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TBT: Six steps to help you join the CDI ranks

Editor’s note: This article originally appeared on the ACDIS website in November 2015. To read the original article, click here.

There is a lot of discussion about how to be a good CDI specialist, but as the profession grows and facilities look to hire new CDI team members, many more people are looking to get into the field.

A few months ago, we received an email asking us what we would recommend to CDI hopefuls. After combing through our resources, consulting with our Boot Camp instructors and Advisory Board members, and interviewing working CDI specialists, here are six simple steps to help you set your feet on the CDI career path.

1. Learn as much as you can

When Shiloh A. Williams, MSN, RN, CCDS, CDI specialist (now CDI program manager) at El Centro Regional Medical Center in Holtville, California, initially applied for a CDI position, she knew nothing about CDI, coding, or the revenue cycle. She did a Google search before her interview and read up on DRGs, codes, and common diagnoses. Her research, coupled with her prior nursing experience and clinical knowledge, won her the position.

“I scoured the ACDIS website for information, ideas, and best practices,” Williams says. “Now that I’m doing the job, I am constantly turning to ACDIS resources for staffing and department metrics.”

Regardless of the field or position, any candidate who learns as much as possible about the role and company prior to sitting for an interview will have a distinct advantage. You may not have hands-on experience as a CDI specialist, but that doesn’t mean you can’t learn as much as possible about the field.

Review the materials on the ACDIS website—much of it is free—and take lots of notes. Read the ACDIS Blog and the CDI Strategies e-newsletter for timely tips and news updates. The ACDIS Helpful Resources page and ACDIS Radio are also fantastic free options to learn about the field and the industry.

It’s also a good idea to look through CDI job postings to see what facilities are looking for in terms of knowledge and experience. Some noteworthy topics to research include:

  • DRG basics
  • ICD-10 codes
  • How to read a medical record and research a chart
  • Hospital quality initiatives

2. Attend a local chapter meeting

If you have a local chapter in your area, call or email the leadership and ask if you can attend a meeting. This is a great opportunity to network with local CDI specialists, learn about the job from working professionals, and discuss timely topics and issues relevant to the field.

Networking may also lead to potential mentorship and job shadow opportunities that you wouldn’t have otherwise. Williams relied heavily on her mentors early in her CDI career.

“I was able to work alongside Marion Kruse, a well-known clinical documentation improvement and Medicare expert,” she says. “My passion for my work was fueled by her knowledge and expertise.”

Check the Local Chapter page on the ACDIS website for more information and meeting schedules.

3. Job shadow CDI staff

If you have a CDI program at your facility, ask the program staff if you can shadow them for a day to learn more about the work they do.

If your facility doesn’t have a CDI program, reach out to neighboring hospitals and see if their program would host you for a morning or afternoon.

Job shadowing is one of the most important things a prospective CDI specialist should do before applying for a job in the field, says Mark LeBlanc, RN, MBA, CCDS, director of CDI services at the Wilshire Group, and former ACDIS Advisory Board member.

“It’s a great opportunity to watch a CDI specialist work, ask questions, and see the work in action,” he says.

“It’s also a chance to see how you have to interact with staff on the floor. You need to be outgoing, and you have to be able to speak to all different levels of professionals, from providers to coders, so you can get things done.”

Also take advantage of other networking opportunities, such as reaching out to members of the ACDIS Advisory Board. “The board would definitely be willing to spend a few minutes with someone to talk about CDI,” LeBlanc says.

4. Analyze your skills

Typically, the most important attributes for a top-notch CDI specialist are extensive clinical knowledge and awareness of disease processes and complications, comorbid conditions, medical coding, and Medicare reimbursement.

A balance of clinical expertise and coding knowledge makes a candidate ideal, says Bonnie Epps, MSN, RN, CDI director at Emory Healthcare in Atlanta.

“I think [CDI] work would be easier if we all were proficient in coding,” says Epps. “If someone is interested in CDI, they should try and learn something about what coding is and why it’s important.”

Those with clinical backgrounds wishing to enter the field need to understand that CDI specialists have little to no contact with patients. Although their clinical acumen will definitely be put to use, they will no longer have any sway over the patients’ day-to-day care.

CDI work is based solely on what is written in the clinical documentation. For former bedside nurses, this requires a novel way of thinking and a willingness to learn new skills, Epps says.

“[An applicant] should be able to pick up the skills to read the chart, analyze the chart, and learn the coding rules and language,” says Epps. “You must be willing to learn these things and think in new ways.”

Communication skills (both written and verbal), imagination and creativity, and analytical and problem solving skills are also a must.

“You have to be willing to work with others and collaborate,” says Epps.

5. Train yourself

Programs typically train new CDI specialists for three to six months through in-house mentoring, job shadowing, and formal classroom learning. They often send new staff members to a CDI Boot Camp and/or have consulting training available.

However, if you are serious about getting a job in the field and want to expand your knowledge, it may be a good idea to sign up for an online learning program or a CDI Boot Camp on your own time. You’ll receive a comprehensive overview of the job and required knowledge, which will make you a more competitive applicant for prospective employers.

If you would like to work on training yourself, here are some helpful resources:

LeBlanc says prospective CDI specialists should also brush up on their anatomy and physiology— especially important with the advent of ICD-10.

6. Apply for the job

You’ve done the research. You’ve decided the job is a good fit for your personality and skill set. Maybe you’ve even job shadowed a CDI specialist or networked with CDI professionals at a local event. Now it’s time to apply for the job. There are plenty of facilities out there that will hire new staff even if they do not have CDI experience. Highlight any related training and skills in your resume and during interviews.

Keep in mind, you do not need to have the Certified Clinical Documentation Specialist (CCDS) credential to become a CDI specialist. The CCDS represents a mark of distinction for those who have been working in the field for a number of years. In fact, you must be a working CDI specialist for at least two years before you can sit for the exam. CDI career path.

Note from the Associate Editorial Director: Thoughts about leadership

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Associate Editorial Director Melissa Varnavas

By Melissa Varnavas

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

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

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

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

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

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

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

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

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

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

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

LauriePrescott_May 2017

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

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

Shadowing staff

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

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

To positively influence your learning, consider first sitting alongside your CDI manager or mentor as he or she reviews a variety of common diagnoses. Where larger teams exist, consider rotating such shadowing experiences and taking note of how different individuals’ experiences and strengths affects how they conduct their reviews. Also, arrange time to shadow an experienced inpatient coder as well. You will find each person has his or her own method, and no method is necessarily better than the next.

Tandem reviews

After shadowing teammates, try tandem record reviews where your mentor, manager, or other CDI staff member reviews the record first and then turns the record over to you to let you try your hand at it. Then compare notes. Also consider flipping this activity with the new CDI specialist reviewing the record first and then turning it over to your CDI manager or mentor to see where you were successful or where opportunities for additional information might exist.

Spend some time documenting and developing your own review processes; you will need to develop a method or sequence of record review and stick with it. For example, jumping from one section to another in search of a particular tidbit or clue may cause you to lose focus. In such situations, the larger clinical context may be lost on that elusive detail, costing you valuable productivity time—you may not see the forest through the trees, so to speak.

Take time to discuss items you may have missed and where this information was found. If queries need to be written, draft them together. This process may seem laborious, but with a few afternoons concentrated on such work, you will begin to feel more comfortable finding your way through the complexity of the medical record to the valuable nuggets of information you need.

Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

 

Note from ACDIS Director: The changing tide of sepsis definitions

ACDIS Director, Brian Murphy

ACDIS Director, Brian Murphy

By Brian Murphy

These days it seems sepsis is constantly in the news. Hardly a day passes where the efficacy of some new life-saving drug is being advocated or disputed, a sepsis DRG downgraded, or Sepsis-2 versus Sepsis-3 definitions debated. We’ve also had some major recent news from the likes of the Surviving Sepsis Campaign.

CDI specialists inhabit a world in which they need to navigate three sets of reporting requirements: Sepsis-2, Sepsis-3, and SEP-1, the latter from the National Quality Forum measure for public reporting of sepsis.

How can CDI specialists make sense of it all? I recommend reading our most recent ACDIS White Paper, “Where are we now with sepsis?”

The paper covers in detail the multiple issues around this tricky diagnosis, from the problems inherent in administrative versus clinical data, to systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock prior to the new Sepsis-3 definitions in 2016, and the definitions post Sepsis-3. The article also includes a nice bulleted summary and takeaways for your CDI department and medical staff.

Special thanks for principal authorship go to ACDIS advisory board member Sam Antonios, MD, FACP, SFHM, CPE, CCDS. Though primary authorship goes to Antonios, the entire ACDIS advisory board reviewed the work prior to publication.

To download the new White Paper, click here.

I would also encourage any of our ACDIS members who haven’t been by our resource pages in a while to check out all our White Papers and Position Papers. We’ve been publishing some helpful guidance of late, and more is on the way.

I hope this paper proves helpful in your continued mission of clinical accuracy in the patient chart.

If you have suggestions for topics you’d like to see the advisory board address, please let me know via email at bmurphy@acdis.org.

Note from ACDIS Director: Your CDI civic duty—vote in the advisory board election

If you’ve ever read one of our Position Papers, White Papers, a Note from the Board in our bi-monthly CDI Journal, or listened to an ACDIS Quarterly Conference call, then you know what a crucial role the ACDIS advisory board plays in the leadership of our association.

That’s why we need you, our ACDIS members, to take a few minutes out of your day for a very important duty: Voting for our next group of board members.

ACDIS advisory board members serve a voluntary, three-year term. Members of the board write articles, answer member questions, review conference materials, set direction for our CDI Practice Guidelines committee, and more.

Read more about our board members and their responsibilities on the ACDIS website by clicking here.

This year, seven finalists have stepped up to run and volunteer their time and energy. They deserve to have our members make an informed choice and cast their votes. Out of the seven nominees, the four with the most votes will be elected by popular vote of the ACDIS membership, for terms effective April 2017 through April 2020.

This vote by our membership is an important responsibility and we hope you take a few minutes to fulfill it.

View our voting page (open to ACDIS members only) here.

How to vote

  1. First, log onto the website with your username and password. You must be an ACDIS member in good standing. If you have forgotten your username/password, please write or call our customer service team: customerservice@hcpro.com, or 1-800-650-6787.
  2. Go to our voting page by clicking here.
  3. Read through the candidates’ bios/qualifications and reasons they are running, and then write down your top four votes.
  4. Click the yellow “vote” button.
  5. Our voting tool requires you to rank the candidates. Your top choice should be ranked number one, your second choice number two, etc. on down through number seven. If you’d like, you can just rank your top four candidates.
  6. Click the gray “vote” button. It will ask you to you review your choices.
  7. Once you are satisfied, click “confirm” and you are done. Our website only allows you to vote once.

You have two weeks to cast your ballot; voting opens today, Thursday, March 16, and closes end of day Friday, March 31.

Thank you for your attention to this important matter!

Note from the Director: CDI success requires more than a credential

Which credential/certification/licensure makes for the best CDI specialist? RN? RHIA? MD?

If you answered all of the above—or none of the above—you’re on the right track, according to a new Position Paper written by the ACDIS Advisory Board published on the ACDIS website.

To be blunt, no licensure or credential can identify whether someone will succeed as a CDI specialist. Not even ACDIS’ own Certified Clinical Documentation Specialist (CCDS) certification can guarantee that. We do, however, require anyone who sits for the CCDS exam to have two years of experience as a CDI specialist, so we feel good about the competency of our CCDS-credentialed professionals. CCDS holders must understand the basic core competencies and have demonstrated their skills in the field already.

But is that person a guaranteed fit with your culture?

Is that person dependent on an encoder or other computer assisted coding/natural language processing (CAC/NLP) tool that your hospital does not have?

There are many other factors that make up a good CDI specialist. As the new Position Paper explains, these factors include:

  • Effective verbal and written communication
  • Self-directed with an ability to work independently to complete the work at hand
  • The ability to think critically
  • A commitment to lifelong learning

The new Position Paper also notes that a strong clinical foundation is a must for any CDI specialist, and hiring an RN, MD, or an RHIA with strong clinical acumen will certainly fulfill that requirement. But, it’s no guarantee of success as the paper states:

“Credentials do not guarantee whether one will succeed as a CDI professional. Credentials merely identify the body of knowledge in which that person was originally trained. Prior bodies of knowledge certainly assist one’s success, and credentials and/or licensure provide identification of one’s stated profession and their level of education or achievement, but they do not ensure CDI competence. There is a number of necessary skills that cannot be ensured or captured by a credential.

It always comes down to the person. Why should CDI be any different?

If you’re wondering whether a Position Paper represents ACDIS’ official stance on an issue, you can find the answer here. Our recently published “Hierarchy of Authority” explains the order of significance of our published articles. ACDIS Positon Papers are peer-reviewed and represent the consensus opinion of the advisory board. We hope you find “ACDIS’ ‘Hierarchy of Authority’ of published articles” helpful as you navigate our website.

Editor’s note: This article originally appeared in CDI Strategies. Brian Murphy is the director of the Association of Clinical Documentation Improvement Specialists. Contact him at bmurphy@acdis.org.

Conference Q&A: Ericson sheds light on alternative payment models

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Cheryl Ericson, MS, RN, CCDS, CDIP

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. For today’s Q&A, we caught up with Cheryl Ericson, MS, RN, CCDS, CDIP, the manager of clinical documentation services with DHG Healthcare, who will present “Leveraging CDI to Improve Performance under Alternative Payment Model Methodology.” Ericson is recognized as a CDI subject matter expert for her body of work which includes many speaking engagements and publications for a variety of industry associations. She currently serves on the advisory board for ACDIS and its credentialing committee (CCDS).

Q: Could you tell me a bit about what makes Alternative Payment Models (APM) different for CDI?

A: Participation in voluntary APMs is very complex and requires a high level of commitment from the healthcare organization. More than 800 hospitals, however, are required to participate in the Comprehensive Care for Joint Replacement Model (CJR) and an additional 1,100 or more hospitals will be required to participate in the episode payment for AMI and coronary artery bypass grafts (CABG). Because participation is based on randomly selected Metropolitan Statistical Areas (MSAs) many hospitals may be unprepared for the impact. These models are retrospective so the hospital is paid as usual under the applicable MS-DRG, but following the completion of the performance year the hospital may be required to return some of their payment to Medicare or they may receive an additional payment. This type of model, like many of the outcome measures included in the mandatory value-based methodologies, require CDI specialists to look beyond the current episode of care. The mandatory quality programs, however, only use a 30-day timeframe. In comparison, an episode of care in the APMs extends 90 days beyond hospital discharge or the date of surgery.

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

A: Attendees can expect to learn:

  1. The difference between the mandatory value-based programs such as HVBP, HRRP, HACRP, and mandatory APMs
  2. A better understanding of the mandatory bundled/episode based payment methodologies
  3. Strategies to incorporate into the CDI process to accurately reflect organizational performance under the mandatory bundled/episode payment methodology

Q: What is one tool CDI professionals cannot live without?

A: A grouper that supports risk-adjustment efforts.

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

A: As the fee-for-service population decreases, which was reliant on CC and MCC capture, CDI specialists need to understand and modify their efforts to reflect modern CMS reimbursement strategies to support organizational financial health.

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

A: Like most, I enjoy reconnecting with friends. I have the added bonus of reconnecting with former ACDIS Boot Camp participants. It’s great to learn how people have advanced in their career as the CDI profession continues to grow!

Q: Fun question: What is your favorite candy?

A: Dove Promises dark chocolate with almonds. Yum!

 

Guest Post: Tips for appealing MS-DRG denials

Sam Antonios, MD

Sam Antonios, MD

by Sam Antonios, MD, FACP, FHM, CPE, CCDS

Over the last 18–24 months, health- care organizations have seen a surge in MS-DRG denials, sometimes referred to as clinical validation denials.

When reviewers from Medicare Advantage health plans, Recovery Auditors, or other private or contracted health plans analyze a clinical case submitted for reimbursement, they may determine that a particular disease should be removed from the claim. They argue that the clinical documentation in the medical record does not support the diagnosis submitted. In the vast majority of these cases, the removed diagnosis is a CC or MCC, which causes the MS-DRG to shift to a lower payment.

MS-DRG audits are nothing new, but their frequency has significantly increased over the last two years. In some circumstances, the volumes have been over- whelming. There have also been reports of cases where denials have been egregious, unjustified, or made with disregard for the treating physician’s opinion.

Although there is no surefire way to win an appeal, here are some tips to increase the likelihood of overturning MS-DRG denials.

One: If you believe the case has merit, file an appeal, even if the variance in dollar amount is insignificant. It may be tempting to let go of denials that minimally affect the reimbursement, but when the treating provider’s documentation is available, complete, and accurate, and the coding is correct per official coding guidelines, organizations should appeal. This maintains consistency and makes the appeals about data integrity, rather than payment.

Two: Write clearly and summarize first. The appeal reader will likely not want to spend a lot of time figuring out the intent of the appeal. The first few lines need to describe the clinical case and need for appeal succinctly. Additional details can be included in later paragraphs.

Also, remember to reference review articles, clinical guidelines, or other findings to support your appeal.

Three: Learn how to navigate the electronic health record (EHR) to find relevant information. The history and physical and the discharge summary may not capture the entire clinical picture.

Learn where to locate, and how to decipher, emergency department documentation, consultant reports, progress notes, nursing notes, and other provider documentation, which can often include vital information to a support an appeal.

Additionally, respiratory notes can reveal the status of the patient, including lung exams, respiratory effort, and need for respiratory treatments. The goal should be to offer a complete and accurate clinical picture of the patient.

Four: If possible, review records from transferring facilities to help describe the patient’s case. These records are likely scanned into the record later in the patient care process, but they should be collected before an appeal. Creatinine levels, electrolytes, and other laboratory findings can help differentiate acute and chronic symptoms and conditions.

Five: Keep track of denials electronically. Preferably, use denial-tracking software. If such software is not available, or too costly for your facility, spreadsheets can be just as effective. Remember to update and back up these records regularly.

Editor’s note: Antonios is the CDI and ICD-10 physician advisor at Via Christi Health in Wichita, Kansas. A board-certified internist, he manages the hospital EHR system, works closely with quality leaders to tackle challenging documentation requirements, and engages with physicians on CDI and quality initiatives. This article is an excerpt from its original which appeared in the Sept./Oct. edition of the CDI Journal. Contact him at Samer.Antonios@via-christi.org.

Note from the Advisory Board: Collaboration begins with appreciation

Paul Evans

Paul Evans

by Paul Evans, RHIA, CCS, CCS-P, CCDS, and Anny Yuen

The debate regarding which profession makes the “best” CDI specialist unfortunately continues. Many facilities and consulting firms, initially trained to believe that only nurses could perform the duties of a CDI specialist, continue to propagate such expectations.

Yet we believe other clinicians (e.g., physicians, physician assistants, foreign medical graduates) and nonclinicians (e.g., coders and health information management [HIM] professionals) also perform well in the CDI role with appropriate training.

When considering candidates for an open CDI position, CDI managers need to take a closer look at their initial job descriptions and make sure they accurately reflect not only the current needs of the department and the expanded role CDI specialists need to play, but also changes in industry expectations.

Anny Pang Yuen

Anny Pang Yuen

We’ve seen instances where programs take sample roles and responsibilities wholesale, and fail to customize their expectations or include professionals outside nursing. It has long been ACDIS’ stance that facilities should find the candidate best suited to the particular position. ACDIS has long expressed itself as an inclusive organization, welcoming coders, nurses, physicians, case managers, quality staff, and all who are interested in learning more about the value of complete and accurate documentation in the clinical record.

Further, in order to sit for the Certified Clinical Documentation Specialist (CCDS) credential, ACDIS lists out several levels of required education and skills. Among them, professionals must have an associate-level college degree—as the role of CDI specialist requires a high level of cognitive analysis and the integration of significant clinical acumen and awareness of healthcare reimbursement processes.

On the coding side, educational differences between those holding the Certified Coding Specialist, the Registered Health Information Technician, and the Registered Health Information Administrator® credentials are vast and may include formal college credits, anatomy and physiology, pharmacology, and pathophysiology, among other areas. However, because some facilities do not require coders to have advanced degrees, the conventional wisdom often gets reiterated—that coders in general have no clinical training or knowledge.

As HIM professionals engaged in CDI efforts at our facilities and as active members of the ACDIS Advisory Board, we stand to represent those from the coding side of the house who have effectively leveraged their experience to help advance the CDI mission. We have proven that we can per- form duties as CDI specialists and lead successful departments, while promoting the team dynamic between providers and HIM and CDI.

Not all coders can serve as CDI specialists, and neither can all nurses. Being a CDI specialist takes creativity and strong understanding about clinical documentation and indicators. The first step to true collaboration requires a deeper awareness and appreciation of the talents each individual, regardless of professional background, brings to the table.

Editor’s Note: This article originally published in the Sept./Oct. edition of the CDI Journal.

Review ACDIS advice regarding use of prior information in query creation

Cheryl Ericson

Cheryl Ericson

Last year at around this time, the ACDIS Advisory Board released a white paper reviewing the role of CDI specialists in assessing information in the medical record from prior treatments.

Codes cannot be assigned based on previous conditions. However, there’s a gray area clouding whether CDI professionals can pull information forward to clarify a diagnosis being treated during the current episode of care, says Cheryl Ericson, MS, RN, CCDS, CDIP, manager of CDI services at DHG Healthcare, during an ACDIS Radio discussion on the topic.

ACDIS created the white paper as a means to help CDI programs open a dialogue about such concerns within their facilities and to help CDI managers begin to craft policies and procedures around compliant and ethical practices regarding electronic health record interrogations.

It states:

In particular, CDI specialists face the dilemma of whether to apply information from prior encounters when querying a physician in order to clarify a diagnosis documented in a current admission or episode of care. The CDI profession is divided on this topic: Some are comfortable referencing the historical information within the query when it clarifies a currently documented condition relevant to the current episode of care; however, others believe this practice violates Uniform Hospital Discharge Data Set (UHDDS) definitions regarding an episode of care, as well as coding guidelines.

The paper reviews overarching guidelines and weighs various references such as reporting additional diagnoses and the definition of the term “encounter,” to help CDI programs begin to assess their own practices.

In Arizona where Judy Schade, RN, MSN, CCM, CCDS, works as a CDI specialist at Mayo Clinic Hospital, the population includes a large

Judy Schade

Judy Schade

number of “snowbirds,” retirees who travel to warmer climates for the winter. For these patients, information included in the electronic medical record often represents an important link between the current encounter and conditions which may have developed in another setting since their last hospital visit.

“We might not have the most current information so we need to be careful and to ask the provider where additional information may be needed to validate a diagnosis and pull it forward,” Schade says.

“It’s not enough for the physician to say this is a complex patient,” Ericson says. “They have to document it. If someone has hypertension they’re clinically always going to have hypertension. However, we cannot automatically make that assumption in coding that’s why the physician has to document ‘history of,’ or ‘chronic,’ or something else that is affecting this episode of care and the resources directed toward treating it.”

Such information “is so much more accessible” due to extensive use of electronic health records than it was in the past, ACDIS Director Brian Murphy says. CDI specialists need to determine whether looking back in the medical record, or opting not to look back, artificially limits a CDI professional’s ability to capture diagnosis specificity or whether concerns regarding the compliance of such activities are valid.

For example, Schade cautions that CDI specialists could be pulling forward outdated or inaccurate information as well intentioned as they may be. So “partner with different departments to formulate your policies. We’re moving in a different way of looking at things so we really need to carefully examine this process and develop the best practices,” she says.

The white paper walks through some common concerns but also recommends reviewing recommendations from the Joint Commission, CMS, and your own facility’s compliance, IT, and coding policies, for example.

Editor’s Note: This article originally published in the free eNewsletter CDI Strategies. Subscribe today!