The case mix index is up and admissions continue to rise. You’d think this was wonderful news. Yet, the facility administration complains that reviews are down and queries are low. You don’t have to be a math genius to know that something here does not compute.
Is the education given to physicians and allied health professionals being evaluated? Does anyone evaluate the improvement in documentation?
Numbers are classically low in the summer months in Florida due to the absence of our much loved snowbirds from Canada. Vacations from both CDI professionals and physicians take a toll on productivity. New residents start in July, and the heat index rises to 98 degrees (and I don’t mean the literal temperature, either).
Help! How do you rate the success of your clinical documentation department?
Query response rates are evaluated and the overall numbers of reviews are counted. The revenue elicited from these queries is tallied and viola, the success of a program is in the financial numbers. Wrong!
CDI specialists spend a good deal of their day speaking to physicians and educating them on the benefits of proper documentation. They attend huddles with case management, they are members of committees, they round with specialty teams, and they frequently make presentations at meetings and resident Grand Rounds. Does this not count for anything? There needs to be a better way to evaluate success.
CDI presentations commonly extol the virtues of proper documentation— how it improves mortality and morbidity scores and severity of illness statistics. Physician “buy-in” is stressed at every turn, but where and when do we get to discuss the importance of the hospital administration’s “buy-in?”
A recent hospital audit of 300 medical records turned up some not too surprising facts about physicians. The doctors are still not documenting appropriately, their handwriting is illegible, and the discharge summaries are inadequate.
Recent changes in CMS regulations have made certain wording and diagnosis linking imperative for hospital coding and reimbursement. The new rules are confusing and complicated. Certain words need modifiers, certain diagnosis must be linked to their causative agents, other conditions must be rated as acute, exacerbated, or unstable.
There is an old expression that “You can’t teach an old dog new tricks.” I am starting to wonder if this shouldn’t also include physicians. I work in the Clinical Documentation Improvement office and we strive to educate physicians on the nuances of clinical documentation. This recent audit indicates that we still have a lot of work to do.
I attended parochial school my entire life and I spent most of my formative years having to stay after school for poor penmanship. I still have terrible handwriting and I missed out on a lot of fun. This only goes to explain why I cannot criticize someone for having poor handwriting. The new computer era is upon us and with the advent of electronic medical records it also may be a mute point. I do not give penmanship classes.
However, like that old dog, the problem may be that seasoned physicians are too old to learn new techniques for documenting patient care. Perhaps we need to start educating the physicians sooner, when they are still in medical school.
The problem may be the lack of incentive. Perhaps the physicians need some sort of pay for performance to entice them to change their old habits.
Or the problem may be that hospitals need more upper management support for their CDI departments. Perhaps a series of speeches given by the CEO would get everyone motivated.
The problem may be a lack of educational resources. Perhaps hospitals should invest in teaching tools and educational literature.
The problem may be everything mentioned above and then some.
Clinical documentation teams across the country are working diligently to educate physicians and improve documentation. Blaming the CDI department for the deficiencies of the physicians, will not correct the problem. Secretary of State Hilary Clinton said “it takes a village to raise a child,” cribbing from an old African proverb. Well, maybe it takes a hospital to educate a physician.
CDI specialists should be on the lookout for indications of patient noncompliance with medical treatment when reviewing patients’ charts, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services with 3M Health Information Systems (HIS) and a member of the ACDIS advisory board.
According to Garrison, payers are increasingly denying hospital readmissions and the problem is likely to worsen with the nationwide rollout of the Recovery Audit Contractor (RAC) program and CMS’ increasing scrutiny of the cost of readmissions. “Readmissions can be the result of, or influenced by, patients who leave the hospital and refuse or elect not to follow recommended treatment plans (by choice, by misunderstanding of discharge instructions, or due to costs), which may cause their condition to worsen, resulting in a readmission,” Garrison says.
However, CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report V15.81, hospitals can use this documentation and coded data to help prevent or appeal denials, Garrison says. “If the V code is reported in the top nine diagnosis codes when it is transmitted on the UB-04, (it allows) the payer to have the knowledge that patient noncompliance may have contributed to the readmission,” she says.
“I have always recommend the use of the V15.81 code for noncompliance to both coders and physicians when supported by the clinical documentation,” adds Gloryanne Bryant, RHIA, CCS, CCDS, regional managing HIM director, NCAL Revenue Cycle of Kaiser Foundation Health Plan Inc. and Hospitals in Oakland, CA, and a member of the ACDIS advisory board. “I agree this is helpful, but mostly for understanding which patients really are not following medical instructions. Is it the diabetic patient or the dialysis patient, etc?
“It further explains and provides insight into healthcare resource use, length of stay, costs, and readmission rates,” Bryant adds. ”I would recommend that facilities run a data report on their inpatients with this V code assigned and conduct some audits and reviews to gather insight. I would also track/trend this V code over time and share the information with providers.”
(Note: Glenn Krauss shared the following case study with me during a recent medical record review he conducted. I thought it would be interesting to share the case with members of ACDIS. Feel free to post your comments here.–Brian)
Although query forms and electronic prompts are invaluable tools in every CDI specialists’ toolkit, Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, CCDS, an independent consultant in Janesville, WI, says that they shouldn’t serve as a substitute for face-to-face interactions with physicians. The following clinical scenario demonstrates why.
A patient is admitted to the hospital in hypertensive emergency (blood pressure of 210/130). The patient had previously controlled her high blood pressure with medication which she recently stopped taking. She receives IV Cardizem to lower her blood pressure. The ED physician documents that the patient presented with a severe headache and focal neurological deficits on her right-hand side, including facial droop and difficulty moving her right arm. The clinical impression in the ER is “likely CVA.”
The patient’s focal neurological deficits subside and resolve within the first six hours of the hospitalization, leading the physician to document TIA in the progress notes beginning on day two of the hospital stay. Of note (also on day two), the nurses observe and report to the physician that the patient is exhibiting an altered mental status with some confusion. The physician orders a urinalysis with C&S that shows > 100,000 CFU positive for E.Coli organism. IV antibiotics are started and patient’s fever and altered mental status begin to improve. However, on day three the patient’s altered mental status and confusion begin to worsen and a neurology consult is called.
The consulting neurologist performs an evaluation and documents that the patient’s neurological deficits are related to hypertensive encephalopathy, with no mention of stroke or TIA.
The attending physician, thinking that the patient may have viral meningitis due to continued headache, stiff neck, and waxing and waning mental status with confusion, begins the patient on Acyclovir therapy for herpes simplex virus infection. The patient is eventually discharged on the eighth day, with the following final diagnoses documented in the discharge summary:
“TIA with diffusion weighted MRI evidence of territorial infarct in the front lobe.”
Remote history of smoking
Previous history of stroke
“In this instance the CDI specialist assumed that the physician’s impression was that of TIA with hypertensive encephalopathy, given the hypertensive emergency condition the patient presented with to the ER,” Krauss says. ”Unfortunately, this was an ill-conceived assumption, given the results of the discharge summary.”
Krauss also notes that the physician’s documentation of etiologies for the patient’s clinical presentation does not do justice to the actual patient acuity nor the length of stay of the patient, particularly since the patient’s signs and symptoms align with more than one of the patient’s documented clinical entities, in conjunction with the documentation of TIA in the discharge summary,
Krauss notes that a coder is precluded from assigning anything other than TIA as the principal diagnosis in this case based upon the medical record documentation. Mention of a territorial infarct in the discharge summary appears to be described as a radiological finding versus a more definitive clinical disease process, he says of the case.
The coder in this instance left a written query for the physician. Much to the despair of the coder, the physician answered the query as follows: ‘Your guess is as good as mine.’
Krauss says a better option for resolving this case is for the CDI specialist to engage in a clinical discussion with the attending physician, preferably concurrently or retrospectively if necessary. “We focus so much on leaving queries that we forget about the two-minute conversation,” he says. “This is a good place to educate the physician on the importance of documenting his or her practice of medicine and a good teaching moment.”
Explain to the physician that the diagnosis of TIA does not do justice to the acuity in his medical decision-making, suggests Krauss. “He didn’t mention anything about the herpes simplex virus, meningitis, or the fact that the TIA may constitute a stroke.” For a good reference, Krauss recommends sharing the American Heart Association/American Stroke Association scientific statement paper, “Definition and Evaluation of Transient Ischemic Attack,” available here: http://stroke.ahajournals.org/cgi/content/short/40/6/2276.
The paper states that the arbitrary time threshold of 24 hours may be too broad, given that many studies have shown 30% to 50% of classically defined TIA’s show brain injury on a diffusion-weighted MRI. “In fact, the article goes on to point out also that some groups have advocated for the following definition of TIA: “a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with typical symptoms lasting less than one hour, and without evidence of acute infarction,” Krauss says.
In addition to the newly proposed definition of TIA vs stroke, this case reinforces the opportunity for the CDI specialist to incorporate the concepts of risk of morbidity and 30-day mortality, risk adjustment of potential for 30 and 90 day readmissions, measurement of physician efficiency in the delivery of healthcare, and the MedPac Commission’s proposal for Accountable Care Organizations as a strategy to slow the growth of Medicare expenditures.
“CDI specialists can capitalize upon the opportunity to bring relevant business developments in healthcare that directly impact the physician’s business of the practice of medicine from an operational and financial standpoint,” Krauss says.
Remember the old 80′s ad for the Big Mac? “Two all beef patties, special sauce, lettuce, cheese,
pickles, cheese, onions on a sesame seed bun.”
These lyrics and the associated fast food mania was a sign of what I will call food affluence, when we valued time over money, convenience over quality and taste over nutrition. And yet during that same period, the prevalence of malnutrition in hospitalized patients was investigated numerous times with results indicating the malnutrition was a major concern for elderly, hospitalized patients. The effects of malnutrition and the associated costs were also vastly studied in late 80′s and early 90′s. So why has this issue not resolved?
Of course, the issue is once again poor documentation of the severity of the diagnosis and decision making regarding care of this condition. Unfortunately, the malnutrition codes differ from the usual medical terminology. The severity of the malnutrition is indicated in the codes and while clinical severity is typically indicated in risk not actual diagnosis.
Most nutritional consult forms provide a method for the dietitian to indicate risk for malnutrition, not an actual diagnostic statement. Many forms actually ask the dietitian to specify the level of risk of malnutrition by checking the appropriate box for low, medium/moderate, or high. These indicators do not easily translate into an ICD-9-CM code forcing professional coders and CDI specialists to search for other indicators of the severity of malnutrition to clarify diagnoses with the physician.
In an attempt clarify the need to document the severity of malnutrition in adult hospitalized patients, Coding Clinic addressed the issue in the fourth quarter of 1992. It says:
Hi ACDIS members, I wanted to let you know about a new white paper available for download in the Helpful Resources section of our Web site under the heading “White Papers.” It’s called “Cut through the confusion of altered mental status,” and it offers suggestions on what to when physicians document AMS, as well as how to appropriately query for encephalopathy and/or other more specific diagnoses. It also includes a sample AHIMA-compliant query form.
The source of the white paper is James Kennedy, MD, CCS, of FTI Healthcare. Dr. Kennedy is a unique combination of clinical and coding expertise.
I hope you find this white paper helpful. ACDIS publishes white papers on a quarterly basis on various topics in the CDI profession. If you haven’t seen our Helpful Resources page, check it out!
The outlook wasn’t brilliant for the CDI that day:
The chart stood unattended, with one hour left to stay,
And then when Dr. Cooney didn’t chart, and Dr. Barrow did no more,
A pall- like silence fell upon the patrons of the floor.
A straggling few got up to go in deep despair. The rest
Clung to the hope which springs eternal in the breast:
They thought, “If only Dr. Casey could get a whack at that,
We’d put up even money now, with Dr. Casey at the bat.”
There was ease in Dr. Casey’s manner as he stepped into his place:
There was pride in Dr. Casey’s bearing and a smile lit Dr. Casey’s face.
And when, responding to the query, he lightly doffed his hat,
No stranger on the ward could doubt ‘twas Dr. Casey at the bat.
The usual sneer had fled from Dr. Casey’s lips; his teeth clenched in rage:
He pounded with cruel violence his pen upon the page.
And now the nurse she holds the query, and now she lets it go,
And now the air is shattered by the force of Dr. Casey’s NO!
Oh, somewhere in this favored land the sun is shining bright,
The band is playing somewhere, and hearts are light,
And somewhere men are laughing and little children shout;
But there is no joy at the hospital – mighty Dr. Casey had struck out.
A documentation specialist and I were doing rounds on a unit one day when we ran into a physician who left a query unanswered.
The CDI whispered in my ear:
“I query him about this condition all the time and he usually writes it but I don’t get why he won’t write it without being asked first.”
The physician’s response was simply “out of sight, out of mind.” After a lengthy discussion regarding long standing documentation habits, we realized that this physician wasn’t being non-compliant or difficult—he truly needed the constant reminders. He had developed a pattern of dictation he reverted to whenever looking at a patient’s chart and was in a time crunch.
So this begs the question, how do we change documentation habits and patterns? Do we have any real hope of changing them at all?
For many CDI specialists posting queries is not enough to change a physician’s documentation behavior. Probably the best answer to this question is to keep clinical documentation information in front of physicians. Constant reminders through informational/educational opportunities that are updated monthly can be very beneficial. The format needs to be applicable to the physicians and can vary from hospital to hospital. I caution that once you establish a format be consistent in your approach.
Possible strategies include:
- monthly newsletters
- posters and flyers in the physician lounge
- cue cards that can be easily carried in a pocket and presentations at meetings
But probably the most beneficial method for providing support for documentation that reflects the severity of illness of the patient is for a CDI specialist to be visible on the units when the physicians are on the units. I can’t stress enough the need for personal one-on-one time with the physicians on the floor, the importance for a CDI specialist to be “in their face.”
Pick a CDI topic of the month and go with it. The information needs to remain simple and to the point so you don’t lose the interest of the physician. Again, time is money in their mind so they tend to be more accepting when you get straight to the point. And don’t be afraid to recycle what you’ve used in the past, as reinforcement of new habits is also very beneficial in supporting clear and consistent documentation.
“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”
~Hamlet, Act III, Scene I
I truly think that Shakespeare was a frustrated CDI nurse.
I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:
“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”
If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.
Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?
I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.
Q: Our CDI program is a little over a year old and we do not have a physician advisor/champion. One of my difficulties is I find myself trying to diagnose the patient and then trying to write a query in an attempt to obtain a specific diagnosis. For example, a physician documents in his progress note that the patient’s D-Dimer is elevated much above her normal level and her syncope could be related to this.
It is possible that the patient has had a transient ischemic attack (TIA), but how do I write this query as to not offend the doctor or look like I am diagnosing the patient? Previously, I have written the query as follows: “Please relate the syncope to the med diagnosis when the workup is complete (i.e., TIA, other).”
A: An elevated D-Dimer is a nonspecific test that may point to thrombosis and, in the setting of syncope, does not point to any one disease. Know that a TIA rarely results in syncope unless it involves the posterior (basilar) circulation, which is very uncommon. A pulmonary embolus usually has an elevated D-Dimer and can result in syncope; however the symptoms would be dramatic. Given that D-Dimer and TIA have little direct correlation with each other, the physician would be frustrated but not offended by this question.
I would suggest the following:
Determine whether your hospital has access to any electronic internal medicine references that you can use to learn of the clinical indicators of certain conditions (i.e., TIA, stroke) so that, when you see these indicators, you remember the reference (you can say that “I saw this in Harrison’s Textbook of Medicine”, for instance) and you can query for the clinical significance of that indicator.
You can also use these references to learn about certain laboratory tests or medications so that you can ask open ended questions about them (i.e., “Please indicate for what condition the following pharmaceutical was prescribed; Please indicate the clinical significance of the temperature of 102, WBC of 18,000, and hypotension in the setting of the patient you described to be toxic appearing”). Note that I did not lead the physician as to what to say.
Regarding your question, I would have queried the physician in one of the following manners:
Please indicate the clinical significance of the elevated D-Dimer level of ________ in this patient with syncope.
In light of the elevated D-Dimer, the other laboratory studies, and your history and physical examination, please indicate in your progress notes and discharge summary the likely cause of this patient’s syncope. Hospitals are allowed to code “possible, probable, suspected” diagnoses when written or dictated at the time of discharge (e.g., the discharge summary).
You may also create multiple choice query forms for the common situations that you run into.
Editor’s note: James S. Kennedy, MD, CCS, director for FTI Healthcare in Atlanta, GA answered this question in the April issue of the ACDIS publication the CDI Journal. Check back soon at the HCMarketplace to learn more about the upcoming publication of the Physician Query Handbook authored by Kennedy and his colleagues at FTI.