Author Archive for shoffman

Individual effort equals organizational success

The role of the clinical documentation specialist has been in a state of flux for the past few years. We

Make a difference by getting involved.

wear many hats including that of nurse, coder, teacher, auditor, statistician, politician, and sometimes therapist. How many times have you had to evaluate the mood of a doctor prior to discussing a documentation issue, or been caught up listening to their problems in the office or with a colleague. The job description is constantly shifting.

Our profession has faced changing DRG’s, dealt with the complex nuances of the query process, and the avoidance of “leading queries.” There are additions to the list of Hospital Acquired Conditions, to contend with, concerns about Recovery Audit Contractor reviews, and the advent of ICD-10 to worry about. And that’s not to mention the transition and implementation of Electronic Medical Records.

During these stressful times, it has become apparent that CDI specialists are resilient, intelligent, resourceful, and indispensable! With these changes however comes stress. An article from MED Indiana, on Life Stressors That May Lead to a Cardiac Event listed several stress factors that may be faced in the clinical documentation workplace. They include:

• Changes in work hours or conditions
• Trouble with your boss
• Change in work responsibilities
• Change in work
• Major business readjustments

These situations may sound familiar to you and since most CDI specialists tend to be “long in the tooth,” or seasoned, as they say, we may be more affected by changes than most. This is one of the reasons that the Association for Clinical Documentation Improvement Specialists (ACDIS) organization is so important, for it gives us a forum to communicate, commiserate and share business practices throughout the state. It is a source for education and team building. A presentation at the 2009 National convention titled Restarting or Revamping Your CDI Program: A Case Study by Catherine O’Leary and Colleen Gary discussed various issues relevant to a CDI programs such as:

• How to hire the right team?
• How to retain your team and provide motivation? And…
• How to measure success?

One major issue addressed in the article seemed to be staff turnover. Not everyone can do this job and not everyone enjoys CDI work. It can be a thankless job. Occasionally we are perceived to be in the adversarial position of “Chart Police.”

The Clinical Documentation Specialist role should be well defined and program goals should be set and if needed, reset, again and again. Ongoing education and growth is fundamentally necessary in all professions and CDI is no exception. Involvement in ACDIS and other educational forums helps us get up to date information regarding our profession. And it helps prevent stagnation and boredom.

The experience of our membership is varied: Some have been working in CDI positions for many years in well established CDI departments and others are new and developing their programs from the very start. We need to reach out and help newcomers and they in turn can then help others that join our group in the future. There is strength in knowledge and there is strength in numbers. The ACDIS organization has the potential to someday have a major role in setting CDI policies and protocols.

In the words of Vince Lombardi: “The achievements of an organization are the results of the combined effort of each individual.” ~

Florida ACDIS sets football themed meeting for November

Go Florida ACDIS!

The quarterly ACDIS Florida Chapter meeting will be held on November 13th, 2009 at Shands Hospital at the University of Florida, home of the 2008 NCAA Football National Champion Florida Gators. The team at Shands has put forth a great regional meeting. So, thanks for all the hard work and dedication. Go Gators!

Here’s the agenda:

• Kick Off: 8:40-9:15  a.m., PreGame Registration/Breakfast
• 1st Down: 9:15-9:30 a.m., A word from our sponsors, greetings from George, Sylvia, and Susie
• 2nd Down: 9:30-10 a.m., Defensive Coordinator “This Isn’t a Complication: Bridging the Communication Gap” Francesca Kayser Enneking, MD, professor and chairman, department of anesthesiology University of Florida College of Medicine
• 3rd Down: 10:00-10:30 a.m., Offensive Coordinator “Public Quality Measures and Mortality Risk Adjustment” Millie Russin, RN, MSN, director of clinical process improvement Shands at the University of Florida
• Halftime: 10:30-10:50 a.m., Bathroom break/calisthenics
• Time Out: 10:50-11 a.m., Pictures
• 4th Down: 11-11:30 a.m., Team Physician “CDI – Keys for Success” Mihaela Dragut, MD, CCS physician advisor, Clinical Documentation Improvement UF & Shands Jacksonville
• Tail Gate Luncheon with 3M: 11:30-12:30 a.m., Computer-Assisted Coding Demonstration Clinical Documentation Improvement Software Demonstration
• Touchdown: Recap/Highlights/Next Game

Physician buy in for E/M services

From the Documentation Guideline for E/M Services (Centers for Medicare and Medicaid Services):

To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or established. The Physician must then uses the presenting illness as a guiding factor to determine the extent of key elements of service to be performed. The key elements are:

• History
• Examination
• Medical decision making

History:  The physician must determine the type of history. Is it Problem focused, Expanded focus, Detailed, or Comprehensive.

Exam: The examination may involve several organ systems or a single organ system. The extent of the exam performed is based upon clinical judgment, patient history and the nature of the presenting problem. The type of exam must be determined to be:

• Problem focused
• Expanded focus
• Detailed
• Comprehensive

Medical Decision Making: Medical Decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. A number of options must be considered.

• The number of possible diagnosis and or management options
• The amount and /or complexity of medical records, diagnostic tests and /or other information that must be reviewed and analyzed.
• -The risk of significant complications, morbidity, and/or mortality as well as co morbidities associated with the patient’s presenting problem, the diagnostic procedures and /or the management options.

The level of decision making must be determined to be:

• Straightforward
• Low Complexity
• Moderate Complexity
• High Complexity

Some important points that should be kept in mind when documenting level of risk are:

• Comorbidities/Underlying disease
• Surgical or invasive diagnostic procedures ordered, planned or scheduled.
• Surgical or invasive diagnostic procedure performed.
• The referral for or decision to perform a surgical or invasive diagnostic procedure.

When counseling and/or coordination of care dominates the patient encounter (more than 50%), time is considered the key or controlling factor for a particular E/M service. Presenting problems that affect level of risk include:

1. Minimal: Minor problems such as colds, insect bites, etc.
2. Low:  Two or more self limiting problems such as well controlled hypertension, dontrolled diabetes, cystitis, allergic rhinitis, or simple sprain.
3. Moderate: One or more chronic illness with mild exacerbation or progression, or two or more stable chronic illnesses. An undiagnosed new problem such as a lump in the breast counts as a moderate problem. Also the presence of an acute illness with systemic symptoms such as pylonephritis, pneumonia, colitis, or brief loss of consciousness is also a moderate problem.
4. High: One or more chronic illness with severe exacerbation, progression or side effects of treatment. Acute or chronic illnesses or injuries that pose a threat to life or bodily function, such as multiple trauma, acute MI, pulmonary emboli, severe respiratory distress, acute renal failure, seizures, TIA, CVA, or sensory loss.

The gem in the E/M billing system is that in order to bill for the appropriate level of service, the physician must document appropriately. Physicians cannot be billing for a higher presenting problem with 60 minutes of counseling time when the diagnoses is urosepsis with diabetes, and chest pain. The codes will simply not substantiate the higher billing! Make your physicians aware of the rules.

Look beyond query numbers for program assessment

Now is no time for finger pointing!

The case mix index is up and admissions continue to rise. You’d think this was wonderful news. Yet, the facility administration  complains that reviews are down and queries are low. You don’t have to be a math genius to know that something here does not compute.

Is the education given to physicians and allied health professionals being evaluated? Does anyone evaluate the improvement in documentation?

Numbers are classically low in the summer months in Florida due to the absence of our much loved snowbirds from Canada. Vacations from both CDI professionals and physicians take a toll on productivity. New residents start in July, and the heat index rises to 98 degrees (and I don’t mean the literal temperature, either).

Help! How do you rate the success of your clinical documentation department?

Query response rates are evaluated and the overall numbers of reviews are counted. The revenue elicited from these queries is tallied and viola, the success of a program is in the financial numbers. Wrong!

CDI specialists spend a good deal of their day speaking to physicians and educating them on the benefits of proper documentation. They attend huddles with case management, they are members of committees, they round with specialty teams, and they frequently make presentations at meetings and resident Grand Rounds. Does this not count for anything? There needs to be a better way to evaluate success.

CDI presentations commonly extol the virtues of proper documentation— how it improves mortality and morbidity scores and severity of illness statistics. Physician “buy-in” is stressed at every turn, but where and when do we get to discuss the importance of the hospital administration’s “buy-in?”

It takes a hospital. . .

A recent hospital audit of 300 medical records turned up some not too surprising facts about physicians. The doctors are still not documenting appropriately, their handwriting is illegible, and the discharge summaries are inadequate.

Recent changes in CMS regulations have made certain wording and diagnosis linking imperative for hospital coding and reimbursement. The new rules are confusing and complicated. Certain words need modifiers, certain diagnosis must be linked to their causative agents, other conditions must be rated as acute, exacerbated, or unstable.

Old dogs need to learn new tricks.

There is an old expression that “You can’t teach an old dog new tricks.” I am starting to wonder if this shouldn’t also include physicians. I work in the Clinical Documentation Improvement office and we strive to educate physicians on the nuances of clinical documentation. This recent  audit indicates that we still have a lot of work to do.

I attended parochial school my entire life and I spent most of my formative years having to stay after school for poor penmanship. I still have terrible handwriting and I missed out on a lot of fun. This only goes to explain why I cannot criticize someone for having poor handwriting. The new computer era is upon us and with the advent of electronic medical records it also may be a mute point. I do not give penmanship classes.

However, like that old dog, the problem may be that seasoned physicians are too old to learn new techniques for documenting patient care. Perhaps we need to start educating the physicians sooner, when they are still in medical school.

The problem may be the lack of incentive. Perhaps the physicians need some sort of pay for performance to entice them to change their old habits.

Or the problem may be that hospitals need more upper management support for their CDI departments. Perhaps a series of speeches given by the CEO would get everyone motivated.

The problem may be a lack of educational resources. Perhaps hospitals should invest in teaching tools and educational literature.

The problem may be everything mentioned above and then some.

Clinical documentation teams across the country are working diligently to educate physicians and improve documentation. Blaming the CDI department for the deficiencies of the physicians, will not correct the problem. Secretary of State Hilary Clinton said “it takes a village to raise a child,” cribbing from an old African proverb. Well, maybe it takes a hospital to educate a physician.

Nurses fight for rights as CDI professionals

Clinical Documentation Specialist?

I was reading an article (title undisclosed) recently that discussed the importance of hiring a CDI specialist in a certain hospital settings. They gave a glowing account of the attributes of the clinical documentation specialist and the benefits they have on the business side of medicine.

The article went on to describe how to select a trained applicant. It recommended that the hospital “select a clinically astute coding professional with a strong business background.” It went on to say that hospitals should “consider hospital coders with a business background as likely candidates, because they not only posses business experience, but they also have clinical knowledge and competency in IV infusion and other related coding areas.”

I was horribly disappointed with the implication that a (nurse) clinical documentation specialist could not do the job.

Last year our hospital hosted a team of CDI specialists from a nearby hospital who wished to gain information on growing their program. At the conclusion of the day the manager told us that prior to coming to our hospital he would not have hired an RN. He thought they were unable to understand coding rules and concepts. After spending the day with us, he no longer felt that way.

At the Florida Regional ACDIS meeting that same manager introduced us to his team and he was especially proud to introduce his newest team member—a nurse.

When are the walls going to come down? A majority of the ACDIS members who attended the meeting in Las Vegas were nurses, yet most of the resources for clinical documentation improvement are are geared for coders. I am confused!

When I made the transition from case management to CDI, I was excited to enter a new and growing field. CDI was presented as a new opportunity for experienced nurses who had a desire to grow professionally. Our department had no policies or procedures, or standards for recording or measuring success. We developed the program from scratch.

I am not a coder but I worked very hard to learn the little bit I have learned about coding. I read many books, have taken many courses and asked many questions. I am a Clinical Documentation Specialist. Why is it, that I am the only person who thinks so?

Florida ACDIS regional meeting a success

The Florida ACDIS regional meeting was a great success! Tampa General Hospital hosted the meeting with 25 members representing seven hospitals. Several more tuned in (after technical problems were solved) via the teleconference link.

Darlene Shelffo, RN, Manager, Tampa General Hospital greeted all the attendees and explained the new Florida ACDIS Web site, (www.FLACDIS.com) She also gave a brief description of the TGH CDI program.

Photos were taken outside on the veranda of TGH, with its views of beautiful Tampa Bay and the flagship, Jose Gaspar.

Sylvia Hoffman presented a slide show titled “CDI Physician Education: How to make it interesting and get physician buy-in.” She covered a variety of tactics that can be used to interest physicians and the importance of making the presentation visually pleasing, interesting, relative to the practice of medicine, simple and to the point. She also discussed the need to include dynamic content such as SOI, ROM CMI and E/M Billing.

Dianne Martinez led the group with the business portion of the meeting. A vote was taken on the payment of dues and was approved unanimously. The amount agreed upon was $25 per person/per year. Checks will be mailed to the Secretary/Treasurer and only those members who have paid their dues will be Florida ACDIS members in good standing with the ability to access the Web site and receive the newsletter. Members need not be national ACDIS members to be members of the Florida Chapter. However, Florida Chapter members receive a discount on national memberships.

A vote was also taken to reduce the number of meetings to twice yearly. This was also passed unanimously.

Elections were held and the results were as follows:

• Sylvia Hoffman RN, Tampa General Hospital- President
• Virginia Baily RN, Morton Plant Hospital-Vice President
• Mary Bennati RN, St. Anthony’s Hospital-Secretary/Treasurer

Training your residents

I was having some behavior issues with my dog Libby, and I turned to the internet to get some ideas on training. I was reading the article when I realized that many of the concepts might also be relative to training the new residents at our hospital.  Not to belabor the point or injure the delicate egos of the newly inducted residents I nevertheless realized as I read there were more than a few training techniques that might be applicable to the CDI program. I put together a few of the techniques for everyone to review and decide for themselves.

The arrival of a resident is an exciting time for any household (I mean hospital). The new arrivals means there is a lot for you to do and even more for them to learn

1. Use lots of encouragement, praise, and rewards.
2. Set your resident up to succeed.
3. Put your resident on the right path.
4. Be realistic, flexible, patient, and fair
5. Do not get upset with the odd slip-up.
6. Many behavior problems stem from a lack of communication.
7. Set boundaries for acceptable behavior and stick to them. Be consistent.
8. Identify any triggers that may spark improper behavior.
9. Convey a clear and consistent message, every time.
10. Praise or reward your resident when they do something you want to encourage and create a negative association when they do something less than helpful for documentation clarity purposes.

Become a resident whisperer:
Sometimes it feels like residents, just like any other physician, speak a different language. They communicate  through various means using body language, facial expression, movement, and overall posture and voice. That’s as true for my pet pooch as it is for my next door neighbor and the new resident on the floor. A good trainer/whisperer takes a step back, observes, and understands these gestures.

You need to communicate with your resident instead of merely issuing and enforcing orders. When you open the lines of communication, it  impacts the entire relationship. The advantage allows the resident to choose to work with you. It frees him or her from feeling intimidated or forced to perform under threat of punishment. In practical terms a good CDI trainer employs his or her observation skills, watching, listening, interpreting and developing an understanding of the new resident’s actions, feelings, and needs.

Like anything there will be some people who are better at training residents than others. Heck, like I said at the outset, I needed some help training my dog.

Effective teaching can be learned though. Skilled trainers do not use some sort of mysterious hocus pocus or voodoo. The essential skill are there for anybody to perform.

CDI at Bat

The outlook wasn’t brilliant for the CDI that day:
The chart stood unattended, with one hour left to stay,

Even the best documentation specialists strike out once in a while.

And then when Dr. Cooney didn’t chart, and Dr. Barrow did no more,
A pall- like silence fell upon the patrons of the floor.

A straggling few got up to go in deep despair. The rest
Clung to the hope which springs eternal in the breast:
They thought, “If only Dr. Casey could get a whack at that,
We’d put up even money now, with Dr. Casey at the bat.”

There was ease in Dr. Casey’s manner as he stepped into his place:
There was pride in Dr. Casey’s bearing and a smile lit Dr. Casey’s face.
And when, responding to the query, he lightly doffed his hat,
No stranger on the ward could doubt ‘twas Dr. Casey at the bat.

The usual sneer had fled from Dr. Casey’s lips; his teeth clenched in rage:
He pounded with cruel violence his pen upon the page.
And now the nurse she holds the query, and now she lets it go,
And now the air is shattered by the force of Dr. Casey’s NO!

Oh, somewhere in this favored land the sun is shining bright,
The band is playing somewhere, and hearts are light,
And somewhere men are laughing and little children shout;
But there is no joy at the hospital – mighty Dr. Casey had struck out.

To lead or not to lead: Forming compliant queries

“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”

~Hamlet, Act III, Scene I

Shakespear as CDI? Hummm. . .

I truly think that Shakespeare was a frustrated CDI nurse.

I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:

“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”

If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.

Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?

I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.

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