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Book Excerpt: Teamwork makes the dream work

Lamkin_Elizabeth_web_106x121

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

Prescott_Laurie_web

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.

 

Guest Post: Physician practice CDI could start with help from medical assistants

Rose Dunn

Rose Dunn

by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

The coding function would not exist if there were no physician documentation from which to code. The challenge for coders is not so much that there is no physician documentation; it’s that the documentation they have does not provide them with what they need to assign an accurate and specific code.

The reason for this is that the physician is capturing the clinical nuggets he or she needs. “The physician mind is focused on the associated process of evaluating, treating, and managing the health conditions presented by each patient. The chart documentation provided by the physician is all framed in the language of diagnostic phrasing and language, and [that language] certainly is not about codes,” (Insights from the HCC, n.d.).

Many hospitals have implemented clinical documentation programs to coach physicians on the documentation elements required for the hospital to optimize its coding efforts. However, if physicians don’t feel they or their patients benefit from efforts to alter documentation practices, they quickly disengage. Physicians are accustomed to being paid by their evaluation and management level, not their diagnoses.

Thus, the lack of precision of documented conditions, such as pancreatitis without specifying whether acute, idiopathic, alcohol-induced, sclerotic, or not indicating length of laceration or use of anesthetic or even providing details without a diagnosis (e.g., glomerular filtration range provided to indicate stage of kidney disease) is not unexpected, according to Lucyk et. al. from the University of Calgary (Lucyk, Tang, & Quan, 2016). No, it’s not just a United States problem.

At the office

For the physician practice, the superbill, or encounter form, often contributes to incomplete, unspecified, and inaccurate coding. The superbill often lists the most common diagnoses seen in the practice.

Conditions treated may be forced into those listed on the form or not captured at all. If the physician documents the condition, it may be generic (e.g., asthma, without indication of whether it’s intermittent, persistent, mild, moderate, or severe). In preparation for ICD-10, many practices took the convenient route and selected the unspecified code for each of their most common diagnoses.  Therefore, the more specific ones are not on the form to be selected.

Even if the physician uses the electronic health record (EHR) for diagnosis selection, when a long list of choices appears for the condition, it is unlikely that the physician will take the 30–60 seconds to glance down the list to find the specific one; worse yet, the condition that previously had a code may no longer have one (e.g., accelerated hypertension). The physician may believe that for the current state, diagnoses may not be needed for reimbursement purposes, but that’s short term thinking.

Helping the physician help us

For the physician practice, if we desire details, we need to push some of the responsibility out to others in the practice. It should start at the front desk when the appointment is made and the health questionnaire is returned from the patient. That is when, at minimum, duration or date of onset can be obtained.

There’s value in using the medical assistant (MA) to help with securing some of the diagnosis details needed for ICD-10 and augmenting the physician’s efforts. MAs are typically members of the physician office team. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes. Physicians can benefit from the talents of their MAs and possibly in areas other than ICD-10.

They are one of the first clinical team members to speak with the patient, often collecting the patient’s initial history information, capturing specimens for lab tests, and in some states placing, initiating an IV, and administering IV medications. Since organizations are struggling with capturing start and stop times for IV infusions, perhaps the MA may be another option for capturing start and stop times.

Given their understanding of medical terminology, and with an orientation to ICD-10 code requirements, MAs can quiz the patient and capture some of the details often overlooked by physicians. MAs can save physicians time, supplement the physician’s documentation, and help the physician select a more specific code.

If we look at the ICD-10 injury code elements, most of the elements can be captured in whole or in part by the MA in a short interview with the patient:

  • What was the injury? The MA can query the patient for this information and capture “upper/lower” and laterality, as well.
  • When did it happen? The MA can help the physician establish whether this is an initial encounter for active treatment, whether the patient is in the healing stage, or if the condition is sequela.
  • Where did it happen? Knowing the patient fell at home will not get us to the most specific code. We need to know where in the home, and sometimes even need to ask for the type of home.
  • What was the patient status and what was the patient doing when the injury happened? If the patient has been bitten by a cat, it may be attributed to a patient status of other, but if the person bitten by the cat was a vet tech when she was holding the cat for the vet to give it an injection, the status leads to an activity for income. Assigning the code for the activity of “holding a cat” would lead to the Y code for animal care.

This example shows us that with a little bit of prodding from the MA, we can get the additional information we need for a specified code. [more]

Weekend Reading: Six steps to hospital reimbursement calculations

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Determining a hospital’s individual base rate or reimbursement is a complicated process best left for the hospital chief financial officer (CFO). However, a quick description may better illustrate how the IPPS works. CMS describes the following steps on its website at www.cms.hhs.gov/AcuteInpatientPPS.

Step 1

Hospitals submit a bill to their Medicare fiscal intermediary (FI) for each Medicare patient they treat. The FI is a private insurance company that contracts with Medicare to carry out the operational functions of the Medicare program. Based on the information provided on the hospital’s bill, the FI categorizes each case into an MS-DRG, which determines how much payment the hospital receives.

Step 2

The base payment rate is a standardized amount that is divided into a labor-related and non-labor-related share. CMS adjusts the labor-related share by the wage index applicable to the area where the hospital is located. The non-labor-related share is adjusted by a cost-of-living factor. This base payment rate is multiplied by the MS-DRG’s RW to determine reimbursement for each individual patient encounter.

Step 3

If CMS recognizes the hospital as serving a disproportionate share of low-income patients, the facility would receive a percentage add-on adjustment for each case paid through the IPPS. This percentage varies depending on several factors, including the percentage of low-income patients served. CMS applies the adjustment to the MS-DRG base payment rate, plus any outlier payments received.

Step 4

CMS pays an add-on amount to approved teaching hospitals for indirect medical education. This additional payment varies depending on the ratio of residents to beds under the IPPS for operating costs and according to the ratio of residents to average daily census under the IPPS for capital costs.

Step 5

CMS also provides an additional payment for cases that include technologies that meet the new technology add-on payment criteria.

Step 6

On occasion, CMS may consider a specific patient’s stay as an abnormal situation. Such patients consume a considerable amount of facility resources. CMS identifies these as outliers and increases payments for such situations to protect the hospital from large financial losses due to unusually expensive cases. CMS adds all outlier payments to the base payment rate to determine the final reimbursement payment for the hospitalization.

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.

Weekend Reading: Example of a CDI career ladder

Want to climb the CDI career ladder? Two ACDIS speakers will tell explain how during today's presentations.

Want to climb the CDI career ladder?

With CDI being less than a decade old, many departments are forced to home grow their CDI specialists due to the lack of experienced CDI specialists within the market.Many CDI specialists either transition to CDI from their case management or HIM job or inherited the CDI job function within their department. Therefore, it is rare for a CDI department to have an established career ladder. And yet, as the profession continues to advance, and those original CDI staff members gain experience programs need to develop options for their employees to nurture their intellectual and professional growth.

The objective of a career ladder is to motivate existing staffto stay in the field of CDI. Many individuals seek new professional opportunities when they see no career advancement opportunities or compensation growth available at their institution. Here is an example of what a CDI career ladder might look like:

CDI manager 

5+ years of experience in CDI

CCDS or CDIP Credential

Support effective CDI department staff activities and manage performance of CDI department and staff

Provide staff with continuing CDI education and training

Reconcile fellow CDI specialists’ entries in CDI tracking tool to assure accuracy of provider clarification, abstraction of clinical indicators, and the assignment of initial DRG and working DRG

Generate case mix index (CMI) report and CDI dashboard

Provide educational presentations to various physician groups on specific documentation improvement topics

Active participation in team meetings, physician education, and leadership meetings

CDI Specialist Level 3

3+ years of experience in CDI

CCDS or CDIP credential

Assist CDI manager with reconciliation of data

Assist CDI manager with educational presentations

Assist CDI manager with team training

Maintains productivity standards

CDI Specialist Level 2

2–4 years of experience in CDI

CCDS or CDIP credential

Maintain productivity standards

CDI Specialist Level 1

0–2 year of experience in CDI

Maintain productivity standards

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: Start physician education with quality improvement

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

At their most elemental, CDI programs ensure diagnoses and treatments described by treating physicians accurately reflect the patients’ severity of illness using officially sanctioned International Classification of Diseases 10th Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) terminology, and that such codes are appropriately captured and reported by the treating facility.

Most facilities only focus on this. In fact, most facilities, persuaded by the financial benefits of capturing additional complications or comorbidities (CC) and major complications or comorbidities (MCC) on the CMI of their biggest payer—Medicare—frequently limit the scope of CDI specialists’ reviews to this regard.

The physician advisor should push the facility to expand CDI efforts beyond the scope of CC/MCC capture and fiscal return on investment not only for compliance considerations but also to help earn support from the overall medical staff. Many CDI programs have steered away from the term “improvement” in favor of the term “integrity.” Some suggest that the term “improvement” sets the hospital administration at odds with its physicians implying that physicians’ documentation needs to “improve.” Others imply that for most medical staff, the term evokes a financial connotation—that CDI is about “improving” the facility’s finances over all else.

Whether your program uses the term “improvement,” “integrity,” or some other title, the underlying concern is to address the inherent “value” of CDI efforts in improving a whole host of hospital and patient outcomes. Additionally, the physician advisor needs to assure the medical staff that there is nothing illicit in routine interrogations of the medical record to ensure accuracy. Remember that CMS states:

“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”

While many CDI programs start out fiscally focused, the ultimate goal should be to help physicians craft a record that accurately reflects their patients’ illness—to make their patients appear on paper as sick as they are in person. This documentation must be in the medical record because the pendulum in U.S. healthcare is swinging, and in many case has already swung, from a quantity-driven system to a quality-driven one.

If routinely practiced, CDI efforts improve patient outcomes—simply put better documentation improves the dialogue between physicians. Sadly, most physician discussion of a patient’s care, isn’t a face-to-face—it is the information contained in the medical record that allows one physician to quickly determine what care has been provided for what diagnoses thus far and which conditions he/she needs to monitor and care for.

As an example, try to remember the worst “code blue” situation you were ever involved in during your residency training or recent practice experience.  When you reviewed the chart at that critical moment, was there anything useful in it that could have helped you address that patient’s immediate needs any better?  There is nothing more frustrating or unsettling than to examine the chart of an acutely decompensating patient who has been in your facility for two weeks yet there is no useful information to be found.

Editor’s Note: This excerpt came from the Physician Advisor’s Guide to Clinical Documentation Improvement. 

Weekend Reading: Components of a compliant query

CCDS Exam Study Guide

CCDS Exam Study Guide

A query should include the clinical indicators however it should not indicate the outcome of reimbursement or even quality scores. The goal is accurate and compliant documentation. With accuracy as the goal, there are times when the query will generate improved reimbursement and quality scores, and other times when they will lower reimbursement and quality scores. When communicating the reason for a query, the CDI specialist should speak to the accuracy of the record over reimbursement. Thus, CDI specialists do not want to create leading queries or queries that are not supported by the clinical elements in the health record.

Compliant queries should also include patient identifiers, ensuring that the correct patient is being considered. Queries should also include the name and contact information of the person originating the query. This provides the physician an opportunity to contact the CDI specialist to clarify the query or query process.

Here are the components of a compliant query:

  • Patient name
  • Admit date
  • Account number
  • Name and contact information of individual initiating the query
  • Clinical indicators that support the query
  • Statement or question of the issue

An example of a compliant query joint ACDIS/AHIMA query practice brief, Guidelines for Achieving a Compliant Query Practice, is for clarification of specificity of a diagnosis. This type of query would be appropriate for when documentation of the condition has already been provided but greater specificity is needed for accurate code assignment.

Can the etiology of the patient’s pneumonia be further specified? It is noted in the admitting history and physical examination this obtunded patient had a history of nausea and vomiting prior to admission to the hospital and is treated with clindamycin for Right lower lobe pneumonia. Based on the above, can the etiology of the pneumonia be further specified? If so, please document the type/etiology of the pneumonia in the progress notes.

Editor’s Note: This excerpt is from the CCDS Exam Study Guide, Third Edition, written by Fran Jurcak, MSN, RN, CCDS, and reviewed by Laurie L. Prescott, RN, MSN, CCDS, CDIP.