All Entries in the "Physician queries" Category
Don’t let surgical complication documentation get complicated
There’s still time to sign up for Friday’s (November 20, 1 p.m. EST) audio conference: Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures with Robert S. Gold, MD, and Lena N. Wilson, RHIA, CCS.
Wilson is the HIM operations manager of the clinical documentation improvement program (CDIP) and inpatient coding at Clarian Health Partners in Indianapolis. In her current role, Wilson is responsible for the CDI program at Clarian’s three facilities in downtown Indianapolis, and the inpatient coding operations for the downtown facilities and the two suburban hospitals.
And while many in the CDI world think that Dr. Gold requires no introduction, let me nevertheless tout his expertise as founder and CEO of DCBA, Inc., in Atlanta, GA, a consulting firm that provides physician-to-physician education programs in clinical documentation improvement. He has more than 42 years of experience as a physician, medical director, and consultant.
Surgery documentation is an area rife with concern from both the physician point-of-view as well as from the CDI and coding perspective, like Dr. Gold points out in this Friday’s presentation. Too often CDI programs improve a facility’s risk adjusted mortality index but negatively impact a surgeon’s physician profile. Such outcomes make it difficult to get physician support for CDI. He outlines the following three “Golden Rules:”
- If it is a complication of surgery, it is either a complication or surgery
- If it is a manifestation of a disease unrelated to the surgery it is not a complication of the surgery
- If it is not treated it may not be codable—but it may
Dazed and confused? Or Encephalopathy?
Altered mental status, dementia, or encephalopathy: What’s really going on with your elderly patient that presents with confusion?
The typical scenario is the elderly patient with some minor dementia, who has been living fairly independently, who is described as being more confused than usual. A work up does not indicate any acute neurological conditions but the patient is admitted with altered mental status. Further work up often reveals an underlying infection or metabolic condition. After treatment of the underlying concern, the patient’s mental status returns to baseline and the patient is discharged back to their usual living arrangements.
Don't let dementia documentation confuse you.
The resources consumed in treating this type of patient often include a head CT, neurological consult, neurological checks, EEG, sometimes even a bed in the intensive care unit. But if the physician only documents altered mental status or dementia and not a type of encephalopathy, the true severity of illness of the patient may not be accurately reflected.
So what is encephalopathy?
As defined by the National Institute of Neurological Disorders and Strokes, National Institutes of Health, encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent, metabolic dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation) chronic progressive trauma, poor nutrition, or any reason for lack of oxygen or blood flow to the brain.
The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include tremors, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.
Coding Clinic provided a definition in the first quarter of 1988 (pages 3-4):
Leading the question
Clinical documentation improvement specialists continue to have trouble discerning between leading and non-leading physician queries. The question often comes down to an understanding of the various previous “lives” of professionals. Nurses are used parrying over clinical decision making, so why should their queries regarding documentation be any different from the clinical questions they’re used to asking? Quite simply: because there’s money involved.
Sure it’s true just as Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, said in his
Questions remain over leading queries
article “Is asking for clarification ‘leading’?” that the government never clearly defined the term “leading” and many experts continue to banter over the logistics of the language. However, CDI specialists need to shine a bright light on the differences between the leading and non-leading query to protect themselves and their facilities from the coming onslaught of government auditing agencies.
While the likelihood of true healthcare reform legislation seems to be dwindling, President Barack Obama nevertheless continues to push against apparent payment abuses throughout the system. CDI professionals are meant to be a facility’s first line of defense against such abuses. It a CDI specialist’s job to make sure what was documented in the patient’s medical record is the most accurate description of the care the patient received.
Yet we still hear of facilities focused on Medicare only patients. We still hear about CDI programs directed to only look at records of a certain dollar value. We still hear tales of CDI professionals requesting specific language from physician simply due to some administratively imposed financial quota.
Inappropriate, leading queries, not only open your facility to an inordinate amount of risk but also jeopardize patient care. Generate policies and procedures for your facility that outlines the purpose and intent of your CDI program. Include your administrators, HIM leaders, physician liaisons, and compliance officers in the process. Create standard query forms that allow for the physician to further explain his or her documentation and even to disagree with the reason for the query.
For more information about physician query best practices and the legal architecture on which current query practice is based, read the Physicians Queries Handbook.
The art of communication: Getting back to basics
Communication is defined in the Merriman-Webster dictionary as a verbal or written message,
Face-to-face verbal interactions offer CDI specialists unique physician education opportunities.
exchange of information, or a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior. Consider the evolution of communication within the last century, beginning with the carrying of mail by horse and buggy, then the introduction of the telegraph, telephone, fax machine, and now the internet.
Now consider the evolution of communication as pertains to coding and clinical documentation improvement (CDI). Before the advent and growth of CDI programs, documentation improvement consisted of a retrospective coding query to the physician. The query sought clarification of principal and secondary diagnoses consisting of complications and comorbidities (CCs).
Today, CDI programs shine a light need to educate physicians about complete and accurate clinical documentation. CDI programs highlight that need in the face of increased coding and billing regulatory scrutiny as well as a sound, prudent business strategy to meet the business financial challenges faced by physicians. Savvy CDI specialists therefor have incorporated educational tools into their programs including monthly newsletters, tip sheets, and pocket guides.
The execution of effective communication strategies dictates the successes and failures of a given CDI program. As I have the opportunity to “observe” programs in action, one component of communication often seems to be lacking. This component includes old fashioned verbal communication with physicians about the clinical facts of the case, existing documentation, and possible clinical documentation that may be missing from the health record.
Verbal communication allows the CDI specialist to provide education and reinforce teaching principles, a key point missing from the use of written clinical queries. The use of verbal communication allows the CDI specialist to read the physician’s body language and other cues to determine whether the physician understands the principles being discussed.
Appreciation and understanding of these documentation principles by the physician serves as the basis for educational reinforcement of other tools used in physician clinical documentation improvement efforts, the likes of newsletters, tip sheets, handouts, etc. No clinical documentation improvement program can be successful in the long run without going beyond episodic education of continuous, repetitive clinical queries. Eventually, physicians have a tendency to grow weary of the same day in, day out queries. They become numb to the content.
Physician clinical behavior modification by necessity requires more than leaving queries in the record for the physician to review at a later time. If one thinks about the use of clinical queries, an argument can be made for the evolution of clinical clarification to merely have changed from retrospective to concurrent. The physician is reading the clinical query on the hospital floor as opposed to reading it, culling information post-discharge, from the medical records.
Consider varying and adjusting CDI specialists’ work schedule to improve likelihood of reaching out to physician’s individual patient rounding practices. Reaching out to physicians for provisions of providing education is best served through learning of these practice patterns and adjusting one’s schedule accordingly. Generally speaking, making clinical documentation rounds routinely from 8 a.m. to 5 p.m., with a predetermined lunch break misses out on the opportunity to effectively and efficiently fulfill the roles, goals, and objectives of any program, that is true clinical documentation improvement.
Good Luck.
Supplement to October 2009 CDI Journal: Coding Clinic update
Hi ACDIS members, if you go to our CDI Journal home page you will find a special supplement to the October 2009 issue: A special report reviewing the important developments and guidance in Coding Clinic for ICD-9-CM, third quarter 2009. The source of the article is James Kennedy, MD, CCS, director of FTI Healthcare consulting and author of the Physician Queries Handbook.
In this article Dr. Kennedy breaks down the latest Coding Clinic as it pertains to CDI specialists, reviewing important sequencing considerations, query opportunities, and more. Going forward, ACDIS plans to make this a regular feature exclusively for our membership. Coding Clinic for ICD-9-CM is a vital component of every CDI specialists’ toolbox, and we hope you find the article useful.
If you have any feedback for Dr. Kennedy, please feel free to post it right here.
Take care,
Brian
Does your hospital use the Epic software system? Let’s hear about it
Hi ACDIS members, I’ve had a few questions recently regarding the Epic software system. It was a subject of a member’s question on the most recent quarterly conference call, and I’ve since received a few additional e-mails from facilities that are going to Epic, or plan to do so, and are looking for help from experienced Epic users who have been using the system to leave electronic queries and interface with physicians.
If you would like to share your e-mail address, please feel free to leave it right here by leaving a comment on this post, or you can e-mail me directly at bmurphy@cdiassociation.com.
With more and more facilities going electronic, it would be great to see members sharing best practices, implementation strategies, and other ways of helping one another out with this important transition.
Take care,
Brian
HCCA physician compliance and documentation initiatives
On a recent planning call regarding the 2010 ACDIS conference, participants requested a session about enlisting assistance from risk management and corporate compliance for CDI. So, I was pleased to see our friend Betty B. Bibbins, MD, FACOG, CHC, C-CDI, president and chief medical officer of DocuComp LLC., listed as general session speaker at the Health Care Compliance Association’s Physician Practice Compliance Conference in Philadelphia, October 11–13. As ACDIS Director Brian Murphy, CPC, said when he heard the news “it’s really great to see the integration of CDI in various venues.”
Bibbins session,Clinical Documentation Improvement Programs and Physician Advisors: Working Together to Improve Effectiveness takes place Monday, October 12. During the session, she’ll discuss the importance of CDI to physician practices within the inpatient and office settings and provide a basic overview of the goals and mission of CDI programs.
Teresa M. Bivens, CPC, CHC, deputy compliance officer at the University of Louisville/HSC, also offers a presentation to physicians regarding the importance of appropriate documentation titled The Lighter Side of Documentation. During her program, participants will play a game a real life clinical documentation “Mad Libs,” and she’ll explain how proper documentation can help keep government investigators at bay.
New article of the month: Complications of surgery
Hi ACDIS members, there’s been a lot of talk regarding complications of surgery during our quarterly conference calls. In response, we worked with Dr. Robert Gold of DCBA, Inc. and the ACDIS advisory board, and Mario Perez of J.A. Thomas & Associates, to bring you a new article of the month on the subject.
Please click here to view the article or visit our main page.
As a reminder, you can find an archive of previous articles of the month (as well as many other articles and links) on our helpful resources page.
Take care,
Brian
Get all the information on anemia documentation
I’m just sticking my foot into a wicked pile of super sticky unknown substance by bringing this topic of ‘acute blood loss anemia’ back up. But there’s been so much back and forth with our own ACDIS Advisory Board to iron out the details published in this week’s CDI Strategies, that I was quite surprised when one of our readers e-mailed shortly after publication to ask another question based on the brief.
Another question? I thought we couldn’t possibly write anything more on the topic! Well, I was wrong. Our friend from Washington, DC, asked: “If ‘precipitous drop in hematocrit’ is documented, must the baseline be known? What are the parameters and is it facility specific?”
So I’m throwing the whole thing out here to blog land. Please help me by posting any (and all) information you might have regarding how you approach physicians with queries for anemia.
Update physician education with tips from ACDIS members
A newcomer to the ACDIS group page on Facebook asked recently how to keep physician engagement in clinical documentation improvement high as CDI programs begin to mature.
To be sure, there’s always an initial excitement regarding new programs and the potential they hold for improvement. Sometimes, however, that energy begins to fade. Reading Tina Lewis Simpson’s comment I was reminded of a HealthLeaders Web cast, 5 Ways to Hospital-Physician Quality: Goals, Incentives, Dialogue, Infrastructure, Data, in which Rebekah Wang-Cheng, MD, FACP, medical director for clinical quality at Kettering Medical Center in Dayton, OH, offered several strategies to facilitate physician communication. Consider the following techniques to improve physician education and awareness of your CDI program:
- Educate one-on-one, face-to-face, in real time. When addressing a particular problem with physician documentation, don’t wait, says Wang-Cheng. Use a specific case that happened within the past day or two to illustrate your point.
- Educate in groups. Go where physicians gather, Wang-Cheng says. Offer education sessions during quarterly medical staff meetings, or specialty meetings
- Show data. CDI specialists constantly gather data, benchmark and report this data back to the physicians. When physicians see how appropriate documentation affects patient care and the overall mission/wellbeing of the facility they will be more likely to understand the mission behind your position.
- Walk in their shoes. Shadow a physician for a day to observe the pattern of their care. That way you’ll have a better understanding of the physician’s work flow. Armed with understanding you can adjust your query process to fit their needs as well as your own.
- Say, “Thanks.” If a physician is responsive to your inquiries, praise him or her for their helpfulness. Take your appreciation a step further, says Wang-Cheng, by sending him or her a thank you note to their home so they can show their family. “There’s nothing better than to be able to say to a spouse: ‘Look, someone said something nice about me.’”
- Start at the top. Approach physician leaders in various disciplines. This type of influence will help you “spread and sustain the education,” Wang-Cheng says.
- Listen as much as you talk. Emphasize with the physicians. Realize they have difficulties, both professional and personal, too. Don’t be afraid to admit ignorance but be sure to ask for their assistance when you do.
- Make the physician lounge a welcoming place. A CDI specialist may not have direct involvement regarding the physical location and ambiance of the physician lounge, but he or she can use the lounge as a way to get the word out about the CDI program. Visit often and leave specific, small tokens of appreciation from time to time.
Those interested in additional tips to gain physician support may want to click on Sylvia Hoffman’s blog posts, at right, including: Spring ideas to woo physician support and KISS method applies to CDI physician education, too.
Furthermore, thanks to North Cypress (TX) Medical Center Director of Clinical Documentation Improvement Mike Alcorn, LVN, there are some sample e-mail physician education packages available in our Forms & Tools Library. Read how he created his physician education strategy in CDI Strategies.
If you have any tips or innovative suggestions for how to spice up the physician education component for the more advanced CDI programs please post ‘em here. We love to hear what you’re up to. Besides what’s working for you may help solve a problem for someone else.