Our next quarterly conference call is scheduled for Thursday, February 14, from 1-2 p.m. ET. To access the call, ACDIS members have been provided a toll-free number via email. If you have not received this email please contact ACDIS Member Services Director Penny Richards at firstname.lastname@example.org or by phone at 781-639-1872, ext. 3423.
These calls are offered as a means for ACDIS members to network with one another and to discuss any clinical documentation improvement related issues. We will have a few ACDIS Advisory Board members on the call as well. We encourage your comments, thoughts, and questions during the call.
If you have a question to ask, or suggestions for discussion on the upcoming call, please e-mail me at email@example.com. Conference calls are a great way to ask a question, air any and all concerns, or gather input on a policy or procedure at your hospital. While we cannot guarantee your question or discussion point will be addressed on the call, we will try to work in as many as possible.
ACDIS members chose four new leaders this week via a robust recruiting, review, and voting process. (Read more about the elections process on the ACDIS website.) Our sincere congratulations to the following new board members who will serve a three-year term.
Donald A. Butler, RN, BSN, CDI manager, Vidant Medical Center, Greenville, N.C. Background / Qualifications in CDI: Currently manager of the 10-member CDI team at Vidant (a 860-bed tertiary care center serving the eastern third of North Carolina). Additionally, working with the four other individual CDI specialists at Vidant Health hospitals. Leader of CDI since the program was implemented in March 2006. Served 11 years as a U.S. Navy nurse with a broad variety of clinical experiences, including labor and delivery, emergency, and primary care. Served in several leadership roles (was the department head for an obstetrics/pediatric clinic, performance improvement and accreditation coordinator) as well as program development such as annual school physical program, standardizing asthma and ADD care, emergency case management and CDI. Actively involved with CDI through presentations locally and nationally, participating with CDI Week development and active contributions with the ACDIS Blog and CDI Talk. Honored as the 2011 CDI Professional of the Year by ACDIS.
Sylvia Hoffman, RN, CCDS, CCDI, CDIP, President, CEO, Sylvia Hoffman CDI Consulting; adjunct boot camp instructor HCPro, Inc. Background/qualifications in CDI: Served as a CDI specialist in a 1,000-bed teaching hospital in Tampa, Fla., before starting her own Tampa-based CDI consulting practice. Worked as an educational consultant for documentation integrity with DocuComp, LLC, and was employed as a senior associate in the Forensic Division at KPMG, providing clinical documentation education and retrospective record reviews for compliance, integrity, and quality throughout the south east. Has 15 years acute care-hospital experience and 10 years of case management experience. Presently serves as an adjunct educator for HCPro in the areas of CDI and ICD-10, teaching Boot Camps and providing on-line educational seminars. Past-president of the Florida ACDIS regional chapter.
Walter Houlihan, MBA, RHIA, CCS, Director, HIM and Clinical Documentation, Baystate Health. Background/qualifications in CDI: Worked in the HIM field for more than 30 years, initially coding medical records at Columbia Presbyterian Medical Center, in New York City (NYC) in the 1970’s, then overseeing physician documentation in medical records at academic teaching facilities in NYC and Chicago. At Baystate Health assisted with developing a CDI program that has improved the quality of documentation and subsequently administrative data. Baystate Health received numerous national quality awards, most notably being recognized as a top 60 medical center in the U.S. from Reuters and Leapfrog. Led the effort to prepare Baystate Health for ICD-10 and plans to start the process of dual coding of ICD-9 and ICD-10 in a few months. Has spoken at numerous association meetings and conferences on the importance of improving clinical documentation, most importantly for the continuity of quality patient care and an accurate representation of hospital and provider patient care services. Enjoys the collaboration between ACDIS professionals at meetings in the New England and New York City areas. Member of AHIMA and HIMSS.
James E. Vance, MD, MBA, CEO, Physician Executive Management Services LLC; associate medical director, BCE Healthcare Advisors. Background/qualifications in CDI: Began work in CDI as a physician consultant with JA Thomas and Associates (JATA) in 2003-2004. Now serves as associate medical director for BCE Technology, a physician documentation compliance training organization (2004-present). Specializes in improving physician documentation compliance with Medicare documentation rules, and improving physician medical necessity documentation in the medical record. Experience includes clarifying medical necessity, clinical documentation “beyond the essentials,” case management physician advisor training, and third party physician advisor training for level of care admission decisions. Experience includes developing an “academic” CDI model and RAC appeal physician advisor training.
Voting is now open for four ACDIS advisory board positions, for terms of service starting in 2013 through the end of 2015. Log on to the ACDIS website to select the four candidates you believe are the best fit for the association, and then cast your vote.
The results of the election will be announced in early February.
ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership, expertise, and representation for the membership. The term of service is a maximum of three years.
The voting page includes the nominees’ background in CDI and information on why they are seeking election. The vote will close end of business day on Thursday, January 31.
If you have any questions, please e-mail ACDIS Director Brian Murphy at firstname.lastname@example.org.
Q: My question has to do with coding guidelines regarding secondary diagnosis followed by contrasting/comparative diagnoses. Let me explain a particular scenario. This was a two-day stay over the weekend. The patient was admitted for further evaluation with a history and physical (H&P) indicating worsening dyspnea. However, the discharge summary two days later includes the following documentation:
“His dyspnea is multifactorial due to: acute systolic congestive heart failure (CHF), morbid obesity, hypoventilation, obstructive sleep apnea (OSA), smoking, and lung mass.”
The patient was treated and counseled about CHF and was given a follow-up appointment with a pulmonologist for the evaluation of a lung mass. I could really use some help determining what the principal diagnosis could be. While this type of situation does not seem to happen often, it is actually the second case in a short time that’s come across my desk.
A: The guidelines are clear. When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.
It appears you are reading the narrative of the discharge summary. Without the complete record in hand, I do not know what final diagnoses listing was offered on the discharge summary. Consider the following:
- If the final diagnosis is: Dyspnea, multifactorial, due to acute systolic CHF, morbid obesity, hypoventilation, OSA, smoking and lung mass—then dyspnea is the principal.
- If the final diagnosis does not list dyspnea, then I would consider it integral to these conditions and I sequence the condition that best fit the reason for inpatient admission or that supported the medical necessity for inpatient admission.
Editor’s Note: This question was answered by ACDIS Advisory Board member James S. Kennedy, MD, CCS, Managing Director at FTI Healthcare in Brentwood, Tenn.
Q: A few times I have seen physicians document Schatzki’s Ring. I understand that if the physician documents “acquired Schatzki’s Ring” that maps to code 530.3 no CC/MCC. However, how would it be coded if the physician does not document “acquired” and only documents “Schatzki’s Ring”? Could it be considered an MCC or would we need to query the physician?
I am also wondering what clinical criteria needs to be present, does the patient need to have a related esophageal principal diagnosis or would this diagnosis fall into a congenital defect?
SB: If the physician does not specify the condition as “acquired” it defaults to 750.3. To assign a code for this condition it would have to meet one of the following five criteria for reporting a secondary diagnoses:
- clinical evaluation; or
- therapeutic treatment; or
- diagnostic procedures; or
- extended length of hospital stay; or
- increased nursing care and/or monitoring
JK: AHA’s Coding Clinic for ICD-9-CM, 1st Quarter, 2012, pp. 15-16, discussed this very issue. In it, guidance calls for querying the physician for clarification when documentation indicates “newly diagnosed Schatzki Ring in an adult patient without additional information regarding whether the condition is congenital or acquired.”
Coding Clinic states that code 530.3 should be used if the condition is acquired. When the physician is unable to determine the type, then the ICD-9-CM code defaults to congenital.
“However, Schatzki’s Ring would be a reportable condition only if it meets the definition of a secondary diagnosis, in that it must be clinically significant or symptomatic. In most cases, when a Schatzki’s Ring is found, it is an incidental finding,” Coding Clinic states.
Based on this Coding Clinic it appears to me that Schatzki’s Ring documented as an incidental finding should not be coded. If it is “clinically significant” or symptomatic, then a query is required to determine if the condition was acquired or congenital. If so, code 530.3 can be assigned.
Editor’s Note: This question was answered by ACDIS Advisory Board members Susan Belley, M.Ed., RHIA, CPHQ, Project Manager for 3M HIS Consulting Services in Atlanta and James S. Kennedy, MD, CCS, Managing Director at FTI Healthcare in Brentwood, Tenn.
The deadline for returning completed applications is November 19, 2012. A nominating committee and the ACDIS membership will make final selections by January 2013.
Election to the ACDIS advisory board entails a three?year term of service. Each year ACDIS elects four new advisory board members and four previous members rotate off the board following their term of service. This ensures a continual influx of new ideas and perspectives while maintaining continuity and industry perspective. The role and expectations of ACDIS advisory board members is described on the advisory board page.
CMS chose not to include code 428.0 (congestive heart failure, unspecified) as a CC. That disappoints ACDIS Advisory Board member James S. Kennedy, MD, CCS, CDIP, managing director at FTI Consulting in Atlanta, because in some instances of acute heart failure, no systolic or diastolic heart muscle disease is present, such as in acute aortic or mitral insufficiency.
In other cases the treating physician or surgeon simply did not want to incur unnecessary healthcare spending to get an echocardiogram needed to determine whether the heart failure is currently systolic or diastolic.
“I estimate that 20% of concurrent CDI work is to clarify this very issue which, if classifying 428.0 as a CC was approved as requested, would have reduced the work and hassle involved in clarifying systolic or diastolic heart failure and improve hospital efficiency and cost which, in turn, could be passed along to the government,” Kennedy says.
CMS also finalized the move of code 584.8 (acute renal failure with a specified pathological lesion) from an MCC to a CC based on their analysis of MedPAR data. Although this move is a disappointment, it may result in official follow-up on the advice provided in the AHA’s Coding Clinic, 3rd Quarter, 2011, in which coders were instructed to report acute renal failure due to specified pathological lesions, such as lupus nephritis, to code 584.9 (acute renal failure, unspecified), instead of code 584.8 Kennedy says.
“Perhaps the Cooperating Parties will now revisit this advice and provide official follow-up that allows coders to use 584.8 when a physician links acute renal failure to a specified pathological lesion, such as lupus nephritis, acute glomerulonephritis, interstitial nephritis, or another renal pathology not covered in [codes] 584.5, 584.6, or 584.7, since 584.8 is no longer a MCC,” Kennedy says.
Kennedy is pleased that CMS included mild and moderate malnutrition as CCs. He would like to see ICD-10 embrace the recently published American Dietetic Association / American Society for Parenteral and Enteral Nutrition consensus statement on malnutrition that classifies this entity as “non-severe” and “severe” instead of “mild,” “moderate,” and “severe.” View this reference at http://pen.sagepub.com/content/36/3/275.full.
CMS did not add any MCCs or delete any CCs.
CMS finalized a proposal to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and an additional secondary diagnosis code of certain pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179.
In March 2011, the ICD-9-CM Coordination and Maintenance Committee updated the following code definitions and exclusions:
- 518.5: Pulmonary insufficiency following trauma and surgery
- 518.51: Acute respiratory failure following trauma and surgery
- Respiratory failure, not otherwise specified, following trauma and surgery
- 518.52: Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery
- Adult respiratory distress syndrome (ARDS)
- Pulmonary insufficiency following surgery
- Pulmonary insufficiency following trauma
- Shock lung related to trauma and surgery
- 518.53: Acute and chronic respiratory failure following trauma and surgery
- Excludes: acute and chronic respiratory failure in other conditions (518.84)
- 518.8: Other diseases of lung
- 518.81: Acute respiratory failure
- Excludes: acute respiratory failure following trauma and surgery (518.51)
- 518.82: Other pulmonary insufficiency, not elsewhere classified
- Excludes: acute interstitial pneumonitis (516.33) ARDS associated with trauma or surgery (518.52) pulmonary insufficiency following trauma or surgery (518.52)
- 518.84: Acute and chronic respiratory failure
- Excludes: acute and chronic respiratory failure following trauma
I’d like to discuss some of the limitations and challenges of these codes and their current descriptions.
Postoperative and post-traumatic respiratory failure
ICD-9-CM codes 518.5–518.53 include the description “following trauma and surgery.” Combining trauma and surgery into one code is inappropriate. Patients with trauma, lung contusion, or bilateral traumatic pneumothoraces or hemothoraces will develop post-traumatic respiratory failure. The same is true for patients with crushed tracheas. These patients are distinctly different from those with postoperative respiratory failure. Each group should be tracked differently; therefore, they should be coded differently too.
Research is impeded by not coding and tracking each group separately. That’s because even when a patient experiences trauma, surgery may be the actual cause of the postoperative respiratory failure. The POA indicator does not help clarify the cause of post-traumatic respiratory failure because respiratory failure may or may not exist on admission. [more]
by Dee Schad, RN, BSN, CCDS, CDIP
As a nurse new to the worlds of coding and clinical documentation, it can feel quite overwhelming. Making the transition from the clinical side of nursing to a non-traditional nursing role can be challenging. To make that transition smoother, it may help to reflect back to your earlier days as a new nurse.
When choosing a career in nursing, most nurses say they made that decision because of a desire to help people. Perhaps it was just a pure passion for caring. In nursing school one quickly learns that there are a lot of technical skills combined with critical thinking skills required to be a nurse. At some point in time many of us may have secretly ask: “What about the caring part? When do I get to take care of people?”
As a new nurse on the floor your duties quickly turned to mastering a variety of technical skills such as monitoring patients’ IVs and ventilators, providing wound understanding nursing computer software, EKGs, etc. In those early days the idea of caring for patients seemed almost impossible as you struggled with all those technical challenges required for the day-to-day job.
As you matured into a seasoned nurse, you mastered the juggling act of technical and critical thinking skills and somehow managed to integrate caring into your daily patient care. At that point, you began to feel good again about the nursing profession. Remember how rewarding it was when you finally mastered the technical skills, and were able to apply your critical thinking skills, and still find a way to go above and beyond for that special patient. Remember the moment when you finally realized that passion for your job that initially drove you to choose the nursing profession.
In my many years of working in clinical documentation I have found the journey to be very similar to my early days as a nurse. When considering the career move into the role of a CDI specialist, you find the goal of the program is capturing accurate documentation in the patients chart to reflect true patient acuity, severity of illness/risk of mortality, and to ensure the physician and the hospital receives appropriate reimbursement for the resources used to care for our patients.
Wow…it is all about helping people…Sounds great! Sign me up!
As with those early days in the nursing role, so too with professionals transitioning to CDI efforts; the job can seem very technical and mechanical at first. There is a whole new language to learn; ICD-9, DRGs, principal diagnosis, co-morbid condition, CC, MCC, data abstraction, queries, excisional/non-excisional, etc.
It is easy to get caught up in the mechanics of CDI. It is easy to lose the vision of why we choose to come to this profession.
It is imperative that that we don’t stop when we master the technical side of CDI, the mechanics. Taking clinical documentation to the next level will bring you success as a CDI specialist and take your facility’s program to new heights. It is important, as with nursing, to take time to reflect on why you chose this profession. When you are reviewing a chart, don’t stop investigating when you get the right DRG. Step back and take a real good look at how sick the patient is, compare that with the physician’s documentation to determine if it is sufficient. If the documentation does not capture the severity of illness of that patient, does it really matter if you identified the DRG?
If you find yourself at that point where you are finally beginning to feel comfortable with your CDI technical skills, I challenge you to elevate your efforts to the next level. Have that face-to-face with the physician, research that disease process further, call in your physician advisor for additional input, go above and beyond to get your documentation.
I promise it will feel good. You will remember why you chose this role. You can make a difference. When you do, you will find a renewed passion for the CDI profession.
Editor’s Note: Dee Schad, RN, BSN, CCDS, CDIP, is Director Care Coordination and CDI at Clark Memorial Hospital in Jeffersonville, Ind., and a 2012 inductee to the ACDIS Advisory Board. Contact her at email@example.com.
The following volunteers have agreed to help ACDIS undergo the first audit/review of its popular Forms & Tools Library. Since its inception, ACDIS members have gracious donated their CDI materials to the library; sharing so that others who came after them would not have to labor so long and worriedly.
However, as ACDIS recommends that facilities review their queries annually for compliance, and suggests CDI programs regularly work with their physicians to revise education programs, so to must we take time to audit the materials offered to ACDIS members.
The Forms & Tools Audit Committee will therefore review the various ACDIS libraries to ensure the materials posted there are current, compliant, and useful. The goal is to present a revitalized Forms & Tools Library by mid-fall 2012 and to create a template for future audits/auditors to follow.
Please join me in recognizing the following individuals:
Mohammad K. Ahmed, MD, CCS, CCDS, AHIMA approved ICD-10 trainer, is the Lead CDI Specialist at Bronx Lebanon Hospital Center, New York. He has more than 10 years of wide-range experience in the healthcare field as a physician, medical researcher, coding trainer, insurance claim assessor and CDI specialist educator. Ahmed played a fundamental role in establishing CDI program at the Bronx Lebanon Hospital Center, which is the largest voluntary not-for-profit healthcare system in South/Central Bronx, New York. He focuses on advancement of CDI by reducing preventable denials, managing length of stay, and monitoring the case-mix index by coordinating utilization, case management, HIM managers, and executives. Contact him at Mahmed1@bronxleb.org or call 718/518 5322.
Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, is Regional Managing HIM Director, NCAL Revenue Cycle Kaiser Foundation Health Plan Inc. & Hospitals in Oakland, CA. A founding ACDIS Advisory Board member, Bryant has more than 28 years experience in the HIM field, and has presented on CDI and HIM issues at multiple venues including providing testimony in support of ICD-10 implementation for the House Ways and Means Committee in April 2006. She has served in leadership roles for AHIMA, the California Health Information Association (CHIA), the Society for Clinical Coding (SCC), the AHA Editorial Advisory Board (EAB) on ICD-9-CM for Coding Clinic. Contact her at Gloryanne.H.Bryant@kp.org.
Shelia Bullock, RN, BSN, MBA, CCM, CCDS, is Manager of Clinical Documentation Services at the University of Mississippi Medical Center, in Jackson, MS. A former ACDIS Advisory Board member (2009-2011), she has more than 30 years experience in nursing including the exciting and challenging opportunity to implement and manage the CDI program at the University of MS Medical Center, the only Level 1 Trauma Center, Transplant Center, and Medical School in the state. She is a charter member and on the board of the Mid-MS Chapter of CMSA and she has presented educational programs to physicians, nurses, coders, and at the MS-AHIMA state conference. Contact her at firstname.lastname@example.org.
Tiffany Estes, RHIA, CCDS, is the supervisor of the coding and CDI program at University of North Carolina Hospital. Estes supervises a coding staff of 13, including five physician advisors and a hybrid (RN/HIM) CDI staff of 10. She is responsible for developing and creating an extensive 12-week CDI training program and has created educational tools for physicians, CDI and coding staff. Estes has more than 13 years of coding experience including time spent working in acute care facilities across the country as a senior consultant. She is a member of AHIMA, and is an approved AHIMA ICD 10 CM/PCS trainer. She is also a member of the NC ACDIS Chapter.
Paul Evans, RHIA, CCS, CCS-P, CCDS, is Supervisor of Clinical Data Integrity in the quality department at California Pacific Medical Center in San Francisco, CA. He served as a reviewer for the 2012 revision of The CCDS Exam Study Guide, and is a member of the CA ACDIS chapter leadership team. Evans previously served as a project manager at Laguna Medical Systems where he was responsible for a staff of 12 senior auditors performing compliance reviews at more than 30 hospitals. An ACDIS and AHIMA member, Evans has contributed to multiple articles regarding quality and data management and is a frequent contributor to the CDI Talk networking group on the ACDIS website. Contact him by phone at 415/600-3739 or email email@example.com.
Robert S. Hodges, BSN, MSN, RN, CCDS, is Clinical Documentation Improvement Specialist at Aleda E. Lutz VAMC, in Saginaw, MI. Winner of the 2012 Recognition of CDI Professional Achievement, Hodges is a frequent contributor to both the ACDIS Forms & Tools Library and its email networking group, CDI Talk. He was instrumental in developing a national VHA standardized provider query process which includes a practice brief and query forms that were developed to assist all VA Medical Centers nationwide with implementing CDI programs. Contact him at Robert.Hodges2@va.gov or call 989/497-2500 ext. 13101.
Jeff Morris, RN, BSN, is a CDI Specialist at USA Children’s and Women’s Hospital in Mobile, AL. He first became familiar with coding while working at an outpatient dialysis facility. His experience includes pediatric emergency room, med/surg and telemetry, operating room, critical, and long-term care. He looks forward to completing a formal educational program in coding, as well as obtaining the CCA and CCDS certifications. Contact him at 251/415-1035 or firstname.lastname@example.org.
Tamara Perkins, RN, BSN, is a CDI Specialist at St. Thomas Health Services in Nashville, TN. She has been in healthcare since 1989, and has been involved in CDI efforts since 2008. She first became familiar with coding in 1997 while working at a home healthcare agency. In addition, she has experience in long-term care, medical/surgical units, physician office, and Recovery Audit reviews. Contact her at 615/222-6854, or email Tamara.Perkins@stthomas.org.
Heather Taillon, RHIA, is the Interim Director of HIM/ Coding Compliance at Franciscan, St Francis Health in Indianapolis, IN. A former[p1] ACDIS Advisory Board member (2007-2010), Taillon has also volunteered for the IHIMA executive board. She is a co-author of The Clinical Documentation Improvement Specialist’s Handbook, Second Edition, and has worked on a variety of large HIM projects including documentation imaging, home coding programs and more at a number of facilities. Contact her at Heather.Taillon@franciscanalliance.org.
Linnea Thennes, RN, BS, CCDS, is the Supervisor of the Clinical Documentation Improvement Team at Centegra Health System in northern Illinois. Thennes has more than 30 years experience in emergency medicine and critical care. Her involvement with CDI began in 2006 as a member of the start-up team for CDI at a suburban hospital. Last year she was thrilled to launch a CDI program in a hospital 3.2 miles from home. Thennes has been involved with ACDIS since its inception and was a member of the ACDIS Conference Committee in 2011. She was instrumental in forming the first ACDIS local chapter in April 2007 for CDI from the Chicago area. Contact her at email@example.com.
Charlene Thiry, RN, BSN, CPC, CCDS, is a CDI Specialist at Menorah Medical Center, Overland Park, KS. She has more than four years experience in CDI and more than 30 years experience in the nursing field. She enjoys this captivating field of CDI and considers obtaining appropriate documentation like fitting puzzle pieces together and conducting clinical investigations. Contact her at firstname.lastname@example.org.