RSSAuthor Archive for Melissa Varnavas

Melissa Varnavas

Melissa Varnavas, is the Associate Director of the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS is a community in which CDI professionals share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. With more than 5,000 members, its mission is to bring CDI specialists together. To learn more about ACDIS, go to or call HCPro customer service at 800-650-6787.

Note from Associate Editorial Director: Quotes of note

Melissa Varnavas

Melissa Varnavas

by Melissa Varnavas

As a young journalist on deadline, I stared down a blank white computer screen as the clock ticked toward midnight, pondering an exposition regarding my home town’s complicated municipal budget. In the end, I settled on introducing the article with a quote from Theodore Roosevelt. “Nothing in the world is worth having or worth doing unless it means effort…”

As the article devolved into a collection of quotes from city councilors, my editor at the time simply titled the piece “Beverly Budget Debate: Quotes of Note.”

While not exactly one of my more shining journalistic moments, it is true that certain quotes, like that of Roosevelt’s, reverberate through time, echoing with the truth of the sentiment they express. It’s probably the reason so many ACDIS members include famous quotes in their email signatures.

I love the one from hockey player Wayne Gretzky that ACDIS member Tracy Boldt, RN, BSN, CCDS, CDIP, system manager for CDI at Essentia Health in Duluth, Minnesota, uses in her signature: “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.” The 2016 CDI professional of the year award winner Karen Newhouser played off Gretzky’s quote in her acceptance speech, encouraging those in attendance to use the resources available to them to stay informed about changes in healthcare reimbursement and their effect on CDI efforts.

Another of my favorites related to the CDI profession has long been Mark Twain’s: “The difference between the almost right word and the right word is really a large matter. ’Tis the difference between the lightning bug and the lightning.” Don’t call it congestive heart failure if it’s actually acute-on-chronic diastolic heart failure.

Musing on this, I asked the ACDIS team to put on their thinking caps and come up with a few themselves. Both ACDIS Director Brian Murphy and ACDIS CCDS Coordinator Penny Richards stuck with a writerly theme and the importance of thoughtfully chosen words to convey a message.

Murphy chose John Cheever’s: “A page of good prose remains invincible.”

Richards chose Emile de Girardin’s: “The power of words is immense. A well-chosen word had often sufficed to stop a flying army, to change defeat into victory and to save an empire.”

“Not to mention invited in the auditor or caused claims to be denied,” she added.

ACDIS Editor Linnea Archibald pointed to a quote from Henry Wadsworth Longfellow: “It takes less time to do a thing right than to explain why you did it wrong,” as evidence of the importance of educating physicians on proper clinical documentation habits. Those physicians who take the time to heed CDI professionals’ advice, she says, ultimately end up saving time by getting the documentation correct to begin with.

ACDIS Associate Director of Membership and Product Development Rebecca Hendren chose a quote from Jane Austin, tweaking the details a tad. “It is a truth universally acknowledged, that a physician in possession of poor documentation must be in want of a CDI specialist.” We’ll leave it to you to look up the original wording.

ACDIS Educational Director Laurie Prescott couldn’t settle on just one. Her favorites include:

  • “Good words are worth much, and cost little,” by George Herbert
  • “I like good strong words that mean something,” by Louisa May Alcott, in Little Women (like acute, chronic, and acute on chronic, Prescott added)
  • “It’s always a bit of a struggle to get the words right, whether we’re a Hemingway or a few fathoms below his level,” by Rene J. Cappon (which is why you have CDI specialists to assist you, Prescott joked)

We’re sure you have your own favorites, too. Feel free to share them with us or better yet, why not play this game with your CDI team and post your quotes near physician’s documentation stations and around your CDI department as a fun way to provide a little additional insight into the importance of CDI.

After all, as Aristotle said, “The aim of CDI is to represent not the outward appearance of things, but their inward significance.”

Editor’s note: Varnavas is the Associate Editorial Director of ACDIS. Contact her at

Conference update: MGM Grand hotel discount for ACDIS ends 4/12

MGM Grand exterior hero shot

Don’t miss the hotel discount cut off rate! It ends Tuesday, April 12!

My first trip to Las Vegas was back in 2006. I was a novice traveler at best. Luckily, I was in good company with my team of coworkers. My husband also came with us. With his schedule free, he’d take a swim in the hotel lap pool in the morning, meet me out by the fountains near the hotel’s cabanas for lunch, and have a snack and wine ready for me in our hotel room when the work day is done. We were there over our first anniversary and my sister and brother-in-law ordered us a dozen chocolate covered strawberries and champagne delivered to our hotel room. After the conference ended, we stayed over and spent a beautifully relaxing afternoon floating in pool, slushy drinks in hand.

Beyond reminiscing about a favorite memory, I share this personal story simply to let you know that the MGM Grand, where ACDIS’ 10th Annual celebration takes place in less than a month, is quite the place.

But if you haven’t booked your room yet, time is almost out. There’s only a few more days left to get a discounted hotel room rate for the ACDIS Conference. Reserve your room by April 12 to take full advantage of the discount. The conference takes place from May 9-12 at the MGM Grand in Las Vegas.

When you book your hotel room by April 12, you’ll get the discounted room rate at the MGM Grand for $169, plus a $30 daily resort fee (tax and fees not included).

Make sure to check the dates of your hotel reservation as there may not be availability on the days surrounding the conference. If you plan on extending your stay in Las Vegas for personal reasons, keep in mind that you may need to change hotel accommodations.

While you book your hotel room, make sure to check out the three special, pre-conference educational opportunities:

Many long-time ACDIS attendees have come to know my hubby over the years (he was the guy passing out the extra t-shirts in Nashville and helping at the registration desk in San Antonio, among other sightings). Unfortunately, he can’t come with us this year. He’ll be back at home teaching his middle school students biology, art, and music, and taking care of our two cats Hugo and Katrina. But I do plan to have a soak in the pool and slushy in his honor.

Q&A: Querying for acute respiratory failure

You've got questions? We've got answers.

You’ve got questions? Let us know!

Q: If a patient is extubated post-operatively but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?

A: To determine if this represents acute respiratory failure, the values for impaired oxygen exchange can be used, along with the amount of oxygen being administered to the patient.

The ratio of arterial oxygen concentration to the fraction of inspired oxygen (P/F ratio) can be a helpful tool to identify respiratory failure criteria above for a patient receiving supplemental oxygen:

  • The P/F ratio is an indicator of hypoxemia. This is a useful tool when a patient is on supplemental oxygen.
  • The P/F ratio is provided on arterial blood gas (ABG) tests.
  • A P/F ratio less than 300 suggests acute respiratory failure.

If an ABG test is not available, an estimated P/F ratio can be calculated:

  • The calculation is pO2 divided by FIO2:
    • The FIO2 is determined by the liters of oxygen the patient is receiving expressed as a decimal (e.g., 32% is .32).

An illustration of the calculation shows that if a patient is receiving 3L oxygen by nasal cannula, and has a pO2 of 40 mm Hg. That would be 40/.32, which results in 125 (acute respiratory failure). The P/F ratio is a useful tool to validate the presence of acute hypoxemic respiratory failure when patients are receiving supplemental oxygen. After following this formula, and acute respiratory failure is still in question, then a query to your physician is needed.

Editor’s note: This article was originally published in JustCoding. This question was answered by Robert Stein, MD, CCDS, associate director of the MS-DRG Assurance program for Enjoin. Join him for a webinar on this topic on March 21!

Note from Associate Editorial Director: What’s your query metric?

Melissa Varnavas

Associate Editorial Director Melissa Varnavas

Although many CDI program directors wish for national standards for calculating CDI productivity (e.g., a set number of new reviews and re-reviews per CDI specialist per day), “frequent regulatory changes and broad diversity within the industry prohibit a one-size-fits-all approach,” the ACDIS Advisory Board wrote in a White Paper released in December.

While that fact may be indisputable—new CDI staff simply cannot be expected to be as productive as those with multiple years’ experience and programs with expanded record review scopes cannot be expected to turn over as many records as those simply looking for a lone CC/MCC—CDI programs can take advantage of polling research conducted by ACDIS over the years to help establish baseline metrics and program goals.

For example, a 2014 ACDIS website poll indicated that productivity expectations ran the gamut:

  • 32% review 1–10 records per day
  • 25% review 11–15 records per day
  • 18% review 16–20 records per day
  • 13% review 21–25 records per day
  • 6% review 26–30 records per day
  • 6% review more than 30 records per day

The productivity survey conducted in association with December’s White Paper release found 85% of respondents review 6–15 new patient reviews—only 7% reviewed less and only 5% reviewed 16 new records or more per day.

Ultimately, judging from the data, the Advisory Board suggested that “16–24 total reviews per day (new reviews and re-reviews) is an average range for a CDI specialist, with 20 daily reviews being an acceptable goal to account for variability in review focus,” as noted later in the survey.

The latest survey out from ACDIS probes at a number of additional questions related to CDI physician query practices, including:

  • Do you query for clinical validation, i.e., to confirm presence of a documented diagnosis lacking clinical support?  To date, 85% of the more than 200 respondents do.
  • Does your facility have standard query policies and procedures? More than 75% do.
  • Does your facility have an electronic query system either as part of your EHR or another software system? Only 17% don’t.

The survey which will remain open through March 1, also asks important questions about query auditing and monitoring, resources used to craft query policies, and about respondents’ perceptions regarding the effectiveness of electronic systems.

As I often say, ACDIS thrives on membership participation and we need yours to ensure the data revealed in this 2017 physician query assessment represents the true benchmarks of our industry. Won’t you take a few minutes to share your thoughts?

Click here to take the survey. And thanks!

Guest Post: 2017 hot topics for CDI and HIM professionals

Darice Grzybowski

Darice Grzybowski

By Darice M. Grzybowski, MA, RHIA, FAHIMA

For those still trying to straighten out their budgets and priorities for 2017, I thought it might be helpful to reflect on a few larger industry trends that may significantly change the the focus of our efforts related to health information management (HIM) and clinical documentation improvement (CDI).

Government and legislation: To say the 2016 presidential election may bring change is obviously an understatement. There will undoubtedly be significant movement in healthcare policy, but for now there is still significant work and in some cases, confusion, surrounding the ongoing implementation of accountable care organizations (ACOs), the Affordable Care Act (ACA), ICD-10-CM/PCS, Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), phase two of the Health Insurance Portability and Accountability Act (HIPAA) audit program, and other legislative initiatives.

New technologies and opportunities: Sometimes, the more things change, the more they stay the same. At other times, the speed of change in technology can be dizzying. Does everyone have a coding, EHR, CDI, and revenue cycle solution? How do these solutions enhance the integrity and efficiency of the EHR, CDI, and coding processes? We must work collaboratively with our vendors as our partners but never confuse our professional standards, use good judgment and ethics to strike a balance to select solutions that enhance our performance.

Personal and professional development: It is hard to predict if we’re ready for the changes that may come in a single year, let alone whether we’re ready to meet the opportunities and challenges that may come in the next 10 years or beyond. Advancing digital and mobile technologies, the growing role of artificial intelligence and natural language processing, telemedicine, and the long-term possibility of ICD-11 will shape the future of CDI and HIM in ways that are difficult to predict. Ongoing changes accentuate the need for advanced skills in clinical, coding, and documentation integrity not just to add multiple initials for various certifications onto one’s business card. We must recognize that we need continuous lifetime learning and specialized education to support new roles.

The start of a new calendar is a perfect time to draw your own personal road map and reevaluate what path that you choose to go down. And if you don’t like it, take a turn and readjust—you have the power to do that. Let’s look forward to a year of new possibilities, new leadership in our country, new technologies, and new personal and professional growth. Change can be good, but only if it’s done with the right goals in mind.

Editor’s note: This article was adapted from the original published in HIM Briefings. Grzybowski is the president of HIMentors, LLC, which specializes in HIM operations, education, best practices, EHR/EDMS implementation, CAC, and CDI coding consultation. For information, visit or email Opinions expressed are those of the author and do not represent HCPro or ACDIS.

Guest Post: Tips for new Recovery Audit program denial defense

Laura Legg

Laura Legg

By Laura Legg, RHIT, CCS, CDIP

CMS recently announced the award of a new round of contracts for the Medicare fee-for-service Recovery Auditors (RA). As the new round of RAs roll out, even the most experienced RA response team will need to understand the new challenges we face with CMS’ 2017 changes. Make every effort to ensure your teams are centralized, efficient and organized with excellent communication skills. Also, it is very important to educate your RA response team on changes to the RA rules. Following are a few tips to help you stay on top of the changes.

Compose complete medical records: Your facility should include all required documentation necessary to support each case. If a physician orders a test, make sure the order, results, and interpretation are all included with the medical record and are legible and easily found. Also make sure the discharge summary is as complete as possible. The discharge summary should accurately reflect all confirmed diagnoses and all care administered during the patient’s hospital stay without introducing new information.

Avoid EHR cloning: Cloning, or copy and paste, is being seriously addressed by CMS. RAs may be looking at progress notes for confusion among caregivers due to copy and paste overuse.

Focus on challenging inpatient diagnoses: What diagnoses and procedures challenge coders the most? Some tricky diagnoses are, but are not limited to, sepsis, respiratory failure, renal failure, congestive heart failure, pneumonia, spinal surgeries, and skin procedures. Make sure the medical record documentation support these diagnoses and that coders can easily identify the correct code assignment for them.

Follow RA websites: CMS requires RAs  to keep an updated provider portal which includes a list of issues under review. This resource shows the issue name, type of review, provider type, status impacted, date posted and a detailed description of the issue. It is a good idea to build your internal audit plan around this list and the Office of Inspector General’s (OIG) work plan. CMS will require RAs to broaden their review topics and they must include all provider claim types and may include required reviews based on referrals from the OIG report.

Audit: Be sure that all diagnoses are coded to the highest level of specificity. Ensure that all medical documentation entries are consistent. Be sure internal auditors look at the same data elements reviewed by the RA including principal diagnosis, secondary diagnosis, procedures affecting or potentially affecting diagnosis-related groups, present on admission indicators, and discharge disposition codes.

Reduce denial rates—Under the new rules, additional documentation request (ADR) rates will be affected by your denial rate. More denials will result in more requests and denials still mean a lot of work on the provider end and a drawn-out appeals process. You can improve response rate and efficiency simply by following RA timelines and responding to record request appropriately. Takebacks due to lack of response to ADRs are more common that you think.

Editor’s Note: Legg is the director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. This article was adapted from the original published in Opinions expressed are that of the author and do not represent HCPro or ACDIS.

Guest Post: Documentation for chronic care management

Lori-Lynne Webb

Lori-Lynne Webb

As CDI specialists and coders, it is our job to document and code appropriately for the care being provided. For CDI professionals working with physician practice settings, identifying documentation to support chronic care management codes under the Current Procedural Terminology (CPT) code system can be difficult. 

CPT code 99490, regular (“non-complex”) chronic care management assumes 15 minutes of work by the billing practitioner, according to a January 18, 2017 Frequently Asked Questions publication from CMS. The code incentivizes providers to manage and communicate more thoroughly between the multiple providers for patients with extensive and complicated chronic conditions. In addition to charting the time, the diagnoses for the two (or more) chronic conditions must be documented and clearly connected as medically necessary for this oversight care.

In the 18 months since code 99490 has been implemented, one of the biggest problems is physician reluctance to document and bill for it. Many providers have the basic criteria built into their electronic health records (EHR), yet do not use it. The EHR is the most effective way to meet the  criteria for billing of this code but a basic table in a hard copy chart or file can be just as effective and easy to use.


According to CMS, in fiscal year 2015, only 275,000 Medicare beneficiaries received (and CMS paid for) this service. Considering how many Medicare beneficiaries are enrolled and receiving Medicare services (approximately 54 million), 275,000 services provided with code 99490 is a very small percentage.


An area of continued concern from providers is they must also allow the patient to “opt in” and consent for this care. This can be problematic, as this is a non-face-to-face coordination of care and patients may view this as a charge for a service not rendered appropriately, as they did not physically “see” the provider. I’ve heard of patients complaining to their providers for having to pay for this “invisible” service. Again, it is imperative that the provider communicate clearly to the patient regarding this service and allow them to opt in or out. Physicians have also stated concern about whether they would be able to ensure or maintain 24/7 access to care management services as required by the CMS guidelines.

As a coder, billing code 99490 is one way to help your physician actually get paid for time spent performing this care management service. This service can include telephone calls, coordination of continuing services, and collaboration with specialty physicians which are services that are not normally paid for, or bundled in traditional E/M services. In addition to providing good patient care, the billing/coding of chronic care management code 99490 can also help the practice revenue stream and enhance the patients overall care.

Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via email at or find current coding information on her blog: Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article originally appeared on

Breaking News: The Surviving Sepsis Campaign releases new guidelines for Management of Sepsis and Septic Shock, 2017

Allen Frady

Allen Frady

By Allen Frady, RN, BSN, CCDS, CCS

Management and practice guidelines are not often at the forefront of CDI focus and training. As quality and revenue reviewers, we more often find ourselves involved in clinical definitions and criteria, as we simply try to determine if a diagnosis exists.

As clinical validation and audit activities push CDI specialists closer to denial defense efforts, we must also be aware of the most current recommendations with regards to treatment. Last week in the both Journal of American Medical Association (JAMA), and a number of critical care publications such as the Society of Critical Care Medicine, we got our first peek at newly updated treatment recommendations coming out of the Surviving Sepsis Campaign. Although these publications represent more of an evolutionary update (compared the revolutionary change of definition we saw with last year’s release of Sepsis-3 definition changes) there are some noteworthy talking points here for CDI specialist.

The publication takes a rather comprehensive approach, covering every possible facet of monitoring and treating patients in sepsis (that is, after all, part of the Surviving Sepsis Campaign’s mission). Starting with the initial resuscitation, the update includes a shortening of the initial time for the early directed therapy treatments (for some components such as administering IV fluids) from six hours to three hours.

Monitoring suggestions have also gotten more specific, changing from general parameters for urinary output, mean arterial pressure, and invasive cardiac monitoring to a recommendation of frequent perfusion reassessment and adjustment made on an increased number of data points and focusing on dynamic parameters rather than static ones. The specific IV fluid recuitation recommendation is now 30ml/lg of crystalloid fluids over three hours (assuming stable renal and cardiac function of course).

Reassessment now includes an evaluation of everything from heart rate, to general blood pressure, arterial oxygen saturation, respiratory rate, with the continued recommendation of maintain the map of at least 65 or greater and introducing invasive monitoring for central venous pressure etc. in patients who are in critical status.

It makes further recommendations using lactate levels as part of the ongoing data to measure the amount and effectiveness of necessary fluid therapy.

Studies show that facilities who establish comprehensive sepsis protocols and performance standards have better outcomes. Doing so has become a recommendation across the board. If possible, patients should get blood cultures before starting antibiotic therapy as long as it does not delay antimicrobial administration any significant length of time. Another recommendation is to immediately test for and repeat monitor lactate levels.

The guidelines go on to address the specific antimicrobial selections, vasopressor escalation, source identification and recommendations for things like blood transfusion, anticoagulant administration, use of mechanical ventilation, management of ARDS patients, DVT prophylaxis, nutritional support and use of corticosteroids.

There new guidelines contain a vast amount of treatment information (too much to detail here) but as I mentioned, the recommendations are evolutionary in nature, not revolutionary.  I have been teaching CDS the 30ml/kg guideline along with the importance of lactate and procalcitonin for a few years now.  It is nice to see it in the practice guidelines.

One noteworthy point I want to mention, is the subject of de-escalation of therapy. In some cases, auditors will use a change or drop in antibiotics or a decrease in IV fluid administration as evidence that sepsis was ruled out. Nothing could be further from the truth. One of the reasons they suggest that blood cultures and wound cultures be performed early is so that they can appropriately de-escalate antimicrobial therapy in light of possible findings of the organism. In the era of increasing antimicrobial resistance with the over prescription of antibiotics, and in a critical care scenario when certain antibiotics may be nephrotoxic or hepatotoxic, this is likely to be more a sign of responsible stewardship than an indicator of diagnostic value.

The Surviving Sepsis Campaign specifically mentions the following recommendations:

  • De-escalation to the narrowest effective antimicrobial agent for most serious infections.
  • A thoughtful de-escalation of antimicrobials based on adequate clinical improvement in spite of the possible initial culture findings.
  • De-escalation with discontinuation of combination therapy within the first few days in response to clinical improvement or evidence of infection resolution in septic shock patients.
  • De-escalation of early multidrug therapy is associated with equivalent or superior clinical outcomes in sepsis and septic shock in some observational studies. This one needs more study however.
  • They recommend, daily assessment for de-escalation of antimicrobial therapy in patients with both sepsis and septic shock.
  • Various procalcitonin-based algorithms have been used to direct de-escalation of antimicrobial therapy in severe infections and sepsis. This also needs further study however. In total, the phrase “de-escalation” appears in the article no less than 30 times.

The next time you hear someone argue that a decreasing of vasopressors, IV fluid, or antimicrobial therapy proves there was no sepsis or shock, remind yourself that this has largely been debunked. De-escalation is in fact, a responsible part of sepsis management. Not every patient’s presentation would merit early de-escalation of course.

If physicians are abruptly stopping (not de-escalating) therapy such as antibiotics and or IV fluid and monitoring early in the episode, that could be a sign that either the sepsis was in fact ruled out, or could be that the early goal directed therapy worked exceptionally well. In such a case, a query is in order to ascertain the proper physician documentation that the sepsis was either ruled out, or was an atypical case which resolved early.

The goals here are clearly stated by the Surviving Sepsis Sampaign however—that antibiotic therapy should if at all possible, start being reduced within about three days if the patient is responding well to treatment. What you would likely see here is a change from multi therapy to a single IV antibiotic. In some cases, with antibiotics which have good PO absorption in a patient with no GI pathology, a change to PO antibiotics is possible. In other cases, antibiotics might be discontinued entirely. This is not evidence that there was no sepsis. The same goes for the fluid therapy. These practice reference repeatedly describe the time period as a “few” days. For most people “few” means around three. They further mention an early therapeutic window of only three to five days. Some studies in fact are cited in this paper which show that the shorter treatment periods of three to five days can be just as effective as seven and 10-day treatment protocols. These shorter treatment windows have also been associated with improved outcomes in some studies.

As more and more education and pressure is put on physicians about the dangers of antimicrobial resistance, and as we analyze the impacts long term to the kidneys and liver of hard to metabolize antibiotic therapy and as we see the impacts of over treating patients with antibiotics actually leading to increased readmissions due to the extinguishment of the natural healthy flora and the breeding of resistant organisms, we are likely going to see a trend towards these shorter treatment periods as standard sepsis care.

Link to Abstract:

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Guest Post: Pneumonia coding compliance critical for success

James S. Kennedy

James S. Kennedy

by James S. Kennedy, MD, CCS, CDIP

In ascertaining pneumonia’s clinical validity, I like the criteria established by a work group of physicians convened by the Maryland Hospital Association that support compliant coding. Essential elements to diagnose pneumonia include one of each of the following three elements:

  • Temperature > 38°C or < 36°C and/or leukopenia (<4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)
  • Purulent sputum, cough, dyspnea, tachypnea, supportive findings through physical exam (e.g. bronchial breath sounds, dullness to percussion), and/or worsening gas exchange
  • Supportive imaging

There are many others, such as those from the Annals in Internal Medicine in 2003. These authors state that a negative chest x-ray is an imperfect gold standard in ruling out pneumonia, thus when a physician documents pneumonia with a negative chest x-ray, we must ascertain its clinical validity. If a provider maintains that a patient has pneumonia, especially when it is documented with uncertainty at the time of an inpatient discharge or in response to a clinical validation query, then we are on solid ground to code the condition. Coding Clinic, Fourth Quarter, 2016, page 149, is a valid defense of this principle.

Even though ICD-10-CM classifies pneumonia by its causative organism, querying for the underlying cause is tricky. The AHIMA Standards of Ethical Coding state that coding professionals shall not query the provider when there is no clinical information in the health record prompting the need for a query, and cites that querying for gram-negative pneumonia on every pneumonia case regardless of clinical indicators is an example of unethical coding. Therefore, coders and their compliance personnel must know the clinical indicators supporting a query for the underlying cause of pneumonia as to target them appropriately and judge the validity of the documented response.

In my opinion, the best article addressing this dilemma is the 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society on hospital-acquired and ventilator-associated pneumonia.

In my reading, if a patient requires more than 2–3 days of an antibiotic other than ceftriaxone (Rocephin®), levofloxacin (Levaquin®) at 250–500 milligrams per day, azithromycin (Zithromax®), or similar agents, depending on the agent used that’s described in this article, the provider can support at the time of discharge that the pneumonia was likely due to the associated organism with hospital-acquired or ventilator-associated pneumonia. These include:

  • Staph aureus – vancomycin or linezolid
  • Pseudomonas – ciprofloxacin, levofloxacin (750 mg/day, not lower doses of 250–500 mg/day), aminoglycosides (gentamicin) or colistin – pseudomonas
  • Other gram-negatives – Zosyn®, cefepime, imipenem, or azotrenam

Community-acquired pneumonia is a challenge, given that we often do not know what the causative organism is or that it is often viral in nature. Many physicians will still treat with an antibiotic, even though a study in the New England Journal of Medicine demonstrated an organism in only half of the cases studied and bacterial agent in only one out of seven hospitalized cases.

IDSA also published a guideline for community-acquired pneumonia which has a table of what antibiotics should be used in special circumstances. Options that influence DRG or HCC assignment include:

  • Anaerobes (aspiration pneumonia) – Zosyn®, Unasyn®, or clindamycin
  • Influenza – oseltamivir or zanamivir

Whether to query the physician for the bacteria justifying the use of Rocephin®, Zithromax®, or Levaquin® is an issue that will challenge all of us, especially if we’re working to manage our HCC-related risk-adjustment factor score. I’m open to suggestions if you have strategies that work in your facilities.

One final reminder: inpatient pneumonia cases with sepsis on admission are counted in the CMS mortality and readmission measures cohorts. However, the same cases with a secondary diagnosis of severe sepsis or sepsis with an associated organ dysfunction, are not. As we discussed in my previous sepsis columns, I hope that you’ve worked with your medical staff to define exactly what severe sepsis is and how to identify it at the time the inpatient order is written so that it may be properly documented and coded.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at This article originally appeared in Briefings on Coding Compliance Strategies. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

Guest Post: An obligation to report noncompliance

Rose Dunn

Rose Dunn


One of the many coder/CDI obligations is to report noncompliant activities. Your employer’s compliance plan may direct you to report these noncompliant observations to the compliance officer or a compliance hotline.

When you report your observations, you may do so anonymously or by identifying yourself. It is your decision which approach you take, but regardless, you still have the obligation to report.

Commonly reported coding-relating issues are:

  • Documenting services long after the service was provided and possibly never provided
  • Routinely reporting high-level evaluation and management or MS-DRG codes (upcoding) when the documentation does not support the high level
  • Failure to code to the highest level of specificity when the documentation is present
  • Queries that encourage or lead a physician to add documentation which would increase the level of reimbursement for a particular case
  • Adding charges to a claim for services provided
  • Providing services that are not medically necessary

When a coder/CDI specialist observes actions inconsistent with quality healthcare, the more detail provided to the compliance officer will help in the investigation. Depending on investigation findings, major, minor, or no changes may result. Sometimes, actions observed may appear inappropriate, but upon investigation, the actions were consistent with clinical practice.

For example, a coder/CDI specialist may consider the actions of another staff member to be too zealous in optimizing the codes to achieve higher reimbursement. The term optimization is defined as a procedure used to make a system or design as effective or functional as possible.

When coders “optimize” the coding process, they attempt to make coding for reimbursement as accurate as possible. This process may involve querying the physician for clarification of conditions or augmenting conditions documented. If done in a nonleading way, the organization will obtain the highest entitled reimbursement.

When the investigation illustrates the need to make changes, you will probably see activities such as reeducation, updating of policies, and possibly the removal of staff members.

Qui tam

Unfortunately, there are times when an individual reports legitimate compliance concerns and does not see actions being taken to correct the concern. In these situations, a person may wish to “blow the whistle” and contact an agency outside of the organization to file a lawsuit. This type of lawsuit is known as a qui tam lawsuit.

Qui tam lawsuits are a type of civil lawsuit whistleblowers bring under the False Claims Act, a law that rewards whistleblowers if their qui tam cases recover funds for the government. Qui tam is an abbreviation of the Latin phrase meaning “who as well for the king as for himself sues in this matter.”

Qui tam cases are different from other types of lawsuits, such as those involving personal injuries, because the person bringing the lawsuit is not the one who has been harmed.

A recent example of qui tam is the South Florida case where physician Mario Baez, a partner in a physician practice, turned whistleblower on his partner when he determined that his partner was submitting fraudulent claims. Nearly all the patients seen at IM Medical and Lake Worth Medical were diagnosed with a serious but rare spinal disorder called ankylosing spondylitis, when only 1 in 1,000 people truly have this disorder, according to Baez. The disorder increased the risk score for the physicians who were participating in a Medicare Advantage health plan reimbursement arrangement with Humana. The higher the risk score, the greater the reimbursement. The interesting twist on this qui tam is that Baez was not just whistleblowing on his partner but also on Humana. Humana should have been able to detect this fraudulent activity.

Taking a qui tam action requires much consideration, because often the whistleblower is identified during the legal proceedings. Having legal counsel guidance will be beneficial. If the case is lost, the situation can be embarrassing.

However, if the case is won, there may be financial rewards for the whistleblower depending on how much the whistleblower’s details of the situation contributed to the success of the suit. Regardless, following your convictions to surface inappropriate care should result in better care for patients thereafter, and that is the right thing to do.

Editor’s note: Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. For questions please contact editor Amanda Tyler at This article is excerpted from JustCoding’s Practical Guide to Coding Management.