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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.

Conference Corner: Make time to check out the Poster Session at the Conference in Las Vegas

By Penny Richards, CCDS Coordinator and Member Services Specialist

2016 Poster Session

2016 Poster Session

Along with a dizzying number of education sessions at the ACDIS Conference in Las Vegas next month will be the annual Poster Session. These science fair-style presentations allow a selected group of your colleagues to present their CDI team and facility’s challenges and success stories, condensed onto a poster. Posters will be on display throughout the conference in the Exhibit Hall.

Presenters will be on hand during the morning break on Thursday, May 11, (10:15 to 11:15 a.m.) to talk to you about their poster and answer your questions. You’re sure to come away from the Poster Session with great ideas to incorporate into your CDI program to help build your own success story.

2016 Poster Presenters

2016 Poster Presenters

Here is a list of topics you’ll find at this year’s Poster Session:

  • CDI Report Card: Physician CDI Education
  • How to Avoid a Query Initiative: Educating the Physicians
  • Implementation of the Stop Sepsis Collaborative
  • CDI 2.0: Education for the Newer CDI
  • CDS Competency Validation
  • Putting the PSI in CDI
  • Key Chart Reviews Using SharePoint
  • Improved SOI and ROM Documentation
  • Provider Perspective on Charting Compliance and Query Success
  • Pediatric Malnutrition
  • CDS Coverage and Query Delivery
  • Remote CDI Challenges and Solutions

    Browsing the posters

    Browsing the posters

  • Shared Note Query in EPIC
  • Growth and Success at Tidelands Health System
  • Building a Successful CDS Team
  • Finding Data Hidden in Obstetrics and Prenatal Records
  • Career Ladder: Review Assignments by Units
  • A Retrospective Denials Review
  • Strategies to Improve Provider Query Response Rates
  • Out DRG Analysis and Review Taskforce (DART).
  • Our successful CDI/HII (Health Information Integrity) Remote Team
  • Transition from Traditional CDI Practices to Innovative CDI Practices
  • Shift from Regional to a System Approach to CDI
  • CDI in the Rehab Setting
  • Physician Engagement with TEMPO Board Rounds
  • MS-DRG Groupers Assigned to the MDC 24
  • Revitalizing a CDI Program to Promote Orientation of New Staff
  • Daily CDI Huddle: Team Meeting
  • Oncology Documentation: Improving SOI and ROM
  • Development and Implementation of a CDI Ladder
  • Impact CDS Impact on Quality Reporting and Documentation Accuracy
  • From Failing to Exceeding Goal in Three Months
  • Financial Impact of CDS in Critical Access Hospitals
  • Candyland: A Fun Look at CDIs and Physicians Engagement
  • Complications of Care: A Retrospective Review

You will find a list of all of the posters in your conference bag so you can make notes of which topics you find particularly interesting for follow up after the conference.

We will take photos of each poster and put them on the ACDIS website after the conference. We will also post a one-page description written by the presenter, including their contact information, so you can reach out for more helpful information about their topic.

Maybe you will present your success to conference attendees in 2018!

Book Excerpt: Understanding basic types of denials

Twist_Tanja

Tanja Twist, MBA/HCM

by Tanja Twist, MBA/HCM

You can’t manage what you don’t understand. So, the first step in any effective denials management program is to develop an understanding of the what constitutes a denial, as well as the different types of denials and their contributing causes.

Capture and categorize denials by their specific reason and dollar value, to deep dive into the type(s) of services being denied, the type of claim, the physician, payer, department, person, or situation that caused the denial. Despite a large number of denial reason codes used throughout the industry, all of them generally tie back to a few basic denial types: medical necessity or clinical denials, and technical denials.

Medical necessity or clinical denials

Medical necessity or clinical denials are typically a top denial reasons for most providers and facilities. They are also known as hard denials, in that they require an appeal to request reconsideration. Denial reasons that fall under this category include:

  • Inpatient criteria not being met
  • Inappropriate use of the emergency room
  • Length of stay
  • Inappropriate level of care

The primary causes of medical necessity denials include:

  • Lack of documentation necessary to support the length of stay
  • Service provided
  • Level of care
  • Reason for admission

Providers must ensure physician and nursing documentation clearly supports the services billed and that the physician’s admission order clearly identifies the level of care. One of the most effective means of ensuring compliance is through the implementation of a CDI program,  either internally or outsourced to a qualified vendor. A successful CDI program facilitates the accurate documentation of a patient’s clinical status and coded data.

Implementing a successful CDI program is typically one of the most challenging pieces of the denials management process, but it is the most important for long-term success. First obtain the support of the executives and physician leadership within the organization and second, but equally important, identify a physician champion to serve as the liaison to the physicians, reviewing chart documentation, and providing feedback on how to prevent denials moving forward.

Technical denials

Any nonclinical denial can be categorized as a technical or preventable denial. Causes of technical denials can range from contract terms and/or language disputes or mistakes related to coding, data, registration, or, charge entry errors, and charge master errors. Other technical denials may be caused by claims submission and follow-up deficiencies and denials pending receipt of further information, such as medical records, itemized bills, an invoice for an implantable device or drug, or receipt of the primary explanation of benefits (EOB) for a secondary payer claim.

All healthcare claims need to be submitted in adherence with federal, state, and individual health plan requirements and all claims need to be submitted in a timely manner. Other claim submission errors can be caused by claims being sent to the wrong address or even the wrong payer. Technical denials are known as soft denials because they can usually be reprocessed by providing a corrected claim or other additional information to the payer.

Editor’s note: This article is an excerpt from HCPro’s new handbook in the Medicare Compliance Training Handbook Series, Denials Management, published in January 2017 and written by Tanja Twist, MBA/HCM. This excerpt originally appeared in the Revenue Cycle Advisor.

Conference Conversations: What are ACDIS speakers looking forward to most?

ACDIS 2017

ACDIS 2017

“It’s in Vegas. Need I say more?” jokes William E. Haik, MD, FCCP, CDIP, who presents “Sepsis: 1, 2, 3—RAC Attack!” on Day 1, in Track 1, at 1:45 p.m.

Hardly a week goes by without a mention of sepsis in the medical literature, whether peer-reviewed scientific journals or non-peer-reviewed medical publications. Recently, more evidence has surfaced that seems to support the importance of Sequential Organ Failure Assessment (SOFA) in the risk assessment of sepsis patients, according to a recent White Paper on the topic from the ACDIS Advisory Board. And there continues to be conflict between clinical language, coding language, and the language required by quality assessment programs. (Read the related White Paper on the topic on the ACDIS website.)

But Haik, a founding member of the ACDIS Advisory Board, has a knack for breaking complicated clinical and coding conditions into manageable pieces of information, providing concrete examples of what clinical indicators CDI specialists should look for in the medical record and how to best craft a query to convey the patient’s condition in codeable terminology. Just as he has a knack for a quick comeback and rich and hearty laughter.

“We arm wrestle during my talk,” he says. “Just kidding,” he adds. “In reality, I’m trying to get participants to think inside the box! I want to get everyone to think clinically as a physician would.”

Striking a serious tone, he adds that presentations on quality, hierarchical condition categories, and value-based purchasing represent topics of interest. “I’m really looking forward to expanding my knowledge,” he says.

He’s not alone. The 10th annual conference features many physician presentations including that of Ronald Hirsch, MD, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who presents on Day 2, Track 4, 11:15 a.m. to 12:15 p.m.

Hirsch knows how CMS’ regulations and guidance can confuse even the most astute clinician with its vague and often contradictory instructions. Nevertheless, these regulations affect everyone—doctor, patient, bedside nurse, case manager, CDI, billing and coding, even healthcare executives.

While his presentation “Medicare Regulation Update: Practical Application for CDI Professionals” promises to shed a light on this often opaque information, Hirsch is looking forward to learning just as much from his peers and other breakout sessions throughout the conference.

2016 pre-cons

2016 pre-cons

“With the breadth of courses available at the conference, I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference physician advisor Boot Camp. It will be an honor to hear from Erica Remer and James Kennedy, two of the most renowned physicians in CDI,” Hirsch says.

Fellow physician, Nicole Fox, MD, MPH, FACS, CPE, medical director of pediatric trauma and CDI at Cooper University Health Care in Camden, New Jersey “cannot wait to hear about other program’s successes,” she says.

Fox, who presents “Playing to Win: How to Engage Physicians in Clinical Documentation Improvement,” on Day 3, Track 3, from 11 a.m. to noon, says she’s particularly interested in ambulatory CDI as Cooper University plans for its next area of growth and expansion.

Just as Fox looks forward to hearing other people’s CDI success stories, she’s excited to share her own, too. “One of the strengths of our program is physician engagement,” she says. “Physicians are never taught how to document, so they struggle with this much-needed skill set and are often hesitant to ask for help.”

Cooper University’s CDI program, however, tracks a 100% response rate to its CDI department queries, a rate at least partially attributed to the peer-to-peer education Fox helped establish.

“I think one of the general challenges with physician engagement is not recognizing that the best way for physicians. There is no substitute for a practicing physician embedded in your CDI program who will proactively educate peers and handle any concerns that arise,” she says.

Cooper University also has a remote component to its CDI program. Past ACDIS Achievement Award winner Kara Masucci, RN, MSN, CCDS, and her manager Rebecca R. Willcutt, RN, BSN, CCS, CCDS who both work at Cooper University, join Boston Medical Center’s Lara M. Faustino, RN, BSN, CCDS for a panel discussion on Day 2, Track 2, at 9:15-10:15 a.m., for a panel discussion on remote CDI efforts.

General session networking

General session networking

Like Fox, Faustino’s looking forward to learning from industry experts and peers and, of course, “networking! I always enjoy learning from a variety of CDI professionals from across the nation and it always amazes me how very similar we are, or how vastly different we approach the same types of challenges.”

When Jeff Morris, RN, BSN, CCDS, now CDI supervisor at University of South Alabama Health System in Mobile, first started in the role it was as a liaison between coding and physician staff to provide documentation education related to ICD-10 specificity. With numerous ICD-10 delays, however, Morris transformed the program, added staff, and expanded into focus areas such as CDI in obstetrics and gynecology, which he’ll explore on Day 1, Track 5, at 3:45 p.m.

“I am most looking forward to the networking and collaboration that occurs between CDI professionals during these few days. I always leave the conference refreshed and full of new ideas to bring back and implement at my facility,” Morris says.

There’s a lot to get excited about this year, especially with the 10th anniversary festivities. What sessions are you looking forward to most? What’s your favorite part of the ACDIS conference every year?

Lunchtime

Lunchtime catch-ups

Note from the Associate Editorial Director: CDI Journal focuses on quality

by Melissa Varnavas

Healthcare has often been referred to a both a science and an art. Nevertheless, the healthcare industry continues its hunt for proof of quality healthcare services to, as much as possible, remove the art portion of the art-versus-science debate. That’s why the March/April edition of the CDI Journal pulls from a range of experiences and expertise to examine the many ways CDI efforts touch quality measures.

As Congress continues working to dismantle the Affordable Care Act (ACA), a wide range of vested entities contemplate the future of government payment methods. Hospital value-based purchasing (VBP), part of the ACA, offers a number of incentives—both positive and negative—to more closely tie patient outcomes to reimbursement on a host of measures. VBP represents the most comprehensive government pay-for-performance program, but it’s easy to feel overwhelmed by its various components when also considering the myriad collections of quality-focused programs hospitals and physicians need to navigate.

Quality-tied payments and public reporting measures can seem like the multi-headed Hydra of Greek lore—no sooner has a CDI program focused on, and defeated, one serpent than two other initiatives pop into existence. CDI programs understand the need to expand record review efforts, now that CC/MCC capture isn’t their only documentation goal.

Cheryl Ericson, MS, RN, CCDS, CDIP, does a nice job of summarizing the shift in her “Note from the Advisory Board” on p. 6, and on p. 10, ACDIS Editor Linnea Archibald looks at the various components of CMS’ VBP efforts, including a review of hospital-acquired conditions and present on admissions indicators. These articles help illustrate the complexity of quality concerns.

These aren’t the only measures considered in this issue, either. Advisory Board member Sam Antonios, MD, FACP, SFHM, CCDS, offers three tips for programs to help improve outcomes in regard to readmission reductions on p. 8, and ACDIS member Bonnet Tyndall, RN, CCDS, provides readers with a case study of how her team implemented record reviews for mortalities on p. 19.

All these potential review targets can be daunting, but don’t be intimidated. Take a look through this edition of CDI Journal and note how many of these programs aim to capture some of the diagnoses already found on most CDI programs’ top 10 lists.

As ACDIS CDI Boot Camp instructor Allen Frady, RN, CCDS, CCS, says on p. 22, “times like these are exciting for us CDI nerds.”

Editor’s Note: Varnavas is the Associate Editorial Director for ACDIS, overseeing its various publications and website content. Contact her at mvarnavas@acdis.org.

Conference Conversations: Fox helps make CDI programs “physician-friendly”

Fox, Nicole

Nicole Fox, MD, MPH, FACS, CPE

Editor’s Note: The ACDIS Conference is only a little over two months away. Over the coming weeks, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked to Nicole Fox, MD, MPH, FACS, CPE, the medical director of pediatric trauma and CDI at Cooper University Health Care in Camden, New Jersey, who will be presenting “Playing to Win: How to Engage Physicians in Clinical Documentation Improvement.” Currently, Fox leads a team of 13 CDI specialists and achieved a 100% physician response rate to queries.

Q: What has been the biggest challenge you faced with physician engagement at your facility?

A: Actually one of the strengths of our program is physician engagement. We have a 100% response rate to our CDI queries. I think one of the general challenges with physician engagement is not recognizing that the best way for physicians to receive information is peer-to-peer. There is no substitute for a practicing physician embedded in your CDI program who will proactively educate peers and handle any concerns that arise. Physicians are never taught how to document, so they struggle with this much-needed skill set and are often hesitant to ask for help. But, they respond most effectively to one of their peers.

Q:  What are three things attendees can expect from your session?

A: Attendees can expect an interactive, dynamic presentation. They will have tangible “take-aways” to help make their CDI program physician friendly. They also will have tools to handle difficult physicians.

Q:  What one tool can CDI professionals not live without?

A: An engaged medical director for their program.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: This session challenges non-physicians to see CDI from a physician’s perspective and really evaluate their own program to determine whether or not they are set up for success in terms of physician engagement.

Q: What are you most looking forward to about this year’s conference?

A: I cannot wait to hear about other program’s successes, particularly with ambulatory CDI which is our next area of growth and expansion.

Q: Fun question: what’s your favorite breakfast food?

A: An egg white burrito with quinoa and black beans. It’s awesome with tomatillo sauce. They make a great one at the Wynn Hotel café in Vegas, so try one while you are out at the ACDIS conference.

 

Guest Post: Discharge summary critical to hospital data quality and pay-for-performance, part 3

Time to take action

With the help of our hospital quality improvement (QI) committees, we can take action to restore the integrity of the discharge summary. Consider the following:

  • Advocate timely completion of the discharge summary and overall chart, preferably within a week of the patient’s discharge. The Medicare Conditions of Participation require that the entire medical record be completed (i.e., signed, sealed, and delivered) within 30 days of inpatient discharge; some states, such as California, have stricter deadlines. Summaries must be performed within seven to 10 days if they are to be typed and signed prior to the 30-day deadline. Even with these generous deadlines, good patient care requires that we do our summaries as soon as possible.
  • Insist that discharge summaries meet quality standards. Have the QI committee audit physician discharge summaries for at-risk conditions, such as pneumonia, myocardial infarction, and heart failure. Involve the coding manager or clinical documentation specialist to learn how the terminology used affects resource intensity or risk of mortality determinations. Follow up with a corrective action plan when deficiencies are found.

Thank you again for the efforts you take to ensure data quality. Please let me know of other topics you would like me to address in this column.

Editor’s note: This is the third part in a three-part series. To read the previous two sections, click here and here. Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. 

 

Note from the Instructor: Take personal responsibility for professional advancement

Prescott_Laurie_web

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

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

It has been 10 years since I turned the focus of my career to the practice of CDI. About a year ago, I found myself calling it a “profession.” I have been a proud member of the nursing profession for more than 30 years. In both my personal and professional life, I tried my best to represent my profession and demonstrate that nurses are highly competent, knowledgeable leaders in providing healthcare to patients. Nurses have been granted the privilege of witnessing and assisting others in their most intimate moments of life.

I never wanted to minimize the role of a nurse, nor misrepresent it in any way. I feel very much the same about the profession of CDI. We serve a very important role in our organizations in that we work to ensure our patient’s stories are told accurately and completely.

The profession of CDI encompasses a number of different titles, credentials and professions besides nursing, to include medicine and coding. And I am sure no matter how a person landed in CDI they too are as proud of their specific profession that started them off as I am of my nursing background. And I am sure, too, that most are also proud of the fact they are now a member of the CDI profession. (Read the recently released “CDI: More than a credential,” position paper from the ACDIS Advisory Board.)

Google the word profession and the definitions returned are all similar. Most state that a profession describes an occupation requiring specialized education, knowledge, training, and ethics. Members of a profession are expected to meet and maintain a common set of standards. Skills and knowledge are obtained through the process of lifelong learning and continuing professional development. Indeed, the ACDIS Code of Ethics reinforces that commitment to lifelong learning.

I was always taught that a profession must have a developed body of knowledge. The ACDIS Code of Ethics addresses this as well with the statement, “Clinical Documentation Improvement Professionals must advance their specialty knowledge and practice through continuing education, research, publications, and presentations.” It is up to each and every one of us to grow our body of knowledge.

So my question to you is—what have you done lately to represent your profession?

We all need to be leaders. That does not mean you have to speak at the national conference, or write articles and books, but it could mean becoming a leader within your own hospital organization or helping with your local ACDIS chapter.

When I was working daily in the CDI role, I spread the word of CDI in an activity I called the “CDI Road Show.” I took the road show to anyone, any department that invited me. (And even to some that did not extend an invitation!) I wanted everyone to know what we did because their support of those efforts could help foster our success.

I wanted to represent my profession well; meaning I tried to demonstrate competence, knowledge, and commitment to ethical practice in every activity and exchange performed. This commitment was as much for myself as it was for all the CDI specialists I worked with. If I presented as well prepared and knowledgeable to a provider, the next time that provider spoke to another team member he or she would understand the skills our CDI team brings to the game. If I could speak concisely to administration and communicate both the value of CDI and the needed resources, the administrative team would see all CDI staff as professionals, too.

And so, I encourage you to step up. Volunteer to serve on a committee. Start a “road show” of your own. Mentor a new CDI. Learn something new today.

Most importantly, walk strong and tall and demonstrate to the world the CDI professional that you are.

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.

From the Forum: Using pediatric nursing notes for query creation

From the ACDIS Forum

From the ACDIS Forum

Nursing notes cannot be used for coding and billing purposes. This does not mean, however, that they’re worthless for CDI purposes. Often times, CDI specialists neglect reviewing this documentation because they know it can’t be coded. This is a mistake.

“Often times, it’s the nursing notes that will support queries for encephalopathy, delirium or other altered mental status conditions,” says Karen Bridgeman, MSN, RN, CCDS, CDI educator at the Medical University of South Carolina in Charleston.

While nursing notes can help with clinical indicators to support a query with patients of all ages, nurses’ documentation helps a couple of pediatric-specific diagnoses, for instance, thrush.

“One thing I’ve noted a few times is that nursing usually documents clinical indicators of thrush. The doctor orders Nystatin, but doesn’t document what he/she is treating,” Claudine Hutchinson, BSN, RN, CDI specialist at the Children’s Hospital at St. Francis in Tulsa, Oklahoma, says.

With sticky diagnoses such as malnutrition – an especially difficult diagnosis in pediatrics – nursing notes also often provide valuable information on the patient’s body mass index (BMI), height, and weight. Additionally, the nursing notes often provide clinical indicators to support clinical validity of an already present diagnosis of malnutrition, according to Laurie Prescott, RN, MSN, CCDS, CDIP, CDI education specialist at HCPro in Danvers, Massachusetts.

“Malnutrition in children is based, in part, on their failure to meet developmental milestones and deviations related to their z-score and the pediatric BMI scale,” Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BRL Healthcare in Middleton, Massachusetts, said in response to a question in CDI Strategies.

If the nursing documentation supports a diagnosis of malnutrition based on unique pediatric criteria, then a CDI specialist can use that information to support a query to the physician. Often, nurses record the information used to calculate BMI during the initial physical assessment.

Nurses also often document the present on admission (POA) status of pressure ulcers during initial assessments. Since pressure ulcers fall under the hospital-acquired conditions banner, it is vital to document their POA status. If a physician documents a pressure ulcer, check the nursing documentation for its status upon admission.

We work with our [providers] during rounds to be sure that POA status is documented for any pressure ulcers documented by nursing on the admission assessment,” Jackie Touch, RN, MSN, CCM, CDI specialist at CHOC Children’s in Orange, California, says.

Nursing notes can also provide a valuable education entry point for CDI specialists. “In some instances, it may be as simple as showing the physicians where they can access the nursing documentation. “The physicians did not know how or were unable to view the nursing flow sheets,” at Wake Forest University Baptist Medical Center before the CDI helped address the problem, says Melinda Matthews, RN, BSN, CCDS, manager of inpatient clinical documentation excellence at Wake Forest Baptist Health, which includes Brenner Children’s Hospital in Winston-Salem, North Carolina, in an ACDIS Q&A.

Even though coders cannot use the nursing notes for coding purposes, Prescott advises working the nursing documentation into your regular chart review process.

“[Nursing notes] often assist in understanding the patient’s baseline conditions, and often help us to identify any secondary diagnoses not mentioned in the provider’s initial assessment,” Prescott said in a response to a question in CDI Strategies.

Prescott also advises educating the nursing staff about the usefulness of their documentation in supporting clinical validation and identifying missing diagnoses and opportunities for clarification. The nurses can be a valuable asset in reaching CDI goals, so educate them accordingly, Prescott says.

Editor’s note: This article’s content was taken largely from recent posts on the ACDIS Forum. To participate in the Forum, click here. If you have any questions regarding this or the forum in general, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org.

 

 

Conference Conversations: Brant offers insight into recovery auditor programs

barbara brant

Barbara Brant, MPA, RN, CCDS, CDIP, CCS

Editor’s Note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we spoke with Barbara Brant, MPA, RN, CCDS, CDIP, CCS, a senior consultant with Cotiviti Health Care, presenting “CDI Specialists: Impact Potential in the Audit Process.” Since 2005, she has been involved in the development, implementation, and auditing of CDI programs. Brant has assisted health systems with ICD-10 Gap Analyses and created ICD-10-CM educational materials for specialty physician groups. Currently, she provides training and clinical support for DRG auditors. She lives in Camp Hill, Pennsylvania with her husband Marty.

 

Q: What do you think CDI specialists’ biggest misconceptions about the Recovery Auditor program are?

A: There are really three main misconceptions:

  1. Denials are determined without complete review of the documentation
  2. Recovery Auditor’s only look for “gotcha” errors
  3. CMS Recovery Audit programs are performed to only take back

Q: Recovery Auditors are not at the top of anyone’s best friend list in healthcare, but what important purpose do they serve?

A: The goal of any audit is to identify problematic issues. The purpose of CMS’ Recovery Auditors is to identify and prevent improper payments. Therefore, Recovery Auditors serve a purpose by encouraging healthcare providers to work for solutions to correct identified problems, stabilize provider revenue cycles, and ensure accurate payments for payers.

 

Q: What are three things attendees can expect from your session?

A: The three things that attendees can expect are

  1. To understand that Recovery Auditors perform very comprehensive reviews of all documentation provided.
  2. To obtain knowledge that the guidance for recommended reimbursement changes (higher or lower) is based on extensive peer-reviewed research of best-practices, clinical consensus data and Official Coding Guidelines.
  3. To use information from this session for improved denial data due to CDI performance improvements.

 

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: To encourage use of retrospective audit data to concurrently improve problematic documentation

 

Q: What are you most looking forward to about this year’s conference?

A: Interaction with colleagues and to stay updated on CDI’s expanding roles within the revenue cycle

 

Q: Fun question: what’s your favorite movie?

A: A Christmas Story – a perfectly imperfect loving family!

 

Guest Post: Discharge summary critical to hospital data quality and pay-for-performance, part 2

James S. Kennedy

James S. Kennedy

The third reason that the discharge summary is more important than the H&P is that, given that the ICD-10-CM principal diagnosis establishes the foundation for the diagnosis-related group (DRG) essential to cost-efficiency measurement, we must be crystal clear what condition we determined (after study) to be the reason for which we wrote the inpatient order, how the diagnostic approach or treatment evolved, why the patient had an unexpectedly long length of stay, or why he or she consumed additional resources. If two or more reasons qualify, coders can pick a higher-weighted code if it is supported by the documentation. For more information on principal diagnosis selection, read this related article.

For example, a woman presents with pancreatitis, and the diagnostic workup determines that it is due to gallstones. In MS-DRGs, if the ICD-10-CM code for gallstones is sequenced as the principal diagnosis instead of the ICD-10-CM code for acute pancreatitis, almost double the resources are allocated to that admission. The coder, however, may not choose the gallstones as the principal diagnosis unless the discharge summary shows, beyond a shadow of a doubt, that the circumstances of admission, the diagnostic approach, and the treatment rendered support the gallstones as the principal diagnosis. This may require that we overtly document how the admission was not only to treat the patient’s acute pancreatitis, but also to determine its underlying cause. Under most circumstances, a cholecystectomy would be performed during that hospitalization; however, if the surgery is delayed, an overt discussion on the reason for the delay can help a coder understand why the gallstones could still qualify as a principal diagnosis, even without surgical treatment.

We have the same situation with atrial fibrillation and decompensated systolic or diastolic heart failure. Atrial fibrillation as a principal diagnosis is higher-weighted than heart failure when they coexist. Unless we discuss how the patient’s atrial fibrillation contributed to the patient’s decompensation and demonstrate that it influenced the diagnostic approach and treatment rendered (assuming it did), the coder may be less secure in sequencing atrial fibrillation as a principal diagnosis, however.

Last, but not least, the discharge summary is the only part of the inpatient medical record in which we may document uncertain, probable, likely, suspected, or still-to-be-ruled-out diagnoses, and from which a coder may code those diagnoses as though they existed. Physicians and coders cannot apply this rule on outpatient facility or physician claims. It is only allowed for inpatient facilities. Not only does this affect DRGs, it also factors into the hierarchical condition categories (HCC), and affects our cost efficiency under value-based purchasing and other CMS initiatives.

For example, the physician admits a due to chest pain. After a diagnostic workup, the physician determines the pain is noncardiac and discharges the patient home on a proton pump inhibitor. The DRGs for noncardiac chest pain are lower-weighted than those for heartburn or gastroesophageal reflux disease. Unless we state in our discharge summary that the chest pain was likely due to these conditions necessitating the use of the proton pump inhibitor, the coder must use chest pain as a final diagnosis. It doesn’t help to only state these clinically valid possibilities in the H&P, progress note, or consultation report; someone must clearly cite them in the discharge summary if they are to be reported.

In another example, a patient is admitted with pneumonia whereby all diagnostic studies are negative. Based on the definitive antibiotics prescribed, what organism does the treating physician think likely caused the patient’s pneumonia? If the patient received a full course of vancomycin, might the physician think the pneumonia was due to MRSA? The coder cannot code this thought, however, unless the physician puts it in the discharge summary.

Most HIM professionals agree that physicians procrastinate completing their discharge summaries. Physicians often delegate the task to individuals who may not have the proper insight into the patient’s condition, such as medical students, house staff, or nurses. These summaries often lack underlying causes, complicating factors, and consequences that affect resource utilization and severity of illness. They may not resolve conflicting information provided by various consultants. The result is a subpar summary, which in turn leads to poor data quality.

Editor’s note: To read part 3 of this article, come back to the blog next week! Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.