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media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms.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. Today, we’ve chosen this July 2012 article.
It’s Tuesday. For some CDI program managers that means jumping in the car and driving an hour or more to another hospital in their system to make rounds with CDI specialists there. For some, it’s a routine that happens at least once a week; for others, once a month. Although the requirements of managing CDI programs and their staff at multi-facility hospital systems differ depending on a variety of factors, try the following four best practices for success:
- Standardize policies and procedures; then fine-tune for differences
- Communicate consistently across hospitals
- Know your staff
- Use available resources
Meg McGill, RHIA, corporate director for HIM at Methodist Le Bonheur Healthcare in Memphis, Tenn., manages 19 CDI specialists across seven hospitals. In the beginning, McGill’s primary role related to governing the overall direction of the healthcare system’s CDI efforts.
Each specialist reports directly to either the chief medical officer or performance improvement director at their facility and secondarily to McGill, whose primary job is to communicate CDI program data and effectiveness to facility and system management, she says. After little more than a year, Methodist Healthcare was ready to “take the program to the next level,” says McGill.
“We had to take a step back and take a deep breath to see where we wanted this program to go and how to get there.” So they hired a CDI director, whose No. 1 task,“will be to make sure all the processes are done consistently across all the sites,” McGill says.
Although absence may make the heart grow fonder, lack of communication can quickly turn fondness into indifference.
“You need to get to know your staff so they feel comfortable with you and you feel comfortable with them,” McGill says. But long distances make face-to-face meetings difficult. “It really took me about a year to get to that point because I never really get a chance to see them,” she says.
To keep CDI staff on the same page, McGill holds monthly meetings for all CDI staff with the coding director and two lead coders who also attend. CDI specialists also meet monthly by facility with their immediate directors to discuss productivity, statistics, and facility concerns.
“Communication is definitely one of the big challenges,” says McGill. “You need to be sure you say the same thing individually that you say to the entire group. You have to have open communication and you have to get to know your staff. When concerns come up, they can talk to you one-on-one, pick up the phone and call you, schedule an appointment, or send you an email. Be sure to make time for that. But otherwise I really rely on email.”
As more facilities face the specter of reimbursement losses related to the Readmission Reduction Program, CDI programs may be asked to take a second look at records to help ensure documentation is adequate to fully support the patient’s diagnoses, says Susan Wallace, MEd, RHIA, CCS, CCDS, CDIP, director of compliance and inpatient consultant at Administrative Consultant Service, LLC, in Shawnee, Okla.
While it may seem like “just one more thing” added to the CDI review plate, Wallace says it needn’t be an onerous project.
First, make sure CDI focuses on more than CC/MCC capture and problem-focused reviews. The readmission reduction targets currently include acute myocardial infarction, congestive heart failure, pneumonia, COPD (also COPD secondary to respiratory failure), stroke and elective hip / knee replacements. Beyond the current readmission reduction program, inpatient quality reporting measures also target hospital-wide readmissions, so appropriate risk-adjustment is important for all admissions. p>Second, reach out to other departments such as case management and quality to discuss how they are evaluating readmissions and brainstorm ways CDI can help.
Thirdly, says Wallace, stay informed. Review your facility’s Quality Net data and be familiar with the codes, diagnoses, and documentation requirements for those conditions.
“The Quality Net report to hospitals includes an appendix with factors used for risk adjustment; facilities can look at that data to compare their own facilities to other state and national statistics,” says Wallace. “That’s information that isn’t typically shared or reviewed, so CDI can look for opportunities there. Simply asking for the report can be a way to open the door and begin communications with the quality department.
Editor’s Note: This article originally published in the June 19 edition of CDI Strategies. If your CDI program is reviewing records with readmission reduction in mind, ACDIS would like to hear from and share your lessons learned in an upcoming CDI Journal article. Send your program description to Associate Director Melissa Varnavas at email@example.com.
As one who at times has been responsible for the care and feeding of new CDI specialists, I think it’s time for me to share my views on newbies.
Those of us who’ve come from the nursing ranks, especially those of us who’ve been nurses a long time, are well-familiar with the concept, nurses eat their young. It derives from the tendency of some older nurses to grind the heart and soul out of younger nurses. Greater awareness of the practice has, I think, led to kinder, gentler orientation processes, but many older nurses who go into CDI still have the mindset that they have to be perfect or someone’s going to tear into them. So here’s a few words of advice for new CDI specialists:
1. Nobody dies in this job. I have to admit in the spirit of transparency, that having once shared this concept with a certain new CDI specialist, I received a phone call one day shortly thereafter. “You lied to me.” Now, talk about putting my heart in my throat! What could I have possibly lied about? “You said nobody dies in this job. I went out to review this patient and she died.” Okay, well, yes, patients do die every day despite our hospital’s and our physicians’ best efforts. But they do not die because of anything the CDI specialist did or did not do. Unlike bedside nursing (and ICU nursing, where I came from)–where a wrong medication or forgotten procedure could actually be a life-or-death event–mistakes in CDI don’t actually impact lives. “Nobody dies in this job” is meant simply to take the pressure off those of us who come from the nursing perfection. Did I say perfection? Of course I meant profession.
2. Orientation never ends. Yes, your manager is going to give you an orientation schedule that has a start date and an end date, because they have to. But it’s really not like the orientation I experienced when I was a new nurse where I showed up for work one night and saw my name no longer attached to my preceptor. When I asked, I was told, “You’ve been here eight weeks. You’re off orientation.” As a new CDI specialist you have a right to expect regular bidirectional feedback so that the transition to independent practice is seamless and appropriate. Orientation is a fluid process, and while it’s not unreasonable or unexpected to have goals and target dates, every CDI specialist is unique and orientation needs will differ. If you feel like you’re not getting what you need, speak up. I tell new CDI specialists and prospective CDI professionals that regardless of their previous healthcare background, this will be the toughest learning curve they’ve ever encountered. And that’s not something that can be overcome on a fixed schedule.
3. Speed kills. This is one of those “do as I say, not as I do” moments. My work pace is extremely fast, but I do on occasion miss things because I work so quickly. In the beginning, you are probably going to panic about your productivity. You may have been told you must complete X number of initial reviews and X number of followups daily. I’m not here to tell you to ignore your manager, but if you are working methodically and paying attention to how you approach cases, you will get faster. You will learn what to look for and what information probably won’t make a difference. If you frequently find yourself spending an hour on one case, consider whether you’re getting a return on that investment of your time, or whether you might have the same results if you’d cut it down to 15 minutes. If you just can’t seem to tear yourself away and your manager is imploding, then take your little smartphone and set your timer for 15 minutes at the start of each case. When the timer goes off, walk away. By not getting to the next case, you may be missing an opportunity on another chart that didn’t get opened.
4. It’s okay not to know it all. You may finish your formal orientation process as a whiz in cardiovascular CDI, because you come from a cardiovascular background, you had a cardiovascular CDI whiz for a preceptor, and you saw a wide variety of cardiovascular conditions and complications as part of your orientation process. But the vacancy in the department for which you were hired was on the gynecology floor, where you have zero experience. Fear not. You can still function. Honest. You have learned basic principles that apply no matter where you are assigned, and you will learn, exponentially, as you gain experience. You will learn by making mistakes, and that’s okay. (See #1 above.) The hallmark of a good CDI is recognition that you don’t know everything, having a willingness to learn, and inquisitiveness–you don’t wait for someone to teach you, but go seek out information yourself. As I used to say when I precepted staff nurses at the bedside, the day you think you know it all is the day you need to hang it up. So hang in there, and eventually you will feel more comfortable. The day will soon come when you will likely be a CDI resource, a person your colleagues seek out when they have questions.
5. Seek the next level. You can go to Boot Camp or have a good orientation or take a coding class, and you can learn to function at a basic level, but if you want to advance beyond querying for acute systolic heart failure, you’re going to have to take the initiative and learn. Read, read, read. Network, network, network. Talk to your colleagues. Read and post on ACDIS’s CDI Talk. Somehow, realizing that there’s always new information out there makes the knowledge that you don’t have all that information easier to accept.
So take it easy on yourself! You worked hard to get into CDI and you deserve to give yourself a break.
There is no doubt about it—CDI specialists will be taking on more work and a greater complexity related to that work in 2014 due to the implementation of ICD-10. The question for many CDI managers around the country is: How do I keep my staff intact, given that they’re facing a greater workload, competing pressures, and increased career opportunities from other facilities and consulting firms looking to hire?
“I know my staff is juggling responsibilities and doing so much more than simple chart reviews,” says Samantha Joy, one Illinois-based CDI director whose name has been changed at the request of her facility. Joy took over the program two years ago and grew its staff by 50%. She now has 12 full-time CDI specialists. One has been working at Joy’s facility for eight years; the newest staff member started a few months ago. There are no plans to hire additional staff members due to the ICD-10-CM/PCS implementation.
Although Joy hasn’t had any trouble with staffing turnover in the past, and salaries are in line with the ranges reported in her area (read the 2013 Salary Survey results in the October edition of the CDI Journal), she understands how valuable CDI expertise will be in 2014 and wants to be ahead of the curve. So when her facility’s ICD-10-CM/PCS steering committee began discussing retention bonuses for coding staff, Joy began researching similar trends in the industry for her staff as well.
She found only a few facilities who had developed retention bonuses for CDI staff, but that was enough to convince her it was a good idea. So she drafted a proposal, and received approval in December. According to the proposal, CDI specialists will receive an incentive payment for remaining on as staff, staggered and delivered in the following increments:
- 25% of the incentive payment once they start their ICD-10-CM/PCS training
- 25% of the payment once they complete their training, based on an 85% or higher proved competency rate
- 50% of the payment one year post-ICD-10 implementation
If these staff members leave the facility for any reason they will have to pay back the money they’ve received; and, of course, they must remain in good standing while on staff, completing their regular workload and performing their duties as appropriate, says Joy. Training is expected to begin early in 2014 and take about four or five months to complete. CDI specialists will also review the components of physician training so they understand what physicians have learned and have the ability to fill in the gaps if necessary.
“The question is how to reward my staff for taking on all this additional information, and how can I retain them once I’ve trained them,” says Joy. “There are not a lot of facilities doing this yet—either that or they haven’t thought through to this level of planning so far. So I feel like I am just one more step ahead.”
Editor’s Note: Download a free ICD-10-CM/PCS CDI survey results and analysis. Also, don’t forget to register for the free webinar Six Months until ICD-10 Hits: Last Minute Tips for Coding and Improving Physician Documentation, which takes place Tuesday, April 1 at 1-1:45 p.m., with Coding Boot Camp Instructor Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP, and CDI Boot Camp instructor Laurie Prescott, MSN, RN, CCDS, CDIP.
In 2008, only 11% of poll respondents indicated their CDI program either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient (8% and 3% respectively) areas. How has the climate changed?
According to more than 400 respondents to the question this past month on the ACDIS website poll, 35% now say they conduct outpatient reviews and 61% do not (1% say they only review emergency department records, and 2% plan to start outpatient reviews within the next year).
With the advent of Medicare Administrative Contractors (MAC), which review both Part A (hospital) and Part B (physician) billing, payers are now looking to ensure that physician and facility billing match, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS, an ACDIS Advisory Board member and independent consultant based in Madison, Wisc., in a previous edition of the CDI Journal. This combined review could mean new vulnerabilities for hospital and physician reimbursement, but it also represents a new opportunity for CDI specialists.
“We [as CDI specialists] are trying to get buy-in, support, from physicians,” Krauss says. “But we don’t explain how documentation affects their business. Outpatient documentation review is a good segue for helping physicians understand the importance of documentation in the medical record.”
Although the majority of those participating in the recent ACDIS poll remain focused on inpatient record reviews the trend has shifted from that illustrated in the 2008 poll. As more government initiatives roll out, no doubt CDI will continue to advance into the outpatient arena. If you are currently conducting such reviews, please share with us your story in the comment section below.
Editor’s Note: This article first appeared in the bi-monthly email newsletter CDI Strategies.
Of the nearly 450 respondents to a recent ACDIS website poll, 50% say they conduct pre-payment record reviews, with an additional 7% indicating their facility is considering implementing such reviews in 2014. Of that 50%, 35% of CDI departments conduct such reviews themselves.
Ever wonder how many records your CDI counterparts at the hospital down the street have to review? Has your CDI specialists’ list of duties expanded exponentially over the years but the productivity expectations remain the same?
Please take a few minutes to participate in this CDI program structure and productivity survey. In it, we ask questions regarding your CDI program’s reporting structure, the number of record reviews you perform, and whether your facility plans to hire new CDI staff in response to ICD-10.
Your responses will illustrate program structure and productivity trends across the country. We hope the results will help you draw meaningful comparisons with other CDI programs and build a case for hiring additional staff. To participate in the survey, click here.
There are only so many hours in a day. And only so many minutes to explain the complicated process of coding and reimbursement to a less than eager room full of physicians. In an hour-long session, Bryan P. Hull, MD, site lead for ICD-10 enterprise project and assistant professor of medicine at Mayo Clinic Hospital in Phoenix found he spent 30 minutes or more talking about the definition and purpose of the DRG system—over and over again.
“I knew there had to be a better way to do this,” says Hull.
Hull began researching online tools for video creation and came upon VideoScribe which essentially animates PowerPoint presentations making it seem as though someone has been videotaped hand drawing the presentation.
With a solution in hand, he just needed a story-line for his presentation and support from his CDI teammates, which he readily received.
“Some people stay up late at night thinking about the meaning of life,” Hull states at the outset of the five minute video, as an artist’s hand quickly sketches a cartoon image of a Greek philosopher. “Other people think about the possibility of life on other planets,” he adds as the artist colors an alien head in a thought bubble. “But in care management, other things keep us up at night; things like clinical documentation improvement.”
The video goes on to describe the role of documentation in quality reporting and the role of the CDI specialist in helping physicians capture that documentation. Hull provides two case examples of patients with pneumonia and walks through the different conditions, demonstrating how variables such as home oxygen, COPD, and other conditions affect the patient’s severity of illness, length of stay, and the DRG assignment.
Now, Hull goes to the meetings, runs the video, and makes himself available to support the CDI team members. “We start the video and the physicians recognize my voice and laugh,” he says. “They really get a chuckle out of it. It opens the door to the CDI team to take over the presentation and drill down into more detailed documentation improvement initiatives.”
Mayo has played the video at all its Phoenix divisions and even at the enterprise-wide CDI conference held in the fall. Now, Hull envisions adding other videos focusing on DRGs 177, 178, 179, and turning them into a collection.
“We’ve gotten a lot of feedback from the providers regarding the videos. We can measure the difference, the improvement in the documentation overall. While that may not be due specifically to the video we know that our training matters.”
I’m sure most of you are familiar with the holiday favorite “On the first day of Christmas.” The song, written in the 18th Century, recounts the delivery of increasingly fabulous gifts beginning on Christmas day and continuing through to the feast of the Epiphany, or “Twelfth Night.”
The original lyrics (which included something about five gold rings and geese a-laying) have been reworked to both entertaining and memorable results over the decades. In 2008, Bonnie Epps and Jamie Doster of Emory HealthCare in Atlanta, adopted the song for CDI professionals.
It went: “On the first day of Christmas my CDI manager gave to me. . . one CDI program. One the second day Christmas my CDI manager gave to me. . . two POA’s. . . and one CDI program. . .”
You get the gist. The rest of the countdown included:
3 – Doc MS pain
4 – E-mails from the boss
5 – Educational CD’s
6 – CCs
8 – Re-reviews
9 – DRG’s wrong
10 – Reason codes
11 – Queries answered
12- ADT feeds
Today, five years later, we may very well have some new lyrics to add to the song. How about “On the first day of Christmas my CDI manager gave to me:
- CDI program
- Reviews for patient safety indicators
- Claims denials
- Medical necessity reviews
- DRG mismatches
- New CDI staff members to train
- Educational presentations to deliver to physicians
- EHR implementation meetings
- Outstanding queries
- Coding articles to read
- Secondary diagnoses to review
- ICD-10-CM/PCS educational sessions to attend
What would you add to this list? Post your suggestions below! Merry Christmas!
Establishing a CDI program doesn’t guarantee compliant documentation and/or coding. Queries that focus on obtaining ‘buzz’ words that add reimbursement but don’t add anything to clinical care overlook two important factors that relate to overall revenue integrity:
- Clinical context
- Quality of clinical documentation
Both of these factors are essential for decreasing the financial risks associated with Recovery Auditor, Medicare carrier, Fiscal Intermediary, and Medicare Administrative Contractor (MAC) post-payment and pre-payment reviews and recoupments. As stated in the most recent Recovery Audit Program Final Scope of Work, Recovery Auditors are required to employ registered nurses and clinicians who must review medical records for medical necessity and clinical validation.
Diagnostic conclusion statements previously carried sufficient weight for coders to confidently assign an ICD-9-CM diagnosis code that would withstand the test of time in the event of an outside review. However, these statements are insufficient as a matter of clinical documentation integrity when they don’t incorporate a clinical context for understanding. The clinical context of the documentation plays an integral role in establishing medical necessity for the hospital admission as well as the patient’s continued stay.
The following case study represents best practice for appropriate and proper documentation in support of the clinical context and medical necessity for admission.
Chief complaint: Chest pain, headache, cough, and fever unabating
HPI: The patient is a 35-year-old female who initially came to the ED two days prior with complaints of a severe, bothersome, ongoing cough for one week, productive of thick yellow sputum. She has also had a fever for three days as well as worsening shortness of breath present mainly on exertion. She also had chest pain in the substernal area that has been continuous and worsening for the past four days, but increased with coughing. She has had headaches for approximately three days and primarily when coughing. She has had decreased p.o. intake for two days. In the ED, she was given IV Rocpehin x 1 and sent home with a prescription for Biaxin™. The patient stated that she did fill the prescription but that she was taking Motrin® and Tylenol® for the pain. She stated that neither medication helped her and that her temperature went up to 103°. Thus, she came back to the ED. In the ED, a chest x-ray was repeated today. The x-ray continues to show left lower lobe infiltrate that worsens with increased haziness and more of a white out picture. Her white count was 15,000 with 12 bands, 18 neutrophils. As a result, it was determined that the patient had failed outpatient treatment and required inpatient hospital admission.
Impression and plan: Pneumonia with sepsis. The patient is being admitted because she meets the severe sepsis criteria with temperature of 103°, tachycardia with heart rate of 140, infection of pneumonia, and white blood cell count 15,000 and neutrophils 18. She has also failed reasonable outpatient management. She is being placed on IV Rocpehin and IV Zithromax®. Blood cultures have been sent. She will get Duoneb® and be placed on pneumonia protocol.
Clearly, the clinical documentation in the above case study accurately and effectively captures the patient’s true severity of illness and the physician’s clinical judgment, thought processes, and clinical rationale for admission.
In its FY 2014 IPPS final rule, CMS states that there will be a presumed inpatient status when a patient remains hospitalized for two midnights. Effectiveness of clinical documentation in support of the physician’s decision to admit as an inpatient assumes even more importance in light of this change.
Auditors will be looking for a clear outline of the physician’s clinical rationalization and reasonable expectation of a hospital stay that spans two midnights. Diagnostic conclusion statements will no longer sufficiently capture the clinical context and medical necessity for inpatient admission.
The most effective approach to CDI involves synergy between coders and CDI specialists. The query process can—and must—expand beyond the traditional realms to incorporate clinical context and medical necessity. This will take a collaborative approach involving the CDI and the coding staff.
CDI specialists are on the front line, and they have the opportunity to reach out to physicians and provide one-on-one education about:
- Perils of the EHR
- Cutting and pasting documentation
- Need for succinct documentation of the HPI
- Need for progress notes that provide an accurate account of a patient’s progress while he or she is hospitalized
Coders review the record at its completion, essentially acting as an outside reviewer.
Quality documentation is an essential part of the revenue cycle process. When considering the quality of your documentation, ask yourself the following question: What purpose do CDI specialists and coders serve if the hospital fails to be reimbursed for the excellent clinical care provided? Your answer will be the impetus to expand the thrust and focus of CDI.