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.
Regardless of location, physician documentation in the record must be complete and legible. It must clearly indicate the rendered service and the extent of services performed, and it must include information that justifies the physician’s work performed during the patient encounter. Asking whether laypersons could easily understand a patient’s clinical needs and how the physician addresses those needs is an easy way to determine whether the physician provided appropriate documentation.
Medical record documentation generally consists of the following information as described in the Documentation Guidelines for Evaluation and Management Services:
- Documentation of each patient encounter
- Reason for encounter (chief complaint), relevant history, physician exam findings, and prior diagnostic test results
- Assessment, clinical impression, or diagnosis,
- plan of care
- Date and legible identity of the observer/physician
- Rationale for ordering diagnostic and other ancillary services (purpose should be easily inferred if not explicitly documented)
- Past and present diagnoses (this information should be accessible to treating/consulting physicians)
- Identification of appropriate risk factors
- Ongoing progress of the patient’s care (e.g., changes in treatment, revisions of diagnosis[es])
CDI specialists can assist physicians with E/M reporting requirements by ensuring that patient medical records are complete and accurate. This is an area of increased scrutiny by all payers, including Medicare through contractor initiatives, to reduce improper payments for E/M services that are insufficiently documented. Ensuring compliance with established, mandated principals and guidelines governing E/M assignment can be a primary focus of CDI specialists.
Editor’s Note: This excerpt is adapted from The Documentation Improvement Guide to Physician E/M by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI.
When I started learning how to be an educator, I quickly learned the saying “seven times, seven ways.” The idea being we need to hear information repeatedly and receive it in a variety of ways before we are able to learn and incorporate that information in our daily practice.
Consider querying for clarification between renal insufficiency and renal failure, where the physician reads the query and asks you to just tell him what he should write. I would not start explaining the differences within the code set applied to these two terms or enter into a lengthy conversation about why the specificity is needed. Instead, point out the clinical indicators relevant to the patient as compared to the diagnostic criteria established for acute renal failure. Ask the physician to clarify if the kidneys are exhibiting failure or insufficiency based on the established criteria.
Stick to the facts. Keep it simple. Keep it relevant to the specific patient at the moment of conversation.
In this scenario, the physician needed a quick explanation. But let’s apply our “seven times, seven ways” theory by later following up on that interaction with an educational mailer or documentation tip via email to the physician. This second round of information could further highlight the needed differentiation and why this added level of specification is important to support issues such as extended length of stay, severity of illness, or resource consumption. Other ways to provide education include hanging posters in the physician lounges or documentation areas. I once even threatened to place fliers on a physician’s windshield!
The point is, that you may not always have the time (or the physician may not have the time) to engage in one-on-one education but you can use your physician queries as the first step in a more prolonged, detailed education campaign. We need to build upon each educational opportunity to reinforce the teaching. Repetition can be very valuable.
Complex metrics regarding physician response rates and staff productivity help the CDI manager quantify the CDI program benefits to facility administrators and to CDI program staff when presented properly. The manager helps communicate facility priorities to his or her team and to illustrate the needs of the CDI department to hospital administrators. Furthermore, the manager must maintain awareness of any changes in government regulations and industry guidance. Changes in the larger industry will affect the CDI team’s productivity, and any metric must be discussed within the context of these changes.
The manager should review not only the percentage of charts examined by the team, but also the number and type of queries needed each month. It is important to document the outcomes of these reviews. The aggregate data can then be used for process improvement and to support corporate compliance activities. The following is a list of items to review routinely and share with the compliance committee and administration when relevant.
- Trends in types of queries: one condition being queried routinely (e.g., a type/phase of congestive heart failure [CHF])
- Trends by physicians: multiple queries to the same physician regarding the same condition (e.g., a physician continuing to use the term urosepsis after repeated queries and communication as to the need for further specificity)
- Trends by individual CDI specialists (e.g., a CDI specialist continuously querying for specification that is already documented in the chart)
A change in ICD-9-CM Official Guidelines for Coding and Reporting may affect the query percentage for a period of time. A good example is the increased documentation specificity required for heart failure when coding guidelines were revised and reindexed to allow for greater specificity in reporting the phase and specific type of heart disease. Prior to the implementation of MS-DRG, it was only necessary for the physician to document “heart failure” or “CHF.” Both terms were considered CCs.
If one looks back far enough, many CDI teams’ data show a surge in queries for the period of time immediately prior to and following the implementation of the MS-DRG system.
In summary, team performance cannot be determined solely through measurement of query volume. Many factors influence this indicator and it should not be used to determine a program’s effectiveness, but rather should be used as an indicator of opportunities for improvement (e.g., physician education, form revision) or performance improvement over time.
The diagnoses in each major diagnostic category (MDC) correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. MDC 1 to MDC 23 are grouped according to principal diagnoses. Patients are assigned to MDC 24 (Multiple Significant Trauma) with at least two significant trauma diagnosis codes (either as principal or secondaries) from different body site categories. Patients assigned to MDC 25 (HIV infections) must have a principal diagnosis of an HIV Infection or a principal diagnosis of a significant HIV related condition and a secondary diagnosis of an HIV Infection.
MDC 0, unlike the others, can be reached from a number of diagnosis/procedure situations, all related to transplants. This is due to the expense involved for the transplants so designated and because these transplants can be needed for a number of reasons which do not all come from one diagnosis domain. DRGs which reach MDC 0 are assigned to the MDC for the principal diagnosis instead of to the MDC associated with the designated DRG.
Of course, many different conditions can take place at the same time or have underlying causalities. Consider the pneumonic M.U.S.I.C., which you may have heard before, used as a reminder to document the:
- M for Manifestation: e.g., sepsis, heart failure, chest pain, angina
- U for Underlying cause or pathology: e.g., UTI, alcoholic cardiomyopathy, GERD, coronary atherosclerosis
- S for Severity or specificity: e.g., severe sepsis, diabetes out of controlled, systolic or diastolic heart failure
- I for Instigating or precipitating causes: Indwelling Foley cath, NSAID use, carbon monoxide poisoning
- C for Consequences or complications: Septic shock, diabetic neuropathy
When given a diagnosis, place it one of these categories and then look for the other four, linking them with terms such as “due to,” “resulting in,” and the like.
Let’s follow this process using the example of chest pain
- Manifestation: Describe the nature of the pain such as pleuritic or “with respiration”, angina, heartburn, biliary colic, radicular
- Note that phrases such as musculoskeletal, chest wall, atypical pain do not change the DRG
- Underlying cause: Angina pectoris (as an example)
- Coronary atherosclerosis or thrombosis, coronary spasm, hypertrophic cardiomyopathy, complication of coronary stent or previous CABG, etc.
- Note that the code for coronary syndrome X was removed from ICD-10
- Severity or specificity: Stable angina, accelerated angina (a complication/comorbidity [CC]), myocardial infarction (manifested by elevated troponins, a major complication/comorbidity [MCC])
- Note that the code for angina decubitus was removed from ICD-10
- Instigating or precipitating causes: Cocaine abuse, trauma, anemia, hyperthyroidism, atrial fibrillation, accelerated or malignant hypertension
- Consequences or complications: Ventricular tachycardia, shock, acute systolic heart failure due to “stunned myocardium”
Now let’s look at another example of how one might document the condition of altered mental status, again using the M.U.S.I.C. pneumonic.
- Manifestation: Dementia, delirium, psychosis, stupor, coma
- Note that the phrase unresponsive does not have a code
- Underlying cause: Various encephalopathies such as stroke, Transient Ischemic Attack (TIA), Alzheimer’s disease, Lewy-body dementia, encephalitis
- Severity or specificity: Correlates with manifestation and underlying cause
- Note that acute states (e.g., acute delirium) are more likely to be CCs
- Instigating or precipitating causes: Drug toxicity (document whether the drug was an overdose or not properly taken as prescribed), cerebral embolus due to atrial fibrillation
- Consequences or complications: Acute respiratory failure, syndrome of inappropriate antidiuretic hormone secretion (SIADH) leading to hyponatremia resulting in a metabolic encephalopathy