The new ACDIS Career Center allows you to upload your resume, browse open positions, and sign up for alerts about new jobs specific to your criteria. If you’re looking to hire, we have job posting options (discounted for ACDIS members) as well as the ability to browse our resume database. Click here to learn more.
Here are the latest job postings:
- Client Service Technician 2: Boston, MA—GE Healthcare
- Clinical Documentation Specialist: Columbia, MO—University of Missouri Health Care
- Manager, Clinical Documentation Program: Bay City, MI—McLaren Bay Region
- Clinical Documentation Improvement Specialist: Mineola, NY—Winthrop-University Hospital
One of my favorite occupational movies is Pushing Tin. Its take on air traffic control is from before 9/11, and just to make it more interesting, it stars actors familiar to the Gen-X population (John Cusack, Billy Bob Thornton, Angelina Jolie, and Cate Blanchett). Of note, the dialogue includes a tongue-in-cheek observation: pilots don’t actually land the planes—the air traffic controllers do.
This sarcasm reminded me of what happens with the medical chart—no matter what the providers write (and despite what diagnoses are still “up in the air”), CDI specialists are there to guide the chart to where it needs to land…hopefully without a “crash and burn” moment. Here are a few ways in which we do that:
- Present on admission (POA) clarification: Just as a pilot needs to request permission to take off, we must also request information such as POA in order to properly assign a working DRG. Putting a diagnosis that wasn’t POA in the principal diagnosis spot can be akin to a flight path headed toward Spokane when you thought you were going to San Diego. You’ll wind up in the wrong place.
- Consistency in documentation: Planes pass through various airspaces during longer flights, with handoffs between air traffic controllers (see one example at A Flight Across America – FAA). Safely landing the plane depends on smooth transitions. In patient care, lengthier patient stays can mean that several providers from different service lines will be documenting in the chart. Despite the electronic medical records’ copy and paste functions, charting can be like the whisper game…what was said at the beginning comes out distorted at the end. CDI specialists keep the chart on the path to appropriate and compliant coding and billing. This can even mean querying retrospectively when the discharge summary is missing key diagnoses.
- Case mix index (CMI) improvement and recover audit contractor (RAC) audit-proofing: – An air traffic controller has several airplanes to navigate on his or her scope. They are keenly aware of airport and airspace traffic. CDI specialists are also privy to environmental information, such as which providers are consistently documenting symptoms instead of diagnoses and which diagnoses are being further scrutinized by the RAC for clinical validation. With our bird’s eye views, both air traffic controllers and CDI specialists strategize for efficiency and optimal outcome. An air traffic controller aims to get more flights to arrive on time and safely; a CDI specialist strives to increase the CMI through educating providers and clarifying diagnoses without clinical support.
- Allowing for “flexibility within the form:” Sometimes, an air traffic controller has a high volume of aircraft in the airspace at one time. This can mean that one or more planes need to “take a spin” in the sky before being lined up for approach to the airport. CDI specialists also must demonstrate this flexibility in terms of diagnoses. Patient condition and timing of documentation and diagnostics will sometimes require us to be patient and wait until the next day to place a query. Ebb and flow is important in both positions.
- Participation in safety initiatives: One statistic quoted in the film is that an air traffic controller is in charge of more lives in a shift than a surgeon is in his or her entire career. There is only a certain amount of “near misses” allowed in air traffic control (under three in a two and a half year period, according to the movie) before a controller is pulled from the job. Health care providers are also under scrutiny for never events and hospital acquired conditions, and CDI specialists place queries to help with PSI and HAC documentation.
Although one of the requirements to become an FAA air traffic controller is to enter the FAA Academy before your 31st birthday (oh, how that ship has long ago sailed!), it’s still possible to practice chart traffic control from the comfort of your facility by being a CDI specialist. It can be a thankless, “unseen” job, but in both air traffic control and CDI, things run smoother with us than without us!
Editor’s note: This article was originally published and written by Wendy Frushon Tsaninos, RN, MSTD, CCDS, CMSRN, CCS, Lead Clinical Documentation Improvement Specialist at Maxim Health Information. Connect with her on LinkedIn by clicking here.
We recently got an e-mail from a customer asking us for a comprehensive list of CMS quality measures that CDI specialists should be aware of. Our lovely boot camp instructor, Sharme Brodie, RN, CCDS, CDI education specialist for HCPro in Middleton, Massachusetts, put together this handy spreadsheet highlighting the different measures and where the information is pulled from. Please note—this information pertains to quality measures as of July 2016 only, and will be outdated by next year at this time. ACDIS members can click here to access.
Want more information and training on quality? Consider signing up for out CDI for Quality Boot Camp. This intensive three-day course is available live and online, and covers publically reported quality data and how code assignment affects quality metrics, including (but not limited to) the Hospital Value-Based Purchasing Program. Students learn the why and how of reviewing complex cases involving Patient Safety Indicators (PSI) and hospital-acquired infections (HAI), and leave with measurable strategies for improving their hospital profiles and positively influencing their facility’s value-based incentive payments. Click here for more information.
by Penny Richards
Sarah LaSource didn’t set out to do anything extraordinary on July 8. She took the CCDS certification exam—and lots of folks have done that. But she did what no one else has—walked out with the highest score we’ve ever seen anyone get on the exam, either the old or new version.
Sarah scored 116 out of 120, or 96.6% on the exam. Her secret? “I studied hard!”
She planned to take the exam in late June but some work matters arose that forced her to change her exam plans. She took the extra time to study.
She used several resources as she prepared: The CCDS Exam Study Guide, The Clinical Documentation Improvement Specialist’s Complete Training Guide, and The 2016 CDI Pocket Guide (all from HCPro) and the ACDIS/AHIMA joint brief “Guidelines for Achieving a Complaint Query Practice.”
“I took the practice test (in the CCDS Exam Study Guide) several times,” she said. “The first time was to establish a baseline to find my weaknesses, then I went back over those points exclusively to hone in on my deficiencies.”
Sarah is a clinical documentation specialist at Jackson Madison County General Hospital in Jackson, Tenn., and will celebrate three years in the role in September. Her background is in SICU, case management, and utilization review.
“I got into CDI when my husband transferred to Tennessee to go to grad school,” she told me. “I applied here for an opening in case management, and when I met with the recruiter she told me about the CDI opening. I knew someone at my former employer who was in CDI and who tried to get me into it.”
She is pleased she made the move to CDI.
“This is right up my alley,” Sarah says. “I like to try new things and this is challenging. Definitely the favorite thing I’ve done so far in my nursing career.
“It was a difficult test,” she said. “The biggest challenge was the wording on some of the questions. I went back and changed some answers, something I usually don’t do. I’m glad I did!”
Congratulations Sarah. The hard work paid off in a big way.
To support credible reporting, most successful CDI programs use a process known as reconciliation to confirm the accuracy of CDI data and metrics. Reconciliation of data entry at the time of final coding is necessary to capture the true outcome of the CDI process. Data entry that captures concurrent work should be reviewed at the closure of the case. A solid reconciliation process allows for final review of data entry for accuracy, including:
- Baseline information
- Includes DRG, severity of illness (SOI), and risk of mortality (ROM)
- Query information
- Impact and topic specificity
- Physician response
- Confirm query was answered
- Agreed versus disagreed
- Alignment of the final codes and DRG between concurrent CDI specialist and coder
- Confirm query was answered
- Resulted in documentation in the medical record that allowed for accurate coding of the condition
- Confirm who answered
Because the goal of a concurrent review is to ensure accurate clinical representation in the final coding, it is important for review and discussion to occur when the final codes and DRG do not match those identified by the CDI specialist. Reconciliation should include clear criteria guiding the process and outline communication pathways for further review and discussion of cases where there are questions or discrepancies between the expected or working CDI DRG and the coder’s final DRG. Developing and supporting this valuable process is vital to demonstrate program outcomes and success. The CDI team needs to understand this part of the process to fully comprehend the parameters of their role. The process for final coding and billing must be plainly visible to the documentation team and monitored for effectiveness. Ensuring that these processes are clearly known, executed, and monitored will guarantee program success.
Editor’s Note: This excerpt is from the CCDS Exam Study Guide, Third Edition, written by Fran Jurcak, MSN, RN, CCDS, and reviewed by Laurie L. Prescott, RN, MSN, CCDS, CDIP.
Physician advisors serve a variety of purposes beyond documentation improvement, including assisting case management, utilization review, quality, and coding departments, among other assignments, according to a recent benchmarking report and survey from ACDIS.
“The problem you run into is that the physician advisor role gets co-opted,” says Anthony F. Oliva, DO, MMM, FACPE, Vice President and Chief Medical Officer at JA Thomas/Nuance Communications, Inc., based in Burlington, Massachusetts.
As the physician advisor for a 15-hospital system, Erica E. Remer, MD, FACEP, CCDS, clinical documentation integrity advisor of University Hospitals in Cleveland, knows how difficult it can be to manage competing obligations.
“I work full-time in my system, and still it can feel overwhelming,” Remer says. “How can you accomplish everything and help your CDI program move forward if you have all these competing obligations?”
While CDI programs need to be flexible, keeping in mind the limited availability of the physician advisor, parameters should be set regarding how much of the advisor’s five to 10 hours per week should be spent on which tasks, says Louis Grujanac, DO, AHIMA ICD-10-CM/PCS trainer, an independent consultant based in the Chicago area.
“There’s five minutes here and five minutes there, and before you know it that physician advisor’s time is spent up and the CDI program has no additional room for larger education efforts, assessments, or growth analysis,” he says.
Tracking the physician advisor’s time should fall to the CDI program administrator or manager; the time tracking should weigh the advisor’s efforts against the larger needs of the program and ensure that individual physicians or CDI specialists aren’t monopolizing the advisor’s time with minutiae as opposed to bigger-picture educational or program improvement activities.
Q: I am with a CDI program that is starting to explore the severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do.
I was told that regardless of the actual final impact on SOI/ROM we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?
A: I very much agree with your practice of claiming those in which you see a change in SOI/ROM related to your query. I believe you are being encouraged to claim impact for any query that allows for an increase in SOI/ROM. So, for example, if you query for MCC capture, that would likely affect SOI/ROM and I would claim the impact for both MCC capture and SOI.
Say you have a patient that is admitted for COPD exacerbation with heart failure and diabetes. When you query to capture the MCC of the acute respiratory failure, and the physician responds appropriately, you would claim the credit for the MCC capture. But this query likely would also increase your SOI/ROM (I do not have access to an APR grouper but my guess is that it likely would).
I would think that although your goal in the query was not to increase SOI/ROM, if it did indeed do so, I would take the credit for this as well.
I would also suggest you seek out your peers on the ACDIS Forum as they likely could share with you how they analyze their metrics.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at email@example.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.
Here’s how it works: When a membership is within 60 days of expiring, the customer will see a renew button in the top right menu. Click the renew button. You will be redirected to the login to the HCPro/ACDIS store. After logging in, go to “My Purchases” and select to renew ACDIS.
Not a member? Consider joining us! ACDIS is the premier association for CDI professionals, and members receive a number of great benefits, including:
- Access the entire newly updated ACDIS website, including its Resource Library full of customizable documents, sample query forms, tracking sheets, sample policies and procedures, even job descriptions
- In-depth articles and gain industry expertise contained in the bimonthly, electronic newsletter the CDI Journal
- Participate in the ACDIS Forum where you can network with your CDI peers, swap solutions, and discuss best practices
- Join quarterly conference calls with fellow CDI specialists, guest speakers, and ACDIS Advisory Board members
- Receive weekly tips, news, and regulatory updates delivered in the association’s email newsletter, CDI Strategies
- Two postings per year to our newly launched Career Center
- Connect with local ACDIS chapters in your area, for further networking opportunities
- Receive special discounted rates for the annual ACDIS conference, the Certified Clinical Documentation Specialist (CCDS) certification, and other CDI-related products
A Note from the ACDIS Director: Risk Adjustment is the new mantra for CDI, and we’ve got you covered with a new boot camp
By: Brian Murphy
One size does NOT fit all when it comes to health insurance. Beneficiaries range from the extremely healthy 65-year-old—the poster child for “65 is the new 45”—to a 65-year old suffering from COPD from a lifetime of smoking, cancer, and a hereditary condition such as Type 1 diabetes. The result is often a huge disparity in the amount paid out for the care of these two patients.
The insurance market has adapted to these wide disparities with the concept of risk adjustment. Certain payers like Medicare Advantage now offer plans with options for coverage based off demographics and health status of the beneficiary. Risk adjustment applies not just to healthcare reimbursement, but also quality monitors such as 30-day mortality measures, 30-day readmissions, and Medicare spending per beneficiary. Healthcare organizations must be aware of how documentation supports risk adjustment and educate providers of the importance of complete and thorough capture of their patient’s health status to support accurate code assignment representing the potential risk their patients possess.
One size does also not fit all when it comes to educating CDI specialists and coding professionals involved in risk adjustment. To meet this need we’ve launched a brand new boot camp: The Risk Adjustment Documentation and Coding Boot Camp. This boot camp offers CDI and coding professionals involved with risk adjustment concrete strategies to make real differences in accurate payment and quality monitors.
This class is a first for HCPro: A true joint development between our CDI and coding educators to cover what is truly a marriage of skillsets. Risk adjustment requires coding and CDI professionals to work together as one team to ensure the capture of the most appropriate risk score for each patient. The Risk Adjustment Documentation and Coding Boot Camp reviews both inpatient and outpatient coding guidelines and their application to the CMS-Hierarchical Condition Category methodology, and includes detailed instruction on the individual HCCs and identification of opportunities for improved documentation. Clinical scenarios are used to demonstrate concepts and validate learning.
“CDI specialists are the logical intermediary since their role already includes documentation improvement for hospital inpatient services,” says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM/coding for HCPro. “To add to their already versatile role, risk adjustment documentation is right in their wheelhouse.”
“I see many CDI programs working to expand into the outpatient arena and there appears to be a struggle to find their identity or focus for their record reviews. Knowledge of principles of risk adjustment can provide that focus,” adds Laurie Prescott, MSN, RN, CCDS, CDIP, director of CDI education for HCPro. “Documentation for outpatient services and primary care is a slightly different beast than the more familiar territory of acute inpatient care for most CDI professionals. This different focus requires a melding of two skill sets that of CDI and that of coding professionals to succeed.”
Risk adjustment documentation is based on records from hospital inpatient, hospital outpatient, and provider services. Although CDI is firmly rooted in inpatient services, as more and more hospital systems purchase physician practices their focus and review scope increases. The arms reach wider to ensure documentation on the whole is optimized not just for inpatients but in all settings related to the hospital system to obtain accurate reimbursement. “The CDI team is already clarifying diagnoses like specific manifestations of diabetes mellitus and possibly the significance of pathology reports for metastatic cancer, so why not multi-purpose the focus to extend to conditions that may affect risk adjustment scores?” Prescott says.
Coding professionals apply the coding guidelines to assure accurate code assignment. They often must prioritize these diagnoses in an inpatient setting. However, the importance of capturing vague or missing diagnoses has not traditionally been stressed in the outpatient setting since payment is based principally on CPT codes. Because diagnosis codes are used to calculate a patient’s risk score it is important to apply the principles of concurrent review and documentation improvement in the outpatient and professional services arenas as well, McCall notes.
Both CDI and coding professionals can assist providers in creating documentation that is complete and thorough to support the concepts of risk adjustment.
“We must document in a manner that allows capture of the patient’s true health status to assure that both the healthy robust 70-year-old woman and the fragile, compromised 70-year-old man are well differentiated within the risk adjustment model. Again this requires efforts from both CDI and coding professionals,” Prescott says, noting that this class also benefits payers who must be proficient in recognizing accurate versus inaccurate code assignment for patients covered under their risk adjusted plans.
Our first class is taking place in July and more are offered this fall. We hope to see you in Boot Camp!
To learn more about the Risk Adjustment Documentation and Coding Boot Camp or to register, click here.
Taking into consideration the various requirements governing the capture of healthcare data, CDI programs can easily itemize the basic elements needed for compliant queries.
Query forms should be vetted and approved by the organization and should be tracked or documented in some manner. They should not be written on sticky notes or other slips of paper that may run the risk of being discarded or discounted.
The growing adoption of electronic medical records and CDI software has made it easier for CDI professionals to ensure all necessary query elements are present. Nonetheless, CDI staff must understand what these elements are. Because it must meet the basic tenets of information exchange, the query form should include the following:
- Patient name or identification number
- Admission date and/or date of service
- Health record or account number
- Date the query was initiated
- Date the query was closed
- Name and contact information of the individual initiating the query
- Name and contact information of the physician responding to the query
- Statement of the issue in the form of a question, along with clinical indicators specified from the chart
In addition to ensuring compliance, these elements allow CDI staff to track and monitor the number of queries being initiated, who is initiating them, the number of queries being answered, and who answered them.
Tracking provides data that can be used to show program value and physician involvement. Conversely, the data can be used to swiftly recognize any problematic trends with a CDI specialist or provider, which is critical for process improvement and remediation efforts.
Editor’s note: This excerpt was taken from the Essential CDI Guide to Provider Queries, written by Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS.