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Q&A: Determining standard clinical criteria for common diagnoses

Go ahead, ask us!

Go ahead, ask us!

Q: I understand that most CDI departments develop a standardized list of clinical indicators/criteria to support query efforts. Is this something we need to develop or is it available in the encoder process? If we need to develop this, how do we go about that?

A: While the AHA’s Coding Clinic for ICD-9-CM (ICD-10-CM/PCS) often lists clinical indicators for specific diagnoses, the publication should not be used as a stand-in for the provider’s own clinical judgment, as reiterated in Coding Clinic, First Quarter, 2014, p. 11.

CDI programs should work with the physician team to develop a standardized list of clinical indicators for the team to use in query creation, CDI and physician training, and record review. Such mutually developed criteria is particularly helpful for highly vulnerable or often miss-documented conditions such as levels of malnutrition severity, acute and chronic respiratory failure, acute kidney injury, encephalopathy, etc.

Research nationally established guidelines for these common, core conditions (e.g., ASPEN criteria for malnutrition, or RIFLE or NKIDO criteria for renal failure), then work with the specialty most closely related to that diagnosis (e.g., pulmonologists for acute respiratory failure). This criteria could then be consistently used by CDI and coding staff to initiate a query to support the diagnosis.

Guest Post: In search of the clinical truth

Cesar M. Limjoco, MD

Cesar M. Limjoco, MD

Editor’s Note: This article was originally published in CDI Monthly, by DCBA, Inc., and shared on the social media network LinkedIn. It has been adapted from its original and is republished here at the invitation and permission of the author and participants.

“Many CDI programs have set as their goals: accurate coding, maximum reimbursement, increased case mix index (CMI) and better risk-adjusted scores,” says Cesar M. Limjoco, MD, vice president of clinical services at DCBA, Inc. in Atlanta, Georgia.

“But are they missing the mark? Are they setting their targets low and setting themselves up for a fall?” Limjoco asks. “The goal sets the tone for one’s actions. The end justifies the means.”

CDI programs with preset agendas can slip into focusing solely on those priorities at the expense of the clinical truth, he warns. Like a racehorse wearing blinders to limit distractions, CDI specialists can be blinded to all but the racetrack before them. Without a broad perspective they may have a tendency to arrive at incorrect conclusions, he says. For example, if these end goals take precedence it becomes easier to see (and query for) a variety of diagnoses that may not be true given the entire picture of the patient’s condition, Limjoco says.

“As you may have heard before, medicine is both an art and a science. A provider does not come up with a diagnosis just from laboratory and other workup. There are false positive and false negative results. The provider has to marry the workup results with the clinical picture of the patient,” he says.

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TBT: Pediatric efforts offer new CDI opportunities

Starting a pediatric CDI program? Read how.

Starting a pediatric CDI program? Read how.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article “Pediatric efforts offer new CDI opportunities” which originally published in the October 2013 edition.

“We’re seeing more and more children’s facilities starting CDI efforts,” says ACDIS Advisory Board member Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. “The largest growth comes from multi-hospital systems that already have CDI programs in place. They see the potential of expanding to their affiliated children’s facility.”

With roughly 500 children’s facilities in the nation, Gold sees both the probable benefit and difficulty inherent in such CDI expansion. Children’s hospitals do not have Medicare patients—the typical starting point for traditional, short-term acute care hospitals, he says. In fact, most are paid on a contract basis related to a certain percentage of the actual charges of the care provided “so there was little financial incentive for children’s facilities to implement CDI,” he says.

Furthermore, children’s facilities do not have the external scrutiny that adult hospitals face. Where typical healthcare facilities turn to HospitalCompare,  HealthGrades, and other public quality report cards, children’s programs have few options, says Gold. He notes that Parents Magazine publishes an annual “Top 10” list, but that it is based on anecdotal data from its subscribers and research. So it can be difficult to persuade administration to expand CDI efforts based on physician ego, or quality scores either.

At the Medical University of South Carolina (MUSC) in Charleston, Karen Bridgeman, MSN, RN, CCDS, CDI specialist, started building the case for expansion by examining data from the University HealthSystem Consortium and National Association of Children’s Hospitals and Related Institutions. This data allowed MUSC to compare benchmarks regarding patients’ severity, mortality, and facility case-mix index (CMI). They took the 25 top and bottom DRGs and divided them into two categories—high-volume, low reimbursement and low-volume, high reimbursement—for Medicaid, Blue Cross, and commercial payers.

The data suggested that a higher level of clinical complexity existed than was being depicted in the medical record, Bridgeman says. Asthma and bronchitis, seizures, and neonatal care fell into the high-volume, low yield bucket; that cardiothoracic conditions and Level III neonatal ICU fell into the high-yield, low volume bucket; and that chart review of pediatric patients could help with respiratory failure, cystic fibrosis, sickle cell, and chemotherapy documentation improvement.

“We found the physicians writing respiratory distress, but that just wasn’t clear enough to determine whether it was an shortness of breath or a respiratory failure,” Bridgeman says. “Sepsis and shock weren’t being documented at all.”

Q&A: Advance CDI efforts by expanding reviews beyond low-hanging fruit

Apple tree and the low-hanging fruit of CDI

There’s more fruit in the tree!

Q: At what stage should an established program most likely experience a reimbursement plateau? One may naturally expect the physicians to improve as CDI programs hammer them with education. After we’ve gathered all the low-hanging fruits and go for the mangos? We ran the top principal diagnoses and also top diagnoses for our system. We are a home-grown program, about three years old now. Our team made $6 million last year. I know there are many query opportunities and ideas for program expansion but how do we find the right areas for our facility?

A: I am unaware of any industry standards that identifies a timeline of expectations for a plateau of reimbursement/physician documentation improvement. If you have a relatively stable medical staff with few changes, the program should mature and demonstrate physician documentation improvement more quickly than an organization that experiences high turnover of physicians, such as a university or teaching hospital. A teaching hospital may never plateau as the influx of residents and the constant rotation among specialties means educating physicians and capturing the “low hanging fruit” never ends. Each organization will have their own rate of turnover and educational needs for medical staff.

Such programs would have a lower query rate but maintain increased levels of CC/MCC and severity of illness/risk of mortality (SOI/ROM) capture. In other words, the physicians have retained and applied the education, they require less questioning but their documentation supports higher reimbursement levels.

The second variable in this equation is that as a CDI program matures the staff will find “different trees of low-hanging fruit” to pick. At the beginning, you learn to recognize potential documentation opportunities amongst the apples and oranges and begin to see a decrease in queries related to these but you learn there are opportunities in the lemon trees and the mangoes.

Don't get overwhelmed! Just ask for help!

Don’t get overwhelmed! Just ask for help!

Lastly, organizations are constantly adding new services, new procedures and with each change CDI programs may identify entirely new opportunities. In other words, I have not seen in my experience a leveling off but more of an evolving focus as a program matures.

Self-education and participation in CDI networking are important in advancing your own career, your own knowledge, and your CDI program efforts. If you do not currently have tracking systems in place for individual CDI specialists’ and individual physicians’ query behaviors, you may want to. This might identify specific learning needs for individuals that could be targeted. For example, what diagnoses are the CDI specialists querying for? Does one CDI staff member miss sepsis opportunities or are there opportunities the entire team needs to learn about? If there a specific physician that needs intervention on a particular diagnoses?

Most successful CDI programs work closely with their coding teams. Expand on this collaboration by having the coding staff bring forward any trends or difficulties they’re seeing in daily practice. Ask to review any retroactive queries for trends and trouble spots. Identify any documentation improvement opportunities the CDI staff may have missed. The idea being, you and your CDI team won’t miss that opportunity next time.

If you do not have access to your organization’s Program for Evaluating Payment Patterns Electronic Report (PEPPER), seek out access. PEPPER is produced by CMS and it compares your organization to like organizations within your region. It identifies where you maybe an outlier for specific diagnoses and CC/MCC capture. You may be able to identify improvement opportunities in areas where you are a low outlier compared to your peers.

I often found my new fruit by reviewing the code set. Just opening up the code book and seeing what specificity was needed in code assignment for specific diagnoses often demonstrated for me areas of needed improvement. I would suggest doing that with theICD-10-CM code book. You can start asking questions related to ICD- 10 now so that the learning curve will not be so steep come October of next year.

Lastly, an exercise I suggest for new CDIs and one that might require repeating as the definitions do change is to take the list of CC/MCCs and highlight those diagnoses that are often seen within your population. You may find there is a “fruit basket” just sitting there that you never considered. If you identify codes that you have not thought to ask for look them up in the code books and learn what terms are needed to support their documentation. I promise you this effort will bring to light at least one diagnosis common to your population that you might not be capturing on a regular basis.

Wikipedia tells me there are over two thousand different fruits in the world so you have many to harvest!

Guest Post: Marketing your CDI program

Kelli Estes

Kelli Estes

by Kelli Estes, RN, CCDS

Maintaining an organizational presence through the continued marketing of your CDI program is one of the most valuable steps you can take towards leveraging long-term success. Hospitals cannot afford to have their CDI program become an “out of sight, out of mind” idea six months to a year after launching.It is very important to maintain a level of CDI enthusiasm among providers throughout the year. In reality, the CDI initiative must become part of the cultural norm in order to attain the longevity of its effects everyone desires to see.

Too often, CDI programs kick-off with quite a buzz in the air. There is typically an organizational presence from the intentional promotion carried out for weeks or months leading up to the implementation date. Unfortunately, after six months to a year, the CDI team loses steam and finds themselves without much fizz among providers. Following are a few ideas to effectively market CDI programs:

  1. Mark your calendar for the week-long celebration of CDI Week which just took place the third week in September. Use this time to:
    • Provide snacks in the doctor’s lounge throughout the week
    • Attach CDI tips to candy as a fun giveaway and to educate providers
      • Attaching a CDI tip to Smarties candy is always cute
      • Dum-Dum suckers will get a nice laugh too
    • Host CDI week giveaways as your budget allows
      • Starbucks or Dunkin Donuts coupons
      • Restaurant gift cards
      • Nook, Kindle, or iPad for a Grand Prize giveaway
    • Provide special recognition for star documenters
    • Host a special “lunch and learn” education session to be led by the CDI physician advisor or the star documenter of the year!
  1. Feature CDI news on a centrally located bulletin board for everyone to see.  Be sure to update the board at least monthly by providing CDI tips to include new ICD-10 information and also showcase the top documenters for the month. You can get really creative because I’ve never met a physician who didn’t like a bit of friendly competition.
  1. Contribute short articles or quick tips in any physician newsletters that go out regularly. Make it personal, feature various CDI staff at different times to allow the providers to get to know the CDI team members better.
  1. Work with your IT department to implement CDI tips as computer monitor screen savers to promote CDI awareness.
  1. Develop a CDI intranet site to allow the CDI team to provide access to electronic tip sheets, slide presentations, video teaching, etc. This is a convenient way for providing access to CDI information at the leisure of providers.
  1. Throughout the year, develop a poster series with CDI tips to be placed in various locations commonly used by providers.

As you can see, there are many ways to market your CDI program, but nothing will trump relationship building between your CDI team and the providers.  The more time the CDI staff can spend on the patient care units, the more credibility the team will earn. Becoming a trustworthy resource to providers in their environment will only stand to have an invaluable benefit to the overall success of your CDI program!

Editor’s Note: Estes has spent more than a decade as a CDI specialist and consultant, presently with DCBA Inc., in Atlanta. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. Contact her at kestes@dcbainc.com.

TBT: CDI input helps EHR implementation succeed

Learn how new technologies will affect CDI efforts in this week's free webinar.

CDI involvement in EHR implementation is key.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the April 2012 edition of the CDI Journal.

“We saw the EHR train as it was whisking by. We were shouting ‘Wait! Wait! What about CDI?’ ” says one CDI specialist. “They didn’t know CDI existed. The [implementation team] hadn’t thought about us and how we interact with the record or what we might need from an electronic system. So now we’re trying to play catch-up and do the best we can with what we’ve got.”
CDI specialists probably think phrases like “interoperability” and “meaningful use” need not cross their minds—EHR implementation belongs in the hands of the IT or HIM department, right? The answer to that question is yes and no, says Barbara Hinkle-Azzara, RHIA, (formerly) Vice President of Operations for Meta Health Technology in New York City. The individual end-user (i.e., the CDI specialist reviewing medical records on the hospital floor) “may not need to be involved in ‘checking off the boxes’ to certify meaningful use is met, but certainly adapting to an EHR and adhering to meaningful use requirements affects the information CDI professionals review and how they will ultimately perform their jobs.
“EHR systems will change the CDI specialists’ experience,” she says.
A CDI program director or physician champion can play a pivotal role in the implementation of initial and ongoing assessment efforts for EHRs and their components, says John Pettine, MD, FACP, CCDS, CDI director at Lehigh (PA) Valley Health Network.
“CDI staff should get involved and do it now before it is too late. Otherwise, CDI professionals are at the mercy of decisions made without their input, which can be tragic to the success of the program going forward into ICD-10,” he says.