All Entries in the "AHIMA" Category
The clock strikes twelve…
Now that you have the extra time...
…and the documentation coach will turn into a pumpkin if you’re not on time. As a CDI specialist, what has been your approach to ICD-10? Are you hoping it will go away? Are you waiting for 2014? Are you preparing now?
Although the official start date for ICD-10 CM and ICD-10 PCS is expected to move out to October 1, 2014, the start of fiscal year 2015, most hospitals should be, and are, preparing now.
AHIMA has produced an ICD-10 checklist, with a detailed timeline and suggestions as to who should be involved at what stage of the process. CDI specialists aren’t specifically mentioned until the very end, as one group of the many users who will need ICD-10 education, but their role will be critical.
According to the timeline, you should have already looked at your physicians’ documentation to see if it will stand up to ICD-10 coding requirements, and should be developing and implementing strategies to address any weaknesses in that documentation. You can’t do that if you don’t know ICD-10. If you are not expert in anatomy and physiology (A&P), get refresher training now. While you are likely not coding the chart, you are ensuring that the documentation is sufficiently detailed to meet ICD-10 (especially PCS) coding requirements, and that means having expert understanding of A&P.
If your hospital hasn’t decided what changes to it needs to make in its electronic documentation processes, get involved. (See related articles CDI input helps EHR implementation succeed and E-nvolved: The case for planning EHR implementation available in the CDI Journal archives.) You are the experts on documentation requirements. It will be much easier to work the documentation requirements into your electronic system before implementation than to try to retrofit a process into an existing system later.
You may think it is too early to learn about ICD-10, or that if you learn it now, you will forget it by the implementation date because you are still using ICD-9. Think back to when you first learned the MS-DRG system and ICD-9-CM codes. How long did that take? Aren’t you still learning? Don’t you have to give yourself time to become competent so that you could educate your doctors?
Consider this: Everything you teach physicians about documentation for ICD-10 will improve their documentation under ICD-9. Your coders are not going to complain that you enabled the physician to be too accurate. When you send a query, physicians generally doesn’t know or care about the coding rule or the classification system that triggered the query. They just know they have to answer to the level of detail you’re asking, so start sending questions that generate ICD-10 compliant answers. When you learn ICD-10, you can start guiding your physicians in the right direction, and the official transition in 2014 will be much less painful.
I liken the preparation for ICD-10 to that, a little more than a decade ago, for Y2K. Some people feared disasters including nuclear holocaust, and when nothing happened on 1/1/2000, they were almost disappointed. In reality, the preparation had been impressively thorough and left nothing to chance. Although the world might not end if we aren’t ready for ICD-10, getting all the details covered before the official implementation date can make the actual conversion more like distant thunder clap than an Armageddon explosion.
Training seminars, boot camps, and books abound. Take advantage of everything that’s offered, and ask for training if you haven’t received any. If you’re just starting to train, review CMS’s overview of ICD-10. The World Health Organization offers an ICD-10-CM online training tool that’s free and easy to use.
As a CDI consultant, I knew that at some point I would be required to provide ICD-10 documentation education to new CDI specialists. So I decided to pull out the ICD-10-CM official guidelines and actually compare them side by side with the ICD-9 CM guidelines. Not only did I learn about ICD-10-CM, but I refreshed my knowledge of ICD-9-CM.
Then I began putting together a presentation on ICD-10-PCS, and by working my way through the definitions and the rules, I educated myself. By the time I finished creating my PowerPoint, not only did I have a greater understanding of the complexity of the documentation requirements, but I was able to code a simple procedure. I was very proud of myself, too! Now, I didn’t become an ICD-10 expert that day, but by challenging myself to work with it, I found it much less frightening and much less mystifying.
Please don’t wait for education to come to you. Please don’t wait for someone else to tell you what your CDI process should be. Put the “special” in CDI specialist.
WWRD: What would the RAC do?
RAC focus areas need to be on your CDI program's radar screen but it need not take over your program's focus.
There has been much discussion based on what Recovery Audit Contractors (RAC) and other state and federal regulatory bodies are doing or what their next move will be (though does anybody really know?!?).
We’ve all heard the stories of denials of well documented and clinically substantiated conditions; of the role the RAC reviewer incentive structure plays in RAC determinations, of confusing correspondence addresses, etc. Whether or not the stories are true doesn’t matter as much as the attention such stories garner. We’ve also heard of the fear that prevails and this makes me wonder about the effect of these reviews on our day-to-day workflow.
I recommend we stop, take a deep breath, and think…Why not switch our focus from “what would the RAC do” back to what care was provided and how was it documented in the medical record?
Now, I’m not saying we should ignore RAC, or forget that they are there. Believe it or not, they do keep us grounded. I’m just saying let’s try not to make them the focus. Let’s try not to work according to the WWRD principle.
We are currently in the midst of a nationwide movement toward quality and public reporting. It is commendable that our national focus has turned to the quality of healthcare. And providing quality care is all about doing the right thing at the right time. If we stay true to who is at the center of this movement, ‘the patient,’ and set the stage for the right process to ensure that we do the right thing at the right time, good outcomes will prevail.
Let us take that thought and apply it to the world of CDI. The concurrent process of CDI, in and of itself, takes place at the ‘right time,’ while the patient is still in the hospital and we have all the necessary medical record, laboratory, and dietary information available to us. Through our consistent, thorough review of the information contained within the record we can help clarify ambiguous information, identify potentially omitted diagnoses, and ensure the record accurately captures all the clinically relevant care provided.
Although our task can be complicated, we have available to us several documents that assist us in our endeavors to do the ‘right thing:’ ACDIS’ Code of Ethics, AHIMA’s 2008 practice brief, Managing an Effective Query Process, the 2010 document, Guidance for Clinical Documentation Improvement Programs, and their 2010 publication, Clinical Documentation Improvement Toolkit. In order for our day-to-day CDI practices to be able to withstand audit scrutiny we must use these guidances, plus our own facility-specific policies and procedures to guide us.
When we stray from our ethical and moral core, and away from the guidelines in place to protect us, we could find ourselves alone and exposed. There have been several discussions (most recently during the November 17, 2011 ACDIS Quarterly Membership Conference Call) regarding the dangers of leading queries and the potential legal implications involved. We all need to operate within the guidelines and be prepared to stand up and defend the information contained within the medical record.
If we center our attention on doing the ‘right’ thing, focus on our responsibility to the patient, and continue to assist in the precise and complete representation of the patient encounter within the medical record, we will have done our job, and possibly kept the RAC at bay. Let us do what we do best, according to the guidelines, and let the policies and procedures that are in place steer us on the right path.
Don’t think about what RAC would do; think about doing the right thing at the right time for the patient.
Book Excerpt: Clearly establish your program query processes
According to AHIMA, the query process has become a common communication and educational method to advocate proper documentation practices to ensure data accuracy and integrity. Queries may be made for the following situations:
- Clinical indicators of a diagnosis but no documentation of the condition
The 2012 CDI Pocket Guide.
- Clinical evidence for a higher degree of specificity or severity
- A cause-and-effect relationship between two conditions or organism
- An underlying cause when admitted with symptoms
- Only the treatment is documented (without a diagnosis documented)
- Present on admission (POA) indicator status
Definition of a Query:
A question posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.
Whom to Query?
Any physician or other qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis, including
(Attending Physician, Consultants, Specialists, Emergency Physician, Anesthesiologist, CRNA, Intern, Resident, Fellow, Physicians Assistant, Podiatrist , Nurse Practitioner). When there is conflicting information, the attending physician should be queried since he/she is ultimately responsible for the final diagnoses.
When to Query?
When there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure.
AHIMA states that a query may be appropriate when documentation in the record fails to meet one of the following five criteria:
- Legibility
- Completeness (abnormal results without comment)
- Clarity (cause of symptoms)
- Consistency (disagreement/conflicting info)
- Precision (more specific)
When Not to Query
- Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Coding Clinic 2000 Q2 P 17: “When documentation in the medical record is clear and consistent, coders may assign and report codes.”
- Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet the five criteria: legibility, completeness, clarity, consistency, or precision.
- In situations where the clinical information or clinical picture does not appear to support the documentation of a condition or procedure, hospital policies should provide guidance on a process for addressing the issue without querying the attending physician.
Editor’s Note: This post is an excerpt from the 2012 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS.
Santa’s not the only one watching to see if you’ve been bad or good
Singing: He sees you when you’re sleeping. He knows when you’re awake. He knows if you’ve been bad or
What will the jolly old elf will bring to the RAC offices?
good, so be good for goodness sake.
Remind you of anyone? No? Here’s a hint. It rhymes with knick-knack but these groups aren’t known to be particularly “nice.”
Audit contractors (Recovery Audit Contractors or RACs) are not Santa, but they are watching you, and they certainly know if you’ve been naughty.
Let’s be realistic, all of your facility healthcare data is being scrutinized, analyzed, and compared. Statistical data gives audit contractors an idea of which hospitals fall off the bell curve, and what diagnosis qualify as low hanging fruit.
If your hospital has a 30% sepsis admission rate and all other hospitals in your area have a 10% rate, then you pretty much are going to stand out like a sore thumb. Do not fool yourselves. It is not because your CDI department is that much better at capturing sepsis as a diagnosis.
Take a look at how your facility does business and whether it may be pushing the envelope when it comes to leading queries and creative coding. Does your hospital follow AHIMA’s recommendations when it comes to formulating compliant queries? The brief clearly states that:
“Individuals who perform the query function should be familiar with the AHIMA Standards of Ethical Coding, which direct coders to assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.”
Next, review and update your own internal policies and procedures. Many hospitals create these policies and then never check to make sure the rules are being followed. The AHIMA guidance states:
“Individuals performing the query function should follow their healthcare entity’s internal policies related to documentation, querying, coding, and compliance, keeping in mind that data accuracy and integrity are fundamental HIM values. Only diagnosis codes that are clearly and consistently supported by provider documentation should be assigned and reported. A query should be initiated when there is conflicting, incomplete, or ambiguous documentation in the health record or additional information is needed for correct assignment of the POA indicator.”
Lastly, create an audit process to ensure that both your own policies and AHIMA recommendations are being followed. Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes. They can consider several methods for this ongoing process. Queries can be reviewed retrospectively to ensure that they are completed according to documented policies. This might include reviewing determining whether the:
- query was necessary
- language used in the query was not leading or otherwise inappropriate
- query introduced new information not otherwise included in the medical record
Based on the results of this review, the healthcare entity may need to identify specific corrective actions. For example, any cases identified as containing inappropriate queries which resulted in inaccurate code assignment will require corrective action and possibly rebilling. Inappropriate queries should be tracked, trends identified, and appropriate education, training, and/or disciplinary action taken when warranted.
No one wants to get a lump of coal in their stocking. And no one wants to give the RAC or other auditor a Christmas bonus. Take time this holiday season to make some New Year resolutions and ensure that your facility is compliant and knowledgeable. You will then reap the rewards of a stocking filled with peace of mind.
AHIMA names new chief executive, annual conference starts Sunday
Meet Brian Murphy at AHIMA Booth 1207
Lynne Thomas Gordon, MBA, RHIA, FACHE, took over as CEO of AHIMA on September 29, according to a recent AHIMA release. Thomas Gordon joins AHIMA after serving as associate vice president for hospital operations and director of the Children’s Hospital at Rush University Medical Center. She also is a member of the Rush University faculty in the graduate program in health systems management.
“The combination of Lynne’s executive skills and healthcare knowledge will help lead AHIMA and its members through complex issues and the healthcare industry’s transformation of managing and integrating HIM with a new generation of technology,” said AHIMA Board President Bonnie Cassidy in a release.
The 83rd AHIMA Convention and Exhibit begins Sunday and ACDIS is proud to support the efforts of the HIM professionals who work so diligently to ensure the accuracy and security of the medical record. A few former ACDIS Advisory Board members will be presenting during the conference. ACDIS Director Brian Murphy will be in attendance, so be sure to stop by booth 1207 and pay him a visit.
Book excerpt: Query retention
Establish policies and procedures around query retention.
The AHA’s statement that queries should not replace physician documentation in the medical record raises the issue of query retention. Should CDI staff keep the query form as a permanent part of the medical record, remove it from the record and store it separately, or simply remove it from the record and eliminate it completely once the concern is resolved? The answer to this question remains open to debate.
AHIMA indicates that it is not advisable to record queries on handwritten sticky notes, scratch paper, or other notes that can be removed and discarded from the medical record. Its preferred formats for capturing physician queries include:
- A facility approved query form
- A facsimile transmission
- An electronic communication on a secure e-mail that complies with the HIPAA
- A secure electronic messaging system
To some, this instruction seems to imply that AHIMA recommends CDI programs keep physician queries as a permanent part of the medical record; however, the brief does not mandate that hospitals keep their query forms on file. Its brief “Managing an Effective Query Process” states:
“Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query would be a permanent part of the patients’ health record. If it will not be considered a permanent part of the patients’ health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subjected to health record retention guidelines.”
Editor’s Note: This article was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition, byMarion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS
Tip: Use free resources to help you start your ICD-10 preparation efforts
The more I learn about ICD-10, the more worried I get. At this point my worries are more related to knowing enough to be dangerous but not knowing nearly enough to truly understand or feel confident about our CDI program’s preparation efforts. Two recent ACDIS polls touched on feelings about ICD-10 (What are your initial impressions of ICD-10? and What is your planned primary method/vehicle for ICD-10 training?).
The conversion to ICD-10 is going to happen on October 1, 2013. There seems to be two opposing trains of thought about this implementation deadline:
- We have plenty of time.
- We are directly on top of this deadline and had better get our plans together.
In one sense, education of CDI specialists during the first six months of 2013 would (or should) be enough to prepare for individuals to complete their daily jobs. If CDI staff receive training on ICD-10 codes too far in advance then they will require an intensive refresher shortly before the conversion. However, if we wait too long we take a risk that all of the best training resources are fully committed and are unable to meet our facility needs.
A number of other potential problems need to be considered also. Where will your facility find the additional funds for training its CDI staff, for example? You’d need to know when training budgets are proposed and align the various learning objectives to your training expectations. And, of course, you’ll have to get that ICD-10 training budget approved. If you ask for funds too early, you risk being denied by your CFO.
Consider whether or not you’ll use in-house expertise for additional staff training. If so, expect to extend your training schedule further. It will take additional time to train a single individual on the various important aspects of ICD-10 and still more time for that individual to focus their training to your facility and various staffing needs.
Planning for your CDI program’s ICD-10 training needs really does need to start now but don’t worry, there are a number of resources I’ve found that seem exceedingly helpful. These include the following:
- 3M. As a significant vendor of all things related to inpatient coding, 3M also offers a number of free ICD-10 preparation tools including:
- AHIMA. Of course one would expect that AHIMA would be a premiere resource for all things related to this important transformation. The Association offers an e-newsletter, a resources page, and it even offers suggested tasks for inpatient coders.
- AMA. The American Medical Association offers a crash course of basics that CDI professionals might look to for help with training their own physicians. This site contains a number of links to helpful information also.
- Becker’s Hospital Review. Offers an article on 10 steps to prepare for ICD-10.
- CDC. This is where you can find the most direct information regarding changes to the proposed ICD-10 coding guidelines and updates to the codes themselves.
- CMS. CMS offers its overview of ICD-10 including detailed information on the procedural coding system, otherwise known as PCS.
- HCPro’s ICD-10 Trainer Blog. This includes several posts by Christina Benjamin regarding low-cost resources for ICD-10 education and a roundup of additional ICD-10 resources.
- The Milestone Group. Offers a white paper “5 Steps for a successful transition.”
There are a number of additional training options which range from more formal classroom programs to individualized educational offerings from consulting services, but I wanted to highlight some starting points that are free and easily available.
Editor’s Note: This article first appeared in this week’s issue of CDI Strategies. Subscribe to the free e-newsletter. Butler earned the 2011 CDI Professional of the Year Award. He is the Clinical Documentation Improvement Manager at Pitt County Memorial Hospital, in Greenville, NC. Contact him at dbutler@PCMH.COM.
Pennsylvania AHIMA holds CDI symposium
The following is the agenda for the Friday, March 25, Pennsylvania AHIMA’s clinical documentation improvement symposium which will be held from 9 a.m. to 2:30 p.m. at the Robert Packer Hospital, in Sayer. Register online by Wednesday, March 23, via KnowledgeConnex.
- 8-9 a.m.: Registration
- 9-10 a.m.: CDI and Core Measures, presented by Barbara Lopez of St. Mary Healthcare
Register for PAHIMA's CDI symposium
- 10-11 a.m.: Transfer DRG Case Study, presented by Michele Johnson, RN, BSN, CDI supervisor, with Wellspan
- 11:15 a.m. to noon: AHIMA CDI Tool Kit, presented by Paula Frost, PHIMA CDI co-chair
- Noon to 1 p.m.: Lunch
- 1-2 p.m.: CDI Programs, presented by Mary Parana, RN, case manager at Kane Community Hospital
- 2-2:30 p.m.: Networking, other business, adjourn
Q&A: Re-billing an account after a late query response
Develop a policy for post-bill queries to maintain compliance.
Q: AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” appears to allow the initiation of post-bill queries as a result of an audit or other internal monitor. Historically we believed that a query completed after the initial bill was not permitted to be submitted for rebill (unless the documentation was present and the coder missed it) because the documentation was not present at the time of the original coding and bill submission. We have had a few cases in which our CDI nurse has initiated a concurrent query that was continued retrospectively; however the coder released the bill prematurely in error. If the physician answers the query after the bill has dropped would it be appropriate to rebill the account?
We have also had coding audits with recommendation that a query should have been initiated. Would it also be appropriate to initiate a post bill query in this situation? Again, we have not been rebilling up to this point but if it is permissible then we would develop a policy which would include billing parameters. We want to ensure that we are interpreting the guidance in the practice brief correctly.
A: “Managing an Effective Query Process,” p. 4, discusses initiating post-bill queries as a result of an audit or other internal monitor. The guidance states:
Healthcare entities may design their query programs to be concurrent, retrospective, post-bill, or a combination of any of these. Concurrent queries are initiated while the patient is still present. Retrospective queries are initiated after discharge and before the bill is submitted; post-bill queries are initiated after the bill has been submitted.
Concurrent queries are initiated “real time,” during the course of the patient encounter or hospitalization, at the time the documentation is naturally done. They thus encourage more timely, accurate, and reliable responses. Retrospective queries are effective in cases where additional information is available in the health record, in short stays where concurrent review was not completed, or whenever a concurrent query process is not feasible.
Post-bill queries are initiated after the claim is submitted or remittance advice is paid. Post-bill queries generally occur as a result of an audit or other internal monitor. Healthcare entities can develop a policy regarding whether they will generate post-bill queries and the timeframe following claims generation that queries may be initiated. They may consider the following three concepts in the development of a post-bill (including query) policy:
- Applying normal course of business guidelines
- Using payer-specific rules on rebilling timeframes
- Determining reliability of query response over time
A post bill query is always appropriate when, after an audit, an error was found. The goal of a CDI program is complete and accurate documentation regardless of the financial impact. All overpayments should always be re-billed regardless of the length of time since initially billed. According to MLN Matters article SE 1027:
Column: The myth of ‘meaningful use’
The search for 'meaningful use' in electronic health records continues.
We, in the United States, will soon need to adopt the electronic health record (EHR). Over the past few years, of course, healthcare entities have slowly converted from the traditional handwritten medical record toward one that is totally digital. There have been a myriad of interim steps, from models which simply scan the handwritten documents into a computer system to those which begin with an electronic template complete with check boxes and drop down menus.
Some programs use dictated and transcribed elements for physician or mid-level provider entries. Some programs take the electronic record and utilize fuzzy logic to search for key words, phrases, and abnormal lab results in an attempt to assign ICD diagnosis codes.
But what is the purpose of this transition? What is the stated goal? What is the real goal to be achieved with an EHR? There are two major reasons for the development and adoption of the EHR. One we are close to achieving, the other, in my opinion, just doesn’t exist.
The desire to ensure that an electronic model of a patient’s encounters contains all of the elements needed for somebody’s perception of a “complete” record has led to the currently marketed and sold models. To know that a patient’s problem list is present, that his or her medication list and reconciliation is there, to know that the history and physical (H&P), progress notes, discharge summary, nursing notes, and all the rest of the elements that make up a traditional patient’s chart are present is a great reason to have an electronic record. It forces people to remember to make these entries. Also important is the electronic records ability to:
- Keep the patient’s inpatient and outpatient encounters available in one compendium
- Track crossover treatments provided by different specialists
- Monitor for drug interactions
- Track scheduling and follow-up visit dates
The potential to facilitate practice guidelines and order sets based on best practice is great—if the physician knows how to set them up and use them or, in specific cases, elect not to use them for the benefit of the outlier patient. So, for these reasons, I say good for the companies who have put such an important functionality together.
But, there are still problems with implementation of the so-called complete EHR. In the January 2011 edition of the Journal of AHIMA, Genna Rollins writes about the experience of Barbara Drury, president of Pricare Consulting. According to the article, Drury experienced difficulties with the EHR recording inappropriate dates at inappropriate times. She also expressed frustration with the inability of tracking patient data when someone does not have access to the electronic record and worried about those who would then develop alternative, manual, work-arounds.
Yes, there are still process issues.
