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Guest Post: Minute for the medical staff, part 1

James Kennedy, MD, CCS, CDIP

James S. Kennedy, MD, CCS, CDIP

By James S. Kennedy, MD, CCS, CDIP

Those of us who care for critically ill patients intuitively know who will have a long hospital stay and who will die. As such, intensive care unit (ICU) scoring systems based on clinical indicators such as Acute Physiology and Chronic Health Evaluation Three (APACHE-3) or Simplified Acute Physiology Score Three (SAPS III) in adults or Pediatric Index of Mortality Two (PIM2) in children have been developed, though validity in an individual patient varies.

Medicare, state governments, and private enterprise, such as Vizient, Truven, Quantros, and 3M, also have scoring systems based on the ICD-10-CM codes derived from explicit, clear, and consistent provider documentation. As such, how we define and document diagnoses that predict morbidity and mortality is essential if we want our patient’s risk to be accurately portrayed.

Physician definitions and documentation are crucial

In navigating the ICD-10-CM maze, we must remember the following as written in the Coding Clinic for ICD-10-CM, Fourth Quarter, 2016:

  • Code assignment is based only on provider documentation of a codeable condition, not on w a superbill definition or a clinical abstraction form of the medical record. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can diagnose the patient.
  • While physicians may use a particular clinical definition, or set of clinical criteria to establish a diagnosis, the ICD-10-CM code is based only on his/her documentation, not on clinical indicators supporting these definitions or indicators. In other words, regardless of whether a physician uses the new clinical criteria for sepsis (Sepsis-3), the old criteria (Sepsis-1 or Sepsis-2), his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same. As long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned.
  • A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system. As such, if the physician documents a condition that does not meet a facility’s definition, the physician may be approached to clarify whether he or she really thinks the patient has the documented condition. These queries are not a criticism of a physician’s judgment, but represent a request to be reassured that the diagnoses are based on the physician’s best medical judgment and that he or she will participate in any defense of codes based on documentation which may be subsequently denied.

Editor’s note: This article originally appeared in Revenue Cycle Advisor. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. To read the second part of this article, return to the blog next week.

 

Note from Associate Director: What to expect at the ACDIS Symposium: Outpatient CDI

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Associate Director Rebecca Hendren

By Rebecca Hendren

Outpatient CDI is a fast-growing area of focus for those working in the field. In a recent member poll, 33% of our audience reported that they either have an outpatient CDI program or they are planning to launch one within the next 12 months. The topic was a hot one at our 10th annual conference in May and many are looking for guidance regarding how to get started in outpatient CDI, including building a program, staffing, and determining return on investment.

Our new, two-day conference coming this September will answer many of these questions and help us kick-off our CDI Week celebrations. The ACDIS Symposium: Outpatient CDI, being held September 18-19 in Oak Brook, Illinois, features presentations from organizations who have already built successful outpatient CDI programs and who will share their experiences in getting started and maintaining a program.

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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.

 

TBT: Six steps to help you join the CDI ranks

Editor’s note: This article originally appeared on the ACDIS website in November 2015. To read the original article, click here.

There is a lot of discussion about how to be a good CDI specialist, but as the profession grows and facilities look to hire new CDI team members, many more people are looking to get into the field.

A few months ago, we received an email asking us what we would recommend to CDI hopefuls. After combing through our resources, consulting with our Boot Camp instructors and Advisory Board members, and interviewing working CDI specialists, here are six simple steps to help you set your feet on the CDI career path.

1. Learn as much as you can

When Shiloh A. Williams, MSN, RN, CCDS, CDI specialist (now CDI program manager) at El Centro Regional Medical Center in Holtville, California, initially applied for a CDI position, she knew nothing about CDI, coding, or the revenue cycle. She did a Google search before her interview and read up on DRGs, codes, and common diagnoses. Her research, coupled with her prior nursing experience and clinical knowledge, won her the position.

“I scoured the ACDIS website for information, ideas, and best practices,” Williams says. “Now that I’m doing the job, I am constantly turning to ACDIS resources for staffing and department metrics.”

Regardless of the field or position, any candidate who learns as much as possible about the role and company prior to sitting for an interview will have a distinct advantage. You may not have hands-on experience as a CDI specialist, but that doesn’t mean you can’t learn as much as possible about the field.

Review the materials on the ACDIS website—much of it is free—and take lots of notes. Read the ACDIS Blog and the CDI Strategies e-newsletter for timely tips and news updates. The ACDIS Helpful Resources page and ACDIS Radio are also fantastic free options to learn about the field and the industry.

It’s also a good idea to look through CDI job postings to see what facilities are looking for in terms of knowledge and experience. Some noteworthy topics to research include:

  • DRG basics
  • ICD-10 codes
  • How to read a medical record and research a chart
  • Hospital quality initiatives

2. Attend a local chapter meeting

If you have a local chapter in your area, call or email the leadership and ask if you can attend a meeting. This is a great opportunity to network with local CDI specialists, learn about the job from working professionals, and discuss timely topics and issues relevant to the field.

Networking may also lead to potential mentorship and job shadow opportunities that you wouldn’t have otherwise. Williams relied heavily on her mentors early in her CDI career.

“I was able to work alongside Marion Kruse, a well-known clinical documentation improvement and Medicare expert,” she says. “My passion for my work was fueled by her knowledge and expertise.”

Check the Local Chapter page on the ACDIS website for more information and meeting schedules.

3. Job shadow CDI staff

If you have a CDI program at your facility, ask the program staff if you can shadow them for a day to learn more about the work they do.

If your facility doesn’t have a CDI program, reach out to neighboring hospitals and see if their program would host you for a morning or afternoon.

Job shadowing is one of the most important things a prospective CDI specialist should do before applying for a job in the field, says Mark LeBlanc, RN, MBA, CCDS, director of CDI services at the Wilshire Group, and former ACDIS Advisory Board member.

“It’s a great opportunity to watch a CDI specialist work, ask questions, and see the work in action,” he says.

“It’s also a chance to see how you have to interact with staff on the floor. You need to be outgoing, and you have to be able to speak to all different levels of professionals, from providers to coders, so you can get things done.”

Also take advantage of other networking opportunities, such as reaching out to members of the ACDIS Advisory Board. “The board would definitely be willing to spend a few minutes with someone to talk about CDI,” LeBlanc says.

4. Analyze your skills

Typically, the most important attributes for a top-notch CDI specialist are extensive clinical knowledge and awareness of disease processes and complications, comorbid conditions, medical coding, and Medicare reimbursement.

A balance of clinical expertise and coding knowledge makes a candidate ideal, says Bonnie Epps, MSN, RN, CDI director at Emory Healthcare in Atlanta.

“I think [CDI] work would be easier if we all were proficient in coding,” says Epps. “If someone is interested in CDI, they should try and learn something about what coding is and why it’s important.”

Those with clinical backgrounds wishing to enter the field need to understand that CDI specialists have little to no contact with patients. Although their clinical acumen will definitely be put to use, they will no longer have any sway over the patients’ day-to-day care.

CDI work is based solely on what is written in the clinical documentation. For former bedside nurses, this requires a novel way of thinking and a willingness to learn new skills, Epps says.

“[An applicant] should be able to pick up the skills to read the chart, analyze the chart, and learn the coding rules and language,” says Epps. “You must be willing to learn these things and think in new ways.”

Communication skills (both written and verbal), imagination and creativity, and analytical and problem solving skills are also a must.

“You have to be willing to work with others and collaborate,” says Epps.

5. Train yourself

Programs typically train new CDI specialists for three to six months through in-house mentoring, job shadowing, and formal classroom learning. They often send new staff members to a CDI Boot Camp and/or have consulting training available.

However, if you are serious about getting a job in the field and want to expand your knowledge, it may be a good idea to sign up for an online learning program or a CDI Boot Camp on your own time. You’ll receive a comprehensive overview of the job and required knowledge, which will make you a more competitive applicant for prospective employers.

If you would like to work on training yourself, here are some helpful resources:

LeBlanc says prospective CDI specialists should also brush up on their anatomy and physiology— especially important with the advent of ICD-10.

6. Apply for the job

You’ve done the research. You’ve decided the job is a good fit for your personality and skill set. Maybe you’ve even job shadowed a CDI specialist or networked with CDI professionals at a local event. Now it’s time to apply for the job. There are plenty of facilities out there that will hire new staff even if they do not have CDI experience. Highlight any related training and skills in your resume and during interviews.

Keep in mind, you do not need to have the Certified Clinical Documentation Specialist (CCDS) credential to become a CDI specialist. The CCDS represents a mark of distinction for those who have been working in the field for a number of years. In fact, you must be a working CDI specialist for at least two years before you can sit for the exam. CDI career path.

Tip: Advance CDI’s cause through technology

CDI and technology

Technology changes the way CDI operates every day.

Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query.

Then, electronic health records (EHR) came on the scene, changing the CDI process for nearly everyone.

“Simply put, the advent of EHRs and e-queries changed how CDI specialists work—and the days of misplaced paper queries and incoherent penmanship are all but gone,” according to a special report out from ACDIS and HealthLeaders Media, in partnership with Optum360, “Leveraging technology to advance CDI efforts.”

Like all changes, EHR comes with rewards and challenges. CDI programs gain the flexibility and supportive data to meet the needs of the healthcare systems they serve. All while increasing productivity.

“With any new system, issues are going to have to be addressed,” Kathy McDiarmid, RN, CDI specialist at Beverly Hospital, a member of the Lahey Health System in Massachusetts, told the CDI Journal in December.

“There will be little things that physicians forget,” she says. Yet armed with intimate knowledge of the programs chosen, CDI staff can help physicians navigate the EHR and provide real-time assistance once the programs are in use, says Colleen Stukenberg, RN, MSN, CMSRN, CCDS, director of resource management at FHN in Freeport, Illinois, in a 2016 CDI Week Q&A for ACDIS.

In order to fully leverage the new technology, according to the report, CDI specialists need to understand the technology first. This knowledge gives them another platform from which to reach out to physicians. The CDI team can be a resource and help ease the transition to a new system for the physician.

To learn more about leveraging your EHR system to improve physician engagement and productivity, read the entire report by clicking here.

Guest Post: Addressing unspecified codes

Rose Dunn

Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

When CMS told the American Medical Association (AMA) physicians could have a one-year grace period to become comfortable with ICD-10-CM/PCS coding systems, they made a bad decision. The agreement allowed providers to be less conscientious about their diagnosis coding, leaving them to focus only on the first three characters of the code for medical necessity purposes. In actuality, some providers took the compromise as a license to map their superbill codes and submit “not otherwise specified” (NOS) and “not elsewhere classified” (NEC) codes to all payers.

Matthew Menendez of White Plume Technologies estimated in 2016 the average rate of unspecified code use at the time was 31.5%.

“Payers want the more detailed diagnosis information available in ICD-10. The reason that both government and commercial payers advocated for the migration to ICD-10 and invested millions of dollars to rewrite their adjudication processes was for the granular diagnosis data on their insured patient populations. Payers want to leverage detailed ICD-10 codes to drive down the cost of healthcare in the United States and if the provider community does not supply this data they will begin to deny claims,” Menendez said.

The NEC cases, the NOS cases previously accepted by Medicare are now perfect targets for a retrospective review by any of the government contractors.

Since the grace period between CMS and the AMA ended September 30, 2016, CDI and HIM program managers should review physician practice records both prospectively and retrospectively.

Prospectively, audit a sampling of records to identify documentation deficiency trends pulling NEC and NOS records specifically and offering tips to physicians for documenting the necessary specificity. Target these records for the physician prior to the patient’s return, so the physician can be prepared to capture the necessary information concurrently while the patient’s being seen.

In some situations, though, a more specific condition may not be possible. If unspecified codes are applied to accounts, they should go through a second review process (pre-bill) by a more senior coder or the coding manager.

Retrospectively, coding managers should monitor the continual use of NEC and NOS codes to determine the magnitude of the issue. If greater than 5% of the claims fall into an unspecified bucket in any single payer group, it should be concerning and spur additional CDI educational outreach.

Editor’s note: This article is adapted from JustCoding’s Practical Guide to Coding Management. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Note from the Associate Editorial Director: Thoughts about leadership

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Associate Editorial Director Melissa Varnavas

By Melissa Varnavas

I was just in the office kitchen joking with ACDIS Director Brian Murphy about how I’d always envisioned myself being a bigwig in a national healthcare association.

In our “Meet a Member” articles in the CDI Journal and CDI Strategies, we often ask folks about their first job and about their journey into the world of clinical documentation improvement. My first job was stuffing envelopes with some type of business collateral in the back room of a New England scuba diving shop. I also cleaned a dentist office. My later high school and college years I spent teaching daycare.

I had other jobs, too—secretary for an IT division of LibertyMutual, reporter and then editor of my hometown newspaper, managing editor for a radiology newsletter here with HCPro.

Most of you hail from diverse backgrounds, as well. Many of you worked in ice cream shops or fabric stores; started your careers coding in the neighborhood physician office or as floor nurses in hometown hospitals.

My dream job, that person I always wanted to be when I was little, was either a newspaper reporter or a teacher.

In my current role as the associate editorial director for ACDIS, I’m blessed with being able to work in both these roles. I get to play reporter, to talk to our members, to listen to their stories and retell the tales of their struggles and triumphs, sharing them with the rest of the membership so that we might all learn from their lessons and leverage their wisdom and growth in our own practices.

Over the past decade, we’ve grown together from these shared experiences. Like me, many moving into the CDI profession understand little other than broad concepts about what the position might entail. Those new to CDI learn by on-the-job training, taking a CDI Boot Camp, studying training textbooks, and hopefully through their ACDIS membership as well.

As ACDIS has grown over the past decade, we’ve watched our members’ careers grow, too—from CDI specialists performing record reviews to management roles to directorships over multiple hospital CDI programs.

So, my thought on leadership is this—that like so much in life, one may not set out with the intention of becoming a leader in any particular field or of any particular group but through grace and compassion end up becoming such because they step forward into the unknown, ever curious, ever engaging in the process of continued learning, ever generous with the knowledge they’ve obtained, ever giving back to those bright inquisitive CDI lights coming after them.

Editor’s note: Varnavas is the Associate Editorial Director for ACDIS and has worked with its parent company for nearly 12 years. Contact her at mvarnavas@acdis.org. ACDIS publishes a wide-variety of materials to help CDI professionals advance their careers, including: a position paper on the topic of CDI leadership, one on CDI credentialing, and one about defining CDI roles; a note about the value of the CCDS; a white paper on the topic of CDI career ladders and a sample ladder; two Q&As regarding career advancement; career advice from a CDI leader; and advice as to using the Salary Survey for career advancement.   

Summer Reading: New CDI staff exercises to perfect the review process

LauriePrescott_May 2017

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

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

Shadowing staff

Often, the first step in becoming comfortable with the CDI record review process comes from simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your facility, reach out to ACDIS via its CDI Forum or local chapter events. Consider calling nearby facilities, asking for their CDI department manager. Many CDI specialists willingly open their doors to those just starting out. If your CDI manager is willing (or has connections of his or her own), perhaps you will be able to shadow a neighboring facility to get a better idea of how different CDI programs function as well.

Many CDI program managers ask candidates to do this during the interview process so both parties better understand the basic competencies and expectations of the job. Other program managers gradually introduce new CDI specialists to the process by shadowing experienced specialists at least once per week for a set number of hours or records per day. Other programs may require new staff members to jump into the reviews as soon as possible.

To positively influence your learning, consider first sitting alongside your CDI manager or mentor as he or she reviews a variety of common diagnoses. Where larger teams exist, consider rotating such shadowing experiences and taking note of how different individuals’ experiences and strengths affects how they conduct their reviews. Also, arrange time to shadow an experienced inpatient coder as well. You will find each person has his or her own method, and no method is necessarily better than the next.

Tandem reviews

After shadowing teammates, try tandem record reviews where your mentor, manager, or other CDI staff member reviews the record first and then turns the record over to you to let you try your hand at it. Then compare notes. Also consider flipping this activity with the new CDI specialist reviewing the record first and then turning it over to your CDI manager or mentor to see where you were successful or where opportunities for additional information might exist.

Spend some time documenting and developing your own review processes; you will need to develop a method or sequence of record review and stick with it. For example, jumping from one section to another in search of a particular tidbit or clue may cause you to lose focus. In such situations, the larger clinical context may be lost on that elusive detail, costing you valuable productivity time—you may not see the forest through the trees, so to speak.

Take time to discuss items you may have missed and where this information was found. If queries need to be written, draft them together. This process may seem laborious, but with a few afternoons concentrated on such work, you will begin to feel more comfortable finding your way through the complexity of the medical record to the valuable nuggets of information you need.

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.

 

Q&A: Rejections for claims for removing impacted cerumen

ask ACDIS

Ask ACDIS

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

Many times in the ED, codes for services provided are driven by the chargemaster structure in cooperation with either a charge sheet or a menu in the electronic health record. When this is the driver, it is very easy for the person entering the charges/services to enter a line item for the right ear and one for the left ear. This could be because they are not versed in coding rules (modifiers -RT and -LT equal -50) for the surgical procedures. They may not be thinking of this as a “surgical procedure” as clinically it was “just an irrigation.” Or, there may not be an option for a bilateral procedure on the menu. It may be that the system is responsible for changing two unilateral procedures to report as a bilateral procedure, and this translation is broken. Follow the process through and see where the disconnect is.

CMS also changed the medically unlikely edit (MUE) number for CPT code 69209 as of April 1, 2017. Prior to April 1, the MUE was 2; however, this was changed to 1 as of April 1. You may want to check your claims prior to April 1 dates of service to insure that the payment you received was correct based on the bilateral payment methodology under the OPPS.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question. This Q&A originally appeared in Revenue Cycle Advisor.

Conference Committee Insights: Getting to the Heart of Accurately Defining Cardiac Ischemic Syndromes

conference committee

Apply by June 20, 2017

By Deidre Barnett, MHCL, BSN, RN, CCDS

Editor’s note: Barnett is a CDI specialist at MedPartners HIM in Tampa, Florida. She was one of the 12 member 2017 Conference Committee. For more information regarding the conference committee and to apply for the 2018 committee, click here.

With CMS piloting the bundled payment for acute myocardial infarction (AMI), CDI efforts in clarifying cardiac conditions is a very hot topic right now so I was glad to attend “Getting to the Heart of Accurately Defining Cardiac Ischemia,” presented by Christopher M. Huff, MD, FACC, and Garry L. Huff, MD, CCS, CCDS. The discussion also ties right in with the recent Official Guidelines for Coding and Reporting which call for the assignment of a code Type 2 MI as an NSTEMI without needing this documentation from the provider—we used to have to query.

The father and son Huff team did an excellent job on both sides of the discussion. Review and explanation of the pathophysiology from a cardiologist delved into the nitty gritty of what meets criteria for an AMI. Review of related diagnoses that occur on the spectrum from ischemia, injury, and infarction were covered in detail. The CDI implications were well defined–citing the importance of clinical validation when the criteria are not met but also explaining how the potential query as related to other diagnoses will impact the SOI/ROM.

It’s important to understand that all AMIs should meet certain criteria to be classified as an AMI. Type 2 MI is sometimes difficult to classify since it has a different etiology than the typical Type 1 AMI caused by an embolus (either blood clot or atherosclerotic plaque). There is a spectrum of myocardial injury that rises to the level of infarction when the criteria are met.

Therefore, as CDI specialists, we learned that it’s important to review every record for the AMI criteria and query appropriately for validation (if the criteria do not appear to be met) or inclusion (if the criteria are met and the provider does not document the STEMI/NSTEMI).

It was invaluable to have the pathophysiology reviewed as well as the CDI opportunities addressed in the same presentation.