? In this case, would it be when the physician treats the encephalopathy or the UTI? Clinically speaking, this patient would be safe to discharge when he or she returns to baseline in mental functioning, not when the UTI is resolved.

A UTI (even a complicated one) can be treated in the outpatient setting. Also, look at the totality of the record: Was the focus of the treatment the “altered mental status” (was a CT scan performed, etc.) or was it on a UTI?

Not every patient with a UTI has encephalopathy. However, if they are sick enough to need inpatient care, they likely have more going on.

Encephalopathy also isn’t as big of an audit target as UTI is. Yes, auditors do deny encephalopathy claims since it is an MCC—but so is severe malnutrition, acute respiratory failure, etc. Think about what type of claim is usually more vulnerable.

When the UTI is the principal diagnosis and encephalopathy is the MCC, there is only one MCC in the record. When encephalopathy is the principal diagnosis, the UTI can be added as a CC.

When the encephalopathy is a principal diagnosis, auditor denials are not the issue; the real concern is with the documentation not supporting it as a reportable condition. Think of encephalopathy as on a continuum with acute confusion, delirium, and encephalopathy, because everything isn’t encephalopathy. It can, oftentimes, only be accurately diagnosed when working backwards asking, “when does the patient return to baseline,” and “what treatment was necessary?”

It would be interesting to find out if the infection control team supports the diagnosis of a UTI, as, often, the UTI is a process of elimination diagnosis because the urine is “dirty.” But it doesn’t always clinically meet the definition of a UTI by Centers for Disease Control guidelines. If that is the case, what is the provider really treating? They could be treating the altered mental status. However, that is only a symptom, and the goal of CDI is to find a diagnosis associated with that symptom. That diagnosis could be acute confusion, delirium or, in some cases, encephalopathy.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass, contributed to this post.