All Entries in the "Books" Category
Book Excerpt: Documentation pocket cards as physician training tool
Many programs have developed their own home-grown documentation pocket cards, or tip sheets, based on the clinical topics most apropos to their specific facility. Some handouts are a simple piece of paper developed by the CDI team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program.
In general, a pocket guide explains that physicians must document underlying conditions, not simply the signs and symptoms of the concerns, and link the disease to the underlying cause whenever possible. It also directs physicians to document “suspected,” “likely,” or “probable” in the absence of a definitive diagnosis.
Many facilities include prompts for more specific diagnoses such as systemic inflammatory response syndrome (SIRS) and multiple organ failure and an alphabetical list of important conditions frequently forgotten by physicians, such as:
- Acute exacerbation of chronic obstructive pulmonary disease (COPD)/asthma
- Malnutrition
- Metabolic/respiratory acidosis
- Metabolic/respiratory alkalosis
- Sepsis/severe sepsis/septic shock
- Systolic/diastolic heart failure
- Pneumonia
If generating a tip sheet for your facility, list common nonspecific terms physicians frequently use to describe patient care and compare them to similar ICD-9-CM terms that, when coded, reflect a greater severity of illness (SOI) for the patient. For example, “cystitis” may also be “urosepsis”/ “urinary tract infection (UTI),” or it may be “sepsis due to UTI.” Each term progressively increases the patient’s SOI.(6)
Some tip sheets also include Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) quality measures, history and physical (H&P) documentation, discharge summary consistency, POA, and hospital-acquired conditions (HAC). Employing such cards during both initial and subsequent training programs:
- Ensures everyone speaks the same language
- Promotes facility-wide team building
- Provides additional avenue of education regarding CMS/RAC updates
Editor’s note: This article was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN, and Heather Taillon, RHIA.
Pamela P. Bensen, MD, MS, FACEP, CEO of Medical Education Programs, Inc. in Buffalo Junction, VA, created a laminated pocket guide for physicians available in packs of 25.
Book Excerpt: The CCDS Exam Study Guide
Since we’ve been talking so much about The CCDS Exam Study Guide this week, what with Fran Jurack’s post about writing the book, the introduction of ACDIS CE and credentialing coordinator Kerry Neenan, and last week’s endearing post from Jennifer Love about her experiences preparing for and taking the test, I thought you might appreciate a little excerpt from the book itself.
Fran decided that it would be a good idea to address top documentation concerns organized by major diagnostic category (MDC), and in Chapter 4 of The Study Guide, she covers everything from HIV to sepsis, Encephalopathy to excisional debridement. Since congestive heart failure (CHF) continues to be on many CDI specialists’ lists of clarification hot topics, I’ll share what Fran had to say on that topic. Here goes:
“CHF is a temporary or chronic clinical condition resulting from failure of the heart to maintain adequate circularion. It is a costly and deadly disorder that affects almost 20% of hospital admissions. It is estimated that 20-50% of patients with heart failure have preserved systolic function or a normal left ventricular ejection fraction (EF). Specificity of the type of heart failure is extremely improtant for proper coding of the condition. It is also important to clarify the underlying condition (in this case, some type of acute heart failure) as well as all the comorbid conditions. These patients often present with a chief complaint of shortness of breath and are treated for acute respiratory distress…
“When determining whether the condition is acute or chronic, assess the history of the patient. If the patient has no history and CHF is documented, the CHF should be identified as acute, as it is a new condition for the patient. The aggressiveness of the treatment also indicates acute versus chronic.
“For example, the physician’s decision to use IV Lasix rather than the patient’s usual oral dose might indicate treatment of an acute event of a chronic CHF diagnosis, and as such represents an opportunity for the CDI specialist to query the physician. Changes in other cardiac medications and use of high-flow oxygen devices may also indicate acute on chronic events. Pleural effusions are considered part of the CHF process and will be excluded as a CC when coded in conjunction with any CHF code. “
Nearly 50 people have registered to take the CCDS exam on Saturday, June 5, after the 3rd Annual ACDIS Conference. The cutoff date for registering for the paper test in Chicago has passed. And there is an exam “blackout” period from June 5 through July 14, 2010, to allow for the processing and assessment of the updated version of the exam. Although CCDS credential hopefuls cannot sit for the exam during that time, we encourage those interested to begin the application process. Beginning July 15, qualified applicants may take the updated exam at AMP Assessment Centers as usual.
