Author Archive for Fran Jurcak

Dazed and confused? Or Encephalopathy?

Altered mental status, dementia, or encephalopathy: What’s really going on with your elderly patient that presents with confusion?

The typical scenario is the elderly patient with some minor dementia, who has been living fairly independently, who is described as being more confused than usual. A work up does not indicate any acute neurological conditions but the patient is admitted with altered mental status. Further work up often reveals an underlying infection or metabolic condition. After treatment of the underlying concern, the patient’s mental status returns to baseline and the patient is discharged back to their usual living arrangements.

Don't let dementia documentation confuse you.

The resources consumed in treating this type of patient often include a head CT, neurological consult, neurological checks, EEG, sometimes even a bed in the intensive care unit. But if the physician only documents altered mental status or dementia and not a type of encephalopathy, the true severity of illness of the patient may not be accurately reflected.

So what is encephalopathy?

As defined by the National Institute of Neurological Disorders and Strokes, National Institutes of Health, encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent, metabolic dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation) chronic progressive trauma, poor nutrition, or any reason for lack of oxygen or blood flow to the brain.

The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include tremors, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.

Coding Clinic provided a definition in the first quarter of 1988 (pages 3-4):

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Don’t cut out ‘excisional’ when considering debridement queries

This is one case when you can't 'cut it out.'

Recently a client contacted me regarding a surgeon who asked the coding department to stop querying him about excisional debridements. His comment was that all his debridements are excisional. He’s a surgeon and he cuts. Bottom line.  So please stop pestering him with the queries.

As most of us know, this clearly isn’t enough to code a record and has been the reason for a significant number of concurrent and retrospective queries across country in many, many hospitals. The simplest solution, of course, is for the physician to use the words excisional debridement but as we all know, that simple solution doesn’t always translate into simple reality.

What the client wanted to know was if they could make the assumption based upon his comment, that whenever he documented debridement, that he meant excisional and code to excisional. Again, I believe most of us would say that the documentation doesn’t indicate excisional and needs further clarification. So how do we get the documentation and not irritate the physician?

In an attempt to help clear the water surrounding the word “excisional,” many coding departments and documentation teams have made attempts to develop policies and procedures for clarifying this procedure. This became especially important with Recovery Audit Contractors (RACs) and other auditing agencies focusing on this specific procedure. Add to the mix the increasing number of elderly patients that are admitted with wounds that require care and then the number of non-excisional methods of treating these wounds. Clearly there is much to consider.

So what’s the best approach? Of course education is important. Physicians must understand the importance of their documentation and how a single word (or lack thereof) impacts the severity of illness, risk of mortality, and reimbursement. Communication of coding guidelines and definitions becomes an important function of a documentation improvement team.

Whether through queries, newsletters, posters or presentations, it is important for a documentation team to recognize the need for an ongoing method to provide support and resources to healthcare providers regarding documentation. We need to help providers learn the vocabulary that best represents the diagnosis and care they provide to the patient. Making assumptions or creating policies that allow for ambiguous interpretation of documentation will only create other problems.

So, clearly this particular surgeon needs to understand that if he performed an excisional debridement then he needs to document “excisional debridement.” Providing him with the information that defines an excisional versus non-excisional debridement is also important. Hopefully, once this information is shared, he will understand the need to include the appropriate words in his documentation. If not, that leaves the query process as an important part of the documentation process.

In answer to the question of whether it’s okay to eliminate queries for excisional debridement if the physician documents just debridement, only the provider knows the depth to which he or she cut and therefore it becomes the responsibility of that healthcare provider to document accurately and appropriately. I know this answer doesn’t necessarily make a CDI specialist’s day, but look at the bright side; it’s another opportunity to have a conversation with a physician and spread the word of complete and consistent documentation!

The CCDS exam experience

“Only a life lived for others is worth living.” – Albert Einstein

Interesting that a man most known for his intelligence is quoted for his humanity and belief about sharing with others. With that thought in mind, I thought that I would share with the ACDIS membership my experience with test taking and the Certified Clinical Documentation Specialist (CCDS) exam so that others may benefit from my experience.

The most frequent question that I’ve had lately from other CDS’s once they’ve learned that I have taken the CCDS is exam is what I thought of the exam and what is the best way to prepare. I have been working with and training CDS’s for several years and the first word of advice that I can offer is to be confident that your knowledge base and experience gained from working in the role on a daily basis will serve as the best resource. Having a strong clinical background, knowing coding guidelines, understanding how to analyze the data and being able to communicate RAC purpose are areas that you should be confident in before you should consider taking the exam. However, like every other exam one takes as an adult, there is no true way to “study” for this exam. Instead, as a former nursing professor, I would like to offer some advice on test taking that might be helpful.

I made sure that I got a good night’s rest before the exam. Not easy to do in Vegas. Upon awakening the morning of the exam, I ate a protein rich but light breakfast and arrived at the test site early. I found my place, made a trip to the restroom and then spent a few moments relaxing and just getting comfortable in my assigned space. I find that this is key to staying relaxed and confident and doing well.

Once the test began, I made sure to read the directions carefully and listen to the instructions supplied by Brian Murphy. Although those of us who took the first exam in Vegas took a paper/pencil exam, I realize that most of you will take a computerized version. Probably the most important strategy to think about when taking a test by computer is time management. Do a quick calculation of how much time is allotted for the exam and divide by the number of questions on the test. This lets you know the average time that can be allotted for each test item. Keep your watch nearby but don’t look too often, stay focused to the questions and not the time remaining.

Ok, now the actual test taking. Read the question carefully, look for the central idea of each question. What is the main point? Eliminate those answers you know to be wrong, or are likely to be wrong, don’t seem to fit, or where two options are so similar as to be both incorrect. Once you decide on an answer don’t change it unless you made a mistake, or misread the question. Computerized tests do not usually allow you to easily go back and review answers. Since I’m a firm believer in the “gut-instinct” theory that works fine for me. Over analyzing questions usually leads to changing a correct answer to a wrong answer. So once you’ve read and completed a question move on! Never change your original answer unless you are sure it is completely wrong.

If you get panicked or frustrated, sit back, close your eyes and refocus. If necessary stand up and go to the restroom. To do well, you must remain calm, focused and comfortable. Don’t’ worry about the pace of others. Especially in a computer environment, most of the other test takers aren’t even taking the same exam. Therefore it is pointless to become concerned with the speed of the test takers around you.

So you’ve finished the exam, now what? Before reviewing results, it’s always important to take stock of the experience and learn from it. Jot down problem questions, thoughts, items you’d like to review or look up to clarify your knowledge. Pat yourself on the back! You’ve just completed an extensive exam and you deserve congratulations for having the strength to finish the exam. Regardless of how you’ve done, this was an exhausting experience and you are deserving of a small reward, hopefully a certificate to frame and hang in your office!

Preparation tips:

• Arrive early
• Be comfortable but alert
• Stay relaxed and confident

During the test:

• Make sure to read the directions carefully
• Don’t rush but pace yourself
• Read the entire question and look for keywords
• Always read the whole question carefully
• Don’t make assumptions about what the question might be
• Keep a positive attitude throughout the whole test and try to stay relaxed. If you start to feel nervous take a few deep breaths to relax.
• Bring a watch to the test with you so that you can better pace yourself

Best of luck as you enter the certification process!

Feeding the brain on malnutrition documentation

Remember the old 80’s ad for the Big Mac? “Two all beef patties, special sauce, lettuce, cheese,

Documenting malnutrition might be easier than building a Big Mac.

pickles, cheese, onions on a sesame seed bun.”

These lyrics and the associated fast food mania was a sign of what I will call food affluence, when we valued time over money, convenience over quality and taste over nutrition. And yet during that same period, the prevalence of malnutrition in hospitalized patients was investigated numerous times with results indicating the malnutrition was a major concern for elderly, hospitalized patients. The effects of malnutrition and the associated costs were also vastly studied in late 80’s and early 90’s. So why has this issue not resolved?

Of course, the issue is once again poor documentation of the severity of the diagnosis and decision making regarding care of this condition. Unfortunately, the malnutrition codes differ from the usual medical terminology. The severity of the malnutrition is indicated in the codes and while clinical severity is typically indicated in risk not actual diagnosis.

Most nutritional consult forms provide a method for the dietitian to indicate risk for malnutrition, not an actual diagnostic statement. Many forms actually ask the dietitian to specify the level of risk of malnutrition by checking the appropriate box for low, medium/moderate, or high. These indicators do not easily translate into an ICD-9-CM code forcing professional coders and CDI specialists to search for other indicators of the severity of malnutrition to clarify diagnoses with the physician.

In an attempt clarify the need to document the severity of malnutrition in adult hospitalized patients, Coding Clinic addressed the issue in the fourth quarter of 1992. It says:

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Breaking documentation bad habits

A documentation specialist and I were doing rounds on a unit one day when we ran into a physician who left a query unanswered.

The CDI whispered in my ear:

“I query him about this condition all the time and he usually writes it but I don’t get why he won’t write it without being asked first.”

The physician’s response was simply  “out of sight, out of mind.” After a lengthy discussion regarding long standing documentation habits, we realized that this physician wasn’t being non-compliant or difficult—he truly needed the constant reminders. He had developed a pattern of dictation he reverted to whenever looking at a patient’s chart and was in a time crunch.

So this begs the question, how do we change documentation habits and patterns? Do we have any real hope of changing them at all?

For many CDI specialists posting queries is not enough to change a physician’s documentation behavior. Probably the best answer to this question is to keep clinical documentation information  in front of physicians. Constant reminders through informational/educational opportunities that are updated monthly can be very beneficial. The format needs to be applicable to the physicians and can vary from hospital to hospital. I caution that once you establish a format be consistent in your approach.

Possible strategies include:

• monthly newsletters
• posters and flyers in the physician lounge
• cue cards that can be easily carried in a pocket and presentations at meetings

But probably the most beneficial method for providing support for documentation that reflects the severity of illness of the patient is for a CDI specialist to be visible on the units when the physicians are on the units. I can’t stress enough the need for personal one-on-one time with the physicians on the floor, the importance for a CDI specialist to be “in their face.”

Pick a CDI topic of the month and go with it. The information needs to remain simple and to the point so you don’t lose the interest of the physician. Again, time is money in their mind so they tend to be more accepting when you get straight to the point. And don’t be afraid to recycle what you’ve used in the past, as reinforcement of new habits is also very beneficial in supporting clear and consistent documentation.