The following is one example of a possible open-ended query:
“Dear Dr. Phil,
The patient’s sodium (Na) was 129, the progress notes indicate low serum sodium level, ‘¯Na.’ An order was written to place the patient on .9NS. Please clarify the associated diagnosis being treated.”
In this scenario, the physician is highly likely to respond and document “hyponatremia.”
The 2013 ACDIS/AHIMA query practice brief describes an obtruded patient with a history of vomiting treated for pneumonia. The open-ended query asks the type/etiology of the pneumonia, which, in that example, most likely result in a response of “aspiration pneumonia.”
Sometimes an open-ended pneumonia query can be problematic, however. For example,
“Dear Dr. Oz,
The patient’s progress note indicates he is being treated for pneumonia with vancomycin. Please clarify the type of pneumonia being treated.”
Although the wording of this query does a great job of not leading, it may not result in the most clinically appropriate answer (methicillin-resistant Staphylococcus aureus pneumonia). In many cases, the physician will respond “bacterial pneumonia,” which will still lack the specificity needed for coding purposes. Other physicians may respond “complex” or severe pneumonia.
In such situations, the CDI specialist would have to use a second query in an attempt to further clarify the issue. The use of open-ended queries works best when the potential answers are limited, involve commonly used terminology, and when physicians essentially understand the type of documentation required.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
Different CDI programs have different core responsibilities. New CDI programs typically focus on clarifying the medical record to identify the patient’s principal and secondary diagnoses. Accurate capture of these conditions often leads to a shift in the MS-DRG assignment with a correlated shift in a patient’s expected length of stay (LOS) in the hospital and the relative weight (RW) or reimbursement for resources expended.
Many programs get their start by improving the facility’s direct reimbursement and case mix index, due to the improved capture of these conditions. Later, however, programs expand to a broader focus, one which aims to ensure the accuracy of the entire medical record for a variety of purposes, including more robust quality metrics, public profile review, and other concerns.
CDI programs have different foci. It is important for you to understand the mission identified for your program. Talk to your manager or mentor to identify overarching goals of the CDI program and how these goals are measured.
Program reporting structure
According to a January 2014 ACDIS survey, nearly 50% of respondents indicated their CDI programs are housed under HIM, followed by little more than 20% that indicated their programs were housed under case management. Other respondents indicated their CDI programs fell under either finance or quality. Those results shifted somewhat from the early years of CDI implementation where, according to a 2010 survey published in the CDI Journal, 45% reporter to the HIM department, 27% reported to case management, and 23% reported to finance.
Common best practice, as these surveys seem to indicate, is for the CDI team to report to the HIM department since their efforts serve the primary goal of ensuring a complete and accurate medical record. Additionally, the alignment of the CDI and coding staff under the management of the HIM department director typically means the staff members will be able to engage each other openly and that staff will receive clear communications regarding common goals and objectives.
However, many programs report to the case management department. The common thinking here relates to the experience of the CDI staff members, as many employees make the transition to CDI from the case management ranks. Such shifts make it easier for these professionals to wear two hats during difficult staffing times and allows for some integration of CDI efforts toward capturing documentation needed to ensure medical necessity and reduce readmissions.
CDI specialists can help case management by providing the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected timeline of patient discharge and identify those who may be outliers in resource consumption and LOS. Every MS-DRG has an associated RW, GMLOS, and average length of stay. A key component of MS-DRG reimbursement is the inclusion of anticipated room and board charges based on the GMLOS associated with the principal diagnosis and applicable comorbid conditions. When reviewing a patient without complication/comorbidity (CC) or a major CC (MCC), the CDI specialist (in conjunction with case management) can assist in determining whether the extended LOS is possibly due to an incomplete, vague, or missing diagnosis as opposed to discharge planning issues.
Still, other programs report to finance or to quality.
Regardless of your CDI program’s structure, you should have clearly established duties as differentiated from the roles of coders, case managers, or others, since the CDI specialist looks to interrogate the patient’s medical record to identify any ambiguous diagnoses and clarify any clinical indicators in the medical record prior to the patient’s discharge.
When CDI professionals have dual roles, it can be confusing as to which hat you need to be wearing for which tasks. Careful consideration should be made when CDI specialists are assigned a variety of roles or expectations. If the role becomes all encompassing, it may result in a lower level of achievement of identified goals due to the variety of foci in effort.
Although you may always consider yourself a nurse or a coder or other professional, once you take on the CDI mantle that is the role that must take precedence. Many defer to the role they find most comfortable. For example, those experienced in case management or utilization review may lean on their skills in that area, focusing their record review toward their area of expertise at the expense of the CDI program’s actual mission: typically record accuracy and reimbursement.
Similarly, many new to the CDI role, especially nurses and physicians, find it difficult to move from caregiver or provider role to CDI specialist. The CDI specialist, just like coders, cannot freely interpret or add documentation with assessments or evaluations on their own. Only the treating physician can diagnosis the patient, since it is his or her clinical opinion that guides the treatment and care of the patient.
All program reporting structures can prove effective, it just depends on the overall goals of the program, support of the facility leadership, and the ongoing evaluation, support, and effort of the CDI team.
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.
The differences between the ICD-10 and ICD-9 code sets are primarily in the overall numbers of codes, their organization and structure, code composition, and level of detail. ICD-10-CM contains about 70,000 diagnosis codes compared to approximately 14,000 in ICD-9-CM, and approximately 72,000 in ICD-10-PCS (procedure) codes compared to 4,000 ICD-9-CM codes. ICD-10 codes are also longer and use more alphanumeric characters.
Punctuation within both the tabular and alphabetic indices still plays an important role in code interpretation and selection. When coders need to find their way around the codes, they can use either the alphabetic or tabular index. The biggest variation is that the ICD-10 tabular index uses more tables to drive digit selection. While very similar to ICD-9, CDI specialists and coders should review the ICD-10 indices to ensure accurate code selection.
Each ICD-10-CM code is three to seven characters long. The first is an alpha character, the second is numeric, and the third through seventh can be either alpha or numeric, with a decimal after the third character. Alpha characters are not case-sensitive. ICD-10-CM uses a placeholder character “X,” as the fifth character to allow for future code expansion in a particular area.
In ICD-9-CM it takes multiple codes to fully describe the patient’s clinical picture. Take, for example, diverticulitis of the large intestine with perforation or peritonitis with bleeding. Under ICD-9-CM coding conventions, there are two codes to assign, one for the diverticulitis with hemorrhage/bleeding and one for the peritonitis. Under ICD-10-CM conventions, there is a combination code to capture this clinical event, K57.41.
Pressure ulcers are another category of codes that this difference can be seen in that ICD-10-CM provides a more precise and descriptive code through combining the site and stage of the ulcer all in one code category, L89. For example, a Stage III pressure ulcer of the heel codes to L89.603.
The ICD-10-PCS codes are used for hospital claims for inpatient procedures. These codes differ from the ICD-9-CM procedure codes in that they have seven characters that can be either alpha (non-case sensitive) or numeric. The numbers 0-9 are used. Letters O and I are not used to avoid confusion with the numbers zero and one. The codes do not contain decimals.
Because ICD-10-PCS boasts more than 155,000 possible code combinations (ICD-9 only has 17,000), the increased number of codes allows ICD-10-CM/PCS to be far more specific than its predecessor. So, to report the new codes, the medical record documentation needs to reflect not only the procedure performed, but also how the physician performed it.
For example, the fifth character identifies the surgical approach for the procedure. (See Figure 2.1.) This forces the coder to consider how the procedure was performed at a level of detail previously unnecessary. And, more importantly for CDI staff, physicians previously did not necessarily need to document that level of specificity either.
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.
The draft ICD-10-CM Official Guidelines for Coding and Reporting state that “traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.” the tabular list note at the beginning of the Injury, Poisoning and Certain other Consequences of External Causes (S00-T88) tells coders to “use secondary code(s) from Chapter 20, External Causes of Morbidity, to indicate cause of injury.”
Codes within the T section that include the external cause do not require an additional external cause code. S codes describe various types of injuries related to a single body region, and T codes describe injuries associated with unspecified body regions as well as poisonings and certain other consequences of external causes. Although CDI Specialists have not typically queried for external cause codes (E codes in ICD-9-CM and V00-Y99 codes in ICD-10-CM) these combination codes will require additional documentation from the provider detailing the events surrounding the injury once the new code set implementation takes place.
Regarding the circumstances of the injury, when no intent is indicated, the default is accidental, according to the Official Guidelines for Coding and Reporting. Although the available codes include “events of undetermined intent,” they should be used only if the physician specifically documents that the intent cannot be determined.
In ICD-10-CM injuries are grouped by body part rather than by category. The organization aligns with how providers document injuries–often a systematic progression from head to toe after the most serious injury is assessed. The focus of treatment can be misleading to those without a clinical background or expertise coding traumatic injuries.
For example, a patient may be int he ICU for a neurological injury that requires a high level of nursing care and repeat imaging but if the coder does not review the nursing and imaging report, all he or she may notice is that an open fracture of the limb was treated with required antibiotics and surgical care.
Although the grouping changed from ICD-9 to ICD-10, the Official Guidelines for Coding and Reporting are similar, calling for separate codes for each injury unless a combination code is required. Remember that a code can only ever be reported once, so duplicate codes should never appear on a claim. Also, use of a combination code may require a query if the documentation does not already support use of a particular combination code. The Figure below illustrates some of the changes in the injury code set.
The 2015 CDI Pocket Guide helps you take clinical findings and dig deeper, and look for additional details—such as medications and other conditions—to develop the most accurate picture of the patient’s condition.
Authors Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS, draw on more than fifty years’ cumulative experience and provide the clinical coding authority to strengthen patient care quality and resource utilization, and improve compliance and reimbursement.
The new 2015 edition of our popular CDI best-seller includes critical new updates from the 2015 IPPS Final Rule, and additional ICD-10 documentation tips to ensure you are ready for the national Oct. 1, 2015 compliance deadline. New to this year is additional information on Value-Based Purchasing (VBP) and how CDI specialists can incorporate VBP initiatives into their health record reviews.
What’s new in this edition:
- Addition of pediatric clinical indicators and diagnostic criteria
- New Key References for Shock, Neoplasms, Pneumothorax, Functional Quadriplegia, Cystic Fibrosis, Asthma, Intellectual Disability, and more
- Standardized Key References format for each clinical topic: Definition, Diagnostic Criteria, Treatment, References, Coding and Documentation Challenges, and ICD-10
- Content expansion of “MCC/CC” section to “Comorbid Conditions” that includes secondary diagnoses with a high impact focus for MS-DRG and APR-DRG, quality, and CMS Pay for Performance outcome metrics
- Strategies for integrating CMS Pay for Performance initiatives into your CDI program
- Expanded Reference citations of medical literature and other authoritative sources to support diagnostic definitions and criteria
- Exclusive web-based resource center with detailed supplemental information and updates for all CDI Pocket Guide customers
- Expanded and updated ICD-10 tips and strategies
Twenty years or so ago, CDI specialists might have been called record reviewers or had a title associated with “optimizing” the documentation in the medical record. In the course of the MS-DRG implementation and related documentation and coding adjustment payment decreases, CMS indicated in its FY IPPS final rule that there is “nothing inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment… supported by documentation in the medical record.” And so facilities began to formalize the CDI role.
As benevolent a mission as CDI may seem to have, for many facilities the focus of concurrent physician queries continues to be identifying information to increase reimbursement. When such efforts do not reflect the care provided to the patient or are conducted in a leading manner, these practices could be construed as fraud–particularly when data patterns appear to illustrate inconsistencies with national norms.
Of course, healthcare providers must ensure the financial solvency of their organizations, just as government officials must ensure the solvency of their healthcare funding programs. Both sides of this fiscal conundrum face growing financial frustration as both sides continue to search for an underlying cause to answer the dilemma of expanding healthcare costs.
Nevertheless, when a facility submits a claim to the federal government for payment of activities that were never provided, it risks being accused of False Claims Act violations, investigations by the office of the Inspector General and in some cases prosecution by the Department of Justice.