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Sunday Reading: Demystifying present on admission indicators

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Present on admission (POA) indicators are a designation added to a code to better define the timing of a clinical finding. They are associated with most (but not all) conditions, and providers have been required to report POA indicators since October 1, 2007.

To be considered POA, one of the following conditions must be met:

  • The physician included the phrase “present on admission”
  • The condition is included in the patient’s past medical history list
  • The condition was diagnosed during the admission but was chronic in nature
  • The diagnosis was documented on admission as “possible,” “probable,” “rule out,” “suspected,” or “differential on admission” and was subsequently confirmed at discharge
  • The condition developed during an outpatient encounter, such as in the emergency room, physician’s office, outpatient surgery, or observation prior to the inpatient order being written
  • The signs and symptoms of the condition were clearly POA and the documented condition was linked to a presenting symptom

Reporting options include:

  • Y = Condition was present at the time of inpatient admission
  • N = Condition was not present at the time of inpatient admission
  • U = Documentation is insufficient to determine whether condition was POA
  • W = Provider is unable to clinically determine whether condition was POA
  • Unreported/not used (or “1” for electronic billing) = Condition is exempt from POA reporting

If a condition cannot be identified as POA, its corresponding ICD code will likely not meet the criteria for a principal diagnosis and should be scrutinized before being assigned as such. However, the ICD Official Guidelines for Coding and Reporting does allow for a condition that was not clearly identified as being POA in early notations to be accurately classified as POA in later documentation, particularly if the condition required further analysis or study to be correctly recognized. CDI specialists should query for clarification when the status on admission is unclear.

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

Sunday Reading: Identifying 7th character

CDI Specialist's Guide to ICD-10

CDI Specialist’s Guide to ICD-10

The location of a character has meaning as well as the value of the character. Some codes require a character in the 7th position that provides additional information, such as the episode of care. A 7th character is typically used with injuries—most fractures will require a 7th character to define the episode of care—and pregnancies.

The most common 7th characters are as follows:

A – Initial encounter

D – Subsequent encounter

S – Sequelae, treatment for condition that arises as a direct result of the acute illness or injury

Not only are codes that require a 7th character invalid without it, but the 7th character can be found only by using the tabular list, since the possible value of the 7th character can vary with the type of code.

Placeholder use [more]

Book Excerpt: Pay for performance basics

The Physician Queries Handbook

The Physician Queries Handbook

In 1999, the Institute of Medicine reported that medical errors caused more than 50,000 preventable deaths each year, with an associated cost of $20 billion. The 2006 Institute of Medicine report “Preventing Medication Errors” recommended:

“incentives… so that the profitability of hospitals, clinics, pharmacies, insurance companies, and manufacturers (are) aligned with patient safety goals;…(to) strengthen the business case for quality and safety.”

When healthcare providers receive incentives for performing better— that is, providing better care in a more cost-efficient manner and meeting pre-established targets for the delivery of healthcare—along with —disincentives, such as eliminating payments for negative consequences of care (medical errors) or increased costs, the quality of care for Medicare beneficiaries will improve. This is a fundamental change from the traditional fee-for-service and DRG payment methods. The various approaches used to accomplish this agenda are discussed below.

Signed on February 8, 2006, the Deficit Reduction Act (DRA), required CMS to identify hospital-acquired conditions (HAC) that: [more]

Sunday Reading: The electronic query process

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

Traditionally, CDI programs’ paper queries were either developed in-house or were provided by a consultant. Some CDI printed these forms on brightly colored paper and dubbed them the “pink sheet” or the “purple sheet” according to their preference. Others developed a special tabbed folder included in medical record so physicians can easily find the paper query forms and respond to the CDI staff.

Many manually tracked their query data (e.g., physician query response rates, CDI/HIM agreement rates, DRG improvement statistics) using Excel spreadsheets. Although these spreadsheets work well for some, specialized CDI software vendors tout how their programs help CDI staff organize patient load and work more efficiently. In addition to providing an electronic query format and automated method to gather data, such software may help CDI specialists obtain more robust data that can be tracked and analyzed over time. The data can then be used to communicate program successes and determine areas in which education or process improvement is needed.

Prior to pursuing CDI software vendors [more]

Book Excerpt: Hospital value-based purchasing

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Almost immediately after introducing the MS-DRG system in 2007, CMS submitted a report to Congress outlining its plans to establish a value-based purchasing (VBP) program, as required by the Deficit Reduction Act of 2005.

According to the law, the VBP needed to include consideration of:

  • The development and selection of measures of quality and efficiency in inpatient settings
  • Reporting, collection, and validation of quality data
  • The structure, size, and source of VBP adjustments
  • The disclosure of information on hospital performance

Around 2011, CMS established its first set of parameters gathering data and setting expectations for hospital improvement over time. Facilities that show improvement receive additional reimbursement. Those that do not show improvement lose reimbursement. Initial performance measures were under the following two “domains:”

  1. Clinical process, composed of 12 measures
  2. Patient experience, composed of the Hospital Consumer Assessment of Healthcare Providers and Systems survey

Additionally, beginning in 2013, outcome measures (such as high 30-day readmission rates for heart attacks, myocardial infarction, and pneumonia) saw a reduction in payments. By 2015, a portion of Medicare payments were linked to effective implementation of electronic health records and enacted for preventing certain hospital-acquired conditions (HACs).

Other measures included in the FY 2014 IPPS Final Rule to take effect in FY 2015 included:

  • Central line–associated bloodstream infection (CLABSI)
  • Agency for Healthcare Research and Quality’s (AHRQ) public safety indicator (PSI) composite
  • Medicare spending per beneficiary

New measures for FY 2016 included:

  • Immunization for influenza (IMM-2)
  • Catheter-associated urinary tract infection
  • Surgical site infections for colon surgery and hysterectomy

Additional Reading

Become familiar with VBP measures, since these frequently overlap with CDI target areas. Also, review the following articles regarding VBP measures. By knowing the details of the measurements, you can help ensure the related documentation is captured.

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

Sunday Reading: Self-assessment of CDI effectiveness

CDI Specialist's Guide to ICD-10

CDI Specialist’s Guide to ICD-10

Use CDI policies and procedures as a starting point for audits and other reviews. Effective audits will illustrate trends, such as whether records are being reviewed in a timely manner, whether clinical indicators were included on the query form, whether the query language was leading or otherwise inappropriate, and query closure rates. Such efforts will become ever more important as programs begin to track the effectiveness of their ICD-10-CM/PCS education and query efforts.

Does the CDI staff leave the same clinical queries again and again for specific physicians? Does your facility’s medical staff even consider it necessary to respond to clinical queries as a whole? Many departments observe the 80/20 pattern [more]

Sunday Reading: Creating a Verbal Query Policy

The Physician Queries Handbook

The Physician Queries Handbook

Verbal queries, in particular, have remained a source of contention for hospitals simply because they are difficult to audit and monitor. Coders and CDI specialists know that they are not supposed to lead physicians to a diagnosis, yet when questions are posed verbally, there is a significant risk that this will take place during course of conversation meant clarify documentation. Hospitals need to specify—in their policies and procedures—why a coder or CDI specialist will initiate a verbal query as well as what the content of that verbal query will include. Consider adding the following language:

“The CDI specialist may have a discussion about a patient with a physician. This discussion will be an opportunity to educate the physician and to obtain specificity in the documentation. The CDI specialist may discuss the clinical findings and documentation with the physicians involved in the care of the patient. The role of the CDI specialist is to educate the physician on the specificity of verbiage which can result in improved capture of severity of illness. In addition, [more]

Sunday Reading: Diagnostic Testing

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Review the results of laboratory testing, cultures, imaging results, electrocardiogram, and rhythm strips in search of significant abnormalities and then determine whether supporting documentation exists for treatment with medications, fluids, oxygen administration, or further testing to confirm the significance as a code-able condition.

Coders cannot assign a code based on test results. However, such clinical indicators support a CDI query and help ensure query compliance. Always search diagnostic and imaging studies for clinical indicators to support existing diagnoses, to support further specificity of existing diagnoses, or to support queries for missing diagnoses significant to the patient encounter.  [more]

Sunday Reading: Query Reviews

Start educating physicians now

The CDI’s Guide to ICD-10

Query forms themselves in many cases will help start ICD-10-CM/PCS-related conversations and educational opportunities with providers. Medical staff should be involved in the ongoing creation and review of query forms.

As is the case with ICD-9-CM, the medical staff most closely linked to a particular condition should vet the clinical guidelines incorporated in the query forms as you adapt them to ICD-10-CM/PCS. Many facilities have clinical guidelines to help determine types of congestive heart failure (CHF) based on recent medical literature and as supported by the cardiology department.

The CDI team at [more]

Sunday Reading: Ongoing opportunities for physician education

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

After initial educational efforts, be sure to provide additional CDI training sessions for physicians on an ongoing basis. These sessions should:

  • Inform new medical staff members
  • Provide updated information regarding regulatory and coding initiatives
  • Describe changes to ICD-9-CM (ICD-10-CM/PCS) terminology
  • Provide analysis of how physician responses to CDI initiatives affect outcomes

Some facilities employ highly creative methods for ongoing education in the form of newsletters, posters, and even pop-up boxes when the physician logs into the hospital computer. For example, one hospital system created an electronic screensaver that stated “pneumonia season is coming, don’t forget the importance of clarifying gram positive versus gram negative pneumonia.” Another hospital placed posters with documentation tips specific to surgeons in the bathroom stalls of the surgery changing rooms.