All Entries in the "AHIMA" Category
AHIMA calls for CDI presentations
Could CDI be becoming a healthcare buzz word? It seems like everywhere I looked over the past few weeks healthcare documentation improvement specialists played a prominent role.
Remember I mentioned the Health Care Compliance Association’s upcoming CDI presentation at its Physician Practice Compliance Conference in Philadelphia? This week I heard about American Health Information Management Association’s (AHIMA) call for speakers for its June 2010 conference.
The AHIMA program focuses on CDI and coding and takes place in San Antonio, TX. Over the two-day speakers are expected to talk about CDI program challenges and best practices and explore the difficulties of communicating across CDI and HIM channels. According to the AHIMA release, the deadline for presentation proposals is Friday, October 23. For information, contact Kathy DeVault, RHIA, CCS, manager of professional resources at AHIMA at Kathy.DeVault@ahima.org.
Don’t worry the AHIMA program doesn’t overlap with the ACDIS 2010 annual show in Chicago — that’s June 3-4 (or 2-5 if you plan to attend the pre conference and take the CCDS exam). And not to repeat myself, but how great is it to watch the documentation improvement profession gain the credence it deserves from its sister organizations. Communicating a consistent message at a variety of professional organizations can help CDI illustrate its value to rest of the healthcare system in America.
Few IPPS changes final rule could cause CDIs trouble
There are a few changes in the IPPS final rule that may prove problematic for clinical documentation improvement specialists, according to Robert S. Gold, MD, CEO of DCBA, Inc., Atlanta.
Hypoxic ischemic encephalopathy (HIE), for example, has its roots in the pediatric population. So it will be important to recognize that the code for an adult with HIE is 348.1— anoxic brain damage. “And we need to be specific about the causes of encephalopathy in the neonate,” says Gold, “they’re not all HIE.”
The 285.3 code for anemia due to anti neoplastic treatment is different from anemia due to neoplastic disease and different from aplastic anemia from chemotherapy. The CDI specialists has to know what cell lines are missing and determine the true cause of the anemia in order to frame the question to the physician properly.
Gold also suggested that CDIs require better specificity of location of blood clots currently under treatment with Coumadin in order to assign the right code for deep vein thrombosis. He also suggested that physicians need to document whether the condition is new during the patient’s current hospital stay or whether it had been under treatment from a previous hospitalization.
Finally, Gold urged healthcare professionals to “work to preserve” the terms acute renal failure and acute kidney injury and to totally downplay the new definition of acute kidney failure. “This is a misunderstanding currently under discussion. You don’t want to promote the use of a term that might not last long. You don’t want to have to re-teach,” he says.
New ACDIS white paper available for download–encephalopathy
Hi ACDIS members, I wanted to let you know about a new white paper available for download in the Helpful Resources section of our Web site under the heading “White Papers.” It’s called “Cut through the confusion of altered mental status,” and it offers suggestions on what to when physicians document AMS, as well as how to appropriately query for encephalopathy and/or other more specific diagnoses. It also includes a sample AHIMA-compliant query form.
The source of the white paper is James Kennedy, MD, CCS, of FTI Healthcare. Dr. Kennedy is a unique combination of clinical and coding expertise.
I hope you find this white paper helpful. ACDIS publishes white papers on a quarterly basis on various topics in the CDI profession. If you haven’t seen our Helpful Resources page, check it out!
Take care,
Brian
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.
ACDIS news makes ADVANCE headlines
ACDIS makes the news
ACDIS hasn’t hit the New York Times yet but the way the profession, and this association, are going we’ll make headlines in the mainstream media in no time.
For now, however, a big bowl of congratulatory recognition to our Director Brian Murphy, CPC, and Advisory Board Member Bill Haik, MD, director of DRG Review Inc., Fort Walton, FL, featured in Lynn Jusinski’s article “New Certification Unveiled: ACDIS introduces the certified clinical documentation specialist exam” published in the magazine ADVANCE for health information professionals.
I wondered where else our good name was popping up so I did a quick Google news search and found an article Mr. Murphy wrote in the journal For the Record in July 2008 titled “Organization Serves CDI Specialists’ Needs”.
From now on, whenever I find a mention of ACDIS or clinical documentation improvment programs on the World Wide Web, I’ll post them to our ACDIS groups on LinkedIn and Facebook.
Advice for coding educators: ‘Start ICD-10 plans now’
When should schools start teaching ICD-10-CM instead of 9? AHIMA recommends a three-step process that starts with academic planning this fall and transitions through a hybrid educational method in 2010 and finally full ICD-10 curriculum integration by 2011. In its practice brief “Transitioning to ICD-10-CM/PCS-An Academic Timeline” published in the April edition of the Journal of AHIMA, the association recommends:
- Preparation- Start with the August 2009 academic school year to consider the impact of the transition and begin to formulate plans.
- Hybrid-Begins in the August 2010 school year because educators will face the challenge of incorporating both coding systems into an already full academic schedule.
- Full Implementation-Starts with the August 2011 academic year for associate and baccalaureate degree programs. This is the final stage of the curriculum change with ICD-10-CM/PCS being taught as the current classification system.
AHIMA to start CDI work group
Back in March, AHIMA sent out the call for volunteers to help establish a new work group on clinical documentation improvement. The initiative comes as part of the association’s e-HIM effort and aims to determine industry needs and CDI best practices, according to a release.
“We were overwhelmed with the number of people who wanted to volunteer,” says Kathy DeVault, RHIA, CCS, manager of professional practice resources at AHIMA in Chicago.
ACDIS Advisory Board members are among the list of volunteers. DeVault planned to notify participants and begin a series of weekly, work-group calls in early April but the influx of interest pushed the start date back slightly.
Tip: Adapt policies and procedures for physician queries
One policy fits all.
When AHIMA released its “Managing an Effective Query Process” brief in September 2008, it raised a number of concerns among them the responsibility of a CDI program to draft consistent policies and procedures for conducting physician queries. In a recent ACDIS poll, 29% of respondents said they did not have a query policy in place and 43% said their facility allows CDI staff a “flexible” query system.
Be careful about developing multiple rules for your facility query process, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services for 3M Health Information Services in Atlanta. The Department of Justice and the Office of the Inspector General “don’t care who asked the question”—either the HIM professionals in the coding department or a registered nurse in the CDI program—if the query leads the physician to document in an inappropriate way. So make sure when you develop your policy that you establish one approach and that everyone involved in the CDI program—coder, nurse, physician advisor—follows that approach.
Hear what Gloryanne Bryant, RHIA, CCS, senior director corporate coding HIM compliance department at Catholic Healthcare West in San Francisco had to say during the ACDIS quarterly conference call:
The quarterly conference calls allows ACDIS members to speak with each other and industry experts as an informal networking opportunity. Those who are unable to listen to the call “live” may access the MP3 recording of the call on the ACDIS Web site.
ACDIS has a number of sample policies and procedures available in the Forms & Tools section of the Web site. Download a sample inpatient physician query policy that you can adapt to your facility’s needs.
New information on CCDS certification, Code of Ethics posted
Hi everyone, we’ve recently added some new informational Web pages on the upcoming Certified Clinical Documentation Specialist (CCDS) credential. You can find them here: www.cdiassociation.com/certification. The links to the pages are located along the top of the screen. I hope you find them helpful.
I also wanted to let you know about a few new developments regarding the CCDS:
1. We’ve received a lot of questions about the location of the Assessment Centers. To find the test center nearest you, visit the Applied Measurement Professionals Web site and click on your state when the map comes up. You will be able to take the CCDS exam at these Assessment Centers starting in mid-late June (for details on how to schedule a test at an Assessment Center, please see our Program Handbook). The Assessment Centers offer computerized testing and the results are instant.
2. We had to narrow down the “standard drug reference guide” that test-takers can bring into the exam to five specific titles. Please note that in addition to DRG Expert published by Ingenix, test-takers can bring one of the following five drug guides into the test with them:
- Mosby’s Nursing Drug Reference
- Nurse’s Pocket Drug Guide
- Physicians’ Desk Reference
- PDR Nurse’s Drug Handbook
- Nursing Drug Handbook /Lippincott’s
3. Finally, we are proud to note that we have launched an ACDIS Code of Ethics. This document is intended to serve as a guide for the professional behavior of ACDIS members and nonmembers who hold the CCDS credential. ACDIS is indebted to the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC), who allowed us to borrow from their organizations’ own Code of Ethics to help ACDIS construct its own.
You can read the ACDIS Code of Ethics here: http://www.hcpro.com/acdis/code_of_ethics.cfm.
Thanks, and as usual, your comments and questions are appreciated,
Brian
Physician queries: White paper, ACDIS survey, book
Only a few months ago AHIMA released guidance for physician queries so it is no wonder that concerns remain for most CDI professionals. They want to know how to query, what to query, and when to query. For those just starting CDI programs, these questions are paramount to forming an effective CDI process.
ACDIS has begun working on a book regarding physician queries which we hope to release later this year. Please let me know if there’s a particular issue you think we need to address by either sending an e-mail to mvarnavas@cdiassociation.com or posting a comment to this blog.
You can access a free white paper “Master physician queries: Clarify coding with compliant questions” written by our own Shannon McCall, RHIA, CCS, CCS-P, CPC-I,
Shannon McCall
ACDIS board member and director of coding and health information management for HCPro, Inc. Just click on the link, fill out the information, and check the physician query box.
Also, as a reminder, the physician query benchmarking survey remains open until February 13, 5 p.m. One lucky participant will be chosen at random to receive a free admission to this year’s ACDIS conference at Caesar’s Palace in Las Vegas. If the winner already has a paid seat to the conference then he or she gets a free pass to the pre-conference event, ICD-9 Coding Essentials: What every CDI specialist needs to know. (Which Ms. McCall teaches, by the way! I’m signed up for this session myself and am really looking forward to it!)
ACDIS will publish the survey results and post them on the Association Web site.