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Book excerpt: Defining clinical documentation and coding standards in the revenue cycle, integrating real-time auditing, part 2

Lamkin_Elizabeth

by Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit every open chart and query providers to obtain clarifications and additional documentation when needed.

Placing CDI staff on the clinical units to audit chart documentation in real time and personally interact with physicians and other clinical staff, often helps with education effectiveness as well. The CDI specialist can query the physician to explain why the documentation does not meet criteria or does not really tell the story of the patient’s condition.

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Guest Post, Part 2: Where do we stand with clinical validation?

clinical validation poll(1)

According to an ACDIS poll, 70% conduct clinical validation reviews.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:

  • Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
  • Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

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Guest Post, Part 1: Where do we stand with clinical validation?

clinical validation queries

According to a recent survey, 44.88% send 5 or more clinical validation queries monthly.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.  The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This has been incorrectly interpreted by some to mean that clinical validation of documented conditions is no longer required for code assignment on claims.

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Summer reading: Defining documentation and coding standards in the revenue cycle, part 1

Lamkin_Elizabeth

Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules. A facility’s revenue cycle plan should define the necessary education on documentation, when and how this education will be delivered, and how compliance with education will be reported.

It is difficult to hold physicians and other medical staff accountable for applying the rules if they are not educated on what the most current rules require. Physician engagement increases if education includes why documentation is so important and why it must be done correctly while the patient is still in the hospital. Physicians normally do not receive formal education or training on documentation to meet regulatory and coding criteria in their training programs or through continuing education; therefore, it is up to the hospital to stay current on regulations and documentation rules and to provide training to physicians.

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Note from the Associate Director: Announcing a new outpatient version of the CDI Pocket Guide

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Associate Director Rebecca Hendren

By Rebecca Hendren

Outpatient CDI is a fast-growing area of the profession. So, I’m excited to announce a new resource that will be an incredibly useful tool for those expanding to the outpatient arena. Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, authors of the CDI Pocket Guide, are currently finishing their work on a new version focused on Hierarchical Condition Categories (HCC): the 2018 Outpatient CDI Pocket Guide!

One of our guiding principles at ACDIS is to be at the forefront of changes in the industry. We want to provide our members with guidance, information, and resources they can turn to for education and clarification as they venture into new CDI focus areas. We’ve been publishing articles exploring the growing outpatient and ambulatory arena for several years now and will continue to do so as this segment of the profession grows and changes. We want to keep our fingers on the pulse of what’s going on and share that knowledge with our members.

We bring together leading thinkers in the profession who can share their expertise, whether through articles in the CDI Journal, innovative sessions at our annual conference or the new outpatient-focused ACDIS Symposium, or lively discussions in the ACDIS Forum.

I’m delighted that the trusted authors of the CDI Pocket Guide are equally forward thinking and partnered with us to develop a this new resource.

Please continue to let us know what information you need and what resources you would like ACDIS to offer. We really do listen to you and use your feedback to develop our editorial directions.

Editor’s note: Hendren is the associate director of membership and product development at ACDIS. Contact her at rhendren@acdis.org.

Summer Reading: Stepping out on your own

LauriePrescott_May 2017

Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

‘Flying solo’

After a few trial runs, new CDI specialists should be given the opportunity to review records on their own. Before composing any queries during this initial stage, the manager or mentor should review a draft of the query proposed and provide feedback to identify any additional opportunities and compliance concerns, as well as to save the fledgling staff member from any potential physician ire due to a misplaced query.

Such feedback should reinforce concrete rules of the CDI road and should be supported by official rational from governing bodies such as AHA Coding Clinic for ICD-10-CM/PCS, Official Guidelines for Coding and Reporting, ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, or in-house policies and procedures.  Of course, mentors and managers should offer their expert opinions and tips on how to practice effectively, as well. This feedback should also offer the new staff member an opportunity to voice questions and concerns, and accelerate the learning process. This step in the process can continue until the new staff member and the preceptor agree that the new CDI specialist is functioning well independently and is comfortable “flying solo.”

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Summer Reading: Tips for preparing for the CCDS exam

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

Once you have met the two-year minimum work experience requirement required to sit for the Certified Clinical Documentation Specialist (CCDS) credential exam, it’s time to study. Start by reviewing CCDS Exam Candidates Handbook for information on applying to sit for the exam as well as the process for taking the test. The following are a few additional tips that many successful candidates have used to earn their certification:

  • Discuss with peers and supervisors
  • Join a study group
  • Visit the CCDS discussion board on the ACDIS Forum
  • Start studying early like a few months prior to sitting for the exam
  • Review a new content area each week
  • Spend extra time studying areas where you feel less confident
  • When reviewing practice questions multiple times, make sure you understand the concept and don’t just memorize an answer
  • Take a day or two to prepare your mind and body for the exam
  • Get a good night’s sleep and eat a good meal before taking the exam
  • Leave plenty of time to arrive for the exam

Once you are set to begin the exam, take a deep breath, exhale, and let your knowledge and experience guide you through successful completion of the certification.

Editor’s note: This article is an excerpt from the “CCDS Exam Study Guide,” by Fran Jurcak, MSN, RN, CCDS. To read more about certification, visit the ACDIS website, here.

 

Book Excerpt: Teamwork makes the dream work

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Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

CDI specialists do not work alone. They form a team with case management (CM) and physicians for concurrent documentation analysis and improvement. The case manager advises the physician on patient status, the CDI specialist ensures the documentation reflects the status and care, and the physician advisor is there to support CM and CDI if there is conflict with a physician or clinical staff. The physician advisor can take advantage of every interaction to transform potential conflicts into teaching opportunities.

For example, a patient is scheduled for surgery as an outpatient but the surgery is on the inpatient-only list (CMS, OPPS final rule, 2016). The surgery scheduling department checks the inpatient-only list and notifies the physician that CM is going to review for status. The surgery department then alerts registration, which notifies the CM, who checks to make sure all requirements for the inpatient surgery are met. The CM advises the physician on correct status and, ideally, the physician follows the CM’s advice.

The CDI specialist checks the documentation for compliance and coding, and queries the physician if the documentation is incomplete. If the surgeon refuses to change or complete the documentation, the CDI specialist escalates the issue to the physician advisor. The physician advisor contacts the physician and explains the reasons for inpatient status and additional documentation. The surgeon completes the documentation as requested. If these steps are completed, coding and billing will clearly know what claim to drop without requiring a bill hold and clinical review.

Additionally, this three-part team of CDI specialist, CM, and physician advisor are able to gather real-time feedback on whether the electronic health record (EHR) is user-friendly, and report findings back to the executive team and IT. In some cases, problems with the EHR are simply user error or lack of training, and the CDI specialist can play a role in teaching providers to use the EHR.

Throughout this process, the HIM department works with CDI and supports physicians through functions such as timely transcription and ensuring chart completeness. Together, CDI and HIM look to ensure appropriate orders, signatures, and all required elements of the medical record. This includes ICD-10 coding and documentation to monitor ICD-10 compliance. HIM has traditionally been responsible for the organization of the medical record but now must have a collaborative relationship with IT and the EHR vendor to ensure the record works well for all stakeholders.

Finally, HIM will also review the medical record upon discharge for completeness. The next step is to code the record for payment. If all the previous steps in revenue cycle have occurred correctly—required forms are in place, patient status is clearly documented with a care plan, and discharge status is clear and accurate—then the coders should have all the elements needed for accurate coding. There should be very few physician queries from HIM if coding is clearly supported through documentation. Getting all of this right while the patient is in the hospital will facilitate accurate coding and produce a clean claim to avoid back-end corrections and delayed billing.

Editor’s note: This article is adapted from The Revenue Integrity Training Toolkit by Elizabeth Lamkin, MHA, ACHE. Lamkin is CEO of PACE Healthcare Consulting and specializes in system development, quality and billing compliance. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Conference Corner: How to use the new ACDIS bookstore booth

Those who’ve attended multiple conferences may recall the previous ACDIS bookstore booth as a pretty hectic place, both for the attendees and the staff involved. With those memories in mind, the ACDIS team worked to redesign the booth for this year’s conference.

The booth has three distinct areas: one for browsing and asking questions, one for purchasing your books, and one to demo our e-learning courses and chat with our sales staff. This layout will streamline the experience of shopping at the booth for everyone involved.

Please take a few moments to review the following steps to ensure you know how the booth setup works.

  1. First, head over to the tables at the booth to browse the book and product selections. ACDIS team members will be present to answer any questions you might have.

    step 1

    Step 1: Choose your books

  1. After you’ve selected which books to purchase, head over to the checkout area. Once there, tell the staff member which book(s) you’d like. They’ll retrieve them from the bookshelves and you can pay right there.

    step 2

    Step 2: Make your purchase

  1. To demo a CDI e-learning course or chat with one of our sales reps, head on over to the final area of the booth.

    step 3

    Step 3: Chat with a sales rep and demo our e-learning

If you have any questions about the booth setup while at the conference, head on over. The staff is happy to help walk you through the process.

 

Note from Associate Editorial Director: Quotes of note

Melissa Varnavas

Melissa Varnavas

by Melissa Varnavas

As a young journalist on deadline, I stared down a blank white computer screen as the clock ticked toward midnight, pondering an exposition regarding my home town’s complicated municipal budget. In the end, I settled on introducing the article with a quote from Theodore Roosevelt. “Nothing in the world is worth having or worth doing unless it means effort…”

As the article devolved into a collection of quotes from city councilors, my editor at the time simply titled the piece “Beverly Budget Debate: Quotes of Note.”

While not exactly one of my more shining journalistic moments, it is true that certain quotes, like that of Roosevelt’s, reverberate through time, echoing with the truth of the sentiment they express. It’s probably the reason so many ACDIS members include famous quotes in their email signatures.

I love the one from hockey player Wayne Gretzky that ACDIS member Tracy Boldt, RN, BSN, CCDS, CDIP, system manager for CDI at Essentia Health in Duluth, Minnesota, uses in her signature: “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.” The 2016 CDI professional of the year award winner Karen Newhouser played off Gretzky’s quote in her acceptance speech, encouraging those in attendance to use the resources available to them to stay informed about changes in healthcare reimbursement and their effect on CDI efforts.

Another of my favorites related to the CDI profession has long been Mark Twain’s: “The difference between the almost right word and the right word is really a large matter. ’Tis the difference between the lightning bug and the lightning.” Don’t call it congestive heart failure if it’s actually acute-on-chronic diastolic heart failure.

Musing on this, I asked the ACDIS team to put on their thinking caps and come up with a few themselves. Both ACDIS Director Brian Murphy and ACDIS CCDS Coordinator Penny Richards stuck with a writerly theme and the importance of thoughtfully chosen words to convey a message.

Murphy chose John Cheever’s: “A page of good prose remains invincible.”

Richards chose Emile de Girardin’s: “The power of words is immense. A well-chosen word had often sufficed to stop a flying army, to change defeat into victory and to save an empire.”

“Not to mention invited in the auditor or caused claims to be denied,” she added.

ACDIS Editor Linnea Archibald pointed to a quote from Henry Wadsworth Longfellow: “It takes less time to do a thing right than to explain why you did it wrong,” as evidence of the importance of educating physicians on proper clinical documentation habits. Those physicians who take the time to heed CDI professionals’ advice, she says, ultimately end up saving time by getting the documentation correct to begin with.

ACDIS Associate Director of Membership and Product Development Rebecca Hendren chose a quote from Jane Austin, tweaking the details a tad. “It is a truth universally acknowledged, that a physician in possession of poor documentation must be in want of a CDI specialist.” We’ll leave it to you to look up the original wording.

ACDIS Educational Director Laurie Prescott couldn’t settle on just one. Her favorites include:

  • “Good words are worth much, and cost little,” by George Herbert
  • “I like good strong words that mean something,” by Louisa May Alcott, in Little Women (like acute, chronic, and acute on chronic, Prescott added)
  • “It’s always a bit of a struggle to get the words right, whether we’re a Hemingway or a few fathoms below his level,” by Rene J. Cappon (which is why you have CDI specialists to assist you, Prescott joked)

We’re sure you have your own favorites, too. Feel free to share them with us or better yet, why not play this game with your CDI team and post your quotes near physician’s documentation stations and around your CDI department as a fun way to provide a little additional insight into the importance of CDI.

After all, as Aristotle said, “The aim of CDI is to represent not the outward appearance of things, but their inward significance.”

Editor’s note: Varnavas is the Associate Editorial Director of ACDIS. Contact her at mvarnavas@acdis.org.