At our office in Middleton, we sit beside a row of windows overlooking a parking lot and—at the moment—rolling hills of autumnal foliage shrouded in mist. About an hour ago, a big ‘ole crow landed on the window ledge and poked at each window pane before spreading its blue-black wings and sailing off to a nearby tree.
So, I thought I’d spend this note “crowing” about the publications available to ACDIS members and let you know about a few items coming in the next month or so.
In case you missed it, the September/October edition of the CDI Journal, covers a number of controversial concerns including:
- The professional background of CDI specialists
- The state licensure needs for nurses in CDI
- Changes to Official Guidelines for Coding and Reporting
- Tips for appealing denials
- Sepsis-3 in the pediatric realm
Speaking of Sepsis-3, ACDIS Advisory Board member Paul Evans, RHIA, CCDS, CCS, CCS-P, delves into some thoughts about addressing reviews and queries in the white paper “How ‘R’ are you coding severe sepsis? Why the R-code matters.” In it, Evans reviews the various clinical guidelines for sepsis diagnosis as well as coding and documentation requirements. He offers case study examples of situations CDI professionals may very well face within their typical record reviews and provides some query examples.
ACDIS white papers are in-depth articles which discuss CDI best practice, advances new ideas, increases knowledge, or offers administrative simplification. It is less formal than a position paper, so as Evans writes in this release, his aim is to simply “review some of the aspects of differing definitions of severe sepsis and demonstrate why the coding of severe sepsis is important while providing some practical tips.”
Another white paper released just this week focuses on the need for a consensus of clinical definitions related to pediatric respiratory failure. A work group consisting of coders, pediatric nurses, physicians, and CDI professionals from the ACDIS membership met over the course of a year to review data from the field and coalesce various documentation conundrums those working in this area face.
“The lack of specific clinical criteria for the diagnosis of acute respiratory failure in the pediatric population, without intubation or arterial blood gas measurements, have led to the development of numerous institution-specific criteria for this disease,” the work group states.
While the white paper outlines prevailing CDI-related concerns, provides clinical scenarios, and offers some suggested actions. It also seeks additional insight and clarity from the institutions, such as The Society of Critical Care Medicine and The Society of Pediatric Critical Care Medicine, regarding clinical definitions of pediatric respiratory related diagnoses.
Finally, I very much enjoyed working with our friends over in HealthLeaders Media on a special section titled “From Finance to Quality: CDI Departments Expanding Their Reach,” in its most recent magazine.
Many CDI program leaders agonize over how to make the case for expanding their program efforts into quality-related record reviews, says Dee Banet, RN, MSN, CCDS, CDIP, director of CDI at Norton Healthcare in Louisville, Kentucky, and a past ACDIS Advisory Board member in the report. And yet, as government increasingly ties payment to quality with initiatives like pay-for-performance, the dividing line between patient care and fiscal concerns is slowly dissolving.
These highlights represent just a few of the items recently released by ACDIS. Members of the ACDIS Advisory Board have nearly completed work on a special white paper regarding career ladder creation in the field as well as a new report based on survey data regarding CDI productivity expectations. And, the 2016 CDI Salary Survey garnered more than 1,000 responses this year. So, no doubt, CDI professionals will be excited to dig into that data once the analysis is released later this month!
Now that’s something to crow about!
Editor’s note: Varnavas is the Associate Editorial Director for ACDIS with responsibilities related to its various publications and website offerings as well as the more than 40 local chapters across the country. Contact her at email@example.com.
The Maryland ACDIS Conference hosted its inaugural event, thanks to the chapter’s leadership team and volunteers who put so much time and effort into planning and coordinating. The knowledge gained, networking that took place, and overall fun and comradery were enjoyed by all.
Participants were treated to networking breakfast and lunch sessions and were encouraged to ask questions of one another.
A robust guest speaker lineup included Janice Jacobs, who broke down hierarchical condition coding; Ingrid Connerney, who shared her facility’s experiences with potentially preventable conditions (PPCs); and Kristen Geissler, who discussed “hot-off-the-press” updates for Maryland’s pay-for-performance programs. Sessions were interactive and participants had the opportunity to gain insights from the experts as well as their colleagues.
“What a wonderful Maryland ACDIS-First Annual Conference! You all did an awesome job! The Conference packets were super, and appreciated (I like taking notes). Excellent choice of speakers! I found each presenter to be extremely knowledgeable and their content very pertinent. And thank you to the MD ACDIS members who volunteered to help with the set-up, registration, packet prep, breakfast, lunch, afternoon snack bag, and parting gift. If there were any hitches during the day they were not apparent to me.”
Click here to see additional photos from the event.
Q: Is it written in ACDIS Code of Ethics that, as CDI specialists, we are to “pull” bad or non-credible queries from patient charts and report them to our manager? This is what I have been taught in my current position.
A: As a manager, I would never ask my staff to be confrontational with each other. Queries should be audited on a regular basis—the manager or designee should regularly perform random audits of queries to ensure they are written compliantly and are appropriately assigned (no queries for unwarranted reasons), as well as identifying missed query opportunities.
Many departments also conduct peer reviews where each CDI specialist performs a selected audit of coworkers reviews and queries against facility and industry standards (such as the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice). The group then discuss their findings and exchange ideas about what may have been missed or how a given query may have been more effectively worded.
I would never ask a CDI specialist to pull a query by another coworker like that. If they found something terribly concerning, it should be reported to the manager, and the manager can determine if the query should be pulled, etc.
This example, in my opinion, is not related to CDI ethics as much as it is management and leadership. Every program should have an established method of query audit.
Editor’s note: Laurie Prescott, RN, MSN, CCDS, CDIP, answered this question. Prescott is the CDI Education Director at BLR Healthcare in Middleton, Massachusetts. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.
If you read the ACDIS Blog, you’ve probably come across our featured member series. In it, ACDIS spotlights a member working on the frontlines in an effort to showcase the incredible things CDI specialists do every day. It’s also a chance for readers to get to know one another, to see what other members are doing in their facility, learn a little more about their peers’ backgrounds, how to get involved with ACDIS, along with a few fun personal facts about our members.
Want to volunteer to be our next featured member? The process is simple. Just e-mail us with your interest or nomination a colleague. We will reach out to you and/or your nominee with a series of questions that can be answered via phone or e-mail. We then turn those questions into an article, like this one.
This isn’t a competition or a formal recognition but an opportunity to share a little bit about yourself and connect with the ACDIS community in a conversational way. It’s also an opportunity for us at ACDIS to meet members from across the country and get their feedback.
To submit a nomination, or for any meet-a-member-related questions, please contact ACDIS Editor, Katy Rushlau, at email@example.com.
Those applying to take the CCDS exam or recertify no longer have to write their applications by hand, since ACDIS implemented new editable PDF applications, candidates can complete electronically, on their computer.
The new forms are now available on the ACDIS website for exams, re-exams, and for recertification. Visit the ACDIS site and go to the Certification section. Click on “How to Apply” or “Recertification,” locate the form you need, and click on the link. Or just click the appropriate a link below:
Save the form to your desktop using the format indicated at the top of each form, such as CCDS_EXAM_PRICHARDS (use your first initial and last name—the example uses my name).
Fill out the application with your information, save it again, and then email it to firstname.lastname@example.org.
Do not provide payment information. Instead, click the link on the second page of the application and pay through our secure online store. If you prefer, we will call you for your credit card information. You can indicate in the body of your email that you wish a call. You may also print the completed application and mail it to us with a check.
The new process is really easy and a first step to an online certification and recertification processes.
As always, contact me at email@example.com if you have questions.
CDI efforts span from coast to coast in the United States, and have made their debut down under. Our friend, Nicole Draper, RN, BN, MHA, spearheads efforts at her facility in Darlinghurst, Sydney, Australia.
As the manager of length of stay, documentation, and revenue optimization, Draper works to address and alleviate documentation challenges. Using ACDIS resources and networking with CDI specialists in the United States, she was able to launch a pilot program for one of the first CDI programs in the country.
We heard from her a couple of weeks ago and are pleased to announce that her program was recognized with the 2016 Innovation and Excellence Award—which recognizes achievements across St. Vincent’s Health, a system comprised of four public and eight private hospitals—for growth and sustainability for their efforts implementing a CDI program.
Please join us congratulating Nicole. Click here to read a recent interview we did with her about her program.
Some pediatric physicians frequently document chronic lung disease. Unfortunately, the condition is not specific enough to accurately code a patient’s severity, says Leah Savage, RN, MSN, CCDS, clinical documentation specialist at Kosair Children’s Hospital in Louisville, Kentucky, in a recent discussion on the ACDIS Forum. Pediatric CDI specialists can educate providers by providing a list of more specific terms to obtain better documentation, which may include:
- Bronchopulmonary dysplasia (BPD)
- Chronic lung disease of prematurity
- Cystic fibrosis
- Interstitial lung disease
Physicians use BPD and chronic lung disease interchangeably, says one Forum user. UpToDate defines BPD as the following:
“Bronchopulmonary dysplasia (BPD), also known as neonatal chronic lung disease (CLD), is an important cause of respiratory illness in preterm newborns that results in significant morbidity and mortality”
BPD is not the same as chronic lung disease of prematurity, but one type of the broader chronic lung disease of infancy, says Jackie Touch, MSN, RN, CDI specialist at Children’s Hospital of Orange County in California. Her facility has a task force group that addresses challenging diagnoses and clinical definitions. The American Thoracic Society also provides an in-depth review of chronic lung disease of infancy, she recommends. “We try to have our physicians document BPD if the infant meets clinical criteria for BPD,” says Touch. “Otherwise, we clarify for chronic lung disease of prematurity our coders accept this diagnosis.”
by Amber Sterling, RN, BSN, CCDS
Getting CDI specialists involved at the point of entry in the emergency department (ED) provides numerous benefits to downstream documentation and coding accuracy:
- The entire CDI effort for each case becomes more effective.
- Electronic health record (EHR) documentation begins with an accurate report—important when ED documentation captures the severity of the patient at presentation, which often differs from the documentation of the admitting physician, who sees the patient after he or she has been stabilized.
- Cohesive documentation helps to improve CC/MCC capture rates, and solidifies medical necessity for admission.
Consider these five tactical guidelines to help spur ED CDI efforts.
1. Start Early: The best starting point is early evaluation of patient admission status. Knowing which trajectory the patient encounter will take informs your CDI workflow. Admission status can go one of two ways:
Inpatient admission: For cases where the inpatient admission appears medically justified based on clinical findings and screening criteria, the CDI specialist’s role is simple. The goal is to confirm ED documentation accuracy, since emergency documentation often differs from admitting documentation, which is done after the patient has been stabilized. Incorporating ED documentation in the codeable record will help capture diagnoses and present a clearer picture of the patient’s condition.
Maybe, possible admission: In this case, additional steps should be taken. More documentation is needed in the ED record to support inpatient status. The CDI specialist should work closely with the ED case manager and ED physician to discuss specifically what documentation is required to meet inpatient medical necessity.
Involve the CDI specialist right away, and engage the emergency services physician to clarify exactly what is required to support the admission determination.
2. Use technology to trigger action: The most successful CDI programs take advantage of technology. CDI in the ED is no exception. Use technology alerts, such as a “bed request” or “transfer from ED to inpatient status” as a trigger point for the CDI specialists to review the case prior to patient transfer.
CDI specialist can achieve great success, speaking with attending physicians between the ED and the nursing unit. Signs and symptoms that warranted a visit to the ED often stabilize after several hours of emergency treatment, therapies, and tests. CDI specialists bridge the gap between clinical findings in the ED and patient condition hours later in the nursing unit. If attending physicians aren’t available, rely on your organization’s hospitalists to meet with you, case management, and the patient prior to nursing transfer.
Start in locations that already have a hospitalist program in place who see patients in the ED prior to admission. This gives the CDI specialist the best opportunity to work with both the attending and the ED physician to capture necessary information in the record.
3. Collaborate with case management: From a screening practice standpoint, patients typically must meet a combination of criteria to justify medical necessity for inpatient admission. This gap represents a proactive query opportunity for CDI to make sure all diagnoses are addressed, DRGs are assigned appropriately, and principal diagnoses are identified correctly.
Cross-training in medical necessity screening criteria is essential for CDI specialists assigned to the ED. CDI specialists should also develop a strong collaboration with case management. Knowing case management’s role in the care process prepares CDI to fully understand the workflows, timelines, and criteria that drive clinical documentation. When you better understand decision points, and how your work affects what follows, it is easier to determine what and when to query.
4. Define Your Reporting Structure
The reporting structure is key to how communications are handled within the ED. Roles, responsibilities and communication channels should be clearly defined at the director level. Collaboration should be purposeful and direct to achieve the full benefits of CDI in the ED.
5. Be Prepared for Push-back
Based on my experience launching a program for emergency services, physicians may resist—at first. But once the downstream benefits are realized, your efforts become best practice. A concerted effort to educate the ED physicians on the “why” of a CDI program is needed in the ED, and should be made to help the physicians understand the crucial link their documentation makes in a more accurate and thorough record. As with other CDI efforts, ED physicians are more cooperative once they are aware of how their documentation impacts the quality of care for the patient.
CDI programs in emergency settings carry a unique set of challenges for everyone involved, including CDI specialists, case managers and physicians. These five strategies will position CDI specialists to help streamline documentation workflow in the ED and on the nursing unit.
Editor’s note: Amber Sterling, RN, BSN, CCDS is the director of CDI services at TrustHCS. Sterling has experience in the cardiac ICU, PACU, general ICU, case management, and utilization review. Most recently, she worked as the director of CDI for a five-hospital network, where she developed a CDI quality audit program, trained physician advisors in reconciling cases, creating a retrospective DRG denial review process, and developed and implemented a physician engagement program. Contact her at amber.sterling@TrustHCS.com.
As if coders and CDI specialists aren’t under enough pressure as it is, the advent of the 2017 ICD-10-CM Official Guidelines for Coding and Reporting brings to the table new documentation requirements for pressure ulcer coding.
Considering that these conditions have an effect on length of stay, require additional monitoring and nursing care, and ultimately affect reimbursement for facilities, it’s no wonder auditors scrutinize coding for these conditions. However, a solid understanding of these types of ulcers and the coding requirements can alleviate the “confusion of ulcer codes.
In April, the National Pressure Ulcer Advisory Panel (NPUAP) revised the pressure injury staging system. Since then, the NPUAP has received positive feedback regarding the system, and in August, the Joint Commission adopted the new terminology.
The definitions for each type of pressure injury are now:
Stage 1 pressure injury: Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (e.g., skin tears, burns, abrasions).
Stage 3 pressure injury: Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury.
Stage 4 pressure Injury: Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury.
Unstageable pressure injury: Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema, or fluctuance) on an ischemic limb or the heel(s) should not be removed.
Deep tissue pressure injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (i.e., unstageable, stage 3, or stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
The new staging system identifies the stages of pressure ulcers as 1 through 4 as well as an unstageable ulcer. These are similar to the codes from the L89 category in ICD-10-CM, however the system introduces new terms in an attempt to more accurately describe the stages and descriptions of such injuries.
The NPUAP no longer uses the term “pressure ulcer,” and has replaced it with “pressure injury,” since stage 1 and deep tissue injuries describe intact skin, not open ulcers. The system also introduced the new term DTPI with this update.
by Rebecca Hendren
ACDIS has a number of training and educational materials and it can be hard to decide which program best fits your needs. Our members often ask me to recommend a program for them, so I thought I’d share my short answers to help you figure out which program is best for you.
Our boot camps are our most popular option, covering the basics of the CDI role to more advanced concepts and CDI expansion. Our classes are offered live with our fabulous CDI instructors or online so you can complete the modules at your convenience. Currently we have courses covering the following topics:
- Clinical Documentation Improvement Boot Camp
- CDI for Quality Boot Camp
- Risk Adjustment Documentation and Coding Boot Camp
- ICD-10-PCS for CDI Online Boot Camp
We also have a comprehensive e-learning library, CDI Essential Skills, which is perfect for any new CDI specialist or CDI department onboarding new staff. The online format is engaging and interactive, and covers basic coding and documentation concepts, techniques for provider engagement, and much more.
Finally, I receive a number of inquiries about preparation for the Certified Clinical Documentation Specialist(CCDS) exam. While none of these boot camps are designed to be a credentialing prep class, we do find that the Clinical Documentation Improvement Boot Camp is helpful for those who are interested in the CCDS credential. It covers much of the information that CDI professionals need to master to successfully pass the CCDS exam. Please note, completion of our boot camps does not automatically qualify you to sit for the exam—you must have at least two years’ experience and meet additional requirements.
Stay tuned for more information on our brand new CCDS exam preparation class that is in development for 2017.
Please contact me at firstname.lastname@example.org if you’d like more information on any of these programs.