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Guest Post, Part 2: Where do we stand with clinical validation?

clinical validation poll(1)

According to an ACDIS poll, 70% conduct clinical validation reviews.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:

  • Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
  • Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

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Conference Corner: Thanks to our exhibitors and sponsors

ACDIS would like to take a few moments to recognize and thank all our sponsors and exhibitors of the 2017 10th annual ACDIS conference. Every year, our sponsors and exhibitors help us make the conference memorable. Thank you for helping us make the 10th annual conference the best yet!

The following is a comprehensive list of all our sponsors:

  • Title sponsor: MedPartners
  • Diamond sponsors: Optum360 (also sponsor of the 10th anniversary photo booth), Enjoin, TrustHCS, UASI
  • Platinum sponsors: 3M, Iodine, Sound Physicians Advisory Services
  • Conference specific sponsors: ChartWise, tote bag sponsor; Elsevier, welcome reception sponsor; HCTec, water bottle sponsor, The Claro Group, app sponsor; Harmony Healthcare, door cling sponsor

The following is a comprehensive list of all our exhibitors (in alphabetical order):

ACDIS Lee Health
Administrative Consulting Service (ACS) Libman Education
Addison Group M*Modal
American Health Information Management Association (AHIMA) Managed Resources Inc.
Altegra Health Solutions Maxim Healthcare Services
American Medical Association MedeAnalytics
BRG Healthcare nThrive
Brundage Medical Group Nuance
Caban Resources Ovation Healthcare Technology
CDI Search Group Oxford Healthcare Technology
CDIMD-ePreOP Peak Health Solutions
Chartwise Medical Systems, Inc. Pinson & Tang
ClinIntell, Inc. RecordsOne, LLC
ComforceHealth Saince, Inc.
Dolbey SCL Health
e4 SoftScript Transcription
Elite Medical Staffing Sound Physicians
ezDI Inc. Streamline Health Solutions
Feel Good Inc. Tenet Healthcare
GeBBS Healthcare Solutions Universal Coding Solutions
H3.Group Vincari
HCTec VitalWare
Huron Consulting Washington & West, LLC
Intellis

Local Chapter Update: TN leadership recaps successful January event

IMG_1289

The joint meeting of ACDIS, THIMA, and THA

by Sherri Clark, BSN, RN-BC, CCDS, CCS, Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, and core member of the Tennessee chapter of ACDIS

The joint meeting of the Tennessee Chapter of ACDIS (Association of Clinical Documentation Improvement Specialist), THIMA (Tennessee Health Information Management Association), and THA (Tennessee Hospital Association) occurred on January 27. The meeting took place at the THA headquarters in Brentwood. The subject of the meeting was “The Impact of ICD-10 and Payment Reform on Clinical Documentation Improvement.” Four members of the core team of TN ACDIS chapter leaders (Sherri Clark, Kristie Perry, Cynthia Raymond, and James Kennedy, MD) and one chapter member (Kyra Brown) served on the planning committee for this joint meeting. Attendees were offered a number of hour-long presentations to choose from during the meeting, including:

  • Managing Conflicting Guidelines in ICD-10–CM/PCS
  • CDI, Coding, and Quality – The Three Legged Stool
  • Payment Reform in TN – Health Care Innovative Initiatives
  • Recovery Auditor Prevention Strategies: How to keep the predators away
  • MACRA, MIPS, APMS: Why CDI is a critical ingredient of the alphabet soup?
  • ICD-10-PCS and the Impact on CDI
  • The Case for Category II Codes
  • Hospital Improvement Network and other statewide databases: How are they used and the importance of quality data
  • The Impact of HCCs on Physician Accountability

The meeting drew physicians, coders, CDI specialists, and executives from THA. The presenters for the meeting included members of ACDIS, AHIMA, THIMA, and the THA. ACDIS Director Brian Murphy attended the meeting, as did all of the TN ACDIS Chapter leaders—Sherri Clark, Kristie Perry, Cynthia Raymond, Judy Rochelle, and James Kennedy. The joint meeting qualified for six continuing education units for ACDIS and AHIMA.

Editor’s note: Clark is a Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, Tennessee. She has been an ACDIS member since the spring of 2008 (she even attended the first ACDIS conference that year!) and a chapter leader since 2011 when the chapter was formed. For information regarding upcoming local chapter events, visit the website or email Clark at SClark@mc.utmck.edu.

No more ICD-10 delay: Contact your local legislators today

ICD-10 implementation is not game. Tell your elected officials to stop playing around with the implementation date.

ICD-10 implementation is not game. Tell your elected officials to stop playing around with the implementation date.

Word has begun circulating throughout the healthcare industry that ICD-10 may face additional delay.

A letter drafted by Republican Michigan Representative Fred Upton and Republican Texas Representative Pete Sessions on behalf of the Medical Society of the State of New York seeks an additional two-year delay in the implementation of ICD-10 until October 1, 2017. You can read the letter here: http://www.mssny.org/MSSNY/Practice_Resources/ICD-10/ICD-10-Boehner-Letter.aspx

We at ACDIS strongly oppose further delay to ICD-10. Hospitals and CMS have already conceded with prior delays, at great cost: CMS estimated that the last delay cost the healthcare industry up to $6.8 billion in training, software, and other investments.

Further delay would result in additional costs, and also hurt patient care. The nation’s current coding and disease classification system, ICD-9, is out of date and desperately in need of the additional specificity that is the hallmark of ICD-10. Contrary to statements made in the above letter, improved coding specificity is not just tied to reimbursement, but also quality of care and patient safety.

It goes without saying that a further delay would also greatly damage the work already being done by CDI departments across the country, many of which have been diligently collaborating with their physician staffs with formal education and queries for the additional specificity needed under ICD-10.

ACDIS has received permission from our friends at the American Health Information Management Association (AHIMA) to share the following information with our members. It includes AHIMA’s recommended approach to contacting your local legislator and making your voice heard.

If you click this link, it will take you to Capwiz, a tool that makes it very easy to send letters directly to Congress: http://capwiz.com/ahima/issues/alert/?alertid=63887791. The form is pre-populated with reasons why the industry opposes efforts to delay ICD-10. This can be sent verbatim, or modified with your own thoughts and experiences with using ICD-10. The ACDIS advisory board stresses that you should urge Congress to act now, rather than wait to voice your opinion on the fate of ICD-10.

Congress is due to recess for the year on Friday, December 12. Time is of the essence, so please take action now.

If a delay is to occur, we all need to know in order to prepare and plan for 2015.

In addition, if you’d like to do more, consider the following course of action as recommended by AHIMA:

Call the leaders listed below TODAY and tell them that ICD-10 is needed in 2015.
Follow these 4 steps:

  1. Call Chairman Upton at 202-225-3761.
  2. Ask for the Health Legislative Aide
  3. Use the talking points below:
  • Do not delay ICD-10. We need the code sets in 2015!
  • According to a recent survey, small physician practices are expected to spend between $1,900—$6,000 to transition to the new code set. This is much lower than previous reports. The study can be found on www.coalitionforICD10.org.
  • Physician practices do not use all 13,000 diagnosis codes available in ICD-9. Nor will it be required to use the 68,000 codes that are in ICD-10. The majority of the code increases are due to laterality-which is not currently available in ICD-9.
  • CMS offers a robust plan for physician practices to transition to ICD-10. The Road to 10 can be found here: http://www.roadto10.org.

When you are done, call the other congressional leaders and Tweet also.

Name Phone                              Twitter Handle
Fred Upton 202-225-3761 @RepFredUpton
Pete Sessions 202-225-2231 @PeteSessions
House Speaker John Boehner 202-225-6205 @SpeakerBoehner
Minority Leader Nancy Pelosi 202-225-4965 @NancyPelosi
Kevin McCarthy 202-225-2915 @GOP Leader

Tweet your Representatives and be sure to use the following #s! #ICD10Matters #ICD10NoDelay

On behalf of ACDIS, thank you for making your voice heard on this important issue.

Sincerely,

Brian Murphy

Director, ACDIS

bmurphy@acdis.org

ACDIS at AHIMA 2014

ACDIS and its parent company HCPro were once again pleased to attend the annual American Health Information Management Association’s meeting–its 86th–which took place in San Diego, California. We attended some informative sessions and met lots of great people including (from left): AHIMA Foundation Executive Director Dr. Bill Rudman, AHIMA CFO Denise Froemming, ACDIS/HCPro Events Operations Coordinator Alex Dataldo, ACDIS/HCPro Senior Marketing Manager Sheila McGrath, ACDIS Director Brian D. Murphy, ACDIS/HCPro National Accounts Manager Brooke Drozdowicz, HCPro National Account Manager Chris Ferris, AHIMA Foundation Board of Directors Chairman Dr. Warren Jones.

ACDIS at AHIMA

ACDIS at AHIMA

News: AHIMA outlines steps for data governance

AHIMA releases recommendations for data governance

AHIMA releases recommendations for data governance

AHIMA unveiled its recommendations for healthcare information governance during its annual conference in San Diego earlier this month.

Information governance (IG) or data governance refers to the management, compliance, and control of health information in a given organization. AHIMA principally focuses on the management of medical records but the release of its recommendations broadens its scope to coverage of data information of all types within the healthcare setting, according to a Modern Healthcare report.

AHIMA’s recommendations state that IG efforts maybe more lax than necessary and that HIM professionals should work to educate stake holders on the need for interdisciplinary collaboration on policies and procedures, including engaging administrators to set strategies and priorities for the overall effort, according to a report in For the Record magazine.

According to an article in Fierce HealthIT, the framework focuses on the following eight principles:

  1. Accountability: An accountable member of leadership will oversee the program.
  2. Transparency: IG processes and activities will be documented in an open and verifiable manner.
  3. Integrity: Information will be managed in a way to provide a reasonable guarantee of reliability.
  4. Protection: Appropriate levels of protection will be provided from breach, corruption, and loss.
  5. Compliance: The program will be designed to comply with applicable laws, standards, and organizational policies.
  6. Availability: Information will be managed to ensure timely, accurate, and efficient retrieval.
  7. Retention: Data will be kept for the appropriate period based on legal, regulatory, and other requirements.
  8. Disposition: Data that is no longer required will be disposed of in an appropriate and secure manner.

A minority opinion: Incorporating a new diagnosis in queries compliantly

Use the query practice brief guidelines formulate effective queries.

Use the query practice brief guidelines to formulate effective queries.

One of the interesting realities of the appellate court system is the doggedness of those judges whose views fall in the minority, often resulting in dissenting opinions longer and stronger than those of the majority. We should never be afraid to consider the opinion of those with whom we may not agree. Sometimes it makes us think. Sometimes the minority opinion eventually becomes the majority opinion.

I think I’m in the minority when it comes to interpreting last year’s ACDIS/AHIMA practice brief, “Guidelines for Achieving a Compliant Query Practice.”  Until the revised brief was disseminated, CDI specialists were very, very careful not to use queries to introduce new diagnoses into the record. If a patient had a low BMI, poor intake, documentation of cachexia and muscle wasting, etc., the CDI specialist could not ask the physician about a diagnosis of malnutrition, but could only present the supporting evidence and ask for an associated diagnosis. The physician could be left scratching their head, trying to intuit what words the CDI specialist was seeking.  If one reads the new practice brief at face value, the CDI specialist should, conceivably, be able to ask for a diagnosis of malnutrition as part of a multiple choice query that includes “undetermined,” and “other,” even if malnutrition has never been stated anywhere in the record.

After all, the brief states, “[P]roviding a new diagnosis as an option in a multiple choice list–as supported and substantiated by referenced clinical indicators from the health record–is not introducing new information.” Doesn’t that make it okay?

Ok, here’s where I take the minority–heck, maybe the only one in all of CDI-land–view. Look at the examples of acceptable multiple choice queries cited in the brief.

One such example is a patient with chronic heart failure and an ejection fraction of 25%. Of course, it is not acceptable to query the physician as a yes/no, does the patient have chronic systolic heart failure. The acceptable multiple choice query takes the existing diagnosis of chronic heart failure and asks for greater specificity. By including a diagnosis of chronic systolic heart failure, the query is, in fact, introducing a diagnosis that has not already been stated in the record. However, it is not introducing anything completely new, but, rather, is a modification of an existing diagnosis.  For a brand new diagnosis, the reader is referred to the open-ended query, where clinical indicators are given for a given condition and the physician is asked to document a new diagnosis based on those indicators. And indeed, the brief states, “Although open-ended queries are preferred, multiple choice and yes/no queries are also acceptable under certain circumstances.”  [Emphasis added.]

What that means, for me in my minority opinion, is that we have to look very carefully and cautiously at those certain circumstances. We must pay extraordinarily strict attention to the language already existing in the medical record.  To me, unless there is provider verbiage already within the record that modification would improve or clarify based on indicators already in the record, we should not be asking multiple choice questions or yes/no questions. Once we have a sliver of a diagnosis, then we are able to use the multiple choice query to pin down that diagnosis at its optimum and most compliant level. In my opinion, the brief is not meant to allow us to substitute our judgment regarding clinical indicators for that of the physician. It is meant to prevent us from having to play word games so that the physician isn’t struggling to guess at what we want.

I recognize this is a minority opinion, and I do bow to the will of the majority. Just consider that the practice brief may not be a license to ask anything you want as long as it’s in the form of a multiple choice question.

While strictly adhering to the “no new diagnoses in the query” dictum had once been the majority opinion, the tide has shifted, and both ACDIS and AHIMA have agreed (as demonstrated in the 2013 practice brief) that sometimes naming a diagnosis is warranted–just as long as the clinical indicators supporting it exist.

Reports from the AHIMA ICD-10 Summit

Which countdown to ICD-10 calendar will you use?

Which countdown to ICD-10 calendar will you use?

The AHIMA ICD-10-CM/PCS and Computer Assisted Coding Summit took place this week April 22-23 in Washington D.C., and I was fortunate enough to attend. As you may expect there was a lot of hubbub about the ICD-10-CM/PCS delay. Here is a brief summary of what I learned and you can always read more on the ICD-10 Trainer Blog.

Steven Stack, MD, immediate past chair of the AMA Board of Trustees, gave the keynote address during which he admitted that, yes, the AMA still wants to kill ICD-10 implementation but, no, it was not the motivating factor behind the inclusion of the ICD-10 delay within the bill to patch the Sustainable Growth Rate (SGR). The AMA wants a permanent fix to SGR and actually lobbied Congress to defeat the bill it its entirety, he said. During his presentation, Stack described how physicians struggling to use complex electronic health record systems and referred to the oft repeated line that physicians just want to take care of the patient and don’t want to worry about the documentation piece.
Although CMS has not released a new ICD-10-CM/PCS implementation date, (according to Donna Pickett, MPH, RHIA, medical classification administrator for the CDC) Denise Buenning, MsM, acting deputy director for CMS’ Office of E-Health Standards and Services, told the group at the closing session that the agency is close to having a new official implementation date for the industry.
Meanwhile, AHIMA president Angela Kennedy, EdD, MBA, RHIA, reminded attendees that nothing has changed in terms of the underlying need for ICD-10 implementation–the new code set will provide better data, she says. However, those working in the field can (and need to) do a better job of telling the public why better data is so important. As Deborah Neville, RHIA, CCS-P, from Elsevier explained facilities which do not have a firm grasp of coding and documentation requirements in ICD-9 will need to get that documentation set before ICD-10.
Looking on the bright side, Buenning expects the delay will provide more time for end-to-end testing and give CMS a more robust group of providers to pull from for its testing process.
If anything, the latest delay “eliminates the excuses to not transition to ICD-10,” Buenning said.

 

Happy Health Information Professionals Week and Certified Nurses Day!

Celebrate spring and professional achievement too!

Celebrate spring and professional achievement too!

Maybe it’s the promise of spring that has everyone in the mood to celebrate, after all tomorrow is the first day of that blissful season. Regardless, ACDIS stands at the ready to raise a toast to the two sets of professionals who support CDI efforts all year long.

First, this year’s Health Information Professionals Week takes place March 16th-22nd. This week provides an opportunity to showcase the thousands of HIM professionals who perform their duties throughout the year. ACDIS joins with AHIMA in its 25th anniversary celebration “Transforming Healthcare with Information.”

“The work HIM professionals do to ensure the integrity of health information is imperative to clinical and administrative decision making. Access to accurate information helps all of us make important decisions and leads to a healthy society,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, in a press release.

AHIMA kicked off its celebrations earlier this with “Hill Day” where HIM professionals visit Washington D.C. for lectures and set aside time to meet with their Congressional representatives to talk about the importance of the role of HIM in today’s healthcare landscape.

Secondly, Certified Nurses Day takes place today Wednesday, March 19, as a national day to honor and recognize the important achievement of nursing specialty and subspecialty certification. Obtaining certification represents a milestone of personal excellence along one’s professional journey and we at ACDIS are proud to join our fellow professional organizations the American Nurses Credentialing Center (ANCC) and the American Association of Critical-Care Nurses (AACN), among others, in congratulating those nurses who go the extra mile to earn certification in their areas of specialty.
How many professionals from your state hold the CCDS certification?

1,800 hold the CCDS certification–are you ready to get yours?

Those who have chosen to sit for the Certified Clinical Documentation Specialist exam to obtain their CCDS credential understand the value of certification. Proudly displaying your CCDS pin and certificate not only demonstrates pride in your achievements but also illustrates to the world a personal dedication to industry standards and professionalism.

According to data collected by the American Board of Nursing Specialties in 2013, nurses in the U.S. and Canada held more than 683,684 certifications, an increase of more than 87,111 certifications compared to 2012 survey data. These certifications were granted by 27 different certifying organizations, and 122 different credentials designate these certifications.
For ACDIS’ part, the first CCDS exam was held in May 2009 and 39 months later, in August 2012, the 1,000th person passed. Just a few months later on November 22, the 1,500th person earned the CCDS.
Today, there are nearly 1,800 CCDS credentialed CDI professionals in the country more than 400 others registered to sit for the exam. A majority of CCDS holders are RNs, but ACDIS is proud to count many HIM professionals, as well as quality improvement personnel and physicians, among those who have earned the CCDS.
Whether you have your CCDS or another credential, ACDIS salutes you for professionalism and honor you for taking those next steps to demonstrate your commitment to the healthcare profession.
As a reminder, our parent company HCPro offers a number of ANCC-approved webinar programs including several which are also approved for CCDS, AAPC, and AHIMA credits. To learn more, visit www.hcmarketplace.com.
Upcoming programs include:

Date

Market

Title

03/20/2014

HHH

ICD-10 Coding Proficiency for Home Health: Coding Neurological Diagnoses, Circulatory Diagnoses, and Wounds – Part 3

04/17/2014

HHH

ICD-10 Coding Proficiency for Home Health: Implementing an Action Plan – Part 4

05/15/2014

HHH

Alternative Sanctions and CoP Compliance (WT)

05/15/2014

REV

Principal Diagnosis Selection: Essential guidelines for ICD-10 implementation  (WT)

06/10/2014

REV

Query Compliance: Tools to Identify Query Successes and Opportunities (WT)

06/19/2014

HHH

Face-to-Face Physician Encounters: Strategies for Compliance (WT)

07/17/2014

HHH

Quality Improvement Strategies (WT)

08/21/2014

HHH

Management of Chronic Conditions in Homecare (WT)

Looking to become a CDI specialist? Six tips to make the career transition

Do you have what it takes to become a CDI specialist?

Do you have what it takes to become a CDI specialist?

As some of you may know, ACDIS is working on a CDI staff training manual. The book (due to publish prior to the 2014 conference) will help program managers train their new staff on CDI basics.

But what should those individuals who are thinking about making the leap from either the nursing world or the coding world into CDI do to get themselves up to speed on CDI practices prior to even applying for a CDI position?

It is a good question—one put to us recently by someone in just that position. Her facility did not have a CDI program as of yet, but she felt as though it may soon create one and she wanted to be ready to apply for a position if one became available.

I first congratulated her on being so in tuned to her facility needs, on being an ACDIS member, and for asking the question. We chatted a bit and came up with a few possible tips for others out there who are hearing the rumblings on the wind about the importance of CDI in the new ICD-10 environment and are considering a career change.

It may seem obvious but experienced, credentialed clinical documentation improvement professionals are highly sought after, well compensated, individuals. According to ACDIS’ 2013 Salary Survey, 158 CDI specialist respondents hold the certified clinical documentation specialist certification and of those, 41% earned more than $80,000 annually. As more hospitals seek to implement or expand CDI programs, that type of expertise is expected to become even more valuable. Anecdotally, facilities seeking to bridge expected ICD-10 productivity shortfalls with temporary CDI help could be paying top dollar to consulting or staffing firms–and the firms themselves may struggle to hire as many experienced staff as possible to meet the demand.

The tip here would be to obtain your certification, maintain your ACDIS membership, and stay informed about the nuanced details as they relate to ICD-10. Those who do could be the super-stars of the coming year.

Don’t be discouraged if you do not have experience in the CDI world! According to a recent, AHIMA/TrustHCS study published this summer in Educational Perspectives in Health Informatics and Information Management, more than 80% of all healthcare providers are expected to have a CDI program in place by the end of 2014 with growth areas across all hospital sizes and specialties.

So if you think CDI might be right for you take some time and start doing your research. Here are a couple of ideas to get you started:

  1. Start looking at CDI job descriptions to see if you have the right experience levels.
  2. Sign up for CDI Strategies and subscribe to the ACDIS Blog. Both are free and open to the public so you can become familiar with the issues while you’re making up your mind whether you want to get more involved.
  3. Join ACDIS and review the sample CDI specialist job descriptions and training materials available in the Forms & Tools Library. These are the tools that CDI programs around the country are using to help get their staff up to speed. Those who are familiar with the roles, responsibilities, expectations, and issues headed into an interview will be two-steps ahead of their competitors.
  4. If you work in a facility with an existing CDI program, approach your colleagues and ask them what they like and don’t like about the job. Ask them how their interviews for the position went.
  5. If you are not comfortable asking your own coworkers (or if you do not have a CDI program currently) reach out to a neighboring facility and ask if their manager/team would mind if you job shadowed them for a day to find out if the position is all that you expect it might be.
  6. Join your ACDIS Local Chapter and be sure to network. Chapter members, like ACDIS national members, are generous with their time and advice and are typically willing to offer any tips they can to help expand the profession.

Well, these were the ideas that the two of us were able to knock around during our brief discussion at any rate. Please feel free to add any suggestions, thoughts, or recommendations you may have to help encourage others to join this great—and growing—profession!