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ICD-10 Tip of the Week: Prepare your physicians

Broaden the scope of your CDI efforts by looking for medical necessity indicators and increasing proactive efforts to protect the record against audit risks.

Get physicians involved early. If you haven’t already, start now.

Physician engagement is already something many CDI programs struggle with—95% to be exact, according to the American Hospital Association and Executive Health Resources’ February 2015 CDI Trends Survey. The transition to ICD-10-CM/PCS isn’t going to make it any easier. But there is one thing you can do to help facilitate the transition for your physicians: Prepare.

According to Robert S. Gold, MD, CEO of DCBA in Atlanta, physicians are:

  • Educated, so give them definitions
  • Scientists, so give them data
  • Proud, so illustrate how they rate against their peers (This is a great motivational tool to get physicians improving their documentation. Check out sites like for your physician’s rankings, and compare to other area physicians.)
  • Results oriented, so give them a goal.

Get physicians involved early. If you haven’t already, start now. Employ medical staff leadership or the facility’s chief medical officer on the CDI steering committee. This individual should establish overall program goals, and expectations for physician response, involvement, and training. Higher level involvement also demonstrates value of the CDI program, and may encourage physicians to recognize CDI benefits.

Many facilities employ CDI specialists as frontline educators for physician ICD-10 documentation training. Any number of training tactics may prove to be successful. Find the method that works best for your program. For example, try a multidisciplinary approach:

  • Incorporate ICD-10 documentation tips into physician newsletters
  • Present targeted education during short PowerPoint presentations
  • Craft ICD-9 to ICD-10 crosswalk tip sheets

Some facilities train their staff using their query forms. To do this, review current documentation trends of your facility’s top 10 to 20 MS-DRGs and review against new ICD-10 documentation requirements. Identify areas for improvement and begin to incorporate these elements into existing physician queries and educational presentations.

If your physicians already have difficulty documenting patient acuity for MS-DRGs, your top priority should be to evaluate the quality of physician documentation and assess the need for additional physician education and practical training. Assess the top diagnoses and/or product lines to help prioritize documentation efforts. Determine how many unspecified ICD-9 codes your facility already reports and target queries in these areas for additional specificity.

An effective ICD-10-CM/PCS transition requires teamwork and communication. Seek physician input, and set physician expectations and goals regarding ICD-10. Physician involvement in these discussions helps raise potential conflicts or concerns early on, eliminating confusion later. Also, make sure physicians know whom they can go to if they have a question, and encourage them to do so. A positive relationship with physicians will make the transition to ICD-10 that much easier.

Editor’s Note: The previous information was compiled from a variety of ACDIS resources. For additional information, check out The Physician Queries Handbook, Second Edition by Marion Kruse, MBA, RN; The Clinical Documentation Improvement Specialist’s Guide to ICD-10 by Jennifer Avery, CCS, CPC-H, CPC, CPC-I and Cheryl Ericson, MS, RN, CCDS, CDI-P; or read the following articles from the CDI Journal:

TBT: ICD-10 prep: Dig into documentation

Look for all the clinical indicators in the medical record to ensure appropriate sequencing.

Determine conditions the providers most often treat, then evaluate to see what additional information providers will need to document for ICD-10-CM.

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 the January, 2012 CDI Journal, “ICD-10 prep: Dig into documentation. Start by reviewing your most frequently reported conditions.”

With all of the attention around the increased specificity of ICD-10-CM codes, facilities are concerned that documentation will lack sufficient detail. And as CDI specialists know, physicians don’t always provide enough information for coders to choose the most specific ICD-9-CM code.

Instead of panicking, determine which conditions the providers most often treat, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Massachusetts. Then evaluate the documentation to see what additional information providers will need to document with the added specificity for ICD-10-CM.

“Identify the information that providers can document now,” McCall says. The additional information may not help with ICD-9-CM coding, but providers will already be documenting those details when ICD-10-CM rolls around.

“You can’t use the new codes now, but you can look to see what additional documentation you will need,” McCall adds.

Some things that weren’t important in ICD-9-CM will be needed in ICD-10-CM. For example, if a patient comes in with acute pancreatitis and is also identified as being alcohol dependent, coders can assign separate codes in ICD- 9-CM for acute pancreatitis (577.0) and a code for alcohol dependence (303.xx or 305.xx) with no need to identify whether the conditions are interrelated.

However, in ICD-10-CM, if coders get this same documentation, it will prompt a query to the provider because there is a more specific combination code that can be assigned to identify the conditions being related—code K85.2 (alcohol-induced acute pancreatitis).

Q&A: Are mental function tests necessary for an encephalopathy diagnosis?

Ask your CDI question in the comment section.

Ask your CDI question in the comment section.

Q: I am working on a denial of 348.39 (toxic/metabolic encephalopathy). The auditor asserts that mini mental status exams are required for this diagnosis. Is there documentation of that requirement anywhere? Do all payers ask for that?

A: Glenn Krauss: A mental function test is not necessary if the progress of the encephalopathy is described by the physician and nursing staff. Herein lies the challenge of the clinical validation that payers capitalize on.

CDI specialists are taught to query for “encephalopathy” and “sepsis” in any clinical scenario where the patient exhibits a change in mental status. Typically the CDI specialist queries the physician for further specificity on these diagnoses, the physician responds to the query and documents the diagnosis, and the diagnosis appears once or twice in the progress notes without any documented clinical thoughts as to the contributing factors, relationship to other disease progressions, or abnormal clinical values. All we have is the word “encephalopathy” as a conclusory statement with little or no discussion of the clinical facts of the case.

In today’s cutthroat environment between providers and payers, conclusory statements without any relationship to the case are not sufficient for accurate depiction of clinical acuity and assignment of ICD-9 (soon to be ICD-10) codes.

Consider the diagnosis of acute renal failure: It was so over assigned and possibly over-documented through the CDI query process that CMS downgraded the diagnosis to a CC. This will likely be the case with encephalopathy. CDI specialists should encourage physicians to expand on documentation of their thought processes and clinical judgment, with brief synopsis of clinical rationale and patient’s response to therapy, whether it be improvement in the underlying diagnostic precipitation of the encephalopathy or correction of a drug-drug interaction, and the subsequent improvement or lack thereof of the encephalopathy.

I sometimes wonder if CDI programs are an asset or liability to an organization, contributing to increased denials and additional work of appeals with the capture of CCs and MCCs that are subsequently refuted on the basis of clinical validation by the Recovery Auditors and insurance companies.

A: Lee Fanning, MD: The diagnosis is made when patient comes into the hospital and is related to dysfunction of the brain due to physiological issues (i.e. metabolic) causing the dysfunction. A routine description of how the patient is improving or not, compared to how they were on admission, is enough to determine the patient’s progress or lack thereof. It sounds like those making this denial overanalyzed the need for level of mental status from the physician, when it is often found in the nurse’s notes and usually ordered in time increments consistent with the severity of the acute encephalopathy. I think, with a thorough review of nurses notes, you will find that both neuro function and mental status review can be found to fight the denial. A specific mental function test is not necessary if the progress of the encephalopathy is described by the physician and nursing staff. I would strongly resist this type of clinical pigeon holing.

I don’t think CMS downgrading certain DRG diagnoses, like encephalopathy, because it’s over used by physicians, matters in the long run. Medicare will continue to cut and slash reimbursement in both the coding world and the medical necessity world through the Recovery Auditors and downgraded DRG reimbursement payments. Reducing physician and hospital payments is appealing to both political parties as it decreases the need to ask Congress for more money for our burgeoning cost of health care. In my opinion, the Recovery Auditors are here to stay.

Editor’s Note: Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, Executive Director of the Foundation for Physician Documentation Integrity; and W. Lee Fanning, MD, FACP, Medical Director of Utilization at Carolina’s Healthcare System, responded to this question. Contact Krauss at Contact Fanning at

Conference Update: Speaker Q&A

There is so much to learn from the annual ACDIS National Conference.

The annual ACDIS Conference is in 27 days.

We’re less than a month away from the annual conference! And to help you narrow down your final itinerary, we’re previewing a handful of speakers to help you get a feel for the sessions we’ll be offering. This week, we spoke with our keynote speaker, Donna Smith, RHIA, senior consultant for 3M Health Information Systems, who will present, “Analyzing the Realistic Impact of ICD-10 on APR-DRGs.”

Q: Why is it critical for CDI professionals to understand how ICD-10 will affect APR-DRGs?

A: Historically, the focus has been on MS-DRGs. But, as more states switch to the APR system for their Medicaid population, it’s important to understand how it works. I will review the classification and explain how a patient might advance from one risk of mortality (ROM) and severity of illness (SOI) to another. I’ll also talk about, overall, what kind of changes and shifts were are going to see and how that will affect individual programs.

Q: How is your topic important for everyone in the CDI role, regardless of professional background?

A: Even if a state Medicaid program does not use APR-DRGS for payment, many organizations use the classification system to assess SOI/ROM. Most CDI specialists are interested in those scorings. Severity and risk are calculated a little differently with MS-DRGs. It changes how the case is paid and also indicates complexity of patient care. Both are interrelated and show how sick a patient is.

Q: As an RHIA, how does your perspective differ from other professionals performing the CDI role?

A: As a consultant, I see many different CDI programs. The best teams work as a group and have diverse backgrounds and experience in both nursing and coding. Personally, I bring the coding background. My clinical knowledge is good, and I can talk the talk. But the nurses are the ones who have the clinical understanding.

Q: What do you think is the most important quality for a CDI professional to have?

A: The number one thing is an interest in making sure that patients’ status or condition are accurately reported. That is their goal. They must interact and query physicians to get accurate documentation, so they can capture the clinical condition for a more accurate representation in either the MS or APR classification system.

Q: Why do you think attending the ACDIS conference is important?

A: I have been attending and speaking at the conference for a few years, and it has been really interesting to see the progression of ACDIS. CDI specialists can gain a lot of valuable information just by attending. I always enjoy going to the breakout sessions and finding out new information, and seeing how facilities are doing and how they are advancing their programs.

Book Excerpt: Multiple-choice queries

The Physician Queries Handbook

The Physician Queries Handbook

The 2013 ACDIS/AHIMA query practice brief continues to support the use of multiple-choice queries and provides further guidance. It reinforces the importance of including “clinically significant and reasonable options” and including the clinical evidence.

Many in the CDI industry were concerned about the use of multiple-choice queries when the reasonable choices were limited. For example, CDI specialists struggled on how to use a multiple-choice format when querying for a low serum sodium level. What diagnoses can they list in addition to hyponatremia? Hypernatremia would not be reasonable. Many were concerned that by listing only one diagnosis, they could be accused of leading the physician, even if “other” and “clinically undetermined” were used.

The 2013 ACDIS/AHIMA query practice brief recognizes that in some clinical situations, diagnoses may be limited. To resolve the concern, it suggests that queries should include additional options, such as “clinically undetermined” and “other” with space for the provider to add additional verbiage.

In some situations, such as the hyponatremia example given earlier, it may be appropriate to add options such as “not clinically significant.” This would also be a good choice when querying about radiological and other test findings. Lastly, adding an option of “integral to” (and therefore should not be separately coded) may be appropriate. Some examples of when to consider the “integral to” option include:

Clarifying the presence of a surgical complication: A nicked bowel that occurred while removing dense abdominal adhesions is generally not inherent; however, sometimes surgeons will state it is due to the location of the adhesions.

Clarifying whether a diagnosis is an expected outcome (i.e., integral to) a surgery:

  • Ileus 48 hours post-laparoscopic appendectomy is not inherent, as it does not occur in most patients
  • Ileus 24 hours post-colon resection is inherent, as it occurs in most patients
  • Acute blood loss anemia after joint replacement procedures: the answer tends to vary among surgeons

Clarifying whether a diagnosis is integral to or inherent to the specific disease process: Cerebral edema is not inherent in cerebral hemorrhage, as it does not occur in most patients with this diagnosis

Conversely, hypoxemia is inherent in acute respiratory failure, as it occurs in all patients with respiratory failure.

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

TBT: Outpatient endeavors: Top CDI tactics for outpatient surgery readiness under ICD-10

CDI programs need to work across disciplines to advance documentation efforts into areas of medical necessity and severity of illness, risk of mortality.

Many outpatient areas can benefit from documentation improvement efforts.

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 the October, 2014 CDI Journal, “Outpatient endeavors: Top CDI tactics for outpatient surgery readiness under ICD-10.

The volume of outpatient care continues to rise. In the United States in 2010, there were 100.7 million outpatient department visits, 128.7 million ED visits, and 51.4 million procedures, according to Centers for Disease Control and Prevention FastStats. Those visits translate to a lot of outpatient medical and procedural documentation.

According to a recent article in American Medical News, “more than half of surgeries are outpatient.” Additionally, physicians are increasingly performing many procedures on an outpatient basis. So let’s take a look at some common areas that might benefit from documentation improvement efforts, particularly with an eye toward ICD-10-CM needs.

Cataract surgery documentation

More than 99% of eye surgeries are now performed as outpatient procedures, with cataract surgery listed as one of the most frequently reported diagnoses.

There are specific coding concerns with this diagnosis that need to be addressed for a smooth transfer to ICD-10-CM. There are far more non-essential modifying terms in ICD-9-CM, including:

  • Anterior cortical
  • Anterior polar
  • Black
  • Capsular
  • Central
  • Cortical
  • Hypermature
  • Immature
  • Incipient
  • Mature
  • Cortical
  • Immature
  • Incipient

The ICD-10-CM codes provide close to 30 essential modifying terms for cataracts and more than 100 codes to include laterality. Essential terminology is required for ICD-10-CM within the physician documentation to secure a detailed diagnosis. CDI specialists can help create forms and documentation tip sheets reminding physicians to capture these terms now, far ahead of ICD-10 implementation.

Identifying the gaps in documentation that will occur for cataract surgery, especially to avoid assignment of a not otherwise specified (NOS) code, prevents vague coding decisions and costly gaffes. Consider a physician’s documentation that only states the patient had a “significant cataract.” A CDI specialist would be required to query the provider to obtain additional specificity as well as laterality; otherwise, coders would simply assign a NOS code. So start a sample review of cataract procedures by physician and coder to identify documentation shortcomings.