RSSAuthor Archive for Linnea Archibald

Linnea Archibald

Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

Tip: Advance CDI’s cause through technology

CDI and technology

Technology changes the way CDI operates every day.

Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query.

Then, electronic health records (EHR) came on the scene, changing the CDI process for nearly everyone.

“Simply put, the advent of EHRs and e-queries changed how CDI specialists work—and the days of misplaced paper queries and incoherent penmanship are all but gone,” according to a special report out from ACDIS and HealthLeaders Media, in partnership with Optum360, “Leveraging technology to advance CDI efforts.”

Like all changes, EHR comes with rewards and challenges. CDI programs gain the flexibility and supportive data to meet the needs of the healthcare systems they serve. All while increasing productivity.

“With any new system, issues are going to have to be addressed,” Kathy McDiarmid, RN, CDI specialist at Beverly Hospital, a member of the Lahey Health System in Massachusetts, told the CDI Journal in December.

“There will be little things that physicians forget,” she says. Yet armed with intimate knowledge of the programs chosen, CDI staff can help physicians navigate the EHR and provide real-time assistance once the programs are in use, says Colleen Stukenberg, RN, MSN, CMSRN, CCDS, director of resource management at FHN in Freeport, Illinois, in a 2016 CDI Week Q&A for ACDIS.

In order to fully leverage the new technology, according to the report, CDI specialists need to understand the technology first. This knowledge gives them another platform from which to reach out to physicians. The CDI team can be a resource and help ease the transition to a new system for the physician.

To learn more about leveraging your EHR system to improve physician engagement and productivity, read the entire report by clicking here.

Guest Post: Addressing unspecified codes

Rose Dunn

Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

When CMS told the American Medical Association (AMA) physicians could have a one-year grace period to become comfortable with ICD-10-CM/PCS coding systems, they made a bad decision. The agreement allowed providers to be less conscientious about their diagnosis coding, leaving them to focus only on the first three characters of the code for medical necessity purposes. In actuality, some providers took the compromise as a license to map their superbill codes and submit “not otherwise specified” (NOS) and “not elsewhere classified” (NEC) codes to all payers.

Matthew Menendez of White Plume Technologies estimated in 2016 the average rate of unspecified code use at the time was 31.5%.

“Payers want the more detailed diagnosis information available in ICD-10. The reason that both government and commercial payers advocated for the migration to ICD-10 and invested millions of dollars to rewrite their adjudication processes was for the granular diagnosis data on their insured patient populations. Payers want to leverage detailed ICD-10 codes to drive down the cost of healthcare in the United States and if the provider community does not supply this data they will begin to deny claims,” Menendez said.

The NEC cases, the NOS cases previously accepted by Medicare are now perfect targets for a retrospective review by any of the government contractors.

Since the grace period between CMS and the AMA ended September 30, 2016, CDI and HIM program managers should review physician practice records both prospectively and retrospectively.

Prospectively, audit a sampling of records to identify documentation deficiency trends pulling NEC and NOS records specifically and offering tips to physicians for documenting the necessary specificity. Target these records for the physician prior to the patient’s return, so the physician can be prepared to capture the necessary information concurrently while the patient’s being seen.

In some situations, though, a more specific condition may not be possible. If unspecified codes are applied to accounts, they should go through a second review process (pre-bill) by a more senior coder or the coding manager.

Retrospectively, coding managers should monitor the continual use of NEC and NOS codes to determine the magnitude of the issue. If greater than 5% of the claims fall into an unspecified bucket in any single payer group, it should be concerning and spur additional CDI educational outreach.

Editor’s note: This article is adapted from JustCoding’s Practical Guide to Coding Management. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Note from the Associate Editorial Director: Thoughts about leadership

IMG_1136-small

Associate Editorial Director Melissa Varnavas

By Melissa Varnavas

I was just in the office kitchen joking with ACDIS Director Brian Murphy about how I’d always envisioned myself being a bigwig in a national healthcare association.

In our “Meet a Member” articles in the CDI Journal and CDI Strategies, we often ask folks about their first job and about their journey into the world of clinical documentation improvement. My first job was stuffing envelopes with some type of business collateral in the back room of a New England scuba diving shop. I also cleaned a dentist office. My later high school and college years I spent teaching daycare.

I had other jobs, too—secretary for an IT division of LibertyMutual, reporter and then editor of my hometown newspaper, managing editor for a radiology newsletter here with HCPro.

Most of you hail from diverse backgrounds, as well. Many of you worked in ice cream shops or fabric stores; started your careers coding in the neighborhood physician office or as floor nurses in hometown hospitals.

My dream job, that person I always wanted to be when I was little, was either a newspaper reporter or a teacher.

In my current role as the associate editorial director for ACDIS, I’m blessed with being able to work in both these roles. I get to play reporter, to talk to our members, to listen to their stories and retell the tales of their struggles and triumphs, sharing them with the rest of the membership so that we might all learn from their lessons and leverage their wisdom and growth in our own practices.

Over the past decade, we’ve grown together from these shared experiences. Like me, many moving into the CDI profession understand little other than broad concepts about what the position might entail. Those new to CDI learn by on-the-job training, taking a CDI Boot Camp, studying training textbooks, and hopefully through their ACDIS membership as well.

As ACDIS has grown over the past decade, we’ve watched our members’ careers grow, too—from CDI specialists performing record reviews to management roles to directorships over multiple hospital CDI programs.

So, my thought on leadership is this—that like so much in life, one may not set out with the intention of becoming a leader in any particular field or of any particular group but through grace and compassion end up becoming such because they step forward into the unknown, ever curious, ever engaging in the process of continued learning, ever generous with the knowledge they’ve obtained, ever giving back to those bright inquisitive CDI lights coming after them.

Editor’s note: Varnavas is the Associate Editorial Director for ACDIS and has worked with its parent company for nearly 12 years. Contact her at mvarnavas@acdis.org. ACDIS publishes a wide-variety of materials to help CDI professionals advance their careers, including: a position paper on the topic of CDI leadership, one on CDI credentialing, and one about defining CDI roles; a note about the value of the CCDS; a white paper on the topic of CDI career ladders and a sample ladder; two Q&As regarding career advancement; career advice from a CDI leader; and advice as to using the Salary Survey for career advancement.   

Q&A: Rejections for claims for removing impacted cerumen

ask ACDIS

Ask ACDIS

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

Many times in the ED, codes for services provided are driven by the chargemaster structure in cooperation with either a charge sheet or a menu in the electronic health record. When this is the driver, it is very easy for the person entering the charges/services to enter a line item for the right ear and one for the left ear. This could be because they are not versed in coding rules (modifiers -RT and -LT equal -50) for the surgical procedures. They may not be thinking of this as a “surgical procedure” as clinically it was “just an irrigation.” Or, there may not be an option for a bilateral procedure on the menu. It may be that the system is responsible for changing two unilateral procedures to report as a bilateral procedure, and this translation is broken. Follow the process through and see where the disconnect is.

CMS also changed the medically unlikely edit (MUE) number for CPT code 69209 as of April 1, 2017. Prior to April 1, the MUE was 2; however, this was changed to 1 as of April 1. You may want to check your claims prior to April 1 dates of service to insure that the payment you received was correct based on the bilateral payment methodology under the OPPS.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question. This Q&A originally appeared in Revenue Cycle Advisor.

Conference Committee Insights: Getting to the Heart of Accurately Defining Cardiac Ischemic Syndromes

conference committee

Apply by June 20, 2017

By Deidre Barnett, MHCL, BSN, RN, CCDS

Editor’s note: Barnett is a CDI specialist at MedPartners HIM in Tampa, Florida. She was one of the 12 member 2017 Conference Committee. For more information regarding the conference committee and to apply for the 2018 committee, click here.

With CMS piloting the bundled payment for acute myocardial infarction (AMI), CDI efforts in clarifying cardiac conditions is a very hot topic right now so I was glad to attend “Getting to the Heart of Accurately Defining Cardiac Ischemia,” presented by Christopher M. Huff, MD, FACC, and Garry L. Huff, MD, CCS, CCDS. The discussion also ties right in with the recent Official Guidelines for Coding and Reporting which call for the assignment of a code Type 2 MI as an NSTEMI without needing this documentation from the provider—we used to have to query.

The father and son Huff team did an excellent job on both sides of the discussion. Review and explanation of the pathophysiology from a cardiologist delved into the nitty gritty of what meets criteria for an AMI. Review of related diagnoses that occur on the spectrum from ischemia, injury, and infarction were covered in detail. The CDI implications were well defined–citing the importance of clinical validation when the criteria are not met but also explaining how the potential query as related to other diagnoses will impact the SOI/ROM.

It’s important to understand that all AMIs should meet certain criteria to be classified as an AMI. Type 2 MI is sometimes difficult to classify since it has a different etiology than the typical Type 1 AMI caused by an embolus (either blood clot or atherosclerotic plaque). There is a spectrum of myocardial injury that rises to the level of infarction when the criteria are met.

Therefore, as CDI specialists, we learned that it’s important to review every record for the AMI criteria and query appropriately for validation (if the criteria do not appear to be met) or inclusion (if the criteria are met and the provider does not document the STEMI/NSTEMI).

It was invaluable to have the pathophysiology reviewed as well as the CDI opportunities addressed in the same presentation.

 

 

Measuring the effect of HCCs, part 3

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the first part of this article, click here. To read the second part of the article, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

The effect of hierarchical condition categories (HCCs) may double as hospitals buy physician practices and form health systems made up of a spectrum of different types of providers. Physician reimbursement has become increasingly complex and some physicians find it easier to operate with the support of a larger organization. Organizations that were once solely hospital-based now have to grapple with the complexities of a different set of billing and reimbursement regulations, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee and a hospitalist at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana.

Fee’s seen a lot of interest in HCCs from large multi-practice groups affiliated with a larger organization and some smaller physician practices have also started to pay attention to HCCs, particularly if they work with a larger organization for EHR assistance to support meaningful use. “I think we’re at a tip of an iceberg in terms of interest in HCCs. I think providers have a lot more to learn about HCCs,” he says.

As provider organizations grow, they should create a program to collect and merge patient data for analysis just as payers do. This will give the provider insight into what reimbursement they can expect for certain patient populations and it can help pinpoint what departments need more help.

Organizations must ensure that coders, CDI specialists, and clinicians have the tools and knowledge to successfully navigate the documentation complexities of HCC-based models.

One common pitfalls found in physician practices stems from failure to document chronic conditions, Fee says. Clinicians generally learned that, to maximize the medical necessity of a service, they should document four diagnoses. But in HCC models, clinicians must document beyond the patient’s immediate diagnosis to address any condition which could affect the amount of care and attention the patient may need.

For HCCs, all chronic conditions, including past surgeries, must be documented at least once, annually, during a face-to-face encounter. For example, if a patient has an amputation and the physician documents it the year it happens, but does not document it during subsequent visits, HCC data will not reflect the amputation—jokingly referred to as HCC’s phantom limb

Because HCC data is calculated once a year based on information reported on claims, if the amputation isn’t listed in a given year, the data and risk adjustments for that patient will be created as if the patient never had an amputation, leading to a negative payment impact.

Remember that HCCs are grouped into related “families,” Fee says. Disease groupings with progressively higher severities establish a hierarchy that gives the highest severity the highest weight. HCC12 (breast, prostate, and other cancers and tumors) progresses to HCC11 (colorectal, bladder, and other cancers), HCC10 (lymphoma and other cancers), HCC09 (lung and other severe cancers), to HCC08 (metastatic cancer and acute leukemia). The coefficiencies for these HCCs range from 0.146 (HCC12) to 2.625 (HCC08).

CMS pays for the most severe form of disease reported in a given year. For example, in February 2016 a patient is diagnosed with prostate cancer (HCC12 = 0.146). In July 2016, the patient is diagnosed with metastatic prostate cancer to vertebra (HCC08 = 2.625). HCC08 is higher in the hierarchy than HCC12. All disease groups lower in the hierarchy than HCC08 are dropped. More resources are allocated to sicker patients; therefore, it’s vital that documentation and coding accurately express the patient’s condition.

Looking at the data can be an eye-opening experience, especially for physicians, Fee says. The data will make the connection between accurate documentation that includes chronic conditions and supports a patient’s actual level of severity and risk score, and poor documentation that makes a sick patient appear relatively healthy. The medical record should document the patient’s actual condition, the services that are medically necessary for the patient, and should reflect the hard work clinical staff put into caring for him or her.

 

Note from the Instructor: Take a road trip this summer

road trip

Take a CDI road trip this summer!

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

I recently taught a CDI Boot Camp at a large, multi-site organization, with attendees coming from CDI, HIM, and quality departments from four different sites. We began the week discussing the Official Guidelines for Coding and Reporting, moving through each Major Diagnostic Category (MDC), and talking about concerns related to code assignment and sequencing.

This discussion was very much a review for the attendees who hailed from the CDI and coding departments. The quality staff, however, coming from a variety of roles related to core measures, patient safety indicators, inpatient quality reporting, and hospital value-based purchasing, had continuous lightbulb moments.

One individual literally hit the side of her head and said, “This explains so much. How come we were not taught this before?”

After the first few days, I asked the quality department staff if they have ever told a coder or a CDI specialist that they “coded it wrong.” Almost every attendee raised their hand. I then asked the CDI specialists and the coders if they have ever been told they had coded a record incorrectly by an individual who had no understanding of coding guidelines. Every one of them raised their hands.

We discussed communications with providers, compliant queries, and practices of leading versus non-leading interactions when speaking to providers. Many of those who worked under the umbrella of quality spoke up to say that perhaps their discussions with providers had been leading. They never received education about how to compliantly query a provider for a diagnosis or how to query for removal of a diagnosis.

When we discussed sequencing new rules related to Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, I noticed the quality folks looking at each other and making faces. I stopped the class to ask what was wrong. They responded by asking when the change occurred. When I told them late last year—per guidance from AHA Coding Clinic, Third Quarter 2016—they all sighed and one expressed frustration about not knowing about the change earlier. They had been struggling to understand why admissions for COPD suddenly sky rocketed. One simple discussion answered a question they had been struggling with for months. And, as an added bonus, they learned why the coders were sequencing these diagnoses as they were.

As the week progressed, we talked about the specifics of a number of quality monitors—discussing what populations were included, exclusions, and the adjustments applied to organizations related to reimbursement. Now the coders and the CDI staff were asking why they hadn’t been taught this material before. They began to understand why the quality department was so concerned about the presence or absence of specific diagnoses. The quality staff were saying, “we need your help.” There was a purpose to this class: to knock down silos, learn from each other, and support each other.

I often describe our efforts as a group of individuals driving down a five lane highway. We have coders, CDI specialists, quality staff, case managers/utilization review staff, and denials management all traveling in their own lane. But, we are all heading to the same destination. We are all working to bring success to our organization. We wish to be recognized for the high caliber of care we provide, and consequently reimbursed appropriately for the resources we lend to that effort. Documentation is the key to this successful road trip. The providers are working to navigate safely on this busy highway with only the drivers to direct them.

As we travel down this road, we often swerve into each other’s lane. Often we are forced to swerve because the provider looks for guidance from us, assuming we understand the driver’s manual for the other cars on the road. If we do not understand every other driver’s role and their specific manual, we cannot support each other. We need to keep all our vehicles traveling in the same direction at a safe speed and ensure that as the providers try to cross the road we don’t run them down. It is confusing to providers if the CDI specialists instructs them one way and the denial management team tells them the complete opposite. Then they seek clarification from the quality coordinator and get a third interpretation of the “rules.” The providers are bound to give up and just navigate in the bike lane, never making any actual progress.

So, how do we learn to support each other? We need to step out of our comfort zones and spend some time with the other disciplines driving down that highway. We need to ask questions and answer other’s questions in return. We need to recognize that what we do affects the other’s work and work to support them. Large organizations often foster silos more than smaller organizations as they separate out the job functions more definitively. Often smaller organizations expect one person to wear a number of hats. Even though there are issues with overwhelming one individual, it also breaks down barriers.

Before you panic, I am not suggesting one person does it all. I am suggesting, though, that we intermingle a bit more, shadow different job roles, invite others to shadow us.

Take the road trip together—it’s more fun that way!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

Book Excerpt: CDI’s role in inpatient-only procedure documentation

Mackaman_Debbie

Debbie Mackaman, RHIA, CPCO, CCDS

By Debbie Mackaman, RHIA, CPCO, CCDS

Connect CDI, utilization review, and case management before the patient is discharged

When a procedure converts to an inpatient-only procedure during the surgery, the documentation process may get a little more complex. Analyze what happened during the procedure itself. If the inpatient-only procedure is performed on an emergency basis, it’s likely the admission order was not obtained prior to the procedure. The outcome for the patient will determine the next steps. If the patient expires, no further action is required by the registration or operating room staff. The coding and billing teams take over resolution of the case.

If the patient does not expire, the surgeon should confirm the type of surgery originally scheduled and the reason for the needed change to the inpatient-only procedure. He or she should do so before the patient leaves the postoperative area. The care team needs to make a determination regarding the admission of that patient. Under current CMS guidance, the three-day payment window may apply in this scenario. The case should be held for billing purposes until a thorough post-discharge review can be completed.

CDI staff may be involved in the initial review of the case. If CDI staff suspect an inpatient-only procedure was performed without an admission order, they should work with the coding team to identify the correct procedure code and verify if the procedure in question meets inpatient-only criteria. If it does, obtaining an inpatient admission order should be a priority. At this point, if necessary, the utilization review (UR)/case management (CM) team can step in.

The involvement of the UR/CM team is also critical when an inpatient-only procedure is canceled after the patient is admitted. Although the patient was admitted with the intention of performing the procedure and, therefore, the admission should be covered, each case should be independently reviewed. If the patient does not need acute medical care, his or her status may be changed from inpatient to outpatient, when appropriate, using Condition Code 44. When all conditions are met, Condition Code 44 allows a hospital to change the status and bill the services on an outpatient claim; however, timing is everything.

Editor’s note: This article is an excerpt from the “Inpatient-Only Procedures Training Handbook” by Debbie Mackaman, RHIA, CPCO, CCDS, an instructor for HCPro’s Medicare Boot Camps. To read the Fiscal Year 2017 inpatient-only list, visit the OPPS page on the CMS website and download Addenda E.

Q&A: Best practices in time documentation

ask ACDIS

Got CDI questions? Ask ACDIS!

Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.

A: Time is always one of those really fun things, especially with E/M codes, because CPT puts a vague description of time amount requirements out there. So often, I end up having to query the physicians for time spend performing a procedure. I always like to have them explain the time. For example, he or she could say, “I spent 20 minutes of our 30-minute visit explaining how to properly use a new asthma inhaler.” That explains, how the physician met with the patient for 30 minutes and out of that time, used 20 minutes to explain how to use the new inhaler rather than just saying, “I spent 20 minutes discussing counseling or coordination of care.”

The other area that I always like to mention is sometimes time is best documented as “time in, time out.” Physicians are going to add that time up all day, especially if it’s a critical care patient. Physicians may want to get in the habit of documenting, “I walked in the patient’s room at 9:05 a.m. and we did our full thorough E/M exam and medical decision-making. I walked out of the patient’s room at 9:45 a.m.” So now coders have 40 minutes that a physician spent with the patient. And then a physician may go back into the room three hours later and document, “Patient was not responding well to those previous interventions. I now am back in the room at 11:18 a.m. and I spent from 11:18 a.m. until 1 p.m. with the patient and we’re still working on these interventions.” Then coders can add up all those time increments.

So to me, the best way I’ve found for providers to calculate E/M time is to document how many minutes of the total visit time that he or she spent counseling, doing coordination care, or what the provider talked to the patient about. But when I’m auditing inpatient records, I like to see the time in and time out and a bulk amount of time at the end of the day that I can add up to bill for that full-time increment and to know it’s all accounted for.

Editor’s Note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, answered this question during the HCPro webinar “Coding and Reporting Medical Necessity: Essentials for Coders and Other Healthcare Professionals.” This Q&A originally appeared in JustCoding

Book Excerpt: CCDS exam format

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

The CDI specialist role is complex and multidisciplinary, suitable for clinically knowledgeable professionals who are proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals and objectives. These professionals possess knowledge of healthcare and coding regulations, anatomy, physiology, pharmacology, and pathophysiology. Furthermore, such professionals possess the valuable ability to engage physicians in dialogue and educational efforts regarding how appropriate clinical documentation benefits patient outcomes and the overall well-being of the healthcare system.

Therefore, the CCDS exam content stems from:

  • Analysis of the activities of clinical documentation specialists in a wide range of settings, hospital sizes, and circumstances
  • Input from ACDIS member surveys
  • Input and research of the CCDS advisory board comprised of experienced clinical documentation specialists

The examination is an objective, multiple-choice test consisting of 140 questions, 120 of which AMP uses to compute the final score. The exam questions have been designed to test the candidate’s multi-disciplinary knowledge of clinical, coding, and healthcare regulations, as well as the roles and responsibilities of a clinical documentation specialist. Choices of answers to the examination questions will be identified as A, B, C, or D and consist of the following question types:

  • Recall questions test the candidate’s knowledge of specific facts and concepts relevant to the day-to-day work of CDI professionals. The examination is an open-book test; candidates may use reference resources in answering recall questions, as this is the manner in which accreditation professionals frequently carry out their responsibilities.
  • Application questions require the candidate to interpret or apply information, guidelines, or rules to a particular situation.
  • Analysis questions test the candidate’s ability to evaluate and integrate a range of information in problem solving to address a particular challenge.

According to the CCDS Candidate Handbook, approximately 40% of the questions can be classified as the recall type, 40% as application type, and 20% as analysis type.

Editor’s note: This article is an excerpt from the “CCDS Exam Study Guide,” by Fran Jurcak, MSN, RN, CCDS. To read more about certification, visit the ACDIS website, here.