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Guest Post: EHR just one piece of the documentation puzzle

by Alexandra Wilson Pecci

EHRs alone don't solve documentation problems.

EHRs alone don’t solve documentation problems.

How nurses and doctors communicate—or don’t communicate—using health information technology is the focus of a multi-year study funded by the federal Agency for Healthcare Research and Quality.

The life-and-death importance of nurse-physician communication and the use of electronic health records came to a frightening, critical head last week when a nurse noted in a sick patient’s EHR that the patient had recently traveled to the United States from Africa.

Despite the note, the patient was sent home. He later returned to the hospital and was eventually diagnosed with the Ebola virus.

Revising an earlier statement that blamed the bungled incident on a “flaw” in its (Epic) EHR system, Texas Health Resources backtracked last Friday saying, “As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.”

In either event if the nurse used the EHR alone to communicate that critical piece of patient information, it obviously didn’t work. According to Milisa Manojlovich, PhD, RN, CCRN, associate professor at the University of Michigan School of Nursing, it’s a case of the medium not matching the message.

Editor’s Note: This article originally published in HealthLeaders Media, October 7, 2014.

News: CMS allows ‘meaningful use’ hardship exception applications

CMS offers IPPS proposal.

CMS offers EHR extension.

CMS recently announced that it will once again allow eligible hospitals and professionals to submit meaningful use hardship exception applications. The new deadline for submitting applications is November 30, 2014. The previous deadlines were April 1, 2014, for eligible hospitals, and July 1, 2014, for eligible professionals.

Eligible hospitals and professionals can submit a hardship application by the new deadline if they were unable to fully implement 2014 edition certified EHR technology (CEHRT) due to delays in the availability of the technology. In addition, the application process is open to eligible professionals that could not attest to meaningful use by October 1, 2014, and eligible hospitals that could not attest by July 1, 2014, using the options in the CMS 2014 CEHRT Flexibility Rule.
The Recovery and Reinvestment Act of 2009 requires that CMS apply payment adjustments for eligible hospitals, eligible professionals, and critical access hospitals that are not meaningful users of CEHRT. However, the act also permits CMS to conduct case-by-case reviews of organizations that apply for hardship exceptions.

TBT: The role of CDI specialists in serving long-term care facilities

CDI JournalEditor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the July 2011 edition of the CDI Journal. 

When Jennifer Love, RN, BA, CCDS, accepted a CDI position Kindred Healthcare, one of the nation’s largest long-term acute care (LTAC) providers, she found a brandnew opportunity. As its name implies, LTACs provide care for patients with serious (acute) medical needs over a long period of time, usually between 20 and 30 days. Most CDI specialists work in short-term acute care (STAC) facilities. So Love saw the LTAC opening as a chance to broaden her CDI horizons.

“It is exciting to see CDI expand out like this,” she says. “I feel like I dove into the future.”

The payment system is essentially the same as that of STAC facilities—LTACs use ICD-9 codes and MS-DRGs for Medicare patients, for example. But whereas STACs look to reduce a patient’s geometric length of stay (GLOS), an LTAC patient is expected to require a longer treatment period.

LTACs treat a very specific type of patient, says Love. Patients can be morbidly obese, suffer from bed sores and acute renal failure, and have often undergone tracheostomies.

The top DRGs at Love’s facilities include:

  • 207: respiratory system diagnosis with ventilator support 96+ hours
  • 189: pulmonary edema and respiratory failure
  • 592 and 593: skin ulcers with CC/MCC
  •  870 and 871: septicemia or severe sepsis with mechanical ventilation 96+ hours; and with MCC

If a patient leaves the LTAC sooner (or longer) than expected, a number of questions need to be asked and answered, says Becky Slagell, BA, MHA, RHIT, CPHQ, regional senior director of case management for the Central Region Long-Term Acute Hospital Division at Kindred Healthcare.

“We need to ask ourselves why that patient was discharged earlier than patients with similar concerns. Was [he/ she] truly safe for discharge? Was [he/she] able to go home earlier than normally expected for that type of patient? Did [he/she] transfer back to a STAC? If so, why?” Slagell says.

“There shouldn’t be a high rate of COPD in a LTAC setting,” Slagell says. “That is a chronic condition that by itself does not require our level of care. When a CDI specialist sees that, they’ll look further in the record and see what the situation is. Is there an acute exacerbation of the COPD such as aspiration pneumonia or respiratory failure?”

This complicated level of care makes the role of the CDI specialist very important for this particular setting, says Slagell.

Q&A: Sleep apnea clarification opportunities

Q: Should I query for chronic respiratory failure if the documentation indicates the patient has sleep apnea with and is being treated with continuous positive airway pressure (CPAP) at night?

Ask your CDI question in the comment section.

Ask your CDI question in the comment section.

I love where you are going with this question, it demonstrates your critical thinking, one of the most important skills a CDI specialist can have.

First off, let’s think about the definition of respiratory failure and the biological processes which cause it. Respiratory failure can result from an inability to ventilate (take in oxygen, expel carbon dioxide) or an inability for the gas exchange to occur at the cellular level within the lungs.

The Merck Manual describes it as:

“A rise in [partial pressure of carbon dioxide] PaCO2 (hypercapnia) that occurs when the respiratory load can no longer be supported by the strength or activity of the system. The most common causes are acute exacerbations of asthma and [Chronic Obstructive Pulmonary Disease] COPD, overdoses of drugs that suppress ventilatory drive, and conditions that cause respiratory muscle weakness (e.g., Guillain-Barré syndrome, myasthenia gravis, botulism)… Treatment varies by condition but often includes mechanical ventilation.”

The manual goes on to describe that the balance between load (resistance to ventilation and neuromuscular competence (the drive to breath, and muscle strength) determines the ability to sustain alveolar ventilation. Sleep disordered breathing is listed as a contributing condition that can disrupt this balance.

If you come from case management experience, you might be aware that for a Medicare patient to qualify for CPAP, a sleep study must be performed that demonstrates need based on the number and length of episodes occurring within the study elapsed time.

If the patient is receiving treatment or monitoring within the hospital stay to address the sleep apnea, a query may be warranted. Make sure the hospital is providing CPAP support at night and review the respiratory therapy notes to show consistency within the record before submitting the query.

If your organization does not have agreed upon diagnostic criteria for chronic respiratory failure work with your CDI team and pulmonologists to define this condition and identify clinical indicators to support query. Discuss with the pulmonologist how sleep apnea and the use of CPAP supports this diagnosis.

When I was reviewing records I always thought of obesity alveolar hypoventilation syndrome (Pickwickian’s Syndrome) as a possible secondary diagnosis where obstructive sleep apnea was listed as a diagnosis. Check the patient’s BMI and if you have morbid obesity, consider whether that condition led to the obstructive sleep apnea. This also provides a CC.

Smart question and this is often a query opportunity that is overlooked.

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.

Call for Advisory Board nominations open

Join ACDIS. Get the Journal. Get informed.

Consider volunteering for the ACDIS Advisory Board.

We are currently seeking four new ACDIS members to join our advisory board in 2015. ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership and expertise for the membership. The term of service is a maximum of three years.

The deadline for returning completed applications is Monday, November 17, 2014.

A nominating committee and the ACDIS membership will make final selections by January 2015. The role and expectations of ACDIS advisory board members is described on the advisory board page. If interested, please fill out and submit the application form. Thanks for your consideration of this important opportunity to serve our association.

Guest Post: Marketing your CDI program

Kelli Estes

Kelli Estes

by Kelli Estes, RN, CCDS

Maintaining an organizational presence through the continued marketing of your CDI program is one of the most valuable steps you can take towards leveraging long-term success. Hospitals cannot afford to have their CDI program become an “out of sight, out of mind” idea six months to a year after launching.It is very important to maintain a level of CDI enthusiasm among providers throughout the year. In reality, the CDI initiative must become part of the cultural norm in order to attain the longevity of its effects everyone desires to see.

Too often, CDI programs kick-off with quite a buzz in the air. There is typically an organizational presence from the intentional promotion carried out for weeks or months leading up to the implementation date. Unfortunately, after six months to a year, the CDI team loses steam and finds themselves without much fizz among providers. Following are a few ideas to effectively market CDI programs:

  1. Mark your calendar for the week-long celebration of CDI Week which just took place the third week in September. Use this time to:
    • Provide snacks in the doctor’s lounge throughout the week
    • Attach CDI tips to candy as a fun giveaway and to educate providers
      • Attaching a CDI tip to Smarties candy is always cute
      • Dum-Dum suckers will get a nice laugh too
    • Host CDI week giveaways as your budget allows
      • Starbucks or Dunkin Donuts coupons
      • Restaurant gift cards
      • Nook, Kindle, or iPad for a Grand Prize giveaway
    • Provide special recognition for star documenters
    • Host a special “lunch and learn” education session to be led by the CDI physician advisor or the star documenter of the year!
  1. Feature CDI news on a centrally located bulletin board for everyone to see.  Be sure to update the board at least monthly by providing CDI tips to include new ICD-10 information and also showcase the top documenters for the month. You can get really creative because I’ve never met a physician who didn’t like a bit of friendly competition.
  1. Contribute short articles or quick tips in any physician newsletters that go out regularly. Make it personal, feature various CDI staff at different times to allow the providers to get to know the CDI team members better.
  1. Work with your IT department to implement CDI tips as computer monitor screen savers to promote CDI awareness.
  1. Develop a CDI intranet site to allow the CDI team to provide access to electronic tip sheets, slide presentations, video teaching, etc. This is a convenient way for providing access to CDI information at the leisure of providers.
  1. Throughout the year, develop a poster series with CDI tips to be placed in various locations commonly used by providers.

As you can see, there are many ways to market your CDI program, but nothing will trump relationship building between your CDI team and the providers.  The more time the CDI staff can spend on the patient care units, the more credibility the team will earn. Becoming a trustworthy resource to providers in their environment will only stand to have an invaluable benefit to the overall success of your CDI program!

Editor’s Note: Estes has spent more than a decade as a CDI specialist and consultant, presently with DCBA Inc., in Atlanta. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. Contact her at kestes@dcbainc.com.

TBT: Radiology reports provide useful information in query formation

Lynne Spryszak, previously an HCPro CDI educator authored this excerpt in 2011.

Lynne Spryszak, previously an HCPro CDI educator, authored this excerpt in 2011.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the October 2011 edition of the CDI Journal

Radiology reports, such as CT and MRI scans, x-rays, and ultrasounds, frequently contain detailed information that can lead to more specific code assignment. Coding Clinic advice supports the use of radiology findings to obtain additional information regarding the coding of the specific site of fractures. Specific information often found in CT or MRI scans can assist with diagnoses of cerebral edema or compression of the brain. These two diagnoses, when reported, add severity to a record because they are considered MCCs in the MS-DRG system. They also represent increased ROM in other classification systems. These two diagnoses frequently trigger the following interventions:

  • Intracranial pressure (ICP) monitoring
  • Surgical intervention (e.g., evacuation of an intracranial hemorrhage or insertion of a drainage device)
  • Insertion of a shunt and/or treatment with medications to reduce intracerebral pressure

Compression of the brain and cerebral edema are both serious conditions that can lead to herniation of the brain, brain cell death, and long-term deficits. These conditions often go undocumented because providers assume that a diagnosis of cerebral hemorrhage, brain tumor, or stroke includes anything related to the focal diagnosis. Providers also assume that because these conditions may be evident from findings summarized in the CT and/or MRI scan, there is no  need to document these conditions in their own notes. This is where a thorough review of radiology reports provides the clinical information to support a  provider query for appropriate additional secondary diagnoses such as cerebral compression or cerebral edema. Not every patient with a cerebral hemorrhage  or stroke has cerebral edema or compression of the brain, which is why it is appropriate to report these conditions when present.

Q&A: Defining subacute per coding guidelines

Go ahead, ask us!

Go ahead, ask us!

Q: The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not since the term “subacute” doesn’t really fall anywhere.

A: The Official Guidelines for Coding and Reporting offers no definition as to what is considered acute, subacute, or chronic. I have found subacute to mean something in between acute and chronic which is a vague description at best! For questions such as this I refer to the American Hospital Association’s Coding Clinic for ICD-9-CM (ICD-10-CM/PCS)® for assistance.

Coding Clinic, First Quarter 2011, p. 21 states:

Question: How is the diagnosis documented as “subacute deep vein thrombosis (DVT) code? There are index subentries for acute and chronic, but not for subacute?

Answer: Assign code 45.39, acute venous embolism and thrombosis of other specified veins, for a diagnosis of subacute DVT.

Now, this reference does not specifically describe a CVA but does offer guidance that the term subacute is interpreted as being acute. But I would like to see more guidance related to CVA. So let’s look at Coding Clinic, Second Quarter 2013, p. 10

Question: The patient suffered a subacute ischemic right posterior watershed infarct with small focus of subacute hemorrhage. How should this be coded?

Answer: Assign 434.91 Occlusion of Cerebral arteries, cerebral artery occlusion, unspecified with cerebral infarction AND 431- intracerebral hemorrhage, for the description subacute ischemic right posterior parietal watershed infarct with small focus of subacute hemorrhage. In this instance the patient had an ischemic stroke as well as a hemorrhagic stroke.

I understand that although this Coding Clinic is addressing the fact two codes would be assigned due to the fact there was both an ischemic and hemorrhagic stroke it also reinforces that the wording of subacute would apply to the codes for a CVA versus codes for a history of CVA. Coding Clinic offers much guidance when we encounter those “grey” areas of the code set and should be the reference that you seek in such situations.

 

New Guidelines include information on sequelae, sepsis, fracture coding

We’re still living under a code freeze as we (eagerly) await ICD-10 implementation. However, the four Cooperating Parties are still tweaking the ICD-10-CM Official Guidelines for Coding and Reporting. Both the Centers for Disease Control and Prevention and CMS posted the new guidelines on their websites last week. You can also download PDFs of the codes and indexes as well.

guidelines

CDC released new ICD-10 Guidelines

The Guidelines don’t contain major changes, but CDI and coding professionals should download and read through them. New for 2015 are examples of sequelae, information about sepsis and severe sepsis, and additional information on fracture coding.

The specific examples of sequelae include:

  • Scar formation resulting from a burn
  • Deviated septum due to a nasal fracture
  • Infertility due to tubal occlusion from old tuberculosis

The updated the Guidelines for sepsis, focused on postprocedural infection and postprocedural septic shock. When the patient develops a postprocedural infection and severe sepsis, first report the code for the precipitating complication, such as code T81.4 (infection following a procedure). You should also report R65.20 (severe sepsis without septic shock) and a code for the systemic infection. If the postprocedural infection leads to septic shock, you still code the precipitating complication first, but now report code T81.12- (postprocedural septic shock) and a code for the systemic infection.

ICD-10-CM now includes additional information on the seventh character for pathologic fractures. The seventh character denotes the episode of care. Use seventh character A when the patient is undergoing active treatment, which now includes evaluation and continuing treatment by the same or a different physician.

The Guidelines further state:

While the patient may be seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

You’ll find the same information under the Guidelines for Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes. You’ll also see some additional information on complications:

  • For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem.
  • The guidelines further clarify that seventh character D is used when the patient has an x-ray to check the healing status of a fracture.
  • When it comes to external cause codes, the guidelines now specify that the seventh character for external cause should be the same as the one for the code assigned for the associated injury or condition for the encounter.

You probably know that you only assign a place of occurrence code once. Well, most of the time. ICD-10-CM now specifics that when the patient suffers a new injury during hospitalization (which should be rare), you can assign an additional place of occurrence code.

Editor’s Note: This article was originally published on the ICD-10 Trainer Blog.

Reminder: Changes to the CCDS processes implemented Oct. 1

Changes took place.

Do you have your pin?

The following changes took effect on October 1, 2014:

1. Exam eligibility period will change from one year to 120 days (four months) in which to schedule and take the exam

Candidates will have 120 days (four months) to schedule and take their CCDS exam. Once the application is approved, ACDIS submits the candidate’s names to the exam company. The exam company emails (and mails) the candidate’s scheduling instructions. The candidate is responsible for scheduling his or her exam at a location and date convenient to him or her.

Note: Presently, candidates have a one-year window in which to take the exam. Any candidate sent to the exam company prior to October 1, 2014, will be grandfathered into the one-year eligibility window.

Candidates who do not take their exam within the eligibility period forfeit their exam fee and must reapply.

2. Re-exam fee will change from $100 to $125.

This fee is applicable for a one-time only re-exam for a candidate who fails on his or her first attempt. It also applies to candidates who are absent from their scheduled exam. ACDIS is charged by its testing company for every scheduled exam. Candidates may change their scheduled testing date one time with no fee, and must do so by contacting the exam company at least two business days prior to their scheduled testing appointment.

3. Fees implemented for replacement certificates and lapel pins

Replacements for certificates and pins damaged in transit will be provided at no cost. ACDIS will assess a fee of $25 each for other replacement requests for certificates and lapel pins. The fee is payable by check or credit card at the time of the request.

All replacement orders and payment instructions should be sent to: ACDIS CCDS Administrator, 75 Sylvan Street #A101, Danvers MA 01923 Email: prichards@hcpro.com; Fax: 781-639-5542

Reminder: Your CCDS re-certification is due by the two-year anniversary of the date you passed the exam. There is no current plan to restructure the CCDS re-certification requirements to include any specific number or level of ICD-10-related continuing education units. You may re-certify at your convenience and if you need more time, there is a 45-day grace period.

For example if you passed the CCDS exam on Sept. 1, 2014, you need to re-certify by Sept. 1, 2016. Using the 45-day grace period, it will be due no later than November 15, 2016. To re-certify, you need to submit continuing education credits earned during the two year period that you held the CCDS certification (so, from Sept. 1, 2014 to Sept. 1, 2016).

When you are ready to renew, complete the re-certification application, and send it, along with proof of CEUs and the applicable fee, to the address on the application (mail, fax, or email). The application is available on the ACDIS website.

We send several courtesy email notices as your renew date approaches, but you may not hear from us if we don’t have your correct email address or if our notices are blocked on your end. Make note of when your recert due date (your original exam date is on your certificate and on the score sheet you got when you took the exam). It is your responsibility to know when you recertification is due. If you’re not sure of your exam date, drop me an email and I’ll look it up.