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Summer Reading: Tips for preparing for the CCDS exam

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

Once you have met the two-year minimum work experience requirement required to sit for the Certified Clinical Documentation Specialist (CCDS) credential exam, it’s time to study. Start by reviewing CCDS Exam Candidates Handbook for information on applying to sit for the exam as well as the process for taking the test. The following are a few additional tips that many successful candidates have used to earn their certification:

  • Discuss with peers and supervisors
  • Join a study group
  • Visit the CCDS discussion board on the ACDIS Forum
  • Start studying early like a few months prior to sitting for the exam
  • Review a new content area each week
  • Spend extra time studying areas where you feel less confident
  • When reviewing practice questions multiple times, make sure you understand the concept and don’t just memorize an answer
  • Take a day or two to prepare your mind and body for the exam
  • Get a good night’s sleep and eat a good meal before taking the exam
  • Leave plenty of time to arrive for the exam

Once you are set to begin the exam, take a deep breath, exhale, and let your knowledge and experience guide you through successful completion of the certification.

Editor’s note: This article is an excerpt from the “CCDS Exam Study Guide,” by Fran Jurcak, MSN, RN, CCDS. To read more about certification, visit the ACDIS website, here.

 

Summer Reading: New CDI staff exercises to perfect the review process

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Laurie L. Prescott, RN, MSN, CCDS, CDIP

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

Shadowing staff

Often, the first step in becoming comfortable with the CDI record review process comes from simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your facility, reach out to ACDIS via its CDI Forum or local chapter events. Consider calling nearby facilities, asking for their CDI department manager. Many CDI specialists willingly open their doors to those just starting out. If your CDI manager is willing (or has connections of his or her own), perhaps you will be able to shadow a neighboring facility to get a better idea of how different CDI programs function as well.

Many CDI program managers ask candidates to do this during the interview process so both parties better understand the basic competencies and expectations of the job. Other program managers gradually introduce new CDI specialists to the process by shadowing experienced specialists at least once per week for a set number of hours or records per day. Other programs may require new staff members to jump into the reviews as soon as possible.

To positively influence your learning, consider first sitting alongside your CDI manager or mentor as he or she reviews a variety of common diagnoses. Where larger teams exist, consider rotating such shadowing experiences and taking note of how different individuals’ experiences and strengths affects how they conduct their reviews. Also, arrange time to shadow an experienced inpatient coder as well. You will find each person has his or her own method, and no method is necessarily better than the next.

Tandem reviews

After shadowing teammates, try tandem record reviews where your mentor, manager, or other CDI staff member reviews the record first and then turns the record over to you to let you try your hand at it. Then compare notes. Also consider flipping this activity with the new CDI specialist reviewing the record first and then turning it over to your CDI manager or mentor to see where you were successful or where opportunities for additional information might exist.

Spend some time documenting and developing your own review processes; you will need to develop a method or sequence of record review and stick with it. For example, jumping from one section to another in search of a particular tidbit or clue may cause you to lose focus. In such situations, the larger clinical context may be lost on that elusive detail, costing you valuable productivity time—you may not see the forest through the trees, so to speak.

Take time to discuss items you may have missed and where this information was found. If queries need to be written, draft them together. This process may seem laborious, but with a few afternoons concentrated on such work, you will begin to feel more comfortable finding your way through the complexity of the medical record to the valuable nuggets of information you need.

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.

 

Book Excerpt: CDI’s role in inpatient-only procedure documentation

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Debbie Mackaman, RHIA, CPCO, CCDS

By Debbie Mackaman, RHIA, CPCO, CCDS

Connect CDI, utilization review, and case management before the patient is discharged

When a procedure converts to an inpatient-only procedure during the surgery, the documentation process may get a little more complex. Analyze what happened during the procedure itself. If the inpatient-only procedure is performed on an emergency basis, it’s likely the admission order was not obtained prior to the procedure. The outcome for the patient will determine the next steps. If the patient expires, no further action is required by the registration or operating room staff. The coding and billing teams take over resolution of the case.

If the patient does not expire, the surgeon should confirm the type of surgery originally scheduled and the reason for the needed change to the inpatient-only procedure. He or she should do so before the patient leaves the postoperative area. The care team needs to make a determination regarding the admission of that patient. Under current CMS guidance, the three-day payment window may apply in this scenario. The case should be held for billing purposes until a thorough post-discharge review can be completed.

CDI staff may be involved in the initial review of the case. If CDI staff suspect an inpatient-only procedure was performed without an admission order, they should work with the coding team to identify the correct procedure code and verify if the procedure in question meets inpatient-only criteria. If it does, obtaining an inpatient admission order should be a priority. At this point, if necessary, the utilization review (UR)/case management (CM) team can step in.

The involvement of the UR/CM team is also critical when an inpatient-only procedure is canceled after the patient is admitted. Although the patient was admitted with the intention of performing the procedure and, therefore, the admission should be covered, each case should be independently reviewed. If the patient does not need acute medical care, his or her status may be changed from inpatient to outpatient, when appropriate, using Condition Code 44. When all conditions are met, Condition Code 44 allows a hospital to change the status and bill the services on an outpatient claim; however, timing is everything.

Editor’s note: This article is an excerpt from the “Inpatient-Only Procedures Training Handbook” by Debbie Mackaman, RHIA, CPCO, CCDS, an instructor for HCPro’s Medicare Boot Camps. To read the Fiscal Year 2017 inpatient-only list, visit the OPPS page on the CMS website and download Addenda E.

Book Excerpt: CCDS exam format

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

The CDI specialist role is complex and multidisciplinary, suitable for clinically knowledgeable professionals who are proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals and objectives. These professionals possess knowledge of healthcare and coding regulations, anatomy, physiology, pharmacology, and pathophysiology. Furthermore, such professionals possess the valuable ability to engage physicians in dialogue and educational efforts regarding how appropriate clinical documentation benefits patient outcomes and the overall well-being of the healthcare system.

Therefore, the CCDS exam content stems from:

  • Analysis of the activities of clinical documentation specialists in a wide range of settings, hospital sizes, and circumstances
  • Input from ACDIS member surveys
  • Input and research of the CCDS advisory board comprised of experienced clinical documentation specialists

The examination is an objective, multiple-choice test consisting of 140 questions, 120 of which AMP uses to compute the final score. The exam questions have been designed to test the candidate’s multi-disciplinary knowledge of clinical, coding, and healthcare regulations, as well as the roles and responsibilities of a clinical documentation specialist. Choices of answers to the examination questions will be identified as A, B, C, or D and consist of the following question types:

  • Recall questions test the candidate’s knowledge of specific facts and concepts relevant to the day-to-day work of CDI professionals. The examination is an open-book test; candidates may use reference resources in answering recall questions, as this is the manner in which accreditation professionals frequently carry out their responsibilities.
  • Application questions require the candidate to interpret or apply information, guidelines, or rules to a particular situation.
  • Analysis questions test the candidate’s ability to evaluate and integrate a range of information in problem solving to address a particular challenge.

According to the CCDS Candidate Handbook, approximately 40% of the questions can be classified as the recall type, 40% as application type, and 20% as analysis type.

Editor’s note: This article is an excerpt from the “CCDS Exam Study Guide,” by Fran Jurcak, MSN, RN, CCDS. To read more about certification, visit the ACDIS website, here.

Book Excerpt: Listen to the butterflies

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CDI Field Guide to Denials Prevention and Audit Defense

By Trey La Charité, MD, FACP, SFHM, CCDS

CDI professionals need to take seriously those fluttering feelings found in the pit of the stomach when anxiety arises.

Experienced coders often have what may feel like to the uninitiated as a sixth sense about compliant code assignment. Such professionals employ the breadth and depth of their experience to apply a wide range of coding guidelines to a particular scenario. So when the coding team expresses concern about a medical record’s final coding summary, wise CDI professionals take heed. Likewise, as a CDI professional’s experience grows and he or she becomes familiar with the coding system, common claims denials, and Recovery Auditor targets, they too will develop some degree of extrasensory auditor perception.

Overtime, coders and CDI professionals come to know problematic areas. Facilities that neglect to harness this level of expertise miss a tremendous opportunity to prevent denials before they’re issued.

As a wise man once said, “If it doesn’t pass the smell test, don’t code it.”

When such situations arise, CDI program administrators should take every effort to appease those butterflies.

For example, the 2013 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Process included an addendum recommending facilities develop a query escalation policy. The samples offer suggestions for CDI and coders to bring questions of clinical validity to a manager or steering committee for review.

Many CDI programs also create a reconciliation policy to handle any discrepancies between CDI and coder opinions regarding documentation and coder of a particular medical record. Effective programs establish collaborative methods of communication between the two departments, allowing both teammates the opportunity to ask each other questions and share information supporting their opinions. When unable to reach consensus, the case may get bumped to the coding/HIM manager and CDI manager/director to discuss or for the final determination.

Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS.

 

Book Excerpt: Teamwork makes the dream work

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Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

CDI specialists do not work alone. They form a team with case management (CM) and physicians for concurrent documentation analysis and improvement. The case manager advises the physician on patient status, the CDI specialist ensures the documentation reflects the status and care, and the physician advisor is there to support CM and CDI if there is conflict with a physician or clinical staff. The physician advisor can take advantage of every interaction to transform potential conflicts into teaching opportunities.

For example, a patient is scheduled for surgery as an outpatient but the surgery is on the inpatient-only list (CMS, OPPS final rule, 2016). The surgery scheduling department checks the inpatient-only list and notifies the physician that CM is going to review for status. The surgery department then alerts registration, which notifies the CM, who checks to make sure all requirements for the inpatient surgery are met. The CM advises the physician on correct status and, ideally, the physician follows the CM’s advice.

The CDI specialist checks the documentation for compliance and coding, and queries the physician if the documentation is incomplete. If the surgeon refuses to change or complete the documentation, the CDI specialist escalates the issue to the physician advisor. The physician advisor contacts the physician and explains the reasons for inpatient status and additional documentation. The surgeon completes the documentation as requested. If these steps are completed, coding and billing will clearly know what claim to drop without requiring a bill hold and clinical review.

Additionally, this three-part team of CDI specialist, CM, and physician advisor are able to gather real-time feedback on whether the electronic health record (EHR) is user-friendly, and report findings back to the executive team and IT. In some cases, problems with the EHR are simply user error or lack of training, and the CDI specialist can play a role in teaching providers to use the EHR.

Throughout this process, the HIM department works with CDI and supports physicians through functions such as timely transcription and ensuring chart completeness. Together, CDI and HIM look to ensure appropriate orders, signatures, and all required elements of the medical record. This includes ICD-10 coding and documentation to monitor ICD-10 compliance. HIM has traditionally been responsible for the organization of the medical record but now must have a collaborative relationship with IT and the EHR vendor to ensure the record works well for all stakeholders.

Finally, HIM will also review the medical record upon discharge for completeness. The next step is to code the record for payment. If all the previous steps in revenue cycle have occurred correctly—required forms are in place, patient status is clearly documented with a care plan, and discharge status is clear and accurate—then the coders should have all the elements needed for accurate coding. There should be very few physician queries from HIM if coding is clearly supported through documentation. Getting all of this right while the patient is in the hospital will facilitate accurate coding and produce a clean claim to avoid back-end corrections and delayed billing.

Editor’s note: This article is adapted from The Revenue Integrity Training Toolkit by Elizabeth Lamkin, MHA, ACHE. Lamkin is CEO of PACE Healthcare Consulting and specializes in system development, quality and billing compliance. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Book Excerpt: Understanding basic types of denials

Twist_Tanja

Tanja Twist, MBA/HCM

by Tanja Twist, MBA/HCM

You can’t manage what you don’t understand. So, the first step in any effective denials management program is to develop an understanding of the what constitutes a denial, as well as the different types of denials and their contributing causes.

Capture and categorize denials by their specific reason and dollar value, to deep dive into the type(s) of services being denied, the type of claim, the physician, payer, department, person, or situation that caused the denial. Despite a large number of denial reason codes used throughout the industry, all of them generally tie back to a few basic denial types: medical necessity or clinical denials, and technical denials.

Medical necessity or clinical denials

Medical necessity or clinical denials are typically a top denial reasons for most providers and facilities. They are also known as hard denials, in that they require an appeal to request reconsideration. Denial reasons that fall under this category include:

  • Inpatient criteria not being met
  • Inappropriate use of the emergency room
  • Length of stay
  • Inappropriate level of care

The primary causes of medical necessity denials include:

  • Lack of documentation necessary to support the length of stay
  • Service provided
  • Level of care
  • Reason for admission

Providers must ensure physician and nursing documentation clearly supports the services billed and that the physician’s admission order clearly identifies the level of care. One of the most effective means of ensuring compliance is through the implementation of a CDI program,  either internally or outsourced to a qualified vendor. A successful CDI program facilitates the accurate documentation of a patient’s clinical status and coded data.

Implementing a successful CDI program is typically one of the most challenging pieces of the denials management process, but it is the most important for long-term success. First obtain the support of the executives and physician leadership within the organization and second, but equally important, identify a physician champion to serve as the liaison to the physicians, reviewing chart documentation, and providing feedback on how to prevent denials moving forward.

Technical denials

Any nonclinical denial can be categorized as a technical or preventable denial. Causes of technical denials can range from contract terms and/or language disputes or mistakes related to coding, data, registration, or, charge entry errors, and charge master errors. Other technical denials may be caused by claims submission and follow-up deficiencies and denials pending receipt of further information, such as medical records, itemized bills, an invoice for an implantable device or drug, or receipt of the primary explanation of benefits (EOB) for a secondary payer claim.

All healthcare claims need to be submitted in adherence with federal, state, and individual health plan requirements and all claims need to be submitted in a timely manner. Other claim submission errors can be caused by claims being sent to the wrong address or even the wrong payer. Technical denials are known as soft denials because they can usually be reprocessed by providing a corrected claim or other additional information to the payer.

Editor’s note: This article is an excerpt from HCPro’s new handbook in the Medicare Compliance Training Handbook Series, Denials Management, published in January 2017 and written by Tanja Twist, MBA/HCM. This excerpt originally appeared in the Revenue Cycle Advisor.

Book Excerpt: Review all charts to maintain a compliant CDI program

Trey La Charité, MD, FACP, SFHM, CCDS

Trey La Charité, MD, FACP, SFHM, CCDS

If at all possible, CDI programs should review all hospitalizations in a facility for documentation improvement opportunities. And all charts truly means every chart, including every insurance product, regardless of reimbursement mechanism (i.e., by MS-DRG or per diem), including the no-insurance and charity cases. The reason for this directive is multifaceted. First, reimbursement certainly is not the only purpose of a CDI program’s efforts. Even if a particular payer reimburses on a per-diem (per-day) basis or by a different DRG system (i.e., APR-DRGs), meaning there may not be any reimbursement benefits to improved documentation, CDI efforts still offer significant gains.

In particular, every payer employs some form of risk adjustment methodology to compare the outcomes of care between different providers. In other words, a facility’s providers look better to an insurer if they achieve the same results as a competing facility’s providers but do so caring for sicker patients.

Second, the need for a particular patient’s hospitalization must be justifiable. It doesn’t matter how many high-dollar diagnoses a CDI professional identified in the medical record if the payer – be it Medicare or private insurer – denies the claim. The sicker the patient is – both in fact and on paper – the harder it is for an auditor or a payer to justify that the patient should never have been admitted at all or that the patient should have been cared for in observation as opposed to being admitted as an inpatient.

If a CDI program is understaffed and simply does not have the resources to review all charts, program goals should evolve such that more than just the Medicare cases are reviewed. In other words, a CDI program should not be reviewing only Medicare patients.

If a CDI program reviews only Medicare cases, the government and the Office of Inspector General (OIG) believe that hospitals preferentially targets Uncle Sam’s coffers. Don’t increase your facility attractiveness to those who are looking for additional targets. By reviewing all payers, facilities set the precedent that increased reimbursement from CMS is not the only goal of a CDI program.

Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS.

Book Excerpt: Physician engagement from the start

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Laurie L. Prescott, MSN, RN, CCDS, CDIP

Physician support in the CDI decision-making process from the CDI program’s inception helps physicians see beyond the immediate obligation of documentation to the greater good such documentation provides.

Physicians, as a group, tend to have similar personality traits. For example, physicians are:

  • Educated, so give them definitions
  • Scientists, so give them data
  • Proud, so illustrate how they rate against their peers
  • Results oriented, so give them a goal

Many argue that the best form of physician education is physician involvement. The earlier physicians get involved in CDI development, the greater their investment becomes. At the CDI program’s inception, medical staff leadership or the facility’s chief medical officer (CMO) typically join the CDI steering committee to set overall goals from the program and expectations for physician response, involvement, and training. Physician investment in CDI at the highest levels trickles down through the physician ranks and encourages the involvement of the entire medical staff in day-to-day documentation improvement activities.

Many programs hire a physician advisor to act as a mediator between medical staff and CDI professionals. If your program has a physician advisor, tap into his or her experience. He or she often plays an important role in identifying CDI targets and providing both group and one-on-one education.

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.

 

Book Excerpt: Documenting the discharge process

Birmingham_Jackie

Jackie Birmingham, RN, BSN, MS, CMAC

By Jackie Birmingham, RN, BSN, MS, CMAC

Editor’s note: For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition, by Jackie Birmingham, RN, BSN, MS, CMAC. This excerpt originally appeared in Revenue Cycle Advisor, here.

Whether writing a note, completing a flow sheet, or entering information in an electronic record, a discharge planner is capturing data: facts related to actions, reactions, and decisions. For the purposes of this example, a discharge planner is writing the story about the planning that occurs to prepare for a patient’s transition to the next level of care.

Information entered into the medical record describes the final discharge plan for the patient. Organizations implement documentation policies to guide discharge planners regarding what the medical record must include.

The Conditions of Participation (CoPs) require documentation of the assessment or evaluation of a patient’s discharge planning needs. CDI specialists can use the following CoPs (c) Standard (c) to ensure the minimum evaluation topics are documented including

  • “Admitting diagnosis or reason for registration;
  • Relevant comorbidities and past medical and surgical history;
  • Anticipated ongoing care needs post-discharge;
  • Readmission risk;
  • Relevant psychosocial history;
  • Communication needs, including language barriers, diminished eyesight and hearing, and self-reported literacy of the patient, patient’s representative or caregiver/support person(s), as applicable;
  • Patient’s access to non-health care services and community-based care providers; and
  • Patient’s goals and treatment preferences”

The list above reflects the minimum standards. Discharge planners should use this list as a tool to audit a sample of patient charts to determine whether their hospital meets these minimum requirements. After completing an audit, compare the findings to the facility’s documentation policy to determine whether it addresses all necessary elements. Use this activity as an opportunity to identify potential quality improvement initiatives. Although this list aims to aid in assisting in patient discharge needs, CDI specialists can look to these notes to identify additional documentation improvement opportunities or for evidence supporting the need for a physician query. Additionally, CDI specialists should be aware of the wide variety of documentation required throughout the patient’s care, what each documentation requirement’s purpose may be, and the parties responsible for ensuring the accuracy of those documents.