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Local Chapter Update: TN leadership recaps successful January event

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The joint meeting of ACDIS, THIMA, and THA

by Sherri Clark, BSN, RN-BC, CCDS, CCS, Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, and cord member of the Tennessee chapter of ACDIS

The joint meeting of the Tennessee Chapter of ACDIS (Association of Clinical Documentation Improvement Specialist), THIMA (Tennessee Health Information Management Association), and THA (Tennessee Hospital Association) occurred on January 27. The meeting took place at the THA headquarters in Brentwood. The subject of the meeting was “The Impact of ICD-10 and Payment Reform on Clinical Documentation Improvement.” Four members of the core team of TN ACDIS chapter leaders (Sherri Clark, Kristie Perry, Cynthia Raymond, and James Kennedy, MD) and one chapter member (Kyra Brown) served on the planning committee for this joint meeting. Attendees were offered a number of hour-long presentations to choose from during the meeting, including:

  • Managing Conflicting Guidelines in ICD-10–CM/PCS
  • CDI, Coding, and Quality – The Three Legged Stool
  • Payment Reform in TN – Health Care Innovative Initiatives
  • Recovery Auditor Prevention Strategies: How to keep the predators away
  • MACRA, MIPS, APMS: Why CDI is a critical ingredient of the alphabet soup?
  • ICD-10-PCS and the Impact on CDI
  • The Case for Category II Codes
  • Hospital Improvement Network and other statewide databases: How are they used and the importance of quality data
  • The Impact of HCCs on Physician Accountability

The meeting drew physicians, coders, CDI specialists, and executives from THA. The presenters for the meeting included members of ACDIS, AHIMA, THIMA, and the THA. ACDIS Director Brian Murphy attended the meeting, as did all of the TN ACDIS Chapter leaders—Sherri Clark, Kristie Perry, Cynthia Raymond, Judy Rochelle, and James Kennedy. The joint meeting qualified for six continuing education units for ACDIS and AHIMA.

Editor’s note: Clark is a Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, Tennessee. She has been an ACDIS member since the spring of 2008 (she even attended the first ACDIS conference that year!) and a chapter leader since 2011 when the chapter was formed. For information regarding upcoming local chapter events, visit the website or email Clark at SClark@mc.utmck.edu.

Conference Q&A: DeVault illuminates the shift to outpatient CDI

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Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA

Editor’s Note: Over the coming weeks, we’ll introduce a few of this year’s speakers who are heading to the podium for the ACDIS 10th Annual Conference which takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager, HIM Consulting Services for United Audit Systems, Inc., who presents “Clinical Documentation Improvement – From Inpatient to Outpatient: Defining the different documentation, coding, and reimbursement requirements.” She has more than 25 years of experience in HIM serving as the senior director of HIM practice excellence, coding and reimbursement for AHIMA from 2008 to 2014.

Q: What made your company want to expand into the outpatient setting?

A: We noticed that it was the next natural progression in the CDI world. With hierarchical condition categories (HCCs), Medicare Access and CHIP Reauthorization Act (MACRA), risk adjustment, etc., it’s really a prime time for CDI. Where to start is the hard part. With inpatient documentation reviews, CDI professionals have a captive audience, so to speak. With outpatient, CDI programs need to look at all the different departments where physician documentation plays a role. On top of that, there’s the physician clinics. It’s very complex on how you move the well-oiled machine of inpatient CDI into the outpatient world – everything gets really muddied.

Q: What are three things attendees can expect from your session?

A: At the end of my session, attendees will be able to:

  1. Start to delineate what outpatient CDI looks like in the post-acute care setting. It’s not as simple as duplicating your inpatient CDI program
  2. How inpatient and outpatient CDI roles differ; and
  3. Some tools to build the framework for outpatient CDI. Your CDI framework could look very different and you need to do active discovery. CDI looks different in every setting based on where their needs are.

Q: Who should attend your presentation and why?

A: CDI specialists and anyone who’s involved with coding and CDI – CDI managers, finance side, directors, HIM directors, coding managers, coders, and even physicians! Essentially, it would be good for everybody. Anybody trying to figure out what outpatient CDI looks like should definitely attend. It’s like the transition to ICD-10 in that we need to think about how we eat the elephant one bite at a time. Outpatient CDI is a whole new elephant.

Q: What’s one tool no CDI professional should be without?

A: A CDI specialist should always have their communication skills. A CDI specialist is in a unique position because they live in the middle. They need to have a relationship with providers and then they also need that communication with coders.

Q: What are you most looking forward to about this year’s conference?

A: Networking! Last year, was the first year I was there as a vendor. It’s so fun to meet our clients. It’s great to put a face to a name!

Q: Fun question: what’s your favorite movie?

A: I’m kind of a sap, so I love PS. I Love you. I also really love Brian’s Song.

 

 

 

Guest Post: Clinical validation denial targets

by Erica E. Remer, MD, FACEP, CCDS

Auditors target multiple conditions which for clinical validation denials (CVD). Personally, I found acute kidney injury (AKI) and malnutrition the most commonly defensible targets. On the other hand, I often agreed with auditors on their CVDs for pneumonia and urinary tract infections. Other frequent CVDs included sepsis, encephalopathy, and respiratory failure.

Certain diagnoses are susceptible to CVDs for the following reasons:

  • DRG downgrade: Auditors target medical records with only one CC/MCC because doing so downgrades the DRG and results in less reimbursement.
  • Empiric treatment: Providers start antibiotic therapy early for patients who present with signs of infection (e.g., fever, leukocytosis, altered mental status) on as they seek the infection’s source. Sometimes the physician cannot identify the source or the etiology of the disease turns out to be a different than originally expected. Clinicians also need to be careful to not propagate the original debunked diagnosis via copy and paste, so it gets wrongly coded.
  • Documentation consistency: Physicians should document their medical decision making process throughout the patient’s stay. Best practice is to document when a diagnosis is initially considered (may be in uncertain format), when the diagnosis is definitively ruled in, and when the condition resolves. The physician should recap this information in the discharge summary. Only mentioning a diagnosis once in the medical record, while permissible, raises an auditor’s interest and begs the question of whether the condition really was present.
  • Pursuant to a query: When providers need to be queried to make a diagnosis codable, and they agree without supplying any clinical support, a red flag goes up—and I mean like waving one in front of an auditor like a bull, and not just signaling peril up ahead.

Finally, auditors target diagnoses with uncertain or emerging clinical guidelines. Clinical guidelines change, but it takes time for medical practice to adjust (e.g., malnutrition, sepsis). If a guideline is not universally adopted (for example, discussions regarding the new Sepsis-3 definitions) some variability in medical practice is allowed. That doesn’t necessarily mean a provider is wrong if he or she does not follow the latest guideline. As long as the provider is within the acceptable range of practice, he or she just needs to demonstrate the clinical considerations of the case and the auditor should accept the diagnosis. If a provider deviates from clinical criteria or guidelines, he or she should document the mitigating circumstances (e.g., on beta-blockers, previous antibiotic therapy, contamination).

On the other hand, the provider needs to consider established guidelines. If the average, prudent similarly qualified practitioner wouldn’t call an asymptomatic deviation of sodium by 1 mEq/L, hyponatremia, neither should you.

Similarly, AKI has criteria of change within the previous 48 hours, or deviation from a baseline from seven days ago, but a provider could make a convincing argument that the patient’s serum creatinine (SCr) is always X and the acute derangement is likely to have occurred since the onset of symptoms 36 hours ago. It would be quite serendipitous to randomly have a baseline drawn within seven days of an index visit if AKI preceded hospitalization, wouldn’t it? However, if the SCr is only off by 0.1 mg/dL, you are hard-pressed to spin that as AKI.

While the coder may not really the arbiter of clinical validation, coders should be empowered to refer questionable records for a clinical review either by the CDI specialist, the attending, or a physician advisor/champion, and coders need to know which conditions are vulnerable and which clinical indicators to consider.

Absence of abnormal clinical indicators does not mean the condition is definitively not present; it means the encounter needs clinical review and the condition may require more documentation to support it.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at icd10md@outlook.com. For the third part of this article, return to the blog next week!

Note from the Instructor: Are you a critically thinking CDI?

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

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

I spend much of my time communicating with CDI managers and directors. They work tirelessly to develop and nurture CDI departments, focusing much of their time on training new CDI staff and evaluating the experienced CDI professionals in their care in order to identify areas of education need. Often CDI directors fight for funding to buy the newest software with the latest and greatest bells and whistles. I remember how excited I was to use the new encoder when I was a young CDI specialist. Now there’s computer assisted coding software, software that prioritizes and develops work lists, tracking software, query opportunity software, etc., etc.

This all sounds great, but I think such technology may also be a hindrance when training new staff.

Experienced CDI specialists often complain about the lack of critical thinking skills within the ranks of those new to the industry. I often hear that it is difficult to teach a new CDI staff person because “no one uses the books anymore.” I hear that new CDI staff simply follow the query leads fed to them from the software programs and that they are not thinking for themselves. Managers also complain that many of the more experienced staff seem to be “coasting in their retirement job,” don’t wish to engage with the medical staff or challenge the status quo, and have become overly dependent on the EHR and the software to direct their day-to-day activities.

Please don’t get me wrong, I love the technology we have at our fingertips, but we also must understand that we, the CDI specialists, should be directing the software and not the other way around. This technology is meant to be a tool that assists the living, breathing, thinking CDI specialists. We need to use the skills our experience and intellect bring to the table whether those abilities be regulatory or coding knowledge, clinical expertise, communication skills, or, more importantly, a collection of these talents.

We speak about software in our CDI Boot Camps all the time. In these discussions, I encourage new CDI staff to pick up a code book, and a DRG Expert, and work the chart the old-fashioned way. Many groan when I mention such prehistoric methods to practice CDI, but there is a method to my madness. To effectively work as a CDI and to use the technology to its utmost value, we need to understand the inner workings and decisions the software program was designed to make. We need to know when the software misses something or inappropriately identifies a diagnosis that does not exist.

Critical thinking is defined as an active process of applying, analyzing, synthesizing, and evaluating information. The Critical Thinking Community (http://www.criticalthinking.org/pages/defining-critical-thinking/766) describes it as “ entailing the examination of those structures or elements of thought implicit in all reasoning; purpose, problem, or question-at-issue; assumptions; concepts’ empirical grounding; reasoning leading to conclusions; implications and consequences; objections from alternative viewpoints; and frame of reference.”

My simplified definition is that critical thinking is “thinking about your thinking,” questioning all conclusions and working to ensure you interpret all the facts and evidence correctly.

Critical thinking has been a buzz word for years, especially in healthcare. Many go through the motions of the day, not taking the extra energy to actually think through the record and identify those opportunities requiring intervention. CDI professionals need to attack each day’s tasks with an active focus. We cannot simply depend on a computer program to do the job for us. If all it took was a computer program, no thinking, no experience no effort—we would not be such a hot commodity in the world.

Editor’s note: Prescott is the CDI education director for ACDIS. She serves as a full-time instructor for its various Boot Camps as well as a subject matter expert for the association. Prescott is a frequent speaker on HCPro/ACDIS webinars and is the author of The Clinical Documentation Improvement Specialist’s Complete Training Guide and co-author on the forthcoming volume regarding the role of CDI staff in quality of care measures. Contact her at lprescott@hcpro.com. This article originally appeared in CDI Strategies.

Guest Post: Protecting documentation from clinical validity denials

by Erica E. Remer, MD, FACEP, CCDS

Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes, retrospectively, that a patient was not really afflicted by a condition documented in the medical record and coded by the coder.

If a coder assigns a code for a condition not really present, and removing that code assignment results in a lower-weighted DRG, then it is reasonable for a payer to expect the overpayment back.

However, if the condition was indeed present, medical personnel invested time, energy, supplies, and other resources, the hospital is entitled to reimbursement. Therefore, it is not appropriate to remove a diagnosis which was genuinely present. It is also unfair to remove legitimate diagnoses, because this results in the downgrade of severity of illness and complexity of management, and falsely deflates the quality measures assigned for that patient’s care.

Thorough documentation

It has never been reasonable or compliant for a coder to infer medical conditions from clinical indicators, and it is not reasonable to expect a coder to decide that a condition doesn’t exist if the provider documented it.

The ICD-10-CM Official Guidelines for Coding and Reporting for 2017 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.

Although the provider’s statement may be sufficient to code a particular condition, it does not mean the condition indisputably exists.

The adage is, “if you didn’t document it, you didn’t do it.” But we all know that is not true. No physician documents every thought or action, and it would be absurd to expect them to do so. The dilemma arises when a physician documents a condition without giving adequate evidence as to what led him or her to make the diagnosis.

Concurrently, a documented diagnosis which is not really present could lead other healthcare providers down an erroneous path. Conversely, not providing clinical support for a valid diagnosis sets the stage for future denials.

The legal definition of the standard of care is managing a patient at the level at which the average, prudent, similarly qualified practitioner in a given geographic medical community, would be providing medical care under the same or similar circumstances. There are clinical guidelines and scores which may assist a clinician in making diagnoses, but prudent practitioners also bring their past experience, knowledge, and judgment into play.

Medicine is an art, not a science, and not every patient “reads the textbook.” Many patients’ lives have been saved by a clinician who followed his or her gut. Just because a patient doesn’t strictly meet clinical criteria, doesn’t preclude him or her from having the medical condition that an astute provider diagnosed.

Is there a standard of documentation similar to that legal definition of a standard of care? The purpose of patient record documentation is to foster quality and ensure continuity of care. It is clinical communication. The fallacy is that documentation needs to be expansive and long; it just needs to convey to the subsequent healthcare provider (as well as the coder, utilization/case manager, auditor, lawyer, etc.) what the provider was thinking and why.

What coders can do

Sensible, qualified, and experienced coders or CDI specialists may read documentation and have concerns that a diagnosis is not supported by the clinical indicators.

Do they just unfailingly code a documented condition because the Official Guidelines for Coding and Reporting say that the provider’s statement is sufficient, or do they query the physician? Which conditions are prone to this? What clinical indicators should they be considering? How does one broach this subject with the physician?

The ACDIS/AHIMA’s Guidelines for Achieving a Compliant Query Practice recommend generating a query when the health record documentation “provides a diagnosis without underlying clinical validation.” It notes that “the focus of external audits has expanded in recent years to include clinical validation review,” and instructs coders to follow CMS and Coding Clinic guidelines, and to “query the physician when clinical validation is required.”

The CMS Statement of Work for the Medicare Fee-For-Service Recovery Audit Program 2013 notes that “clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”

I concur that a certified coder who has identified a diagnosis which needs more clinical support does not have the ability to validate it, but has the skills to recognize the necessity for validation.

If your institution has CDI specialists, then you have someone with the appropriate credentials in place to generate a query. The physician is the one who performs the validation by responding to the query in the affirmative, and by providing their clinical evidence for the diagnosis in question.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at icd10md@outlook.com. For the second part of this article, return to the blog next week!

Back to basics: The key skills that represent the cornerstone of CDI success

Wendy De Vreugd

Wendy De Vreugd

During a conversation regarding what basic elements CDI programs need at the onset in order to be successful, ACDIS Advisory Board member Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, Director Case Management Case Management and Clinical Social Work
University of California Irvine Health offered the following suggestions. Contact her at wdevreug@uci.edu.

  1. Selecting staff: Matching CDI key skills/qualification/experience to the CDI role and CDI needs of the facility (academic, community hospital, access hospital, product lines). Staff members also need to be an effective trainer and engaged learner to be able to internalize the CDI mission and explain it to physicians and ancillary staff. Having skills in communication/negotiation (vs. introverted) and knowing one’s own strengths and weaknesses goes a long way in being successful in this role.
  2. Assessing where to start: New program managers (or those tasked with starting CDI reviews) need to understand administrators’ top priorities and focus area for the program. The first task is to meet (or exceed) those expectations in order to move the program forward and meet some of the larger programmatic targets suggested by industry leaders. (Advancing beyond CC/MCC capture and straight Medicare record reviews.)
  3. Creating the return on investment (ROI): Regardless of whether your program is a single CDI staff shop or led by a manager and team of coworkers, those involved need to understand the mission and the metrics used to measure the program’s efforts toward its goals. Providing those metrics to the team and keeping that information sharing going through administrative outcome reports (showing quality progress and revenue/CMI capture) not only ensures transparency but effectiveness as well.
  4. Standardizing queries: As this is the CDI program’s most essential tool, spend some time studying the evolution of physician query practice guidance from AHIMA and ACDIS. Queries do need not be scripted. In fact, each must contain the critical clinical information related to that particular patient encounter. Yet, the program needs comprehensive policies and procedures in place as to how to draft a compliant query, how to follow up with physicians, how to track queries, and how to escalate matters if necessary.
  5. Building critical relationships: As CDI professionals essentially work as intermediaries between physicians and coders as translators between the clinical and coding languages establishing effective relationships with these core groups can’t be understated. CDI teams should meet regularly with HIM/coding staff to share documentation integrity concepts. They should feel enabled to ask coders questions about new guidelines and coding conventions. CDI staff also need to obtain input from other departments such as wound care, pharmacist, respiratory therapist, nursing, ICP, etc.)

These are just a few of the essential ingredients, to be sure. If you’re just starting out and want some additional information, feel free to reach out to Wendy or any of the members of the ACDIS Advisory Board. Learn more about them at our website.

Featured Member: CDI educator receives high praise from colleague

Christi Drum, RN, BSN, CCDS, CDI educator at Lee Health in Fort Meyers is the "rock" of the program.

Christi Drum, RN, BSN, CCDS, CDI educator at Lee Health in Fort Meyers is the “rock” of the program.

A few weeks ago, ACDIS put out a call for members to nominate a colleague to be featured on the ACDIS Blog. We received a number of responses, but this one stood out. Kristi Repetto, RN, BSN, CCDS, director of CDI at Lee Health in Fort Meyers, Florida, nominated her colleague, Christi Drum, RN, BSN, CCDS, and had this to say:

“[Christi] is the ‘rock’ of our department. She has held a team lead role in the past and is extremely knowledgeable. She works collaboratively with our coding department to make sure both coding and CDI receive the same information regarding new updates, education, or query work flow. Christi is amazing!”

Drum began her career in CDI three years ago and, before that, worked as a nurse in the inpatient setting. She is currently a Florida ACDIS chapter member. Drum and her husband have two sons, ages 17 and 15, and one daughter, age six.

ACDIS Blog: Why did you get into this line of work? 

Drum: I was looking for a career change away from bedside nursing that would benefit from my inquisitive nature, attention to detail, and readiness to learn new things, but would also benefit from my years of experience in critical care nursing.

ACDIS Blog: What has been your biggest challenge?

Drum: To accept that little in the realm of CDI is black and white. Chart reviews can be very subjective based on personal clinical experience and interpretation, not only for CDI specialist but for coding as well. Learning to adjust to this as a new CDI staff member was certainly a challenge for me.

ACDIS Blog: What has been your biggest reward?

Drum: My transition to the CDI educator role. I thoroughly enjoy training and orienting new staff members on all things CDI. I’m quite passionate about CDI and love to cultivate that in others. It is a very rewarding job to see others learn and become successful as CDI specialists.

ACDIS Blog: How has the field changed since you began working in CDI?

Drum: I think the biggest change for us has been the buy-in from the physicians. They were initially very resistant and reluctant to work with and learn from the CDI team. We have seen physicians begin to engage, increase compliance, and seek out CDI staff members for new education and learning opportunities.

ACDIS Blog: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on CDI Talk or through ACDIS?

Drum: ACDIS is a wealth of information and a crucial resource in this job. From sample queries and networking opportunities, to physician education and keeping abreast on current news topics, ACDIS offers it all.

ACDIS Blog: What piece of advice would you offer to a new CDS?

Drum: Be patient with yourself! CDI is very different from bedside nursing. It takes time and exposure to learn and remember the many different facets, rules, regulations, requirements, guidelines, Coding Clinics, etc. Also, never stop asking questions. So much in this industry changes so frequently. It is normal and beneficial to seek the help and advice of others in your field.

ACDIS Blog: If you could have any other job, what would it be?

Drum: Something that allowed and paid for international travel and sightseeing.

ACDIS Blog: What was your first job (what you did while in high school)?

Drum: I started working at the age of 14 at Chick-fil-A and worked there for two years. To this day, I still enjoy eating there.

ACDIS Blog: Tell us about a few of your favorite things:

  • Vacation spots: Maui
  • Hobby: Relaxing at the beach and kayaking
  • Non-alcoholic beverage: Unsweetened tea with a little Stevia or flavored sparkling water
  • Foods: Anything gluten free, but I particularly like the sweet treats
  • Activity: Traveling to new places

Editor’s note: The ACDIS Blog occasionally introduces an ACDIS member to the larger CDI community. If you would like to be featured or know someone who would, please email Associate Editorial Director, Melissa Varnavas, at mvarnavas@acdis.org.

 

Thoughts from the field: Expert thinking

Don't sweat it, share your expertise with the CDI community.

Don’t sweat it, share your expertise with the CDI community.

I was looking through old drafts of blog posts and came upon some notes from ACDIS blogger Linda Renee Brown. She wrote that sometimes CDI professionals look for expert advice and that once they identify it, they follow it to the letter. But “What’s an expert?” she asked, and went on to quote an old teacher who broke the term down into its component parts stating that a “ex is a has-been and a spurt is a drip under pressure.” Clearly the teacher (and Brown) meant that anyone can self-describe as an expert but its up to us as individuals to do the extra research and ensure that the advice provided is actually sound.

In clinical documentation, as in any professional field, there exist any number of possible expert resources from which to draw advice and information. Programs instituted on the advice of a consulting firm may have benefited from its initial education and training. Those with extensive electronic health records and eQuery systems no doubt learn from the expertise of its designers and staff as well as the technological tools and resources available within the system.

All types of other experts also exist. The person who hired you, perhaps. The co-worker who offered you a kind word and simple advice which resonates even today. The coder who continues to lend you an ear as you try to decipher the latest recommendations from Coding Clinic.

Yes, even various publications can provide a certain amount of expertise. Coding Clinic of course serves in this role, as the AHA represents one of the four cooperating parties governing code assignment. So, too, does AHIMA and it’s publications, similarly due to its participation on that four-corporation governing body as well as its more than 75 year legacy representing the health information management field.

And, of course, we believe that ACDIS provides expert advice as well. It is the only association totally focused on the daily activities of those working to ensure the complete integrity of the medical record. That’s not why I believe ACDIS’ advice equals sound advice, however. Actually, I believe the strength of the education, insight, interpretation, and analysis provided to its members comes directly from the collaborative nature of the association itself. We depend on the input and opinions of our members. We bring those thoughts and ideas forward in a number of ways, through the Journal, ACDIS Radio, our quarterly conference calls, and more. We encourage your feedback and suggestions on those items and we continue to grow and reassess the state of the profession through your eyes.

As Brown wrote in her notes, “if you’ve been working in CDI for any length of time and you’ve allowed yourself—and have been allowed—to think for yourself and act for yourself and make judgments based on what you know in your core to be right, you don’t need an expert. You are headed in the right direction.”

Whether you’re looking for advice on a particular topic or have an opinion, thought, or CDI success story reach out to your peers here or via the ACDIS Forum. By sharing our expertise we all benefit.

Guest Post: Close the communication gap with case management

Glenn Krauss

Glenn Krauss

Clinical documentation improvement (CDI) specialists and case managers share a common goal but often aren’t on the same page when it comes to improving documentation within the hospital, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, director of enterprise solutions for Zirmed, in Chicago.

Organizations should shift the focus of CDI from merely capturing as many comorbidities and complications (CC) and major comorbidities and complications (MCC) to truly improve the written picture of the patient’s condition.

This change in focus needs to do several things, according to Krauss, including:

  • Recognize any barriers that exist between CDI and other departments they need to work with.
  • Create a supportive environment and reporting structure for CDI that recognizes the limitations of strict reimbursement outcomes and realigns the focus of CDI toward processes and outcomes that incorporate the multitude of uses in today’s fee-for-value healthcare delivery model.
  • Define and agree upon what constitutes true CDI. This should reflect effective communication of patient care, outcomes, and fee-for-value to the mutual benefit of all healthcare stakeholders, including the patient.
  • Revise the job description for CDI to give these staff members more encompassing duties and responsibilities and to better define clinical duties and responsibilities.
  • Develop expanded and more refined key metrics of documentation improvement that are valid and meet inter-rater reliability.

By encouraging CDI to take a more comprehensive approach to documentation you’ll not only improve their ability to work with case management, but also their ability to work toward more accurate billing and fewer denials.

Editor’s Note: This article is an excerpt from Case Management Monthly.

 

A look back: 2015’s noteworthy quotes

Time to celebrate a year's worth of CDI accomplishments!

Time to celebrate a year’s worth of CDI accomplishments!

Another tradition in my household is to take some time around the dinner table on New Year’s day to talk about some of the things we’re grateful for that happened to us in the year that passed. Such reminisces often raise interesting thoughts. All together as a family, we each remember something slightly different, in different way, and when these thoughts come together they create a cohesive whole that gains additional significance.

So I thought I’d take a look back at our year in CDI and pull our little CDI family together in the form of salient quotes from the pages of the CDI Journal the past year. Some interesting themes emerged. ICD-10-CM/PCS implementation was threatened but eventually implemented. CDI programs continued to expand their scope from CC/MCC capture to quality concerns. Programs expanded scope into pediatric and outpatient arenas, too. Some things remained the same, too. Central among them remains the fact that CDI program’s core function is assisting physicians in crafting the most complete and accurate chart possible.

What quotes from 2015 will you take with you into 2016? Let us know in the comments section below!

“It isn’t about the code set per se, it is about documentation improvement. We have to continue to assess documentation quality, and that’s true regardless of which code set you are working within.” ~Kathy DeVault, MSL, RHIA, CCS, CCSP, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

“CDI staff are asking specific questions about ethical behavior. The new [ACDIS Code of Ethics] is founded on the real-life concerns of CDI professionals.” ~Michelle McCormack, RN, BSN, CCDS, CRCR

“You can train people on the technical aspects of the job, but teaching a person to think critically can be difficult, so it is incredibly important to hire the right person.” ~Lisa Romanello, RN, CCDS

“Documentation improvement programs need to become patient centered and follow documentation improvement opportunities across the care continuum, including ambulatory, inpatient, and postacute care.” ~James P. Fee, MD, CCS, CCDS

“Best practice would be to make your queries a permanent part of the medical record to demonstrate CDI/coding efforts in obtaining clarification regardless of the outcome.” ~Cheryl Ericson, MS, RN, CCDS, CDI-P, CDI education director at ezDI

“My biggest reward has been learning what CDI is all about and having the opportunity to continually grow in the field.” ~Fran Platt, BSN, RN

“Each CDI specialist and coding professional must be open-minded and willing to listen to differing opinions, and be able to contribute positively to the discussion of each case.” ~Walter Houlihan, MBA, RHIA, CCS

“Children’s hospitals are now paying more attention to how documented pediatric terminology affects APR-DRG assignment and its reimbursement, particularly since bundled payments are part of CMS’ game plan.” ~James S. Kennedy, MD, CCS, CDIP

“Switching to ICD-10 from ICD-9 is a very costly endeavor, and many healthcare facilities and healthcare-related companies have invested millions of dollars on systems and training.” ~Rebecca A. “Ali” Williams, MSN, RN, CCDS

“The opportunity to network and share documents, tools, and processes has allowed the profession to grow from a group of people who reviewed charts to a profession that drives patient care improvement through the support of accurate and compliant documentation.” ~Fran Jurcak, RN, MSN, CCDS