Editor’s Note: Catch Glenn Krauss’ presentation “Migrating to outpatient ambulatory CDI” during the ACDIS 6th Annual Conference in Nashville, today, Thursday, May 23, at 10:45 a.m.
CDI is an ever-changing and ever-evolving profession. The following is a sample job description and representation of skills required of the “new” CDI specialist; a staff member who can respond to the transformation of healthcare from volume based fee-for-service delivery to a model vested in quality, value, efficiency, and outcomes; a staff member who represents the evolution of CDI efforts beyond the realms of reimbursement.
Review of paper and electronic health records for accurate and complete documentation of all relevant diagnoses, procedures, and ancillary treatments.
Applicants must demonstrate a willingness to maintain awareness of the business of medicine and transitional healthcare changes, including but not limited to value-based purchasing, bundled payments, accountable care organizations, and the readmission reduction program.
Must be devoted to ongoing, continuous learning in clinical medicine; practical understanding of ICD-10 and ability to educate physicians on the merits of preparation as the best practice strategy for ICD-10 readiness in their office and hospital setting; relevant updates and happenings in the business of medicine directly impacting physician’s, updates from CMS carriers effecting physicians such as billing, documentation, and coding guidelines and policies.
Flexible hours required in order to facilitate face-to-face meetings with physicians in the hospital and their private practice.
Applicants should recognize that CDI is a business with the CDI specialist representing a “business within a business,” constantly striving to think outside the box with continuous quality improvement efforts to better the business while seeking greater return on investment. Measurement of return in investment is the extent to which clinical documentation:
1) accurately reflects and reports the patient’s severity of illness equating to intensity of service
2) effectively demonstrates physician clinical judgment and medical decision making in support of medical necessity
3) promotes continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the “progress” of the patient
4) facilitates complete discharge summaries in promotion of post-acute care and facilitation of orderly handoff to patient’s primary care physician
- Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission (see 2014 IPPS proposed rule)
- Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field
- Familiarity with ICD-9-CM and ICD-10-CM Official Coding Guidelines
- General knowledge of what constitutes a complete and accurate record—i.e., complete and thorough clinical documentation beginning with the emergency room reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary.
- Practical knowledge and understanding of official physician E & M guidelines and documentation requirements in support of proper E & M assignment and establishment of medical necessity
- Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine
- Commitment to continuously increasing knowledge in and familiarity in constantly changing updates in the business of medicine directly impacting physician’s business of the practice of medicine today and in the future
- Demonstrated ability to obtain documentation relevant to denials avoidance related to the Recovery Audit program, the Comprehensive Error Rate Testing (CERT) program, and other audit programs, recognizing and promulgating to physicians the synergies of clinical documentation for both the physician and the hospital.
- Ability to review medical necessity denials and provide constructive feedback to providers
- Ability to work with all physician specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each physician specialty on an “as you go” basis.
- Ability to collaborate with case managers to collaboratively capture patient severity of illness and intensity of service to ensure medical necessity.
- Willingness to register for and attend all relevant ICD-10 and other billing/coding related educational offerings by CMS contractors, effectively sharing with physicians on a need to know basis, integrating key concepts and elements as they relate to clinical documentation improvement into daily routines and practices of CDI.
- RN and/or RHIA required; CCDS and/or CCS strongly preferred
By now you should be aware of CMS’s readmission initiative as part of value based purchasing (VBP). Medicare fee-for-service patients, or VA patients, who are admitted for any reason within 30 days of a discharge with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia are included in this initiative.
All Medicare reimbursement (not just for this patient cohort) is reduced up to 1% in fiscal year (FY) 2013 (goes up to 2% next year and 3% in FY 2015), depending on how effectively hospitals manage readmissions. While there are exclusions (for death, AMA, certain planned readmissions, younger patients, and patients with AMI who are discharged the same day) CMS does not differentiate between related and unrelated diagnoses, or preventable versus necessary admissions.
Each hospital’s penalty for this year has already been posted publicly and is readily available for review. You should look up your hospital’s penalty, if you haven’t already. A significant number of major institutions were penalized the maximum, 1%, but they contend that they are being penalized for serving the underserved (homeless, uninsured, etc.) who tend to cycle through the hospital rather than being managed in the community.
The first admission is called the index admission. Regardless of the number of readmissions within the 30 days following discharge, there is only one index admission and only one penalty for readmission. When the 30 days expire, the next admission is a new index admission. However, an index admission for heart failure and a readmission within 30 days for pneumonia is counted as both an index admission for heart failure and an index admission for pneumonia. In addition, same day readmissions for the same problem are incorporated into the index admission.
CMS is expected to add new measures to the readmissions initiative by FY2015, most likely COPD, CABG, PTCA, and other vascular conditions. At that point the maximum penalty will be 3%.
Let’s hope CMS stops there!
Separate from the readmissions initiative are potentially preventable readmissions. Potentially preventable readmissions are those admissions due to premature discharge, incomplete care, or inappropriate transfer, even if the readmission occurs at a different hospital than that of the index admission. CMS expects hospitals to complete care that should have been taken care of on the first admission. Quality Improvement Organizations (QIO) who review records for CMS look at readmissions to see if they may be related. Any admission within 30 days of the discharge date of the index admission is considered, but the QIO may deny the readmission regardless of time since the index admission particularly if there is a “chain” of admissions for the same problem.
APR-DRGs, a 3M™ product, are used to determine if the conditions necessitating the dual admissions are clinically related. A clinical relationship is presumed to exist if there is:
- A continuation of recurrence of the problem causing the index admission, or a closely related condition
- An acute decompensation of an acute condition that may not have been the reason for the index admission, but might reasonably have been related to care during or just after the index admission
- A medical readmission for an acute complication that might have been related to the care during the index admission
- A readmission for surgery to address a continued or recurrent problem that caused the index admission
- A readmission for surgery to correct a complication caused during the index admission
The Office of the Inspector General (OIG) also has its eye on same-day readmissions. It was identified as a target area in the 2013 OIG Work Plan. A Medicare patient’s readmission for symptoms related to or for evaluation or management of the first stay’s medical condition will result in the hospital’s only receiving one DRG payment, combining the original and subsequent stays into one claim.
As CDI specialists, we should be looking at how documentation affects readmissions. Look for documentation that:
- Supports planned readmissions
- Clearly defines the plan of care and the discharge plan
- Shows continuity of care and high quality of care for all diagnoses identified during the stay
Look at how principal diagnoses are documented and sequenced. Simple pneumonia triggers a targeted readmission measure, but aspiration pneumonia does not. See the opportunity?
Review documentation for clinical indicators that might trigger “post-hospital syndrome,” leading to early readmissions: sleep disturbances, malnutrition and delays in feeding, deconditioning, multiple changes in medication, inadequate or excessive sedation, and other stressors of hospitalization.
Talk with your case managers and your physicians when you see this evidence of potential problems. As clinical documentation specialists, get involved clinically and not only improve our numbers and public profile, but improve the care of our patients.
Happy Hospital Week! Take a look at this cool video created by the American Hospital Association and then jump over to their website to see what events they have planned and how you can help celebrate your facility’s connection to the communities you serve.
Editor’s Note: This is the third is a series of posts showcasing speakers and their sessions at the 6th
Annual ACDIS conference in Nashville, May 21-23. On Tuesday, May 21, at 1:30 p.m., Tamara Hicks, RN, BSN, MHA, CCS, CCDS, ACM, and Melinda Matthews RN, BSN, CCDS, will discuss “Partnering with quality assurance: The impact of CDI on quality reporting.” ACDIS caught up with Hicks for the following interview.
ACDIS: Tell us a little about your background.
TH: I got into CDI 14 years ago. I was looking to move away from bedside nursing. I had worked for 15 years in a critical care step-down unit and had recently completed my bachelor’s degree, so I was looking to advance my career and do something new. Little did I know, I was about to become part of something brand new! I became part of the team that kicked off the clinical documentation management program at Wake Forest Baptist Health Winston-Salem, N.C., in 1999. We were a team of seven, and covered only Medicare patients for the whole house. I learned very quickly how few programs there were like this in the country. After a few months, it became obvious that we needed a team leader; I became that leader, and over time, the role evolved and I became the “coordinator.”
Over the next several years, we expanded the team and our scope to include all payers, reviewing for revenue enhancement as well as for severity of illness (SOI) and risk of mortality (ROM). In 2007, I became the manager of care coordination with the documentation improvement team, utilization management, and a team of case managers and social workers reporting to me.
Since that time, the team has continued to grow and expand. There are now 19 clinical documentation consultants, three clinical documentation compliance coordinators, and one supervisor. We have been extremely successful in realizing improvements in documentation and coding, in improving capture of SOI and ROM for our hospital, and in collaborating with areas like quality to ensure appropriate reporting of profiling data for our institution. I know that now, CDI is huge all over the country, but I also know that we have one of the most seasoned programs in the country, and I’m proud to be part of this team.
ACDIS: What has been your biggest challenge developing your topic and presentation?
TH: The biggest challenge was capturing a snapshot of this process because it is actually ongoing. We were required to submit our conference materials in February, and we weren’t even sure what the process would be at that point!
ACDIS: How will your ACDIS presentation help attendees with this topic?
TH: I hope that the work we’ve done here will help other programs be able to do the same at their hospitals.
ACDIS: Tell us something about yourself that we can share with your future audience.
I was once in a community theater production of “Guys and Dolls.” When my husband and I were dating (when in nursing school), he and his sister were involved in the theater. I had seen him perform in “Camelot.” They were casting “Guys and Dolls” and asked me to be a “Hot Box” dancer. I’ve never been into drama or any type of performance art. So this was a real stretch for me! But I thoroughly enjoyed myself (not enough to ever do it again, but it was a great experience). I still know all the songs and most of the lines to “Guys and Dolls!”
ACDIS Note: Tamara says she has never been to Nashville and is looking forward to checking out a new city.
Too many CDI specialists live for the immediate satisfaction of today. Their primary focus is upon getting a diagnosis documented in the record once and then moving on to the next chart, looking to secure another diagnosis and score a “win,” as measured by number of queries generated and number of queries positively responded to by physicians.
The medical record must clearly articulate the physician’s clinical rationale and judgment in support of conclusive diagnostic statements. These statements alone, however, are no longer sufficient in support of diagnosis code assignment from both the physician and hospital perspective, not to mention establishment of medical necessity for inpatient admission as well as physician evaluation and management (E/M) assignment. The clinical facts of the case explicitly documented in the record, supported by the physician’s thoughts and updated plan of care, serve to best reflect the patient’s true clinical condition, acuity, and ICD-9-CM diagnosis code assignment.
If you get this added documentation in the chart, it deprives third-party reviewers of their widely pervasive stand to refute a once documented diagnosis on the basis of its clinical significance and recouping money from the hospital. This is I what I coin the “vision to see beyond immediate results.”
What do I mean by this statement? Let me demonstrate with an example.
What is stronger documentation: A physician responding to a multiple-choice query and writing the term “neuropathy” once in the record, or documenting as follows?
Neuropathy related to prior oxaliplatin dosing. Symptoms have not dissipated despite using a vitamin B complex. This may be a limiting factor in choosing future chemotherapy agents. If the chemo related neuropathy continues, consider stopping the current chemo regimen altogether and see if a short chemo holiday improves the patient’s severe neuropathic pain and then, perhaps, begin a new regimen. My immediate concern right now is to get the patient over the hurdle of her relentless pain in the legs and arms, then discharge the patient and see how she does, bring her back into the office for evaluation in a week and hopefully start a new chemo regimen.
This example, taken from an actual chart, shows the diagnosis of neuropathy with clinical support beyond the typical diagnostic conclusion statement. While neuropathy, aside from acute infectious polyneuritis, is not considered a “CC,” the level of documentation including discussion of the physician’s clinical judgment, thought processes, and medical decision making goes a long way in supporting the medical necessity for inpatient admission and continued stay in the hospital. Helping physicians incorporate explicit documentation of clinical facts undoubtedly adds value to our roles and responsibilities as CDI specialists. Yet this benefit is not immediately measurable in results the hospital’s chief financial officer can equate to in terms of revenue and return on investment for CDI staff.
Nevertheless, even if a condition is not a CC, we should still be seeking specificity from the physician—especially with ICD-10-CM/PCS implementation on the horizon. If we take the time to work with the doctors today on documentation that impacts their payment—i.e., reflects their medical decision-making and ensures medical necessity for procedures and services—they’ll be willing to help us tomorrow.
Keep in mind that taking the extra time with a doctor today might result in a short term loss of productivity. Maybe you only get to 22 charts instead of 25. But you’ll also be ready for when ICD-10 comes, and your physicians will have bought into your CDI program.
Speaking of ICD-10, here is an excellent link comparing ICD-9 to ICD-10 for several commonly-used codes. Use this to focus your CDI efforts on specific code sets: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals-Items/R1199OTN.html.
In short, get the extra specificity today. Strive for clinical support and documentation of all diagnoses, regardless of whether or not something is a CC with such efforts you will find the “vision to see beyond immediate results.”
By Laurie L. Prescott RN, MSN, CCDS
The biggest challenge of being a CDI specialist in my opinion is the education of the physicians. They fly by us like stealth bombers and we have limited face-to-face time to make the impression. Fortunately, the snippets of education we do provide during those brief interactions can be our most valuable tool. So, I try to be ready because I might only get 30 seconds to explain why his or her confirmation of a present-on-admission indicator is so important with a sepsis diagnosis or why we are interested in knowing if the sepsis developed from the dialysis catheter or from pneumonia.
At the end of the day I take an unofficial “inventory” of these conversations and begin to identify other means of getting the information to the physicians.
At my facility, we developed many methods to reach our physicians. We created “doc-u-tips” (little letters we put in their mailboxes on specific subjects) and we include documentation improvement articles in their monthly physician newsletter. We hang posters in their lounge and place them in clear sleeves in the charts to explain documentation guidelines for diagnoses such as respiratory failure and chronic kidney disease.
Drawing from my experience as a nurse educator, I try to follow the mantra “seven times, seven ways,” meaning if you wish to communicate a message you must disseminate the information at least seven times in seven different ways. I once had a physician tell me that you could train a dog with seven repetitive steps but it will take you 21 years to train a physician. I told him that I am too old to wait 21 years for success!
CDI specialists have to face the challenge of how to identify our physicians’ educational needs and we
need to know how to best “package” and “present” our education while ensuring it the information is reliable, based on established clinical criteria. As most experienced CDI professionals well know, physicians are more accepting of the information presented if it comes from their own literature and uses their own established critical guidelines. Sourcing this information to their professional organizations gives me credibility. It shows that I am just not just telling them what we need for coding purposes but asking them to document to the standards established by their own profession.
Lastly, I try to avoid speaking about coding guidelines or what “I need them to say” merely in an effort to accomplish my own job. I encourage them to tell the patient’s story, to provide specific and complete diagnoses, and to provide the diagnostic criteria to support their conclusions.
There are times when I will explain where a specific term will lead in regard to DRG assignment but I try to avoid these comparisons. If I supply them with definitions or diagnostic criteria that explains and supports specific wording of diagnoses they appreciate that. For example, the old challenge of urosepsis versus sepsis. I can explain how ureosepsis will code to a urinary tract infection or I can provide them with the diagnostic criteria of SIRS- showing how their patient meets this diagnosis based on the criteria. This method shows them the meaning of the word(s)/documentation and shows how their choice relates to the patient’s clinical condition.
The ACDIS website and library provides many examples of how our colleagues are meeting these challenges of physician education. I have always felt no need to reinvent the wheel. For example Tiffany Estes, RHIA, CCDS, at UNC- Chapel Hill shared her Physician Documentation Handbook in the Forms & Tools Library. With her permission I am in the process of adapting it for my medical staff. The library is a great way to share information.
Please, let’s expand this conversation: What methods have you found the most effective in reaching your physicians? Where do you find your sources? How do you identify educational need? What “wins” have you been able to celebrate? Do you have a specific challenge you need help with?
I am sure there is someone reading this blog right now that would benefit from your successes or might lend advice to your challenges.
Editor’s Note: Prescott is a CDI specialist at Morehead Memorial Hospital in Eden, N.C. She has more than 25-years’ worth of nursing experience having received her BSN from the University of Vermont and her MSN-ed from the University of Phoenix. She has worked in many aspects of nursing to include med-surg, peri-anesthesia, ICU, nursing administration and nursing education, and began working as a a CDI specialist in 2007.
By Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
What follows below is applicable to a program or organizational perspective, not all who read the ACDIS Blog are interested in this type of program management discussion.
Hospitals that base CDI pay on nursing or HIM pay scales may not be taking into account the value of CDI to the bottom line. We, as CDI professionals, have to continually advocate for the value we bring to the organization. CDI Staff are “value-add,” not “net-loss” employees. It is understandable for a hospital to offer a lower salary for a person new to CDI, but within 1-2 years, that employee becomes very valuable in the CDI world.
Let’s make this easy for the accountants and the chief financial officers in our hospitals to understand (let’s talk quality afterwards, the numbers guys and gals want “hard financial numbers” to justify their investment in CDI).
Think about it this way…. The Advisory Board Company (a Washington, D.C., based global research company) states that a high performing CDI specialist (someone with roughly 2 years’ experience) brings about $1.4 million in revenue to a 250-bed hospital. An “average” CDI specialist brings about $700,000 in revenue, according to a 2012 webinar titled “Creating Top Tier CDI Capabilities.”
Let’s do some math. (All salary numbers are assumptions, not based on mine or any other numbers.)
Costs: Let’s assume 30% overhead on salary for benefits, space, utilities, education costs etc. and build this in to the salary equation. Let’s assume three employees working at a given facility all earn the same salary and the manager earn about 20% more in additional salary. It appears that the national “going rate” (advertised salaries) for a CDI specialist is $75,000; and roughly $90,000 for a CDI manager. (For additional rates review the ACDIS “2012 CDI specialist Salary Survey,” published in the CDI Journal.) So far, for costs we have:
- $315,000 for personnel
- $94,500 for overhead
- $60,000 for software/hardware
- $40,000 for part-time physician advisor salary (This assumes a hospitalist who makes roughly $200,000-$250,000 salary would be paid about a 1/4th or 1/5th of their time).
Revenue: Again these are assumptions, but let’s say that a high performing team (which includes our staff of three and their manager) can earn the facility roughly $1.4 million each with the manager who reviews records part-time earning roughly $700,000 for a total of about $4.9 million. If we consider this in reference to the previous mentioned webinar and within context of anecdotal earning from consulting firms, this looks about right (other organizations say a 250-bed hospital can make as much as $5 million/year with a great CDI program). Let’s say that an average performing team of the same make up earns about $2.45 million.
Return on investment (ROI): Let’s calculate the return-on-investment using the following equation: ROI equals payback after investment divided by that investment or ROI=(payback – investment/investment). So for our high-performing team in the above example the equation would be ($4.9M-$509.5k)/$509.5k=8.62
Some financial people like to see and present ROI in percentages. So multiply the number by 100 and add the percent unit, or 862%, and be described this way: “The potential return on investment for a high performing CDI team is 862%.”
Assuming we have an average performing team ROI = 3.8. In percentage form: 380%
So, don’t you think we easily justify our existence from a financial standpoint? A CDI team represents at minimum a 4 to 1 ROI with the potential being much greater!
Let’s give our staff members’ raises of about 10% to make our team have better standing in competitiveness and retention.
Costs: Specialists $83k x 3 + Manager $100k = $349k + 30% (overhead) = $454k; add $60k (software) + $40k (adviser) = $554k. ROI= 7.84 or 784% for a high-performing staff and 3.42 or 342% for an average performing staff.
How many other departments in the hospital show an ROI as good as this?
The main point of this exercise is to show that most of us CDI practitioners have advanced training and we are in a very competitive and fast-growing career field. Thus, by presenting the value we bring in financial terms, we should be able to justify to administration our higher pay in relation to our nurse and HIM colleagues.
Editor’s Note: Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, is the manager of Clinical Documentation Excellence at Sibley Memorial Hospital in Washington, D.C., and a frequent contributor to CDI Talk, where this post originated. Contact him at firstname.lastname@example.org.
On March 14, 1–2:30 p.m., eastern, past-ACDIS Advisory Board member James S. Kennedy, MD, CCS, will outline the changes to the clinical landscape and discuss the rules governing malnutrition code assignment. He will be joined by Joann Agin, RHIT, CCDS, Regional Manager, Data Quality, Carondelet Health, Kansas City, Mo., and Mindy Hamilton a registered dietitian. Agin and Hamilton worked together to create a comprehensive plan for capturing malnutrition documentation. To learn more about the program, visit the CDI Marketplace.
Last March a Maryland hospital agreed to pay nearly $800,000 to resolve allegations that its employees used leading queries to add malnutrition as a secondary diagnosis.
New guidelines published in the May 2012 Journal of the Academy of Nutrition and Dietetics represents a consensus statement of the American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN). The guidelines indicate that malnutrition should be diagnosed when at least two or more of the following six characteristics are identified:
1. Insufficient energy intake
2. Weight loss
3. Loss of muscle mass
4. Loss of subcutaneous fat
5. Localized or generalized fluid accumulation that may sometimes mask weight loss
6. Diminished functional status as measured by hand grip strength
It further states that malnutrition should be considered within the context of an acute illness or injury, a chronic illness, or social or environmental circumstances to determine whether malnutrition is present and whether it’s severe or non-severe (moderate).
Editor’s note: Portions of this tip were included in the July 2012 edition of the CDI Journal.
by Timothy N. Brundage, MD
Physicians resist change. They fear it. Although comfortable reading medical literature, and comfortable improving patient care with new techniques and medications, having CDI professionals “educate” physicians about improving their documentation habits makes them markedly uncomfortable. Physicians see such discussions and reviews as a threat to their autonomy. They view CDI efforts as the “evil administration” pushing them to document differently, which of course, adds to their discomfort.
Regardless of previous experiences with documentation efforts and regardless of the additional effort it may necessitate, physicians’ response and cooperation is required. Why? Because unfortunately, physician scrutiny is increasing.
In summary, physician documentation is critical for MS-DRG capture and assignment of a relative weight as well as an expected length of stay. Physician documentation begins with legible handwriting and moves to accurate diagnosis and effective management of patient care issues. Consider recommending physicians use a pocket CDI card for accurate diagnosis. Download a sample pocket CDI card here.
Editor’s Note: Brundage is an ACDIS Advisory Board member and physician champion for Kindred Hospital North Florida District in St. Petersburg, Fla. Contact him at DrBrundage@gmail.com. This article was originally published as the “Featured Article” on the ACDIS homepage, February 4, 2013.
At this point CDI has been around for some time. Like most good things, it grows stale after a while, and you need to boost your program with some fresh ideas.
Those working in the CDI field need to think about how we can help physicians with their documentation, in ways that help not only the hospital but the physicians themselves. CDI specialists need to help improving severity of illness (SOI) and intensity of service reporting so that the documentation coincides, and complements, physicians’ Evaluation and Management (E/M) assignment; so the documentation accurately establishes the medical necessity for the patient encounter and the level of service that ultimately gets billed.
There are two distinct E/M codes for day-of-discharge care, or discharge management. The latter two codes are differentiated by the amount of time spent in conjunction with discharge of the patient including:
- patient evaluation
- writing of discharge orders
- medication management
- coordinating care with the case manager and/or social worker
- patient/family teaching
- preparation of discharge paperwork including dictating of discharge summary
The lesser code is 99238 and the greater code is 99239, requiring greater than 30 minutes of physician face-to-face time on the floor carrying out the discharge process.