by Laurie L. Prescott, MSN, RN, CCDS, CDIP
I spend much of my time communicating with CDI managers and directors. They work tirelessly to develop and nurture CDI departments, focusing much of their time on training new CDI staff and evaluating the experienced CDI professionals in their care in order to identify areas of education need. Often CDI directors fight for funding to buy the newest software with the latest and greatest bells and whistles. I remember how excited I was to use the new encoder when I was a young CDI specialist. Now there’s computer assisted coding software, software that prioritizes and develops work lists, tracking software, query opportunity software, etc., etc.
This all sounds great, but I think such technology may also be a hindrance when training new staff.
Experienced CDI specialists often complain about the lack of critical thinking skills within the ranks of those new to the industry. I often hear that it is difficult to teach a new CDI staff person because “no one uses the books anymore.” I hear that new CDI staff simply follow the query leads fed to them from the software programs and that they are not thinking for themselves. Managers also complain that many of the more experienced staff seem to be “coasting in their retirement job,” don’t wish to engage with the medical staff or challenge the status quo, and have become overly dependent on the EHR and the software to direct their day-to-day activities.
Please don’t get me wrong, I love the technology we have at our fingertips, but we also must understand that we, the CDI specialists, should be directing the software and not the other way around. This technology is meant to be a tool that assists the living, breathing, thinking CDI specialists. We need to use the skills our experience and intellect bring to the table whether those abilities be regulatory or coding knowledge, clinical expertise, communication skills, or, more importantly, a collection of these talents.
We speak about software in our CDI Boot Camps all the time. In these discussions, I encourage new CDI staff to pick up a code book, and a DRG Expert, and work the chart the old-fashioned way. Many groan when I mention such prehistoric methods to practice CDI, but there is a method to my madness. To effectively work as a CDI and to use the technology to its utmost value, we need to understand the inner workings and decisions the software program was designed to make. We need to know when the software misses something or inappropriately identifies a diagnosis that does not exist.
Critical thinking is defined as an active process of applying, analyzing, synthesizing, and evaluating information. The Critical Thinking Community (http://www.criticalthinking.org/pages/defining-critical-thinking/766) describes it as “ entailing the examination of those structures or elements of thought implicit in all reasoning; purpose, problem, or question-at-issue; assumptions; concepts’ empirical grounding; reasoning leading to conclusions; implications and consequences; objections from alternative viewpoints; and frame of reference.”
My simplified definition is that critical thinking is “thinking about your thinking,” questioning all conclusions and working to ensure you interpret all the facts and evidence correctly.
Critical thinking has been a buzz word for years, especially in healthcare. Many go through the motions of the day, not taking the extra energy to actually think through the record and identify those opportunities requiring intervention. CDI professionals need to attack each day’s tasks with an active focus. We cannot simply depend on a computer program to do the job for us. If all it took was a computer program, no thinking, no experience no effort—we would not be such a hot commodity in the world.
Editor’s note: Prescott is the CDI education director for ACDIS. She serves as a full-time instructor for its various Boot Camps as well as a subject matter expert for the association. Prescott is a frequent speaker on HCPro/ACDIS webinars and is the author of The Clinical Documentation Improvement Specialist’s Complete Training Guide and co-author on the forthcoming volume regarding the role of CDI staff in quality of care measures. Contact her at email@example.com. This article originally appeared in CDI Strategies.
by Erica E. Remer, MD, FACEP, CCDS
Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes, retrospectively, that a patient was not really afflicted by a condition documented in the medical record and coded by the coder.
If a coder assigns a code for a condition not really present, and removing that code assignment results in a lower-weighted DRG, then it is reasonable for a payer to expect the overpayment back.
However, if the condition was indeed present, medical personnel invested time, energy, supplies, and other resources, the hospital is entitled to reimbursement. Therefore, it is not appropriate to remove a diagnosis which was genuinely present. It is also unfair to remove legitimate diagnoses, because this results in the downgrade of severity of illness and complexity of management, and falsely deflates the quality measures assigned for that patient’s care.
It has never been reasonable or compliant for a coder to infer medical conditions from clinical indicators, and it is not reasonable to expect a coder to decide that a condition doesn’t exist if the provider documented it.
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.
Although the provider’s statement may be sufficient to code a particular condition, it does not mean the condition indisputably exists.
The adage is, “if you didn’t document it, you didn’t do it.” But we all know that is not true. No physician documents every thought or action, and it would be absurd to expect them to do so. The dilemma arises when a physician documents a condition without giving adequate evidence as to what led him or her to make the diagnosis.
Concurrently, a documented diagnosis which is not really present could lead other healthcare providers down an erroneous path. Conversely, not providing clinical support for a valid diagnosis sets the stage for future denials.
The legal definition of the standard of care is managing a patient at the level at which the average, prudent, similarly qualified practitioner in a given geographic medical community, would be providing medical care under the same or similar circumstances. There are clinical guidelines and scores which may assist a clinician in making diagnoses, but prudent practitioners also bring their past experience, knowledge, and judgment into play.
Medicine is an art, not a science, and not every patient “reads the textbook.” Many patients’ lives have been saved by a clinician who followed his or her gut. Just because a patient doesn’t strictly meet clinical criteria, doesn’t preclude him or her from having the medical condition that an astute provider diagnosed.
Is there a standard of documentation similar to that legal definition of a standard of care? The purpose of patient record documentation is to foster quality and ensure continuity of care. It is clinical communication. The fallacy is that documentation needs to be expansive and long; it just needs to convey to the subsequent healthcare provider (as well as the coder, utilization/case manager, auditor, lawyer, etc.) what the provider was thinking and why.
What coders can do
Sensible, qualified, and experienced coders or CDI specialists may read documentation and have concerns that a diagnosis is not supported by the clinical indicators.
Do they just unfailingly code a documented condition because the Official Guidelines for Coding and Reporting say that the provider’s statement is sufficient, or do they query the physician? Which conditions are prone to this? What clinical indicators should they be considering? How does one broach this subject with the physician?
The ACDIS/AHIMA’s Guidelines for Achieving a Compliant Query Practice recommend generating a query when the health record documentation “provides a diagnosis without underlying clinical validation.” It notes that “the focus of external audits has expanded in recent years to include clinical validation review,” and instructs coders to follow CMS and Coding Clinic guidelines, and to “query the physician when clinical validation is required.”
The CMS Statement of Work for the Medicare Fee-For-Service Recovery Audit Program 2013 notes that “clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”
I concur that a certified coder who has identified a diagnosis which needs more clinical support does not have the ability to validate it, but has the skills to recognize the necessity for validation.
If your institution has CDI specialists, then you have someone with the appropriate credentials in place to generate a query. The physician is the one who performs the validation by responding to the query in the affirmative, and by providing their clinical evidence for the diagnosis in question.
Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at firstname.lastname@example.org. For the second part of this article, return to the blog next week!
Editor’s Note: This note originally appeared in the February 9, 2017, edition of CDI Strategies. Click here to see the original article.
Three months from now the ACDIS team will head to our biggest event of the year—our national conference. And in case you haven’t heard it’s a milestone…our 10th. A big number and once again we are bringing the networking, the learning, and the fun.
It’s hard for me to focus in on even as few as four or five sessions that I’m most excited about, but instead of reprinting the entire agenda I thought I’d focus in on my personal top 10 speakers at the 2017 ACDIS conference. Cue the drum roll…
- “AHA Coding Clinic update,” with Nelly Leon Chisen, RHIA: Get the latest updates critical to CDI directly from the source: Chisen is the Director of Coding and Classification for the American Hospital Association, publisher of Coding Clinic. You don’t get much more authoritative than this.
- “Denials and CDI: A Recovery Auditor’s Perspective,” with Barbara Brant, MPA, RN, CDIP, CCDS, CCS and Timothy J. Garrett, MD, MBA, FACEP, FACHE, CHCQM, CIC. Hear straight talk from an actual auditor and what they see in the industry from a denials perspective: Brant and Garrett are from Cotiviti Healthcare. I give these guys credit for coming out to inform and take a little heat!
- “Sepsis: 1, 2, 3—RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines,” with William Haik, MD, CDIP. This session by the dynamic Dr. Haik includes the evolving definitions of sepsis and acute respiratory failure, including calculation of P/F ratio. Even more important now that Sepsis-3 will be the new criteria for the Surviving Sepsis Campaign.
- “ACDIS Advisory Board panel: Past, Present and Future of CDI.” This session with representatives of the ACDIS Advisory Board offers an insider’s look at the CDI profession, including where it presently stands and how it must evolve. OK, a bit of nepotism here as I’ll be on panel :). But seriously, we’re up to a lot!
- “The Post-Acute Care Setting: Integrating CDI into Multiple Outpatient Settings,” with Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA and Beth Wolf, MD, CCDS, CPC. This session examines specific outpatient settings such as home health, hospice, outpatient infusion centers, and clinics with employed providers, each with inter-related requirements for documentation, coding, and billing. They have some great ideas on how to expand your CDI department beyond the acute-care hospital setting.
- “A breakdown of the AHIMA clinical validation brief,” with Tammy Combs, RN, MSN, CDIP, CCS, CDIP and Melanie Endicott, MBA/HCM, RHIA, CHDA, CDIP, CCS, CCS-P. Clinical validation can be a challenging task for both CDI and coding professionals, and representatives who contributed to the 2016 AHIMA practice brief “Clinical Validation: The Next Level of CDI,” will no doubt add some clarity for CDI professionals on this topic. I’m honored to have official AHIMA representation on our podium!
- “Clinical Validation and Denials Management/Appeals: An ALJ’s Perspective,” with Alicia Kutzer, BS, Esq. LLM. Hear from an Administrative Law Judge (ALJ) and former QIC employee who was integral in developing training materials and presentations for proper adjudication of Medicare appeals and defended claim denials at the reconsideration and ALJ levels of appeals. I expect an interesting look “inside the courtroom” if you will.
- “Measuring Clinician Engagement Utilizing a Validated and Reliable Survey Instrument Developed by a Professional Doctorate Candidate,” with Nicole Draper, RN, BN, MHA. Attendees will be inspired to develop or adopt the validated and reliable survey instrument presented during this presentation to assess clinician engagement in their CDI program. Data and results will be shared from this speaker flying in from Australia to present!
- “Getting to the Heart of Accurately Defining Cardiac Ischemic Syndromes,” with Garry Huff, MD, CCS, CCDS and Christopher M. Huff, MD. This session is presented by two physicians including a board-certified cardiologist who completed a fellowship in advanced interventional cardiology at The Cleveland Clinic. Getting real clinical while having some fun!
- (TIE!) Our Two Inspirational Keynotes—“Healthcare, Remixed,” with Zubin Damania, MD (aka., ZDoggMD) and “Josie’s Story: Family-Centered Approaches to Patient Safety,” with Sorrel King. Sorrel King is pure inspiration and has a tragic, real-life story to motivate you to make a change in your own life. Her message on patient safety will resonate with any CDI specialist who reviews Patient Safety Indicators or refers an issue to quality. As for ZDogg… the man is a legend and there is no one more “Vegas” than him. Get ready for Healthcare… Remixed.
Sure, this list is subjective but I know you won’t be disappointed with any of them. Keep in mind my list of favorites just scratches the surface! We have more than 50 sessions to pick from.
As for the location…I’m a big Vegas fan and I’ve been very impressed with the MGM Grand. It’s big (the largest single hotel in the United States with 6,852 rooms) it’s new (built in 1993, constantly refurbished, as recently as 2012) with outdoor pools, rivers, waterfalls, and home to a number of entertainment venues, nightly shows, and world-class restaurants. And it’s located right on the strip.
Yes, there is a walk to the conference space—that’s inevitable with spaces this big and conferences this size—but I can tell you that the walk is MUCH shorter than you may have experienced in 2016 in Atlanta. I hope you enjoy the warm weather and the unforgettable sights and sounds of one of the most memorable places on earth.
So please come on out to this big 10th anniversary celebration of our association, and:
- Be inspired
- Have fun
Just make sure to sign up prior to March 7, 2017 to take advantage of our early bird ($100 off) and ACDIS membership (additional $100 off) discounts.
The team and I hope to see you on the strip!
Editor’s note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. For today’s Q&A, we caught up with Cheryl Ericson, MS, RN, CCDS, CDIP, the manager of clinical documentation services with DHG Healthcare, who will present “Leveraging CDI to Improve Performance under Alternative Payment Model Methodology.” Ericson is recognized as a CDI subject matter expert for her body of work which includes many speaking engagements and publications for a variety of industry associations. She currently serves on the advisory board for ACDIS and its credentialing committee (CCDS).
Q: Could you tell me a bit about what makes Alternative Payment Models (APM) different for CDI?
A: Participation in voluntary APMs is very complex and requires a high level of commitment from the healthcare organization. More than 800 hospitals, however, are required to participate in the Comprehensive Care for Joint Replacement Model (CJR) and an additional 1,100 or more hospitals will be required to participate in the episode payment for AMI and coronary artery bypass grafts (CABG). Because participation is based on randomly selected Metropolitan Statistical Areas (MSAs) many hospitals may be unprepared for the impact. These models are retrospective so the hospital is paid as usual under the applicable MS-DRG, but following the completion of the performance year the hospital may be required to return some of their payment to Medicare or they may receive an additional payment. This type of model, like many of the outcome measures included in the mandatory value-based methodologies, require CDI specialists to look beyond the current episode of care. The mandatory quality programs, however, only use a 30-day timeframe. In comparison, an episode of care in the APMs extends 90 days beyond hospital discharge or the date of surgery.
Q: What are three things attendees can expect from your session?
A: Attendees can expect to learn:
- The difference between the mandatory value-based programs such as HVBP, HRRP, HACRP, and mandatory APMs
- A better understanding of the mandatory bundled/episode based payment methodologies
- Strategies to incorporate into the CDI process to accurately reflect organizational performance under the mandatory bundled/episode payment methodology
Q: What is one tool CDI professionals cannot live without?
A: A grouper that supports risk-adjustment efforts.
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: As the fee-for-service population decreases, which was reliant on CC and MCC capture, CDI specialists need to understand and modify their efforts to reflect modern CMS reimbursement strategies to support organizational financial health.
Q: What are you most looking forward to about this year’s conference?
A: Like most, I enjoy reconnecting with friends. I have the added bonus of reconnecting with former ACDIS Boot Camp participants. It’s great to learn how people have advanced in their career as the CDI profession continues to grow!
Q: Fun question: What is your favorite candy?
A: Dove Promises dark chocolate with almonds. Yum!
By Laura Legg, RHIT, CCS, CDIP
CMS recently announced the award of a new round of contracts for the Medicare fee-for-service Recovery Auditors (RA). As the new round of RAs roll out, even the most experienced RA response team will need to understand the new challenges we face with CMS’ 2017 changes. Make every effort to ensure your teams are centralized, efficient and organized with excellent communication skills. Also, it is very important to educate your RA response team on changes to the RA rules. Following are a few tips to help you stay on top of the changes.
Compose complete medical records: Your facility should include all required documentation necessary to support each case. If a physician orders a test, make sure the order, results, and interpretation are all included with the medical record and are legible and easily found. Also make sure the discharge summary is as complete as possible. The discharge summary should accurately reflect all confirmed diagnoses and all care administered during the patient’s hospital stay without introducing new information.
Avoid EHR cloning: Cloning, or copy and paste, is being seriously addressed by CMS. RAs may be looking at progress notes for confusion among caregivers due to copy and paste overuse.
Focus on challenging inpatient diagnoses: What diagnoses and procedures challenge coders the most? Some tricky diagnoses are, but are not limited to, sepsis, respiratory failure, renal failure, congestive heart failure, pneumonia, spinal surgeries, and skin procedures. Make sure the medical record documentation support these diagnoses and that coders can easily identify the correct code assignment for them.
Follow RA websites: CMS requires RAs to keep an updated provider portal which includes a list of issues under review. This resource shows the issue name, type of review, provider type, status impacted, date posted and a detailed description of the issue. It is a good idea to build your internal audit plan around this list and the Office of Inspector General’s (OIG) work plan. CMS will require RAs to broaden their review topics and they must include all provider claim types and may include required reviews based on referrals from the OIG report.
Audit: Be sure that all diagnoses are coded to the highest level of specificity. Ensure that all medical documentation entries are consistent. Be sure internal auditors look at the same data elements reviewed by the RA including principal diagnosis, secondary diagnosis, procedures affecting or potentially affecting diagnosis-related groups, present on admission indicators, and discharge disposition codes.
Reduce denial rates—Under the new rules, additional documentation request (ADR) rates will be affected by your denial rate. More denials will result in more requests and denials still mean a lot of work on the provider end and a drawn-out appeals process. You can improve response rate and efficiency simply by following RA timelines and responding to record request appropriately. Takebacks due to lack of response to ADRs are more common that you think.
Editor’s Note: Legg is the director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. This article was adapted from the original published in JustCoding.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS.
Every year, the ACDIS Achievement Awards are presented at the annual ACDIS conference. There’s still time to nominate someone! The deadline has been extended to Friday, February 17, 2017, to allow more nominations.
Please nominate a colleague who has made significant contributions to the CDI field, who makes a difference in the profession, or is an outspoken advocate of CDI. We are still accepting nominations in the following categories. Click on the links to view each award’s criteria.
- CDI Professional of the Year
- Recognition of CDI Professional Achievement
- Excellence in Provider Engagement
- Rookie of the Year
All nominations will be reviewed and voted on by the ACDIS Conference Committee in conjunction with ACDIS administration. You may upload supporting material with your nomination. Only one document upload is permitted per nomination. There are three question fields relating to attaching supporting material and if you want to upload files for multiple fields, please combine them into one document or zip them together.
Please fill out the nomination form by Friday, February 17, 2017. Click here: http://app.keysurvey.com/f/1095184/5e51/
Editor’s Note: Over the comings weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we’ve reached out to Ronald Hirsch, MD, FACP, CHCQM-PHYADV, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who will present “Medicare Regulation Update: Practical Application for CDI Professionals.” Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians and serves on the Advisory Board of the American College of Physician Advisors. He is the co-author of The Hospital Guide to Contemporary Utilization Review, published in 2015.
Q: What’s the biggest challenge you’ve encountered related to implementing Medicare regulations?
A: Regulations and guidance from CMS are often vague and occasionally contradictory. These regulations affect everyone, including the doctor, the patient, the bedside nurse, the case managers, CDI staff, the billing and coding staff, and the C-suite (those working in upper administrative roles). Understanding the regulations and implementing them compliantly across the many affected groups is a challenge for hospitals.
Q: What are three things attendees can expect from your session?
A: Let me just list some of these out:
- To hear a simple explanation of the two-midnight rule
- To understand the practical application of medical necessity guidelines for CDI professionals
- To be familiarized with the required patient notifications
Q: What is one tool CDI professionals cannot live without?
A: If they learn the two-midnight rule as I teach it, they will become the hero of their institution.
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: CDI professionals work hand in hand with case managers but often do not understand their work. Gaining an understanding of that work makes them a more indispensable part of the team.
Q: What are you most looking forward to about this year’s conference?
A: As a physician advisor expert, my CDI knowledge is quite cursory. With the breadth of courses available at the conference. I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference Boot Camp for physician advisors. It will be an honor to hear from Erica Remer, MD, and James Kennedy, MD, two of the most renowned physicians in CDI.
Q: Fun question: Do you have any pets?
A: My wife and I just got a new kitten three weeks ago. Leopold is a little wild thing during the day between naps but he loves to cuddle with us at night in bed.
As CDI specialists and coders, it is our job to document and code appropriately for the care being provided. For CDI professionals working with physician practice settings, identifying documentation to support chronic care management codes under the Current Procedural Terminology (CPT) code system can be difficult.
CPT code 99490, regular (“non-complex”) chronic care management assumes 15 minutes of work by the billing practitioner, according to a January 18, 2017 Frequently Asked Questions publication from CMS. The code incentivizes providers to manage and communicate more thoroughly between the multiple providers for patients with extensive and complicated chronic conditions. In addition to charting the time, the diagnoses for the two (or more) chronic conditions must be documented and clearly connected as medically necessary for this oversight care.
In the 18 months since code 99490 has been implemented, one of the biggest problems is physician reluctance to document and bill for it. Many providers have the basic criteria built into their electronic health records (EHR), yet do not use it. The EHR is the most effective way to meet the criteria for billing of this code but a basic table in a hard copy chart or file can be just as effective and easy to use.
According to CMS, in fiscal year 2015, only 275,000 Medicare beneficiaries received (and CMS paid for) this service. Considering how many Medicare beneficiaries are enrolled and receiving Medicare services (approximately 54 million), 275,000 services provided with code 99490 is a very small percentage.
An area of continued concern from providers is they must also allow the patient to “opt in” and consent for this care. This can be problematic, as this is a non-face-to-face coordination of care and patients may view this as a charge for a service not rendered appropriately, as they did not physically “see” the provider. I’ve heard of patients complaining to their providers for having to pay for this “invisible” service. Again, it is imperative that the provider communicate clearly to the patient regarding this service and allow them to opt in or out. Physicians have also stated concern about whether they would be able to ensure or maintain 24/7 access to care management services as required by the CMS guidelines.
As a coder, billing code 99490 is one way to help your physician actually get paid for time spent performing this care management service. This service can include telephone calls, coordination of continuing services, and collaboration with specialty physicians which are services that are not normally paid for, or bundled in traditional E/M services. In addition to providing good patient care, the billing/coding of chronic care management code 99490 can also help the practice revenue stream and enhance the patients overall care.
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via email at email@example.com or find current coding information on her blog: http://lori-lynnescodingcoachblog.blogspot.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article originally appeared on JustCoding.com.
Breaking News: The Surviving Sepsis Campaign releases new guidelines for Management of Sepsis and Septic Shock, 2017
By Allen Frady, RN, BSN, CCDS, CCS
Management and practice guidelines are not often at the forefront of CDI focus and training. As quality and revenue reviewers, we more often find ourselves involved in clinical definitions and criteria, as we simply try to determine if a diagnosis exists.
As clinical validation and audit activities push CDI specialists closer to denial defense efforts, we must also be aware of the most current recommendations with regards to treatment. Last week in the both Journal of American Medical Association (JAMA), and a number of critical care publications such as the Society of Critical Care Medicine, we got our first peek at newly updated treatment recommendations coming out of the Surviving Sepsis Campaign. Although these publications represent more of an evolutionary update (compared the revolutionary change of definition we saw with last year’s release of Sepsis-3 definition changes) there are some noteworthy talking points here for CDI specialist.
The publication takes a rather comprehensive approach, covering every possible facet of monitoring and treating patients in sepsis (that is, after all, part of the Surviving Sepsis Campaign’s mission). Starting with the initial resuscitation, the update includes a shortening of the initial time for the early directed therapy treatments (for some components such as administering IV fluids) from six hours to three hours.
Monitoring suggestions have also gotten more specific, changing from general parameters for urinary output, mean arterial pressure, and invasive cardiac monitoring to a recommendation of frequent perfusion reassessment and adjustment made on an increased number of data points and focusing on dynamic parameters rather than static ones. The specific IV fluid recuitation recommendation is now 30ml/lg of crystalloid fluids over three hours (assuming stable renal and cardiac function of course).
Reassessment now includes an evaluation of everything from heart rate, to general blood pressure, arterial oxygen saturation, respiratory rate, with the continued recommendation of maintain the map of at least 65 or greater and introducing invasive monitoring for central venous pressure etc. in patients who are in critical status.
It makes further recommendations using lactate levels as part of the ongoing data to measure the amount and effectiveness of necessary fluid therapy.
Studies show that facilities who establish comprehensive sepsis protocols and performance standards have better outcomes. Doing so has become a recommendation across the board. If possible, patients should get blood cultures before starting antibiotic therapy as long as it does not delay antimicrobial administration any significant length of time. Another recommendation is to immediately test for and repeat monitor lactate levels.
The guidelines go on to address the specific antimicrobial selections, vasopressor escalation, source identification and recommendations for things like blood transfusion, anticoagulant administration, use of mechanical ventilation, management of ARDS patients, DVT prophylaxis, nutritional support and use of corticosteroids.
There new guidelines contain a vast amount of treatment information (too much to detail here) but as I mentioned, the recommendations are evolutionary in nature, not revolutionary. I have been teaching CDS the 30ml/kg guideline along with the importance of lactate and procalcitonin for a few years now. It is nice to see it in the practice guidelines.
One noteworthy point I want to mention, is the subject of de-escalation of therapy. In some cases, auditors will use a change or drop in antibiotics or a decrease in IV fluid administration as evidence that sepsis was ruled out. Nothing could be further from the truth. One of the reasons they suggest that blood cultures and wound cultures be performed early is so that they can appropriately de-escalate antimicrobial therapy in light of possible findings of the organism. In the era of increasing antimicrobial resistance with the over prescription of antibiotics, and in a critical care scenario when certain antibiotics may be nephrotoxic or hepatotoxic, this is likely to be more a sign of responsible stewardship than an indicator of diagnostic value.
The Surviving Sepsis Campaign specifically mentions the following recommendations:
- De-escalation to the narrowest effective antimicrobial agent for most serious infections.
- A thoughtful de-escalation of antimicrobials based on adequate clinical improvement in spite of the possible initial culture findings.
- De-escalation with discontinuation of combination therapy within the first few days in response to clinical improvement or evidence of infection resolution in septic shock patients.
- De-escalation of early multidrug therapy is associated with equivalent or superior clinical outcomes in sepsis and septic shock in some observational studies. This one needs more study however.
- They recommend, daily assessment for de-escalation of antimicrobial therapy in patients with both sepsis and septic shock.
- Various procalcitonin-based algorithms have been used to direct de-escalation of antimicrobial therapy in severe infections and sepsis. This also needs further study however. In total, the phrase “de-escalation” appears in the article no less than 30 times.
The next time you hear someone argue that a decreasing of vasopressors, IV fluid, or antimicrobial therapy proves there was no sepsis or shock, remind yourself that this has largely been debunked. De-escalation is in fact, a responsible part of sepsis management. Not every patient’s presentation would merit early de-escalation of course.
If physicians are abruptly stopping (not de-escalating) therapy such as antibiotics and or IV fluid and monitoring early in the episode, that could be a sign that either the sepsis was in fact ruled out, or could be that the early goal directed therapy worked exceptionally well. In such a case, a query is in order to ascertain the proper physician documentation that the sepsis was either ruled out, or was an atypical case which resolved early.
The goals here are clearly stated by the Surviving Sepsis Sampaign however—that antibiotic therapy should if at all possible, start being reduced within about three days if the patient is responding well to treatment. What you would likely see here is a change from multi therapy to a single IV antibiotic. In some cases, with antibiotics which have good PO absorption in a patient with no GI pathology, a change to PO antibiotics is possible. In other cases, antibiotics might be discontinued entirely. This is not evidence that there was no sepsis. The same goes for the fluid therapy. These practice reference repeatedly describe the time period as a “few” days. For most people “few” means around three. They further mention an early therapeutic window of only three to five days. Some studies in fact are cited in this paper which show that the shorter treatment periods of three to five days can be just as effective as seven and 10-day treatment protocols. These shorter treatment windows have also been associated with improved outcomes in some studies.
As more and more education and pressure is put on physicians about the dangers of antimicrobial resistance, and as we analyze the impacts long term to the kidneys and liver of hard to metabolize antibiotic therapy and as we see the impacts of over treating patients with antibiotics actually leading to increased readmissions due to the extinguishment of the natural healthy flora and the breeding of resistant organisms, we are likely going to see a trend towards these shorter treatment periods as standard sepsis care.
Link to Abstract: http://jamanetwork.com/journals/jama/fullarticle/2598892
Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.
by James S. Kennedy, MD, CCS, CDIP
In ascertaining pneumonia’s clinical validity, I like the criteria established by a work group of physicians convened by the Maryland Hospital Association that support compliant coding. Essential elements to diagnose pneumonia include one of each of the following three elements:
- Temperature > 38°C or < 36°C and/or leukopenia (<4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)
- Purulent sputum, cough, dyspnea, tachypnea, supportive findings through physical exam (e.g. bronchial breath sounds, dullness to percussion), and/or worsening gas exchange
- Supportive imaging
There are many others, such as those from the Annals in Internal Medicine in 2003. These authors state that a negative chest x-ray is an imperfect gold standard in ruling out pneumonia, thus when a physician documents pneumonia with a negative chest x-ray, we must ascertain its clinical validity. If a provider maintains that a patient has pneumonia, especially when it is documented with uncertainty at the time of an inpatient discharge or in response to a clinical validation query, then we are on solid ground to code the condition. Coding Clinic, Fourth Quarter, 2016, page 149, is a valid defense of this principle.
Even though ICD-10-CM classifies pneumonia by its causative organism, querying for the underlying cause is tricky. The AHIMA Standards of Ethical Coding state that coding professionals shall not query the provider when there is no clinical information in the health record prompting the need for a query, and cites that querying for gram-negative pneumonia on every pneumonia case regardless of clinical indicators is an example of unethical coding. Therefore, coders and their compliance personnel must know the clinical indicators supporting a query for the underlying cause of pneumonia as to target them appropriately and judge the validity of the documented response.
In my opinion, the best article addressing this dilemma is the 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society on hospital-acquired and ventilator-associated pneumonia.
In my reading, if a patient requires more than 2–3 days of an antibiotic other than ceftriaxone (Rocephin®), levofloxacin (Levaquin®) at 250–500 milligrams per day, azithromycin (Zithromax®), or similar agents, depending on the agent used that’s described in this article, the provider can support at the time of discharge that the pneumonia was likely due to the associated organism with hospital-acquired or ventilator-associated pneumonia. These include:
- Staph aureus – vancomycin or linezolid
- Pseudomonas – ciprofloxacin, levofloxacin (750 mg/day, not lower doses of 250–500 mg/day), aminoglycosides (gentamicin) or colistin – pseudomonas
- Other gram-negatives – Zosyn®, cefepime, imipenem, or azotrenam
Community-acquired pneumonia is a challenge, given that we often do not know what the causative organism is or that it is often viral in nature. Many physicians will still treat with an antibiotic, even though a study in the New England Journal of Medicine demonstrated an organism in only half of the cases studied and bacterial agent in only one out of seven hospitalized cases.
IDSA also published a guideline for community-acquired pneumonia which has a table of what antibiotics should be used in special circumstances. Options that influence DRG or HCC assignment include:
- Anaerobes (aspiration pneumonia) – Zosyn®, Unasyn®, or clindamycin
- Influenza – oseltamivir or zanamivir
Whether to query the physician for the bacteria justifying the use of Rocephin®, Zithromax®, or Levaquin® is an issue that will challenge all of us, especially if we’re working to manage our HCC-related risk-adjustment factor score. I’m open to suggestions if you have strategies that work in your facilities.
One final reminder: inpatient pneumonia cases with sepsis on admission are counted in the CMS mortality and readmission measures cohorts. However, the same cases with a secondary diagnosis of severe sepsis or sepsis with an associated organ dysfunction, are not. As we discussed in my previous sepsis columns, I hope that you’ve worked with your medical staff to define exactly what severe sepsis is and how to identify it at the time the inpatient order is written so that it may be properly documented and coded.
Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at firstname.lastname@example.org. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at email@example.com. This article originally appeared in Briefings on Coding Compliance Strategies. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.