Author Archive for Glenn Krauss

Tip: Update physicians on change to consultation E/M code changes

CDI specialists are always looking for ways to build business relationships with physicians. One way to build a good professional relationship is to update them when changes occur to the physician fee schedule. And there’s a big change coming that’s just about to occur.

Effective January 1, 2010, CMS eliminated consultation codes, and rolled payment previously associated with these codes into existing office visit and initial hospital and facility visit E/M codes. From a CMS fact sheet:

CMS is also finalizing its proposal to stop making payment for consultation codes other than the G codes that are used to bill for telehealth consultations, and to redistribute the resulting savings to increase payments for the existing evaluation and management (E/M) services.  CMS will adjust the payment for the surgical global period to reflect the higher value of the office visits furnished during the global period.

Provide physicians with this table from the proposed physician fee schedule, which crosswalks payment for the previous consultation codes into E/M codes (scroll down to “downloads,” and you will find the table in the link “Budget Neutrality Mappings for the Consultation Codes.”

You can view the final rule at the Federal Register Web site: http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf

The art of communication: Getting back to basics

Communication is defined in the Merriman-Webster dictionary as a verbal or written message,

Face-to-face verbal interactions offer CDI specialists unique physician education opportunities.

exchange of information, or a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior. Consider the evolution of communication within the last century, beginning with the carrying of mail by horse and buggy, then the introduction of the telegraph, telephone, fax machine, and now the internet.

Now consider the evolution of communication as pertains to coding and clinical documentation improvement (CDI). Before the advent and growth of CDI programs, documentation improvement consisted of a retrospective coding query to the physician. The query sought clarification of principal and secondary diagnoses consisting of complications and comorbidities (CCs).

Today, CDI programs shine a light need to educate physicians about complete and accurate clinical documentation. CDI programs highlight that need in the face of increased coding and billing regulatory scrutiny as well as a sound, prudent business strategy to meet the business financial challenges faced by physicians. Savvy CDI specialists therefor have incorporated educational tools into their programs including monthly newsletters, tip sheets, and pocket guides.

The execution of effective communication strategies dictates the successes and failures of a given CDI program. As I have the opportunity to “observe” programs in action, one component of communication often seems to be lacking. This component includes old fashioned verbal communication with physicians about the clinical facts of the case, existing documentation, and possible clinical documentation that may be missing from the health record.

Verbal communication allows the CDI specialist to provide education and reinforce teaching principles, a key point missing from the use of written clinical queries. The use of verbal communication allows the CDI specialist to read the physician’s body language and other cues to determine whether the physician understands the principles being discussed.

Appreciation and understanding of these documentation principles by the physician serves as the basis for educational reinforcement of other tools used in physician clinical documentation improvement efforts, the likes of newsletters, tip sheets, handouts, etc. No clinical documentation improvement program can be successful in the long run without going beyond episodic education of continuous, repetitive clinical queries. Eventually, physicians have a tendency to grow weary of the same day in, day out queries. They become numb to the content.

Physician clinical behavior modification by necessity requires more than leaving queries in the record for the physician to review at a later time. If one thinks about the use of clinical queries, an argument can be made for the evolution of clinical clarification to merely have changed from retrospective to concurrent. The physician is reading the clinical query on the hospital floor as opposed to reading it, culling information post-discharge, from the medical records.

Consider varying and adjusting CDI specialists’ work schedule to improve likelihood of reaching out to physician’s individual patient rounding practices. Reaching out to physicians for provisions of providing education is best served through learning of these practice patterns and adjusting one’s schedule accordingly. Generally speaking, making clinical documentation rounds routinely from 8 a.m. to 5 p.m., with a predetermined lunch break misses out on the opportunity to effectively and efficiently fulfill the roles, goals, and objectives of any program, that is true clinical documentation improvement.

Good Luck.

CDIP at the crossroads

The field of clinical documentation improvement has rapidly expanded into a burgeoning profession with strong potential and long lasting value for all healthcare providers involved in the care of the patient. The importance of and necessity for complete and accurate medical record documentation reflective of true patient acuity, risk of morbidity and mortality, and readmission cannot be over emphasized. There is almost always an opportunity to improve clinical documentation in any medical record chart from both a resource intensive reimbursement standpoint and quality of care and clinical outcomes standpoint.

But just as the profession is gaining momentum and increased recognition in the business facet of healthcare, we have reached a crossroads and may be going down the wrong path.

For those of us who have been in the clinical documentation improvement arena for a long time, it is eye-opening to view the advertisements and promotional materials for clinical documentation improvement projects readily available at trade shows and appearing in prominent trade journals. The common promotional theme is increased reimbursement for the hospital, which is not surprising given the fact these clinical documentation improvement programs are marketed strictly on the basis of “reimbursement enhancement.”

Let’s not kid ourselves, every healthcare expenditure that is not direct patient care related must provide for a reasonable chance of return on investment, contributing to the organization’s financial performance in some for or fashion, whether it be additional revenue or at least cost avoidance. But there has been some talk in the industry that some firms have worked into their CDIP contracts a guarantee of specified amount of increased reimbursement for the hospital with the implementation of their programs. 

The aftermath

Clinical documentation improvement programs can be structured to meet the documentation requirements required in the health record to financially sustain the hospital from a financial accounting and quality of care reporting perspective. How the program is structured can dictate success or failure in the rollout and acceptance of the program by physicians and other ancillary service providers.

In speaking with a fellow colleague recently, I heard a valid concern that is worth mentioning regarding where the CDIS profession is now, and where it may be going. Once again it may be going down the wrong route. My colleague pointed out that in some instances, the clinical documentation improvement specialists appear to be focusing on reviewing the record solely for identification and documentation of “missed CCs and MCCs,” almost as if they were “CC/MCC scroungers.”

The very idea of CDIPs being promoted primarily as reimbursement mechanisms perpetuates and drives the ever-increasing viewpoint of CDIS as CC/MCC identifiers. In order to be directed down the right path, we need to stay attuned to the mission of the profession, which is to affect positive change in physician’s patterns of clinical documentation over the long term through provisions and actions of continued physician education. This relentless pursuit of physician clinical documentation education embraces a holistic approach with an emphasis upon the direct correlation between clinical documentation and the continued business financial viability of the both the hospital as well as the physician. A primary focus upon “getting that CC/MCC” documented in the record represents a very small cross sectional piece of what the CDIS can fundamentally contribute to a successful program.

Looking to the future

A recent article caught my attention, certainly an interesting thought to consider as we are at the crossroad of our profession. Clinical documentation improvement efforts are episodic with a bent toward reviewing individual records and utilizing the clinical query process in striving for complete and accurate clinical documentation. In an article that appeared in the July/August 2009 Journal of Hospital Medicine entitled “Transitions of Care Consensus Policy Statement,” the American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions.

Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. You may read a summary analysis of this policy census statement through this link.  http://hospital-medicine.jwatch.org/cgi/content/full/2009/1009/1?q=etoc_jwhospmed

There are seven consensus principles and standards for managing care transition as follows:

1. Accountability
2. Responsibility
3. Coordination of care
4. Family involvement
5. Communication
6. Timeliness
7. National standards and metrics

While each of these standards embraces elements of clinical documentation, the last standard above speaks greatly for the ability of the clinical documentation improvement specialists to jump into the fray of clinical documentation and fulfill a much needed role of assisting in the formulation and development of standardized communication formats for care transitions that can be used for accountability and continuous quality improvement. Minimal required information in the transition record that the CDIS can help facilitate include principal diagnosis and problem list, medication list reconciliation, identification of the coordinating physician/institution, patient’s cognitive status, and test results and pending test results.

Which way?

We are at the crossroads of our profession in CDI. Which direction we decide to take will guide the ultimate success and future of the profession. Decisions made today will certainly impact all of us tomorrow and well into the future.

Focus on improved documentation of physicians’ clinical thinking, not DRG “buzzwords”

CGI Federal, the RAC for Region B (Indiana, Michigan, Minnesota, Wisconsin, Ohio, Kentucky, Illinois), has found a soft target: Medicaid claims for 1-2 day stays. RACs are contracted with other third party payers such as Medicaid to data mine historical provider coding and billing patterns and recoup past payments. Many of these denials and financial recoupments are “self-inflicted” by hospitals, often because physicians aren’t documenting patients’ risk factors or other clinical concerns, only vague symptoms such as chest pain (i.e., “chest pain rule out MI, start MI protocol”).

Too many CDI programs are focused on case mix and DRGs instead of taking a collaborative approach with physicians to improve documentation throughout the record. With nationwide RAC rollout upon us and complex record reviews slated to begin early next year, CDI specialists should work with physicians to help stave off this threat. One area in which CDI specialists can help is encouraging physicians to document their clinical thought processes, judgment, and medical decision making to complement and support diagnostic documentation.

We can’t make up what the doctor is thinking. We need to take documentation improvement to the next level, which is promoting and stressing to the physicians the importance of their patient clinical assessment—i.e., diagnoses, supported by a short discussion of additional clinical concerns and rationales that paves the way for the chosen plan of care.

Encouraging physicians to improve documentation of their thought processes is easier said than done, but an effective tactic is engaging physicians in a discussion on the interrelationship between E/M level assignment, clinical documentation (both in the office and in the hospital), and medical necessity.

While you can’t instruct physicians on what E/M level to select for his or her services—an inducement violation under Stark Law—you can help physicians understand the importance of complete and accurate clinical documentation in establishing medical necessity, the backbone of all E/M assignments.

For more information on education physicians on the concept of medical necessity as it relates to their E/M billing, refer to the following Job Aid on Trailblazer’s Web site. Some of the guidance Trailblazer provides includes the following:

Information used by Medicare is contained within the medical record documentation of history, examination and medical decision-making. Medical necessity of E/M services is based on the following attributes of the service that affected the physician’s documented work:

• Number, acuity and severity/duration of problems addressed through history, physical and medical decision-making.
• The context of the encounter among all other services previously rendered for the same problem.
• Complexity of documented comorbidities that clearly influenced physician work.
• Physical scope encompassed by the problems (number of physical systems affected by the problems).

Identify all the presenting complaint(s) and/or reason(s) for the visit for which physician work occurred:

• Demonstrate clearly the history, physical and extent of medical decision-making associated with each problem.
• Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent and risk to the patient) was affected by comorbidities or chronic problems listed.

Using the Trailblazer guidance, teach physicians that the standard of documentation is the assessment with the plan right next to it. The physician will be making a conscious, concerted effort to document relevant clinical concerns, including patient risk factors and other clinical elements. These are all instrumental in establishing medical necessity for admission through explicit and easily inferred clinical judgment. For example:

Assessment: Concern with acute renal failure. Patient was found on the ground, broke her hip and couldn’t get up for two days. BUN and creatinine are 40/2.6. Patient not producing urine.

Plan: Starting patient on 1L bolus of fluid and continue down to 250ccs/hour. Strict measurement of ins and outs.

The above documentation can be taken right out of a medical record and placed into a RAC appeals letter. But if the doctor just writes “acute renal failure—hydrate the patient,” the result is a weaker record that allows less room for appeal.

CDI specialists should be able to look through the record, find the missing diagnoses, talk to the doctor about it, and tell them how providing this documentation improves their practice of medicine. CDI specialists should review the record in its totality.

Some good news for CDI specialists in their battle to engage physicians in documentation buy-in: The days of separate hospital and physician payment may be numbered. The writing is on the wall for a closer alignment between physician and hospital payment. Take a look at this pilot project of 12 New Jersey hospitals and their participating physicians. Called “gainsharing,” the program offers physicians financial incentives to work with hospitals in lowering costs in a variety of ways. The program also includes stringent quality controls to protect patients, according to the press release.

Take advantage of opportunities for personal growth

A clinical documentation improvement (CDI) specialists’ focuses  on educating physicians on the

Take advantage of educational opportunities where ever you find them.

merits and material benefits of complete, accurate, and effective medical record documentation on the practice of medicine. The CDI specialists’ goal is to affect positive change in physician’s documentation. CDI specialists also help the physician understand and appreciate his/her role in clinical documentation as a proactive and defensive strategy to meet the tough business economic climate challenge of healthcare.

In order to affect positive change and be successful in the role of CDI, the specialist need to view the duties and responsibilities inherent to the position through the eyes of a businessperson. Just as physicians are business people who happen to choose medicine as their line of business, CDI  specialists’ are business people who happen to choose documentation improvement as their line of business.

As a businessperson, the CDI specialists has the responsibility of expanding and continually building upon his/her business skills through personal investment in tools and education as a strategy in becoming more proficient and effective in the business of CDI. It is incumbent upon the CDI  specialist to maintain relevancy in clinical medicine through reading of the medical literature such as JAMA, New England Journal of Medicine, subscribing to Journal Watch publications, Mayo Clinic Proceedings, and other daily newsletters.

Other considerations include subscribing to the Harvard Business Review or Influence without Authority, and investing the time to refresh skills in negotiation and communication through coursework at a local college or adult education class.

A successful and competent CDI specialist will recognize the need for continual education beyond learning the basic CDI crash course taught and promoted by many consulting companies. The likelihood of success of a CDI program rests primarily on the CDI specialist, recognizing the value and worth of proficient business skills as a foundation for the delivery of physician clinical documentation education of long lasting benefit and use to both the institution and the physician.

Quite frankly, there is more to CDI than leaving clinical queries on the record in hopes of the physician answering the query. A CDI specialist can control his/her own destiny through development and honing of business, communication, and negotiation skills.

Let the opportunities begin.

Medicare’s recently released readmission data: The CDI specialists’ role in the accurate reporting of risk

I am sure most everyone has learned of the Medicare’s recently released 30 day inpatient readmissions data for the three clinical conditions of heart failure, heart attack, and pneumonia that may be found on the Hospital Compare Web site. Medicare has already been reporting 30-day mortality data for the three above conditions for sometime now. One of the principle goals of this data reporting initiative is to encourage hospitals as a whole to focus upon their individual readmission data and hopefully invest the resources in efforts to reduce “avoidable” readmissions to the hospital. While the data is supposedly risk adjusted to account for variations in patient acuity, many argue of the methodology in the risk adjustment process.

The Senate Finance Committee include in their healthcare reform proposals, supported by recommendations from the MedPac Commission, that hospitals should not be reimbursed or reimbursed at a reduced rate for high volume clinical diagnoses that result in readmission. A report in the April 2009 New England Journal of Medicine points out that almost 20 percent of the nearly 12 million Medicare beneficiaries who had been discharged from a hospital between 2003 and 2004 were rehospitalized within 30 days, 34% were rehospitalized in 90 days, and nearly 50% were rehospitalized in one year. The costs of these unplanned admissions were $17.4 billion with an estimate of approximately $12 billion billed as avoidable. A 2007 MedPAC report states that Medicare paid an average of $7,200 per readmission thought to be potentially avoidable. Looking at Medicare billing data from 2005-2008, CMS reports that the national 30-day risk adjusted readmission rate was 19.9% for AMI patients, 24.5% for heart failure patients, and 18.2% for pneumonia patients. These numbers are quite astounding and costly to the Medicare program.

So what do these numbers have to do with CDI and CDI specialist’s efforts to effect positive change in patterns of physician clinical documentation? In two words, risk adjustment. Notice the reference to “risk adjusted” readmission. The focus of our CDI efforts should include incorporating the documentation and reporting of all clinical entities, history of and status post conditions that potentially play into risk adjustment methodologies, and not just reimbursement methodologies. Being cognizant of risk factors for readmission associated with different disease processes will be undoubtedly helpful in the CDI specialists’ effort to insure complete and accurate capture and reporting of risk adjusted data.

While the study was conducted in Hong Kong and published in 1999 in Gerontology as an article entitled “Risk Factors for Early Emergency Hospital Readmissions in Elderly Medical Patients,” the following conditions were found to significantly increase the risk of admission:

• Adverse drug reaction COPD
• End-stage renal failure
• Mobility being chair- or bed-bound
• Dysphagia
• Use of a nasogastric tube feeding
• Urinary incontinence and bowel incontinence
• Number of comorbid diseases
• Number of ADL impairments
• Advanced malignancy
• Congestive heart failure

The message here is for CDI specialists to maintain vigilance and efforts at recognizing opportunities for clinical documentation improvement, regardless of whether the clinical condition, past event, or status condition impacts reimbursement or not. As many other CDI professionals have stated in recent blog posts, clinical documentation improvement goes well beyond just generating more revenue for the hospital. We should all strive to be CDI specialists, as opposed to clinical documentation reimbursement specialists.

Draft a holistic approach to CDI program development

Clinical documentation improvement (CDI) programs have evolved over the last few years as

Could it really be so simple?

hospital interest in implementing these programs has grown exponentially. Such interest and evolution seems obvious given the healthcare economic climate and Medicare’s decision in the 2010 IPPS proposed rule to factor in a “behavioral adjustment” for supposed increase in hospital’s case mix absent an increase in patient severity and acuity.

Nevertheless, the field of clinical documentation improvement  is relatively new and continues to evolve with the growth of CDI programs.

The fundamentals of CDI programs consists of physician education on the merits of complete, accurate, and effective clinical documentation that can be translated into the most clinically appropriate ICD-9 codes in support of patient acuity, patient severity and risk of morbidity, mortality, and readmission. Different approaches to affecting positive change in physician patterns of medical record documentation may be used by CDI specialists. Typically, educational sessions, handouts, documentation tip sheets, written clinical queries, verbal queries, and monthly newsletters are used as part of CDI programs for this purpose.

However, one important item to consider in any program is the definition of  “clinical documentation improvement.”  To most, the definition consists of ensuring complete and accurate documentation of clinical diagnoses throughout the record in reflection of patient presentation to the hospital, physician treatment and management of the patient, hospital resource consumption and ultimate MS-DRG assignment.

What is missing in CDI programs is a holistic approach. What do I mean by the “holistic approach?” Holistic documentation improvement entails reviewing physician documentation beginning in the emergency room and continuing with the history and physical (H&P), progress notes, consult notes, and discharge summary to ensure complete, accurate, and effective documentation to complement efforts at capturing all reportable diagnoses associated with an inpatient encounter.

[more]