RSSAuthor Archive for Laurie Prescott

Laurie Prescott

Laurie Prescott, MSN, RN, CCDS, is a CDI education specialist for HCPro., Inc., in Danvers, Mass. A former clinical documentation specialist at Morehead Memorial Hospital, she spent the majority of her nursing career in acute care, primarily medical surgical with experience in ICU, PACU, endoscopy, and one day surgery, as well as medical units. Prescott worked as a unit manager of MED/SURG and ICU units, as an adjunct professor for an ADN program, and then moved to onsite education and clinical support of nursing staff. Contact her at lprescott@hcpro.com.

Summer Reading: Physician Education Discussion Scenarios

LauriePrescott_May 2017

Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example: The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids. For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Could you identify a probable etiology for her pneumonia? The physician responds, “It is probably due to aspiration.” The CDI specialist thanks the physicians and asks, “Could you please clarify that possible cause-and-effect relationship in the record?” She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”  Jane should then document this verbal query and the results as part of the CDI notes for this account. [more]

Summer Reading: Stepping out on your own

LauriePrescott_May 2017

Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

‘Flying solo’

After a few trial runs, new CDI specialists should be given the opportunity to review records on their own. Before composing any queries during this initial stage, the manager or mentor should review a draft of the query proposed and provide feedback to identify any additional opportunities and compliance concerns, as well as to save the fledgling staff member from any potential physician ire due to a misplaced query.

Such feedback should reinforce concrete rules of the CDI road and should be supported by official rational from governing bodies such as AHA Coding Clinic for ICD-10-CM/PCS, Official Guidelines for Coding and Reporting, ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, or in-house policies and procedures.  Of course, mentors and managers should offer their expert opinions and tips on how to practice effectively, as well. This feedback should also offer the new staff member an opportunity to voice questions and concerns, and accelerate the learning process. This step in the process can continue until the new staff member and the preceptor agree that the new CDI specialist is functioning well independently and is comfortable “flying solo.”

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Summer Reading: A letter to new CDI staff

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

Dear Clinical Documentation Improvement Specialist,

I remember my first day as a new CDI staff member very well. I had been through an extensive interview process—three interviews, a written test, and a meeting with the consulting firm that trained me. At the time, all I understood was that I was going review records and help medical staff meeting documentation needs. After more than 20 years of nursing experience, and time spent as a nursing school clinical instructor and in management, staff development, and healthcare compliance roles, I figured this would be an easy jump for me. It was a jump that felt like I had leapt right off a cliff.

I spent my first day training with two inpatient coders and the consultants. These two ladies were an interesting pair. One had been coding for more than 25 years, and I concluded she could diagnose most disease processes better than a number of physicians I knew. The second was new to the inpatient process, having coded in outpatient and clinic settings for a few years. We were implementing a new CDI program. Everyone looked to me to make this program a success. I soon understood this was much more of a challenge than I ever imagined.

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Summer Reading: New CDI staff exercises to perfect the review process

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

Shadowing staff

Often, the first step in becoming comfortable with the CDI record review process comes from simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your facility, reach out to ACDIS via its CDI Forum or local chapter events. Consider calling nearby facilities, asking for their CDI department manager. Many CDI specialists willingly open their doors to those just starting out. If your CDI manager is willing (or has connections of his or her own), perhaps you will be able to shadow a neighboring facility to get a better idea of how different CDI programs function as well.

Many CDI program managers ask candidates to do this during the interview process so both parties better understand the basic competencies and expectations of the job. Other program managers gradually introduce new CDI specialists to the process by shadowing experienced specialists at least once per week for a set number of hours or records per day. Other programs may require new staff members to jump into the reviews as soon as possible. [more]

Q&A: Pneumonia sequencing

Submit your inpatient coding and CDI questions reply to this post .

Submit your inpatient coding and CDI questions reply to this post .

Q: Can you please help me determine the query opportunities and code assignment/sequencing argument related to a patient who was admitted with pneumonia, congestive heart failure, acute respiratory failure, and encephalopathy? I thought that the pneumonia would be the primary and the respiratory failure as secondary as the severity of illness/risk of mortality (SOI/ROM) as well as the MS-DRG would all increase. Yet, I’m getting some push back on this train of thought and I’m not sure where the error in my logic may lay. Any insight you could offer would be much appreciated!

A: This is an interesting and common question. I believe you are asking why would we choose the acute respiratory failure as the principal diagnosis when, if we choose the pneumonia with a secondary diagnosis of acute respiratory failure, we have an MCC and it would provide both higher reimbursement and SOI/ROM. Coders and CDI specialists were once taught that when two or more competing diagnoses are present on admission and they could choose the one providing the highest relative weight/increased reimbursement.

In our CDI Boot Camp we explore the concerns around code sequencing in depth and part of our in-class discussion challenges that traditional thought a bit and perhaps spurs our students to think about the matters differently. The traditional choice, to simply code the highest weighed MS-DRG as the principal diagnosis, often gets challenged by auditors. Which condition, they rightfully ask, actually occasioned the admission? Does a typical patient with pneumonia require an inpatient admission? Not usually. When will the physician discharge this patient; when the pneumonia is resolved, or when the acute respiratory failure is no longer a concern?

My bet is that the physician will send this patient home on antibiotics (treatment for the pneumonia) so the pneumonia is not exactly resolved on discharge is it?

I recently assisted an organization with two DRG validation denials from recovery auditors. The auditors agreed with all coded diagnoses but argued the sequencing choices involved. One such account was acute systolic heart failure and acute respiratory failure. Their argument was the choice for admission was based on the acute respiratory failure, not the heart failure. I could not defend against that logic. Once the patient was able to breath without intervention or assist, she was discharged. She was sent home with adjusted medication for her heart failure continuing and follow up with the cardiologist.

I am not saying you should always sequence one way or another, rather, as a CDI specialist it’s your role to closely review the circumstances of admission and carefully consider which conditions meet the definition of principal diagnosis as “That condition after study that occasioned the admission.”

The Official Guidelines for Coding and Reporting tells us it should be a rare instance that two or more diagnoses qualify as the principal and we believe this guideline is used much more frequently than it should be.

Lastly, just to throw another log on the proverbial fire, depending on the circumstances in your example perhaps the encephalopathy could be the principal admission. Again it would depend on the circumstances of this patient and the treatment rendered.  This example is a great one to discuss with your fellow CDI specialists and coders.

Q&A: SOI/ROM impact

Have a question? Leave a comment below!

Have a question? Leave a comment below!

Q: I am with a CDI program that is starting to explore the severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do.

I was told that regardless of the actual final impact on SOI/ROM we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?

A: I very much agree with your practice of claiming those in which you see a change in SOI/ROM related to your query. I believe you are being encouraged to claim impact for any query that allows for an increase in SOI/ROM. So, for example, if you query for MCC capture, that would likely affect SOI/ROM and I would claim the impact for both MCC capture and SOI.

Say you have a patient that is admitted for COPD exacerbation with heart failure and diabetes. When you query to capture the MCC of the acute respiratory failure, and the physician responds appropriately, you would claim the credit for the MCC capture. But this query likely would also increase your SOI/ROM (I do not have access to an APR grouper but my guess is that it likely would).

I would think that although your goal in the query was not to increase SOI/ROM, if it did indeed do so, I would take the credit for this as well.

I would also suggest you seek out your peers on the ACDIS Forum as they likely could share with you how they analyze their metrics.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.

Q&A: CKD relationship

Ask your CDI question in the comment section.

Ask your CDI question in the comment section.

Q: The coders at my facility have stated auto linking congestive heart failure (CHF), hypertension (HTN), and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” HTN. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record. I referenced the Coding Clinic, Fourth Quarter 2008, which states that unless a causal relationship exists between the heart condition and the hypertension—and the physician documents this relationship in the record—each condition requires its own code, and if the documentation does not make that link, an HIM/coding professional must code the two conditions separately.

I understand that ICD-9 Coding Clinics may not apply in ICD-10, but I cannot find any updated guidance. Our coders are going by the Coding Clinic, First Quarter 2016, which still uses the phrase “due to.”

A: I know of no updated instruction that allows heart disease and hypertension to be an assumed relationship. We teach that the provider must clearly state the heart disease is due to (related to, secondary to, etc.) the hypertension.

Of course, the relationship between CKD and hypertension is a combination that can be assumed if found to be present.

For the patient that has the trifecta—is hypertensive, and has heart failure and kidney disease—we still need the provider to clearly state the relationship between the heart disease and the hypertension.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.

A Note from the Instructors: The value of the CCDS credential

Prescott_Laurie_webby Laurie Prescott, RN, MSN, CCDS, CDIP

Those working in the healthcare field really value their credentials. The letters after a person’s name open many professional doors for an individual. When I worked as a nursing manager, if an applicant held AACN certification that simple fact told me I had likely had an individual who possessed the experience, knowledge, and competency to perform the desired position. I am very proud to now as the CDI Education Director at ACDIS to work for an organization that offers a credential which the majority of employers understand communicates competence and experience in the role of CDI.

The Certified Clinical Documentation Specialist (CCDS) credential is seen as the industry’s preeminent credential within our profession. Many organizations have identified this as a requirement for employment and it has become a valuable credential to have following your name.

Because of its value, we get many requests by individuals to waive or lower the work experience requirements. Many question how to get the experience when they cannot qualify for the job without the credential. However, this credential represents much more than passing a test—it communicates to the world the fact you are a competent leader in the profession of CDI. It tells employers you have both book and practical knowledge, the ability to critically think your way through a medical record review and understand how to impact your organization’s health. It says you understand the many aspects of the role and possess the skills to ensure success. The credential is one you should be proud to list after your name. It has value.

Over the last few months, I have worked with other amazing volunteers who contributed s to the revision of the CCDS exam. (Learn more about the CCDS Exam Committee on the ACDIS website.) I never appreciated how much time, thought, energy, and passion is involved in writing an exam.

We spent much time working to define the prerequisites for this exam, as we understand competence within this role is acquired with experience. The learning curve in this role is one that is not easily accomplished no matter the professional route you traveled. We must have an understanding of anatomy, physiology, pharmacology, regulatory and compliance, coding practices, hospital reimbursement, CMS quality measures, and so much more. We must possess strong communication skills, a thick skin, persistence, an ability to investigate and research as well as the ability to think through our record reviews critically. We must work independently and also possess strong team building skills.

That is a great deal to ask of any one person, but that is role of a CDI specialist.

Of course, the CCDS credential does not guarantee that every holder will be a model employee or a perfect fit for your facility but what it does communicate—not only to potential employers but to yourself as well—that you have reached a level of competency within the role.

If you are the person wondering how you can get hired when you do not qualify to sit for the exam, understand that there are a number of other skills that you already bring to the table. Sell these skills and demonstrate self-direction in learning the body of knowledge needed for the role. Be patient—the credential will follow as you grow in your competency as a CDI specialist. And when you can finally add CCDS after your name, be proud of what those letters communicate.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.

Q&A: Mortality rate, observed/expected

Discerning the principal diagnosis is difficult at best.

Have a question? Ask us!

Q: Do you have any information about mortality rate, observed/expected, or can you direct me to where I might get additional information to better understand this metric?

A: The mortality index is defined by the number of patient deaths in a hospital within a ratio that compares actual deaths within a specific time period to expected deaths pulled from risk of mortality data. This is often referred to as the “O” to “E” death rate.

The observed to expected mortality rate is an example of a risk adjusted measure.

The observed mortality is represented by the actual number of patients that died in the hospital in a specific time frame (month, quarter, year etc.)

The expected mortality is the average expected number of deaths based upon diagnosed conditions, age, gender, etc. within the same timeframe.

The ratio is computed by dividing the observed mortality rate by the expected mortality rate.

The lower the score the better. For example, if the score is a one—it demonstrates that the actual mortality rate is equal to the expected rate. If the ratio is 1.25 it demonstrates the fact that more patients died than what might be expected. If the ratio is .75 it demonstrates that less patients died than were expected to.

This ratio can be affected by the quality of care provided and/or the quality of documentation captured in the medical record. If the CDI team does not help capture the highest severity of illness and risk of mortality appropriate for the physician or facility’s patient population through complete documentation, then the risk adjustment applied to this ratio will not be accurate. If the patient dies, it may appear as though the death could have been prevented.

Many CDI programs perform “death reviews” of these records to ensure that that the documentation clearly reflects severity of illness and risk of mortality. The goal of these reviews is to capture an APR-DRG (all-payer refined diagnosis related group) risk of mortality score of a 4. The higher level of risk of mortality demonstrates that there is a high probability of patient death.

There are a number of software programs that can compute the expected mortality of your patient population. Likely your quality department can assist you in in obtaining your observed to expected ratio and help you identify the ratio for specific service lines (cardiovascular, neurosurgery, etc), specific conditions (heart failure, specific surgical procedures etc.), or by provider.

Although there are many factors that can influence your O to E mortality ratio, it can be used to assess the effectiveness of your documentation improvement efforts as well. But we must ensure that the interpretation of this metric does take into consideration other possible influencing factors as well.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her atlprescott@hcpro.com. For information regarding CDI Boot Camps visitwww.hcprobootcamps.com/courses/10040/overview.

BIG news for heart failure documentation

Prescott_Laurie_webIf you have been a CDI for a number of years, you likely have wished for a dollar for every time you have queries for “specificity of heart failure.” I often joked that I would be asking for differentiation of systolic versus diastolic on my death bed. The latest AHA Coding Clinic has offered us assistance in obtaining this differentiation.

AHA Coding Clinic, First Quarter 2016, pages 10-11, tells us that if the provider describes the ejection fraction with terms such as preserved EF (HFpEF), the coder may interpret this as meaning “diastolic heart failure “or reduced EF (HFrEF) is documented, the coder may interpret this as meaning “systolic heart failure.” It is always a good day when the coding instruction reflects the language used by our providers.

This new direction is effective for discharges after March 18th, 2016. I think it is a sure bet you might ask at least one less query in your record reviews this week based on this new guidance!