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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.

Sunday Reading: Physician Advisor 101

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

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.”

Sunday Reading: Compliance involvement in CDI efforts

The Physician Queries Handbook

The Physician Queries Handbook

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.

Sunday Reading: Case mix metrics

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

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.

Sunday Reading: Productivity and Other Metrics

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

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.

Book Excerpt: Multiple-choice queries

The Physician Queries Handbook

The Physician Queries Handbook

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.