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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.


Sunday Reading: Physician response for queries

The Physician Queries Handbook

The Physician Queries Handbook

Determining parameters for physicians’ responses to queries should incorporate the convenience of the physician as well as the needs of the coding and CDI staff. For example, facilities which determine that query forms will be retained as a permanent part of the medical record may permit the physician to respond to the query directly on the form as long as sufficient documentation also exists in the body of the medical record.

Each facility should check with its state Quality Improvement Organization (QIO) for guidelines, too. Additional options include:

  • We will accept the query as a progress note, as long as the document was signed, dated, timed, and created in the normal course of the chart (i.e., concurrently, at time of coding, or within the medical staff general rules and regulations within 30 days of discharge).
  • We accept the response to the query on the actual query form, unless the query posed a leading question or introduced information not documented in the medical record. We follow the basic standards outlined in the AHIMA physician query practice brief.
  • We do not accept coding summary forms (e.g., physician query forms) as documentation in the medical record when following diagnosis-related group (DRG) validation procedures. There should be an addendum in the medical record that is signed and dated by the physician.

If the program employs a physician advisor, set parameters for his or her involvement in the program to determine the level of involvement and his or her participation in closing outstanding queries. The physician advisor has the ability to speak peer to peer and ideally is perceived as an authority figure by other physicians. This influence can often mean the difference between physician acceptance and participation with CDI goals or complete rejection of the program.

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

Sunday Reading: The Art of Record Review for Emergency Room (ER) Records

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Physician assessments and orders

The notes from the ER physician explain the patient’s initial complaints and physical assessment. Such information helps support requests for clarity related to conditions present on admission (POA) as well as medical necessity for the inpatient admission. Here, the physician lists any tests or diagnostic workup he or she ordered. Usually the end of the ER physician’s documentation will offer a working or differential diagnosis as to why the patient may need to be admitted to the hospital. As the patient’s stay progresses, the CDI specialist may need to query the physician to determine whether differential diagnoses were ruled out or found to be valid.

Concepts to Remember

The ER physician, the physician assistant, and the nurse practitioner are all legally considered care providers. As such, coders can use this documentation for code assignment. However, the attending physician gets the final word in diagnosing the patient. His or her documentation (or query responses) trump that of the ER staff where conflicting documentation exists.

ER nursing assessment

This assessment should reinforce the physician’s documentation. Nevertheless, consider reviewing this area of the medical record to ensure they match and identify any potential query opportunities for diagnoses not captured in the ER physician’s documentation. Identifying any medications the patient takes at home and/or any medications given in the ER may offer clues to existing secondary diagnoses. This assessment may also be used to support the status of POA.

Emergency medical technician (EMT) records

EMT records should reinforce information in the physician notes. Such documentation helps capture information related to the extent of time a patient had experienced loss of consciousness, whether the patient was intubated prior to arrival, whether a Foley catheter was put in place prior to his or her arrival in the ER, or details related to that particular patient’s home situation or baseline condition

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.