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Weekend Reading: Defining a mission

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The Complete Guide to CDI Management

As you begin to think about what your own CDI department may look like, you will need to define your departmental mission. It can be useful to meet with managers of other revenue cycle departments to ensure a clear understanding of their roles within the organization. This will allow the CDI mission and workflow to complement other revenue cycle efforts and may enlist the support of these other departments.

The scope of CDI continues to expand as organizations identify documentation gaps that affect organizational processes, so the CDI manager is often expected to use his or her staff to address these issues. Examine what you hope to accomplish by initiating this effort. Make sure you clearly understand how the organization will measure its success, so you can determine how the CDI department can contribute to that effort. Ask the following questions:

  • Is the emphasis incremental revenue?
  • Is the goal to improve the profile of your facility regarding metrics that can represent the quality of care such as severity of illness (SOI) and risk of mortality (ROM)?
  • Is it truly to improve the quality of your providers’ overall documentation without regard to reimbursement or other factors?

The definition of success will vary based on the desires of your organization, but, as the manager, you must know your mission to guide your department towards its goal. The mission affects staffing, workflow, metrics, and other elements of the program that you need to consider.

Editor’s Note: This excerpt comes from the recently published book, The Complete Guide to CDI Management, by Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP.

Sunday Reading: Illustrating progress and failures

No matter what department or role you serve complete and accurate documentation should be one of your goals.

CDI specialists may have to get creative when it comes to sharing program outcomes with providers.

Sharing program outcomes with physicians is an important part of physician education. Many CDI programs do this at medical executive meetings or through other administrative sessions. They also use this forum to inform leadership of areas where documentation is lacking and ask the committee for guidance to help remove perceived barriers.

At this level, use actual data from public forms such as Healthgrades.com, CMS’ Hospital Compare, The Delta Group, Inc., state level quality sites, and regional insurer databases to illustrate how your specific facility fares against others in terms of key factors such as readmissions, length of stay (LOS), severity of illness, and mortality.

Such data illustrate to the medical staff how the general public views the care provided by the facility. If the data are not positive, if the actual mortality scores are higher than the expected mortality, the public will believe either the physician is incompetent, the facility is negligent, or both, and go to a nearby hospital for treatment in the future.

Save examples where physician(s) ignored or disagreed with a query that would have resulted in substantial MS-DRG impact and present those cases at either a general medical staff meeting or during annual CDI refresher sessions. Make sure to illustrate those diagnoses potentially missed due to lack of documentation specificity, how such lapses may have skewed the patient’s expected geometric LOS, the loss of potential reimbursement to the facility, and the effect on the physician’s specific score card (but be sure to redact the name).

Consider taking specific examples of physician documentation straight from progress notes to illustrate the impact of poor penmanship, inappropriate use of symbols, and lack of complete documentation to illustrate not only signs and symptoms, but also actual diagnoses of conditions. Maintain the educational intent of the display by removing any identifying marks (the names of the physician and patient and the dates) so only the clinical information remains. Walk the medical staff audience down the same path the documentation takes from physician’s pen to the CDI department. Illustrate how many queries were initiated and answered. Then explain what the coder chose and what the ultimate outcome was for patient severity and reimbursement.

Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.

Sunday Reading: Essential Query Requirements

The Physician Queries Handbook

The Physician Queries Handbook

Taking into consideration the various requirements governing the capture of healthcare data, clinical documentation improvement (CDI) programs can easily begin to itemize the basic elements needed for compliant queries.

First, as stated in almost all industry guidance, query forms should be vetted and approved by the organization and should be tracked or documented in some manner. They should not be written on sticky notes or another slip of paper that may run the risk of being discarded or discounted.

Furthermore, because it must meet the basic tenets of information exchange, the query form should include:

  • Patient name or identification number
  • Admission date and/or date of service
  • Health record or account number
  • Date the query was initiated
  • Date the query was closed
  • Name and contact information of the individual initiating the query
  • Name and contact information of the physician responding to the query
  • Statement of the issue in the form of a question, along with clinical indicators specified from the chart

Many hospitals choose to include a disclaimer on their query forms, with language such as:

“In responding to this query, please exercise your expert, independent judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.”

Remember, however, that even the inclusion of such language may not protect the organization against claims denials, allegations of upcoding, or fraud, if a pattern of submitting leading queries is identified. Nevertheless, many organizations consider inclusion of such a disclaimer an important reminder to physicians and CDI professionals that the ultimate decision regarding the patient’s care lay with the provider responsible for that care.

Simple communication basics also help ensure query practice success. Always use “please” and “thank you.” Avoid improper grammar and incomplete sentences. A physician may discount the veracity of the query if he/she cannot clearly identify the objective. Regardless of query format, CDI staff must ensure the query clearly and concisely identifies the clinical indicators and the relevance of the inquiry. Queries should be easy to read and easy to answer. If the physician needs to read the form more than once to understand the query, he/she will not take the time to do so.

Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

Sunday Reading: Operation reports/anesthesia records

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

The anesthesiologist’s preoperative assessment should identify the patient’s current condition as well as any chronic conditions potentially affecting the course of the surgery or the patient’s expected surgical outcomes. Look through this documentation for previously unidentified secondary diagnoses.

The anesthesiologist’s intraoperative report often contains the first documentation clues regarding any complications which may have occurred during the surgery, such as the patient’s estimated blood loss and documentation of any administered fluids and medications. Here the CDI specialist should look for documentation of:

  • Blood products
  • Fluid boluses
  • Volume expanders such as Hespan™, Hextend™, or hetastarch
  • Antiarrhythmics
  • Hemostatic powders
  • A change in the form of anesthesia provided (e.g., if the patient was started with a local or regional anesthetic and changed to a general anesthetic)

The operative report should clearly identify the procedure(s) performed, the approach, any implants and devices inserted or manipulated, etc. This will prove particularly important following ICD-10-CM/PCS implementation, since such information is required to assign an appropriate code. Any insufficient information should prompt a query to the surgeon. If there are inconsistencies compared to the anesthesia record, a query should be assigned to the surgeon.

Lastly, the postoperative diagnosis should match the documentation within the remainder of the record.

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

 

Sunday Reading: Physician communication scenarios

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

The CDI specialist must be both positive and professional in his or her interactions with physicians. But they must also be able to interpret the physician’s body language at the time of the discussion and be able to weigh and recall a particular physician’s communication preferences over time. Beyond understanding the physician’s preference for type of communication, the CDI specialist must also be aware of the personality type of the physician.

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example:  The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids.  For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Do you think the patient’s pneumonia may be due to aspiration?

The physician responds, “It is certainly a possibility.”  The CDI specialist thanks the physicians and asks: “Could you please clarify that possible cause-and-effect relationship in the record?”  She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”

Approach #2 (verbal query): “Good Morning, Dr. Smith, looks like you are busy today. I have a documentation clarification for you if you have a minute.” The physician responds, “Yes, I am busy and would appreciate it if we could talk later.” The CDI specialist responds: “Thank you. I will leave a written query on the chart for you in case we do not see each other before you leave. I hope your day gets calmer.”

In both scenarios, the CDI specialist had the chance to talk to the physician and express the need for documentation clarification. However, the first scenario had the advantage of the physician immediately documenting an answer. In this case the CDI specialist could have also taken the opportunity to educate the physician on the importance of consistent terminology and could have asked him to use the term aspiration pneumonia throughout the rest of the stay and in the discharge summary.

In the second scenario, the CDI specialist informed the physician of the need to clarify documentation but additional follow-up is required to ensure the physician provided the clarification in the medical record. As the saying goes, “don’t win the battle only to lose the war.” In this situation it was probably better to back off politely. Insisting that the physician do it immediately risks angering and alienating the provider, which would make him or her less likely to cooperate in the future.

Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.

Sunday Reading: Case-mix index metrics

The Physician Queries Handbook

The Physician Queries Handbook

Almost every program uses the case-mix index as one metric of CDI program performance. The case-mix index is the sum of all your facility’s MS-DRG relative weights, divided by the number (volume) of Medicare cases for the year. A low case-mix index may denote MS-DRG assignments that do not adequately reflect the resources used to treat Medicare patients, but it is important to remember that the case-mix index is also affected by:

  • Types of services provided by the hospital
  • Volumes of medical and surgical cases
  • DRG assignments
  • Quality of documentation
  • Changes in federal guidelines, (e.g., the reassignment of diagnoses as CC/MCCs, such as when acute renal failure was reassigned from an MCC to a CC

Of the previous factors, only one can be influenced by the CDI team—documentation. And due to the variability that exists from month to month, the case-mix index should be considered a measurement over time rather than a barometer of a particular month’s performance. If you decide to review your case-mix index for short periods of time (e.g., per quarter), make sure you compare the quarter of interest to the previous year, as seasonal variation in healthcare affects the results.

Because surgical MS-DRGs are higher weighted than medical MS-DRGs (because the cost of the surgery is typically higher and therefore represented in higher relative weight), an increase in the volume of surgical cases can increase the overall case-mix index. Conversely, when the volume of surgical cases is flat, and the case-mix index increases, such an increase represents an increasing complexity of medical patients seen by the facility.

Keep in mind economic factors as well. During the recent recession, many people postponed elective surgeries and delayed healthcare, which negatively affected hospitals’ case-mix index, especially if they were considered a more elite or expensive healthcare provider in the community, as consumers looked for lower-cost alternatives.

Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

Sunday Reading: Suggested exercises using the DRG Expert

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Most CDI specialists quickly learn the value of the DRG Expert® in their daily practice. The DRG Expert® typically can be found sitting on a CDI specialist’s desk to assist with “all questions DRG related.”

To help you practice using the DRG Expert® as your resource, we’ve come up with a few exercises.

Activity 1

Locate DRG 374 within the book to answer the following questions:

  • What is the name for this DRG?
  • What is the GMLOS for this DRG?
  • What is the relative weight?
  • Is this DRG grouping a triplet (meaning DRG assignment could change with addition of CC or MCC or lack of CC/MCC) or is it a single-tiered DRG (meaning the DRG will not change if a CC/MCC is present)?

Activity 2

Locate the DRG for septicemia without mechanical ventilation of 96 or more hours without MCC to answer the following questions:

  • What DRG number is assigned to this description?
  • What is the relative weight for this DRG?
  • If the patient were to develop acute respiratory failure during the stay, adding an MCC, what DRG would this change to?

Activity 3

  • An HIV-positive patient is admitted with anaplastic large cell lymphoma. How do you determine which DRG grouping to assign? DRG 974, 975, 976, or 977?
  • If the same patient has an MCC of end-stage renal disease as well, what would your working DRG be?

CDI staff need to have a general understanding of how to use the manual and how to employ the logic for assigning a DRG code. These exercises and real-time practice will help get new CDI specialists up to speed.

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

 

Sunday Reading: Definitions to know when using the DRG Expert

The DRG Expert

The DRG Expert

The DRG Expert® includes an alphabetic index to diseases as well as a numeric listing of diseases (numeric by code assignment). Procedures can also be found listed both alphabetically and numerically. After each listing, there are identified page numbers.

The appendix of the DRG Expert® lists CC/MCCs both alphabetically and numerically. Since CMS’ CC/MCC designations may change annually, this section allows you to quickly identify any changes relevant to your patient population.

The DRG Expert® is not a code book or a medical guide book, so it does not provide an exhaustive list of terms.

If this is your first time using the DRG Expert®, there may be some terms you are not familiar with. Here are three definitions every CDI specialist should know when using the book:

  • GMLOS: The national mean length of stay for a DRG as determined by CMS. It is not a straight average but eliminates the outliers (very short or very long lengths of stay) from the equation. This allows organizations to compare their length of stay with a national benchmark.
  • ALOS: It is the simple arithmetic mean, or what most people refer to as the average; the lengths of stay for the patients in question are added together and divided by the number of patients. This equation does not remove the outliers from the mix.
  • RW: An algorithm which assigns a value to a condition or a procedure that is then adjusted based on a variety of additional factors, such as geographic location. It aims to quantify the expected resource consumption for a specific patient population. Payment for each DRG is based upon the assigned relative weight.

Having these definitions on hand can be a helpful resource for CDI specialists when assigning an MS-DRG code.

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

Sunday Reading: Using the DRG Expert

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Most CDI specialists quickly learn the value of the DRG Expert® in their daily practice. The DRG Expert® typically can be found sitting on a CDI specialist’s desk to assist with “all questions DRG related.”

Although most CDI specialists have access to an encoder, CDI staff need to have a general understanding of how to use the manual and how to employ the logic for assigning a DRG code. An encoder automatically applies rationale to “group” the assigned codes and identify principal and secondary diagnoses and procedural codes to a specific DRG.

The DRG Expert®, published by Optum, is updated annually to reflect any changes mandated by CMS in its inpatient prospective payment system (IPPS) final rule. Optum has varied it’s publication over the years, but the principal structure, format, and use of the manual has remained fairly consistent.

The first section lists the DRGs numerically, from DRG 001, Heart Transplant or Implant of Heart Assist System with MCC, to DRG 999, Ungroupable. This list identifies which major diagnostic category (MDC) the DRG belongs in as well as the page number for the full listing.

For example, DRG 682, Renal Failure with MCC, is listed in MDC 11, Diseases and Disorders of the Kidney and Urinary Tract. When you go to the page listed, it identifies DRG 682, Renal Failure with MCC, and provides information pertaining to the geometric length of stay (GMLOS), the average length of stay (ALOS), and relative weight (RW) of the DRG.

The entry for DRG 682 within the DRG Expert® indicates that DRG 682, Renal Failure with an MCC, has a GMLOS of 4.9 days, an AMLOS of 6.5 days, and a RW of 1.5862. Below this is a list of codes and principal diagnoses that map to this DRG. For example, a principal diagnosis of tumor lysis syndrome, oliguria and anuria, or acute kidney failure with lesion of tubular necrosis will map to DRG 682 if an MCC is also present.

Next on this same page is DRG 683, Renal Failure with CC, and 684, Renal Failure without CC/MCC. The same principal diagnoses listed under DRG 682 apply to these DRGs as well. The presence or absence of CCs and MCCs determines the final DRG assignment.

DRG Expert® also lists DRGs by MDC so you can identify which DRGs fall into what category. For example, DRG 163, Major Chest Procedure with MCC, falls into a surgical DRG within MDC 4, Diseases and Disorders of the Respiratory System. Curious about what procedures would fall into the major chest procedures? Turn to the page listed for DRG 163 for the listing.

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

Sunday Reading: CDI role in capturing present on admission conditions

27438_mb320896_cdipocketguide_cover_265x265A present on admission (POA) indicator must be reported for all principal and secondary diagnoses and external cause of injury codes. This is required to identify complications of care.

The POA indicators are:

  • Y (Yes): Present at the time of inpatient admission
  • N (No): Not present at the time of inpatient admission
  • U (Unknown): Documentation is insufficient to determine if condition is present on admission (a query may be necessary)
  • W (Clinically undetermined): Provider is unable to clinically determine whether condition was present on admission or not
  • 1 (Unreported/not used): Exempt from POA reporting

A POA indicator of U (unknown) is equivalent to N (no), and W (clinically undetermined) is equivalent to Y (yes).

POA definition: Present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

POA documentation. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission. The term “provider” means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.

CMS has no limitation on the time period during which a provider must identify or document that a condition was present on admission.

Editor’s Note: This excerpt was taken from the 2015 CDI Pocket Guide written by Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS. Pre-order the 2016 CDI Pocket Guide today. Click here for more information, or contact customer service at customerservice@hcpro.com or 800-650-6787.