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Guest Post: Restoring the Rembrandt

Rembrant self portrait 1628.

Rembrandt self portrait 1628.

Four years ago, in these very pages, during CDI Week, I wrote about the art of CDI, comparing what we do to creating a fine painting. I wrote about seeing the patient in my mind and trying to create the fullest possible portrait of who they are and what they represent. At the time, I had been a CDI specialist for a few years and had progressed beyond the overwhelming challenge of learning and absorbing this role to being on the cusp of taking a leadership role in our profession. A lot has changed in the past four years, not only for me, but for our profession. I think it’s time to consider a little touching up of our portrait.

Back then, most of us looked at DRGs. Most of us looked at CCs and MCCs. Most of us looked at reimbursement. Many of us focused on Medicare.

Some CDI specialists grabbed for the low hanging fruit and called it a day. We might have talked about severity of illness and risk of mortality. We might have talked about quality and patient safety indicators and hospital acquired conditions and value based purchasing. We might have talked about reviewing all payors. We might have talked about what seemed at the time to be right on the horizon, ICD-10.

Some of our paintings were Rembrandts and some of our paintings were Elvis on black velvet. When we paint our portrait, are we painting from the heart, or we painting by number? Are we taking what we see and looking for every nuance, making the shading just right, or simply filling in the spaces that someone else drew for us?

I think many, many CDI programs have done their darnedest to be the former, and not the latter. I’m very proud of CDI teams that have moved beyond the low hanging fruit and have aspired to, and achieved, greatness. Do we still want to capture those CCs and MCCs? Of course we do. But what we really want to do is paint a masterpiece. Or more exactly, to help the physicians paint that masterpiece so that anyone can recognize what they’ve done as a great work of art. Because healthcare, just like CDI, is an art as well as a science. People are not just a collection of body parts and organ systems. After all the blood tests and radiology exams and other diagnostics, it’s the art and the skill of the physician that makes the difference between diagnosis and symptom, between recovery and illness. And we are here to capture the essence of that art and skill, carefully documented in our medical record. We’ve moved beyond clinical documentation improvement to a world of clinical documentation integrity.

We’ve grown so much as a profession. Thousands of highly skilled nurses and coders have transitioned into our world, and many more are coming.  Certification in CDI as a CCDS or CDIP has validated the expertise of many experienced CDI professionals. CDI teams, under dynamic leadership that understands the value we add to our institutions, have gone far beyond the easy pickings of the CC and the MCC.  They have carefully evaluated the needs of their facilities and trained their focus on severity and mortality and quality and readmissions and medical necessity and clinical indicators and observation cases and developing tools to help their physicians document and a thousand other areas that meet their organization’s current needs and will meet their future needs. They paint a picture with colors so vibrant, so real, so intense, you won’t know if it’s a photograph or a portrait.

Appreciate the skill of the artists, both healthcare provider and clinical documentation expert.  Because they’re grand masters.

Book Excerpt: Pay for performance basics

The Physician Queries Handbook

The Physician Queries Handbook

In 1999, the Institute of Medicine reported that medical errors caused more than 50,000 preventable deaths each year, with an associated cost of $20 billion. The 2006 Institute of Medicine report “Preventing Medication Errors” recommended:

“incentives… so that the profitability of hospitals, clinics, pharmacies, insurance companies, and manufacturers (are) aligned with patient safety goals;…(to) strengthen the business case for quality and safety.”

When healthcare providers receive incentives for performing better— that is, providing better care in a more cost-efficient manner and meeting pre-established targets for the delivery of healthcare—along with —disincentives, such as eliminating payments for negative consequences of care (medical errors) or increased costs, the quality of care for Medicare beneficiaries will improve. This is a fundamental change from the traditional fee-for-service and DRG payment methods. The various approaches used to accomplish this agenda are discussed below.

Signed on February 8, 2006, the Deficit Reduction Act (DRA), required CMS to identify hospital-acquired conditions (HAC) that: [more]

TBT: Pneumonias—or not

Robert Gold

Robert S. Gold

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. We’ve picked up the theme, going back into our archives to highlight some salient tid-bit. This week, we took a look at an ICD-10 article from our April 2014 CDI Journal, “Watch for these ICD-10 coding and documentation traps.”  by Robert S. Gold, MD. Contact him at DCBAInc@cs.com.

“Hypostatic pneumonia” represents one of these problem areas. I have written about it previously in other publications. The code for this condition was developed to describe an expired patient found lying in one position for weeks or months, often severely malnourished and with no protein stores to hold fluid in the bloodstream. Frequently these patients’ lungs have turned to the consistency of liver (called hepatization of the lungs) due to settling of fluid in the dependent portions of the lungs.

In ICD-9, the code for this condition was found under pulmonary edema, or congestion of the lungs, as the lungs became severely congested with blood and debris. This led coders to group the diagnosis along with pulmonary edema and respiratory failure. Some consultants taught this as the right code to assign when there was documentation of “pulmonary congestion.” [more]

New ACDIS swag for CDI Week

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If you follow ACDIS on social media, you may have already heard the news: we’ve got a few new ACDIS goodies on our marketplace. We’re really excited to share these items with you.

First up, try our new ACDIS lunch bag. Carry your midday meal in ACDIS style with this purple lunch tote. Measures 8” high, 7.5” wide and 5.5” deep. Features include two handles, silver foil insulating liner, plastic slot on top for your business card or identification, and side front pockets to hold your cell phone, keys, or luncheon utensils and napkin.

Second, our new ACDIS badge reels. Show your ACDIS and CDI pride on your identification badge reel.

Clips securely to your belt, lapel, pocket or handbag. Extends 30 inches for fast and easy access to security entry points, then retracts back into the white case. Sold in package of five badges so you can share with your team.

For more information about these and other ACDIS products, visit the CDI Marketplace or contact customer service 800-650-6787 or customerservice@hcpro.com.

Use a DRG Expert? Me? Um, no thanks.

If you don't already, start learning how to use the DRG Expert today!

If you don’t already, start learning how to use the DRG Expert today!

“Why do I need to know how to use a DRG Expert to take the CCDS exam? I don’t have to use that book to do my job.”

I hear this a lot. The reason you don’t use a DRG Expert is probably because you use an encoder. Since you can’t take an encoder into the exam room, you’re going to have to rely on the book.

Even if you don’t plan to (or need) to take the CCDS exam, you should still learn how to use the book. It can be a valuable tool for CDI specialists, and is often overlooked in the CDI community. You may find yourself without access to the electronic supports that calculate DRGs for you. Your system crashes. You seek new employment or pickup additional hours in a facility that requires manual research. You have to demonstrate your expertise or defend an assigned DRG. The list of reasons goes on and on.

The June 25 issue of CDI Strategies has an excellent article authored by ACDIS CDI Education Director Cheryl Ericson [more]

Sunday Reading: The electronic query process

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

Traditionally, CDI programs’ paper queries were either developed in-house or were provided by a consultant. Some CDI printed these forms on brightly colored paper and dubbed them the “pink sheet” or the “purple sheet” according to their preference. Others developed a special tabbed folder included in medical record so physicians can easily find the paper query forms and respond to the CDI staff.

Many manually tracked their query data (e.g., physician query response rates, CDI/HIM agreement rates, DRG improvement statistics) using Excel spreadsheets. Although these spreadsheets work well for some, specialized CDI software vendors tout how their programs help CDI staff organize patient load and work more efficiently. In addition to providing an electronic query format and automated method to gather data, such software may help CDI specialists obtain more robust data that can be tracked and analyzed over time. The data can then be used to communicate program successes and determine areas in which education or process improvement is needed.

Prior to pursuing CDI software vendors [more]

ICD-10 Tip of the Week: Staffing considerations

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

The more functions a CDI specialist is expected to perform, the higher the staff ratio should be.

An experienced CDI specialist should have an average daily census of 12-15 new patients and five to 10 established/follow-up cases. A good rule of thumb is one CDI specialist for every 1,200-1,500 discharges per year. The more functions a CDI specialist is expected to perform, the higher the staff ratio should be. Smaller CDI staff should focus on condition clarification only. However, many CDI programs are understaffed—some only employ one CDI specialist. Such staffing will become even more problematic once ICD-10 implementation begins.

Reviews are going to take more time and require more resources. While CDI staff ratios and productivity expectations depend on the program’s mission, CDI programs need to evaluate whether or not their program’s focus is realistic for their staff size. More importantly, they must start considering whether or not they need to bring on additional staff to bridge those anticipated productivity gaps.

Most programs query to identify incomplete, vague [more]

TBT: Pediatric efforts offer new CDI opportunities

Starting a pediatric CDI program? Read how.

Starting a pediatric CDI program?

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. We’ve picked up the theme, going back into our archives to highlight some salient tid-bit. This week, we’re throwing it back to an October 2013 CDI Journal article, “Pediatric efforts offer new CDI opportunities.”

With roughly 500 children’s facilities in the nation, Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta, sees both the probable benefit and difficulty inherent in CDI expansion into this patient population. Children’s hospitals do not have Medicare patients—the typical starting point for traditional, short-term acute care hospitals, he says. In fact, most are paid on a contract basis related to a certain percentage of the actual charges of the care provided “so there was little financial incentive for children’s facilities to implement CDI,” he says.

Furthermore, children’s facilities do not [more]

Conference Update: Call for speakers

The 2016 ACDIS Conference will be held May 24-26, 2016 in Atlanta, GA.

The 2016 ACDIS Conference will be held May 24-26, 2016 in Atlanta, GA.

The Association of Clinical Documentation Improvement Specialists (ACDIS) is currently seeking speakers to present at the 2016 ACDIS eighth Annual Conference, to be held May 24-26, 2016 at the Georgia World Congress Center in Atlanta, GA.

Is that special person you or a colleague?

We seek speakers to present on all aspects of clinical documentation improvement. Advanced CDI sessions that push the profession forward are particularly welcomed. Based on the learning needs identified by participants of the successful 2015 ACDIS Conference, several topics have emerged as areas of great interest within the ACDIS community. We are seeking potential speakers for the 2016 ACDIS conference with expertise in the following tracks and sessions:

Track 1: Management and leadership

Proposed breakout sessions:

  • Metrics: Selecting metrics to measure individual and program progress, analysis and interpretation of data, and presenting to administration
  • Auditing CDI staff: How to audit, how often, and follow-up/training using audit findings
  • Managing CDI staff: Setting productivity expectations, rewarding high performers, managing underperforming CDI specialists
  • Training and orienting CDI staff, establishing career ladders, motivating senior CDI staff, providing continuing education
  • Remote CDI: Management and operational issues
  • Electronic health records (EHR) management, including battling note bloat and copy/paste, managing problem lists, improving EHR CDI/physician documentation functionality through working with vendors, pros/cons of computer assisted coding, etc.
  • Engaging physicians in CDI: initial buy-in and education, ongoing training, tips for working confidently and effectively with providers
  • Managing CDI in a regional/multi-hospital system
  • Principles of effective leadership and department management

Track 2: Clinical and coding [more]

News: AMA/CMS join forces while Congress misses the ICD-10 memo

30031_EO325579_ICD10_banner-ads_300x250

No time to wait.

Those following the episodic turns of the ICD-10-CM/PCS implementation saga witnessed another dramatic plot twist in the narrative this week when the American Medical Association (AMA) and CMS made a joint announcement essentially prioritizing physician ICD-10 education and allowing some flexibility in claims auditing and quality reporting.

“ICD-10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD, in a joint statement with CMS Monday morning, July 6.

Stack’s statement not only marks a sea change in opinion from the AMA. Yet those hoping the agreement might also resolve years of debate and back-room political attempts to delay ICD-10 implementation may just have to keep on hoping until the actual implementation date comes to pass. Last week (July 10) Reps. Marsha Blackburn, R-Tenn., and Tom E. Price, R-N.C., introduced H.R. 3018, the Code-FLEX Act, to allow submission of ICD-9-CM and ICD-10-CM codes for 180 days after implementation.

W. Jeff Terry, MD, a Mobile, Alabama, urologist, sounded off on the problems of ICD-10-CM/PCS implementation in a HealthLeaders Media article, “AMA Delegate Blasts ICD-10 Implementation Requirements,” on Friday, July 1. And previous AMA leaders described ICD-10-CM/PCS’ detriments in Star Wars terms, Healthcare IT News pointed out this week, recalling that past-AMA President Robert Wah, MD, indicated the group wanted to essentially freeze the code set in carbonite.

Despite the new Code-FLEX Act proposal, the AMA and CMS seem to be moving forward with ICD-10 education. Although the details of their agreement seem simple enough, many news headlines seems to state that CMS gave physician practices permission to code incorrectly. When actually, CMS for its part said Medicare review contractors “will not deny physician… claims …based solely on the specificity of the ICD-10 diagnosis code as long as the physician used a valid code from the right family.” (Emphasis added.)

The problem comes, as Michelle Leppert points out in an an article on the ICD-10 Trainer Blog, that CMS does not define a family of codes. Is it a category of codes, such as 500, superficial injury of head? “That could be interesting,” Leppert writes, since the category includes nine subcategories which each also have further subsections.

While those entrenched in ICD-10-CM/PCS drama may say that these concessions read more like snip-its from the Official Guidelines for Coding and Reporting, getting the AMA to effectively bury its opposition is, for once, a welcome shift in the ICD-10-CM/PCS implementation storyline.

Editor’s Note: Portions of this article originally published in eNewsletter CDI Strategies. Subscribe now, for free.