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The AHIMA CDI practice brief: A Q&A discussion with co-chair Gloryanne Bryant

A CDI Work Group run by the American Health Information Management Association (AHIMA) has been meeting for more than a year to address and develop CDI resources and tools. One of the primary objectives of the AHIMA CDI Work Group was the development of a CDI practice brief. The CDI practice brief is expected to provide additional support and enhancements to the previously published practice brief titled Managing an Effective Query Process, which serves as a recommended industry best practice for CDI programs.

ACDIS Advisory Board member Gloryanne Bryant, RHIA, CCS, CCDS, Regional Managing Director of HIM (NCAL Revenue Cycle) for Kaiser Foundation Health Plan Inc. & Hospitals in Oakland, CA, was co-chair of AHIMA CDI Work Group. She recently talked with ACDIS Director Brian Murphy about this important project. A transcript of their Q&A session appeared in last week’s issue of CDI Strategies.

An Irish documentation tale

The CDI leprechaun is a type of fairy in Irish folklore. He or she usually takes the form of an old nurse, clad in a white lab coat, who enjoys partaking in helpful mischief.  The earliest known reference to the CDI leprechaun appears in the medieval tale the Adventure of Doctor Son of Kildare.

Follow the CDI lebrechauns to documentation gold!

The story contains an episode in which doctor falls asleep in the physicians lounge and wakes up to find himself being dragged onto the ward by three luchorpain, or leprechauns. He turns the tables on them and captures his abductors, who grant him three wishes in exchange for their release. The doctor chooses to document better, increase his severity of illness scores and of course, to help his hospital prosper financially. His wishes are granted and the three CDI leprechauns retreated down the hospital corridors.

The CDI leprechaun is a solitary creature whose principal occupation is reviewing charts and improving documentation. The leprechaun can be a practical joker, often leaving queries with obscure riddles such as “the patient has an albumin of 1.5; please document the diagnosis this may represent.”

As well as chart reviews, the CDI leprechaun’s other trade is comorbidity banking. The wealth of these fairies comes from their knowledge of CC’s and MCC’s, which they have printed onto secret pocket cards. Rainbows reveal where the cards are hidden, so a CDI leprechaun will often spend all day reviewing charts throughout the hospital to elude the telltale end of the rainbow.  If you catch a leprechaun, don’t let him or her out of your grasp, for he or she will quickly dash out of your sight.

No one has actually ever caught a leprechaun, but the pocket cards are now free for the asking, since the CDI leprechauns have a heart of gold and a desire to help others.  Physicians need only ask, and the smiling documentation fairy will assist with any wording needs.

Good luck to all and Happy St. Patrick’s day.

Coding Clinic guidance can help with surgical complication documentation

During the November 20, 2009 ACDIS audio conference “Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures”  speakers Robert S. Gold, MD and Lena N. Wilson, MHI, RHIA, CCS, provided a list of Coding Clinic references they thought could be helpful to others. The list includes:

  • Care during surgery: 3rd quarter, 1990
  • Accidental puncture laceration: 2nd quarter, 2007 and 3rd quarter, 1994
  • GI complication code: 3rd quarter, 2003; 4th quarter, 1995; and 3rd quarter, 1995
  • Adhesion code: 3rd quarter, 2003; 4th quarter, 1995; 3rd quarter, 1995; and Sep-Oct, 1985

The program includes a case study from Clarian Health Partners in Indianapolis and illustrates how documentation affects surgeons and their public profiles.  During the program Dr. Gold offers guidelines for reporting surgery complications and explains the disconnect between a hospital’s financial considerations and the physician’s profile.

If you didn’t get a chance to listen to the program, you can purchase an audio-on-demand version from HCMarketplace.com

Create a CDI program ‘vision’

Start your query development by establishing a clear vision.

Editor’s note: The following is an excerpt from the Physician Queries Handbook: Guide to Compliant and Effective Communication.

As the saying goes: you can’t see without strong vision. So, before you build your CDI program or start to establish a physician query process determine the scope, vision, and mission of your facility’s efforts. Early in CDI program implementation, consider the creation of a steering committee that works together to write a vision statement for the CDI program.

In its simplest form, the vision of a CDI program should be precise and accurate clinical documentation that results in appropriate coding, assignment of diagnosis-related groups (DRGs), quality measures, and reimbursement.

Make sure the vision of your program and query process supports the desires of the various facility departments CDI supports. By ensuring that members understand the vision for the program, the role their department plays, and the inter dependencies of their roles, you help everyone involved feel a sense of ownership int eh program and its accomplishments.

Supplement to January 2010 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 January 2010 issue: A special report reviewing the important developments and guidance in Coding Clinic for ICD-9-CM, fourth quarter 2009. The sources of the report are James Kennedy, MD, CCS, director of FTI Healthcare consulting and author of the Physician Queries Handbook, and Laura Doty, RHIT, a director at FTI Healthcare.

This special report breaks down the latest Coding Clinic as it pertains to CDI specialists. This quarter of Coding Clinic features an added emphasis on documentation at the time of discharge, CDI opportunities in diabetic patients, and changes to coding and reporting of obstetrics patients.

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 or Laura, please feel free to post it right here.

Take care,

Brian

Perform clinical assessment prior to query submission

CDI specialists and HIM professionals may often wish they could read physicians’ minds when clinical documentation is lacking, but this superhuman power seems to exist only in books and movies. However, most coders probably would agree that the ability to read minds would be enormously helpful when deciding whether to report uncertain diagnoses. These are conditions for which physicians find clinical evidence that leads to a suspicion but not a definitive diagnosis.

The challenge for coders is that uncertain diagnoses often change or morph into something else during the hospital stay and doctors don’t do a good job of telling us whether it’s ruled out. They change their thought process in the management of the patient and go down another path.

Complex clinical scenarios and inconsistent physician documentation complicate matters. When initial documentation includes an uncertain diagnosis—but the physician does not include that same diagnosis in the discharge summary—a query may be necessary.  Herein lies the confusion.

If you want to be 100% certain, then you’re going to be querying for everything. Instead, CDI specialists need to use their best clinical knowledge to determine when a query is truly necessary.

For example, consider the following scenario:

A patient who recently suffered a heart attack presents to the cardiac care unit with shortness of breath. The physician conducts a thorough history and physical, documents a plan of care, starts the patient on IV Lasix, orders a chest x-ray, and documents ‘possible acute congestive heart failure (CHF).’

Clinical notes indicate that during the second day of the hospital stay, the physician stops the Lasix with no orders for step-down therapy to oral Lasix. A review of the physician orders indicates no further management of acute CHF with commonly prescribed CHF treatment regimens (e.g., other types of diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta blockers, or digoxin).

Upon discharge, there is no mention of acute CHF, and the patient is not given any meds to manage acute CHF.

This is a perfect example of a scenario in which CDI specialists can employ their basic clinical knowledge and avoid a potentially needless query. One day of IV Lasix treatment without patient management may not be considered the standard of care for treatment for acute CHF.

Let’s do our homework before we query. When CDI specialists or coders send unnecessary queries, they begin to lose physicians’ respect.

Ask Santa: Query the right elf for proper documentation ‘gifts’

When I was a little girl, I wanted a turbo-slingshot in the worst kind of way. I told every department

Don't just ask for a sling shot, ask for a turbo sling shot.

store Santa about my secret wish. When Christmas morning came I was heartbroken when the slingshot was not included in my bounty of dolls, clothes, and games. I now realize that perhaps I had told the wrong person. In my embarrassment over the desire to receive a non traditional gift, I failed to tell my mother about the coveted slingshot.

The same is also true of queries. If we ask the wrong person, we will not always get the answer we are seeking. Likewise if we ask the wrong question or an inappropriately worded question, the physician may get confused and ignore the request.

One of my colleagues shared with me a conversation she had with a young resident physician. She left a query asking the doctor if there was a link between a patients’ UTI and their chronic Foley use. She also needed him to document that the UTI was present at the time of admission. The physician was absolutely flummoxed. The query read: “Please state in progress notes what diagnosis the urinalysis report indicates, and if the condition is secondary to chronic Foley use and if present on admission.”

She talked to him the next day and he asked her to explain the unusual request. He told her that the query left him feeling unsure of what was wanted. She explained the hospitals strict policy regarding the wording of queries and the avoidance of leading questions. She carefully went over the patient record and pointed out where the communication breakdown had occurred.

The physician had documented the patient had presented to the emergency room from a nursing home with a Foley catheter in place. He ordered a urinalysis with culture. When the results were obtained a day later, he had simply written U/A positive, start on Levaquin. My clever coworker explained to him that the “U/A positive” documentation could not be picked up by the coders and therefore it was unclear why the patient had been admitted. Furthermore, a link to the chronic Foley with the UTI and the present on admission status were not established in the documentation.

He responded with an enthusiastic “Aha!!” He finally understood. She had asked the right person, the right question, in the right manner.

Now, if I could only get Santa to bring me a laptop for Christmas…

I hope my husband sees the large picture I pasted on the refrigerator with my letter to Santa and an attached query form. “Dear Santa, Please clarify if the above person was a good girl this year and if so, buy her this computer or else!”

A bit leading perhaps, but I will not make the same mistake again. Merry Christmas, Documentation Specialists!

Physician column laments documentation burdens

I often search the World Wide Web for information pertinent to clinical documentation improvement specialists. Quite often I find comments similar the ones posted Sunday, November 29, in The Washington Times by Jason D. Fodeman, MD, an internal medicine resident at the University of Connecticut,  a former health policy fellow at the Heritage Foundation.

If it wasn't documented, it wasn't done.

If it wasn't documented, it wasn't done.

In his opinion piece “Defensive medicine costs: Litigation-inspired tests hinder needed ones,” Fodeman suggests documentation improvement directives stem from burdensome malpractice litigation, insurance requirements, and physicians’ lawsuit fears.  He argues that documentation efforts take time away from patient care.  He writes:

“Primarily this degree of documentation is done out of necessity to keep the pesky lawyers at bay. In fact, by wasting valuable physician time that could be better spent actually seeing patients, it can be counterproductive to a patient’s well-being.”

CDI specialists attempt to overcome such physician perspectives every day. You know improved physician documentation isn’t just about dollars, and it’s not a feigned attempt to reduce medical errors. Complete and accurate documentation improves patient care by affording every healthcare provider with the most complete documenation of a specific patient’s treatment.

While the increased pressure to provide complete documentation may indeed have a tenticle or two stretching from the governmental policy monsters and malpractice boogeymen such criticism of documentation improvement efforts drastically oversimplify an extremely complex healthcare system. One increasingly proven way to shed light on that system is through the education efforts CDI professionals offer hospital physicians daily.

Keep up the good work. Write on.

Establish query policies prior to CDI program launch

Program policies help ensure compliance prior to audits.

Program policies help ensure compliance prior to audits.

An ACDIS member recently recounted a disappointing story regarding her facility CDI program implementation. Essentially, the nurses performing concurrent queries disagreed with the coders at nearly every turn. I’m sure many of you can relate to this predicament. In the end, the facility brought its lawyer and compliance officer to the table. A good move which maybe might have saved some aggrevation if they’d been at the table from the beginning.

The coding rules and regulations are strict and too often seem to conflict with clinical common sense. RNs believe they’re perfectly entitled to ask a physican a basic question regarding patient information in the chart regardless of whether the question may be construed as “leading” by outside auditors.

So I thought it might be a good idea to post a short excerpt from the article Establish physician query protocols to resolve compliance risks in the July 2009 issue of the CDI Journal. In the article Andrei M. Costantino, MHA, CHC, CPC-H, CPC, director of organizational integrity at Trinity Health in Farmington Hill, MI, Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta, and Robert A. Wade, Esq., a healthcare attorney at Baker & Daniels, in South Bend, IN, offer tools to help keep CDI programs compliant with government rules and regulations.

Creating policies and procedures for your query processes is one way to help eliminate risk. Legal penalties for filing false claims due to leading physician queries won’t seem like a misdemeanor if the Office of Inspector General and the U.S. Department of Justice (DOJ) investigate. The CDI program could unduly influence physician documentation. Such influence could in turn cause compliance headaches or, worse, a False Claims Act lawsuit.

Creating policies and procedures for your query processes is one way to help eliminate risk. It’s also the reason many experienced CDI administrators know their compliance officer and legal counsel, and it’s also why new program leaders should introduce themselves to the compliance department as soon as possible, says Costantino.

The CDI Journal is the quarterly publication of the Association of Clinical Documentation Improvement Specialists (ACDIS) and is free for its membership. To become a member contact Sue Calabro at customerservice@cdiassociation.com or call 877/240-6586

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:”

  1. If it is a complication of surgery, it is either a complication or surgery
  2. If it is a manifestation of a disease unrelated to the surgery it is not a complication of the surgery
  3. If it is not treated it may not be codable—but it may