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Book Excerpt: Repeat Reviews


The CDI Specialist’s Complete Training Guide

Your organization may have polices dictating the frequency of record review and re-review, as well as how to determine which records CDI specialists should target for such efforts. Be sure to discuss such parameters and the expectations of the CDI staff within them. The staffing of your CDI department as compared to the number of admission/discharges may also influence standard practices of repeat reviews.

Repeat reviews should examine any physician orders written since the date of the last review for any changes in the plan of care or abrupt discontinuation of a treatment (which may indicate a possible condition was ruled out). Review any diagnostic test or study results, progress notes, and assessments for consistency, incongruity, or ambiguity, as set forth by the Association for Clinical Documentation Improvement Specialists and the American Health Information Management Association physician query practice briefs as reasons for queries.

In general, not all records need to be reviewed every day, but repeat reviews should be scheduled for records in which:

  • A principal diagnosis has not yet been determined
  • A symptom is identified as the principal diagnosis
  • An open query is pending
  • A surgical intervention occurred
  • The patient required a change in care level (either to an intensive care unit or shift from ICU to a general medical unit)

The mission or focus of the CDI department also influences the practice of repeat record reviews.  Programs reviewing records primarily for reimbursement typically stop reviewing the record once no further changes in MS-DRG can be made. Those reviewing for severity of illness/risk of mortality most likely review records repeatedly until discharge, to ensure every possible secondary diagnosis gets identified.

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: Yes/no queries

The Physician Queries Handbook

The Physician Queries Handbook

Based on the 2008 AHIMA guidance “Managing an Effective Query Process,” many in the CDI industry believed that yes/no queries were acceptable only with present-on-admission (POA) queries.

At times, this left the CDI specialists in the awkward position of asking what seemed like a silly question or using really poor grammar.

For example, physicians frequently neglect to cross-document findings from the surgical pathology report. For most CDI specialists, the easiest way to deal with this situation would have been to query the physician and ask whether he or she agrees with the “path report.” Concerned that such a yes/no question violated industry guidance, CDI specialists wrote open-ended queries, such as “please clarify the clinical diagnosis associated with the stage 3 malignant ovarian cancer on the pathology report” or use multiple-choice questions that included limited options or findings different from the pathology report, such as benign, pathology aberration, etc. In both cases, the phrasing tended to confuse and/or annoy physicians.

The 2013 AHIMA/ACDIS query brief expanded the compliant use of yes/no queries to include:

  • Substantiating or further specifying a diagnosis already present (i.e., findings in pathology, radiology, and other diagnostic reports)
  • Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (i.e., hypertension and congestive heart failure, diabetes mellitus, and chronic kidney disease)
  • Resolving conflicting documentation from multiple practitioners (i.e., asking the attending physician who is documenting “renal failure” if he agrees with the “CDK stage 4” documented by the renal consultant

Based on the above-described guidelines, a yes/no format would never be appropriate for a new diagnosis. Moreover, to ensure a yes/no query is not leading, non-POA queries should include “other” and “clinically undetermined” options. The use of these additional options allows this format to meet the standard of not being leading, as it offers the physician numerous alternatives. Additional alternatives include “not clinically significant” and “integral to.”

So, in the earlier example of a patient with a pathology report showing ovarian cancer, the following compliant yes/no query could be composed:

Dear Dr. OZ,

Please clarify and document in the progress notes; do you agree with the pathology report specifying “stage 3 malignant ovarian cancer?”

  • Yes
  • No
  • Other
  • Clinically undetermined

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


Book Excerpt: Providing Physician Education


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-10-CM terminology
  • Provide analysis of how physician response 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.

Ideally, a CDI program could hold an annual brainstorming session and assign individuals to work on various aspects of physician education throughout the year. Keeping such sessions a priority encourages the team to generate innovative ideas and ensures physician education remains consistent. Spread ownership of physician training among the CDI team members, so the burden does not always fall on the shoulders of CDI management. This allows CDI specialists an opportunity to gain valuable public speaking and professional development skills, as well.

Target training to specific service lines

To develop further physician support, consider creating service-line specific documentation improvement training. Such education can allow the CDI program to address particular documentation concerns by MDC or body systems. Orthopedic surgeons, for example, should learn the importance of documenting the specific site of a fracture and whether the fracture is pathological in nature. Orthopedics also need to know to document the suspected cause of back pain, the presence of osteomyelitis for a patient with a pressure ulcer with a notation of whether it was chronic in nature, and any secondary diagnoses (i.e., CCs and MCCs).

By paying attention to these specialty services, the CDI program illustrates its understanding of the unique needs and values each physician specialty provides to the facility. Lastly, it shows the CDI department is willing to learn and adapt and work in creative ways to be of assistance to various departments in the facility.

Consider creating a timetable for service-line focus. This may mean tackling an area monthly, bimonthly, or quarterly depending on the variety of services provided by the organization. Work with physician leadership to identify opportunities for documentation improvement, and to identify industry standards for clinical documentation in that area, similar to the process for creating a specific physician query. Be sure to train CDI staff and members of the HIM department and inform all parties involved of the target area and time line.

When the appropriated time comes, try picking a day to review every chart from that service line, leaving routine queries as needed. Other items such as targeted documentation tip sheets, informational posters, and increased CDI presence within that department can increase awareness of documentation improvement efforts. Rotating such efforts ensures no one group gets all the CDI staff’s attention all the time and ensures no department gets left out of the CDI mix.

Remember that ongoing education is not only for the medical staff. Ask particularly responsive, helpful physicians to provide training to the CDI and coding teams on a particular topic. Opening the dialogue to such an extent illustrates a willingness to learn and exhibits programmatic inclusiveness to all involved. Most physicians are teachers at heart and many will enjoy an opportunity to share their knowledge with others. Asking a physician to share his or her expertise on a topic can have positive effects beyond the original intent of group learning.

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.

Book Excerpt ICD-10 tips for documenting diabetes

CDI Specialist's Guide to ICD-10

CDI Specialist’s Guide to ICD-10

Diabetes is a disease of the endocrine system “characterized by hyperglycemia resulting from absolute or relative impairment in insulin secretion and/or insulin action.” According to the Centers for Disease Control and Prevention, 35.7 million people ages 20 and older have been diagnosed with diabetes or have the condition and do not know it.

Patients can have high levels of blood glucose or sugar for many different reasons. For example, sugar levels can rise when a patient eats certain foods high in starch or sugar. Blood glucose or sugar levels also can rise when a patient’s body produces too much or too little insulin. Diabetes can be caused by other conditions, such as adverse effect/poisoning of drugs (glucosteroids, lithium, niacin), neoplasm of the pancreas, cystic fibrosis, and postpancreatectomy.

There are several types of diabetes, including:

  • Type 1: This occurs when the body does not produce or produces very little insulin. It typically occurs in children and adolescents but also can affect adults. Commonly referred to as “insulin dependent,” as the patient often requires insulin to survive.
  • Type 2: This most common form of diabetes occurs when the body does not produce enough or use insulin properly. It can occur at any age, can often be prevented, and is reversible.
  • Gestational diabetes: This occurs during pregnancy.
  • Secondary diabetes: This occurs when an underlying condition has caused the patient to have diabetes.

Though symptoms differ for each patient and depend on type of diabetes, some patients with diabetes may experience the following:

  • Fatigue
  • Thirst (polydipsia)
  • Unexplained weight loss
  • Nausea
  • Blurred vision
  • Frequent urination (polyuria)
  • Frequent infections (e.g., bladder, vaginal, gum)

Type 2 diabetics are often asymptomatic and diagnosed based on routine medical examination results. Depending on the severity/type of the diabetes, physicians may suggest several treatment options to help a patient manage the disease and live a healthy lifestyle, including:

  • Daily exercise, ranging from a brisk walk to a formal exercise routine
  • A diet of fruits, vegetables, fish, and whole grains, and one that avoids foods high in fat, sugar, or salt
  • Medications, depending on a patient’s ability to control sugars and insulin levels
  • Insulin (Humulin, Humalog)
  • Oral drugs (Glucotrol, Glyburide, Diabeta, Glucophage)
  • Smoking cessation
  • Blood pressure control

Under the previous code set, parenthetical notes at most subcategories identify “use additional code(s) to identify the manifestation” for specificity. Example, diabetic chronic kidney disease (CKD), report codes 250.4x, diabetes with renal manifestations, and a code from 585.x to identify the stage of kidney disease. Patients with type 2 diabetes who require insulin were assigned code V58.67, Long-term (current) use of insulin.

In ICD-10-CM, if the documentation in the medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned; code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin. Code Z79.4 should not be assigned if the insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.

The age of a patient is not the sole determining factor, though most type 1 diabetics develop the condition before reaching puberty. For this reason, type 1 diabetes mellitus is also referred to as juvenile diabetes. If the type of diabetes mellitus is not documented in the medical record, the default is E11, type 2 diabetes mellitus.

In situations where diabetes occurs during pregnancy and for cases of gestational diabetes, refer to Section I.C.15, Diabetes mellitus in pregnancy and gestational (pregnancy-induced) diabetes.

The codes under category E08, Diabetes mellitus due to underlying condition, and E09, Drug- or chemical-induced diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drugs, poisoning).

The sequencing of the secondary diabetes codes in relation to codes for the cause of the diabetes is based on the tabular instructions for categories E08 and E09. For example, for category E08, Diabetes mellitus due to underlying condition, first code the underlying condition. Also, for category E09, Drug- or chemical-induced diabetes mellitus, first code the drug or chemical (T36–T65). For example, “Diabetes ketoacidosis without coma due to cirrhosis of pancreas” would be K86.8, Cirrhosis of pancreas, and E08.10, Diabetes mellitus due to underlying condition with ketoacidosis without coma. Consider also the following situations:

  • Secondary diabetes mellitus due to pancreatectomy. For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pancreas), assign code E89.1, Postsurgical hypoinsulinemia. Assign a code from category E08 and code Z79.4, Other acquired absence of organ, as additional codes.
  • Secondary diabetes due to drugs. Secondary diabetes may be caused by an adverse effect of correctly administered medications, poisoning, or late effect of poisoning. See section I.C.19.e for coding of adverse effects and poisonings and section I.C.20 for external cause code reporting.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10, Second Edition, written by HCPro Boot Camp instructors Jennifer Avery and Cheryl Ericson.

Book Excerpt: Open-ended queries


The Physician Queries Handbook

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.

Book Excerpt: CDI Program Variances


The CDI Specialist’s Complete Training Guide

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.

Discussion Point

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.