Traditionally, physicians’ responsibilities lie with assessing the patient’s needs, diagnosing the patient’s condition, developing a treatment plan, and caring for the individual until he or she can be safely discharged. All of this care needs to be documented in the medical record by the physician.
Few physicians, however, are taught in medical school how their language and documentation affects various other departments, reimbursement (both their own and their hospital’s), quality data, or other data uses. When their documentation is reviewed, it is typically reviewed by another member of the medical staff to ensure appropriateness of care. Period.
Although CDI professionals can help obtain clarification, it is always the treating physician’s responsibility to diagnosis and accurately document that diagnosis in the medical record and it is always the coders’ responsibility to determine which codes are finally submitted.
In the early days of CDI program development, employment of physician advisors seemed optional. Those facilities that employed a physician advisor often used their acumen minimally to address concerns related to outstanding queries and difficult (noncompliant) physicians. Today, it is widely understood that physician advisors to CDI programs play a far more integral role. Today, physician advisors are frequently called upon to address such concerns and many more—from reviewing claims denials from a documentation perspective to providing trending reports, CDI program analysis, and so forth.
Editor’s Note: Today, at the ACDIS pre-conference events, the authors of the above excerpt from The Physician Advisor’s Guide to Clinical Documentation Improvement, James S. Kennedy, MD, CCS, CDIP, and Trey La Charite, MD, will take to the stage before more nearly 100 attendees looking to learn more about the role of CDI for physician advisors.
Today and tomorrow these attendees will dive deep into all things coding, reimbursement, and documentation. They’ll learn documentation tips by clinical diagnosis and explore support tactics. They will come to understand how documentation improvement can support even physicians’ own practice efforts, and improve overall physician and facility quality scores. Tomorrow, some of these attendees will even explore how to engage physicians in documentation improvement across multiple hospitals.
There’s always something more to learn. Thanks to our wonderful speakers and authors, ACDIS offers a variety of ways for you to learn it. To paraphrase a common saying from Kennedy—“If it walks like a duck and talks like duck… it still isn’t a duck unless you document it.”
CDI programs bear the weight of providing a potentially great benefit or a potentially great risk for their organizations, depending on the focus and compliance of their query efforts. CDI programs should include input from their facility compliance officer and legal counsel at various stages of implementation and growth.
Ongoing compliance department involvement can help ensure that CDI queries are structured in a compliant manner and can advise the CDI staff members as to whether query templates are acceptable. Such involvement will help guarantee that your CDI program meets the doctrine and spirit of the existing regulations.
Since CMS represents the nation’s largest healthcare payer, many CDI programs get their start in conducting record reviews for Medicare patients and/or top diagnosis target areas. However, the goal of improved documentation and patient care should be consistent across payers and disease type, not just improved healthcare documentation for patients who happen to have government insurance. In addition, the goal of improved documentation and patient care should not focus only on high-cost services such as acute respiratory failure or any other special circumstance. When there is a lack of consistency in policies and procedures, for example, reviewing Medicare and not private payers, the risk for potential misuse and abuse increases.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
Almost every program, without exception, uses the case mix index (CMI) as a metric of CDI program performance. CMI should not be the only indicator used, as many factors influence a facility’s CMI for any given period, including (but not limited to) the age, acuity, or comorbidities of the admissions; the number and type of procedures performed; the number of admissions in a given month; and the quality of the record’s documentation. Of the previous factors, only one can be influenced by the CDI team—documentation. Due to the month-to-month variability, the CMI should be a measurement over time rather than a barometer of a particular month’s performance and should focus on particular documentation improvement areas in addition to the overall CMI.
To use the CMI as an indicator of program performance, the facility has to exclude diagnoses and/or procedures not influenced by CDI activities, such as mechanical ventilation, surgical procedures (with the possible exception of excisional debridement), tracheostomies, and organ transplants. Documentation improvement efforts will never influence the number and types of surgical procedures performed at a given facility. Tracheostomies and organ transplant procedures have a high relative weight. The number of such procedures performed in a given month will therefore raise or lower the surgical CMI.
Similarly, a sudden change in pre-surgical approval certification guidelines may cause a sudden drop in the number of bariatric surgery admissions, as would the loss of a high profile surgical group. On the medical side, variability in the number of patients assigned to ventilator MS-DRGs can have a major impact on overall CMI. Therefore, hospitals need to be well informed about how they monitor and use CMI as a barometer for CDI success.
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.
A CDI program’s success may be measured against a wide variety of benchmarks, and analysis of an individual CDI specialist’s success must also take those variables into consideration. Such factors include:
- Age of the program. An older program may be asked to tackle more complex reviews, provide more educational outreach, and be involved in more cross-departmental meetings and initiatives, which shifts CDI specialists’ focus away from simple record reviews for CC/MCC capture rates.
- Experience level of the CDI professional and overall team. Clearly, your manager does not expect you, as a new CDI specialist, to review 20 records per day on your first day. When a new CDI specialist (or specialists) joins a team, overall productivity expectations need to be adjusted. Training a new individual requires job shadowing, auditing, lessons, etc., and the best training requires help from the entire team. Similarly, a team with just one year’s worth of experience may not be as efficient as a team whose components have multiple years of experience. These adjustments in productivity expectations need to be clearly documented and communicated to the team and administration.
- Hospital size and program focus. Larger facilities require larger teams—there is, after all, only so much one person can do in one day. However, larger facilities may hone their foci to CC/MCC capture or to patients past a set number of days in order to keep their CDI efforts from getting bogged down. Alternatively, smaller facilities may have the capacity to incorporate more expansive efforts into their record reviews. Program focus matters immensely when determining productivity and other measures of your own success and the success of the program. Programs with clearly defined goals can then benchmark productivity and improvement based on those goals.
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 2013 ACDIS/AHIMA query practice brief continues to support the use of multiple-choice queries and provides further guidance. It reinforces the importance of including “clinically significant and reasonable options” and including the clinical evidence.
Many in the CDI industry were concerned about the use of multiple-choice queries when the reasonable choices were limited. For example, CDI specialists struggled on how to use a multiple-choice format when querying for a low serum sodium level. What diagnoses can they list in addition to hyponatremia? Hypernatremia would not be reasonable. Many were concerned that by listing only one diagnosis, they could be accused of leading the physician, even if “other” and “clinically undetermined” were used.
The 2013 ACDIS/AHIMA query practice brief recognizes that in some clinical situations, diagnoses may be limited. To resolve the concern, it suggests that queries should include additional options, such as “clinically undetermined” and “other” with space for the provider to add additional verbiage.
In some situations, such as the hyponatremia example given earlier, it may be appropriate to add options such as “not clinically significant.” This would also be a good choice when querying about radiological and other test findings. Lastly, adding an option of “integral to” (and therefore should not be separately coded) may be appropriate. Some examples of when to consider the “integral to” option include:
Clarifying the presence of a surgical complication: A nicked bowel that occurred while removing dense abdominal adhesions is generally not inherent; however, sometimes surgeons will state it is due to the location of the adhesions.
Clarifying whether a diagnosis is an expected outcome (i.e., integral to) a surgery:
- Ileus 48 hours post-laparoscopic appendectomy is not inherent, as it does not occur in most patients
- Ileus 24 hours post-colon resection is inherent, as it occurs in most patients
- Acute blood loss anemia after joint replacement procedures: the answer tends to vary among surgeons
Clarifying whether a diagnosis is integral to or inherent to the specific disease process: Cerebral edema is not inherent in cerebral hemorrhage, as it does not occur in most patients with this diagnosis
Conversely, hypoxemia is inherent in acute respiratory failure, as it occurs in all patients with respiratory failure.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
When trying to understand ICD-10-PCS, it’s helpful to take a step-by-step approach to code assignment.
Character one: The first character defines the general type of procedure. Procedures are divided into 16 different sections. Numbers 0−9 define medical/surgical interventions, and letters B−H (except E) define diagnostic or ancillary interventions performed in the inpatient setting. Codes derived from a first character of “0” describe medical and surgical procedures. The bulk of PCS codes (more than 60,000) are located within the medical and surgical section. The next largest section is imaging, with almost 3,000 codes available.
Character two: The second character captures the specific body system impacted by the procedure (e.g., musculoskeletal or central nervous system). There are 31 different body system characters available within the medical and surgical category. The diaphragm is used to differentiate upper body regions from lower body regions.
Character three: This character captures the root procedure. Within the medical and surgical section of codes, there are 31 potential root operations, each of which is based on the objective of the procedure. These 31 root operations are organized into nine groups including those:
- That take out some or all of a body part
- That take out solids/fluids/gases from a body part
- Involving cutting or separation only
- That put in/back or move some/all of a body part
- That alter the diameter/route of a tubular body part
- That always involve a device
- Involving examination only
- That define other repairs
- That define other objectives
Each root operation has a precise definition that will be applied by the coding staff (and CDI specialists who do procedure coding). The provider is not required to document using root operations. In fact, the guidelines state that the coder is responsible for applying the PCS term (root operation) based on provider documentation and will not need to query the provider when there is a correlation between the documentation in the medical record and a PCS term.
For example, the provider may document partial resection, in which case the coder or CDI specialist must know that a resection is the removal of all of a body part. If only a portion of the body part is removed, the correct root operation would be “excision,” not “resection.” This is a new concept for coders: to assign a code not based upon how a provider defines a procedure but rather based on how the provider describes a procedure.
Character four: The fourth character captures body part (the specific anatomical site where the procedure is performed)—for example, the duodenum. Correct assignment of the body part will require a strong knowledge of anatomy and can impact root operation assignment. Some body parts, like the lung, are naturally segmented into smaller sections. In the case of lungs, they are referenced in terms of lobe. The corresponding body part in PCS is based on each lobe of the lung rather than whole lung. If a lobe of the lung is removed, it is a resection of the particular lobe rather than an excision of the lung. Additionally, there are situations where the operative report may not specifically reference the body part necessary for code assignment.
An example is use of the root operation release, in which the body part refers to the structure being released by the surgical manipulation, not the structure that is being manipulated. The provider may document abdominal adhesions, and the coder must be able to identify it is the small intestine being released during the procedure.
Character five: This character captures the approach (the technique used to reach the site of the procedure); approach options for procedures during which a surgeon removes some or all of a body part, including through the skin, through an orifice, or externally. There are specific guidelines regarding how to code a procedure when an approach is discontinued in favor of another approach as well as when the procedure is aborted.
Character six: The sixth character captures the device (any devices that remain after the procedure is completed). This does not include materials incidental to a procedure, such as clips or sutures. It also doesn’t include instruments that describe how a procedure is performed (e.g., instruments for visualization, such as a cystoscope). A device is something that is not incorporated into the body so that it can be removed at a later time. The purpose of the device can impact root operation selection.
For example, the root operation of supplement is defined as the putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part. However, the root operation replacement is defined as the putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part. ICD-10-PCS has a device key that is being continually revised as manufacturers describe their device in terms that can be captured within the ICD-10-PCS code set. The letter “Z” is used when there is not an applicable device.
Character seven: The final character captures any applicable qualifier (additional attributes of the procedure performed, when applicable). Examples include a type of transplant material (allogenic, syngenic, or zooplastic) or more information describing a bypass procedure. Again the letter “Z” is used when there isn’t a qualifier, and the letter “X” is used when it is a diagnostic procedure. The options for root operation, body part, approach, device, and qualifier vary depending on the section of ICD-10-PCS.
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