Q: We are getting pressure from our othopods to send all queries to their nurse practitioner (NP). Our facility bylaws allow NPs to function independently and they are allowed to answer queries without co-signature, so we routinely send queries to NPs who are caring for patients and we have great success with them.
The difference here is that the orthopods want us to send all queries to their NP, even if he/she is not caring for the patient. The ACDIS/AHIMA query guidelines tell us to query the provider that documented whatever needs clarification (though because we have a team approach with hospitalists, we often query the attending caring for the patient now, not necessarily the documenting provider). Our coding department has said they will not accept query responses from a non-treating provider. What do you think?
A: I have seen this happen at a number of facilities. They are using the NP/PA to do the “dirty work.” There are varying opinions on this:
- NP will become very good at documentation and become your best friend
- Queries will get answered in a timely manner
- If they are going to respond to queries they must see the patient. If not, they are a potential liability for the medical group and hospital.
I also wanted to respond to the group regarding who/where you can obtain documentation from:
- Pathology = no
- Echo = no
- Radiologist = no (however, CDI/coding can pull the specific fracture site and/or vessel sites directly from reports as long as the diagnosis is stated in the H & P/PN/Consult/ER, etc.
- EKG = no
- Cath report = yes
However, remember that in a query you can “refer” to that information.
Editor’s note: Deanne Wilk, BSN, RN, CCS, CDI Manager at Penn State Health in Hershey answered this question. Make sure to work with your facility compliance and coding departments in incorporating any recommendations as advice provided is general in nature. Contact Wilk at firstname.lastname@example.org.
By: Melissa Varnavas
More than 700 ACDIS members registered to participate in last week’s ACDIS Quarterly Conference Call. The calls, part of ACDIS membership benefits, features members of the Advisory Board who present on timely issues of the day and respond to participants’ pre-submitted questions.
The February 18 agenda included:
- Capturing appropriate risk adjustments for total documentation integrity
- ICD-10 unspecified codes
- Comparison of onsite versus remote CDI staffing models
- CDI reviews for risk-adjusted payment methods (outpatient CDI efforts)
A discussion around ICD-10-CM/PCS codes resulted in the greatest amount of feedback from both the Advisory Board and the general membership participants both during and after the call. One pre-submitted question asked:
“What is ACDIS’ opinion regarding the new ICD-10-PCS inclusion of arterial lines as a surgical procedure? Some experts say it is a valid procedure, others say it is not.”
“Unfortunately in ICD-10-PCS, central lines/PICC Lines, and arterial lines do not have a default code because of the specificity of the code set,” says ACDIS Advisory Board member Anny P. Yuen, RHIA, CCS, CCDS, CDIP, director of ambulatory CDI for Enjoin.
Coders require documentation of where the line ends, along with the intent of its use, in order to select the accurate body part and device within the ICD-10-PCS tables, Yuen says.
A number of minor proceedures which may not have been considered surgical in ICD-9 are coding to surgical procedures in ICD-10-PCS, resulting in the assignment of higher paying surgical DRGs. In fact, members of the Advisory Board have encountered enough of them to warrant a larger discussion and prompted them to create a poll to determine how the CDI community has been handling these discrepancies (please take a moment to participate in the poll).
“Last week, this very topic came up at our health system and I’ve had conversations with our coders and coding leadership about it,” says Advisory Board member Sam Antonios, MD, FACP, FHM, CCDS,CDI and ICD-10 physician advisor at Via Christi Health in Wichita, Kansas. “ICD-10-PCS is brand new and has never been used before, so it is not surprising that things like this will pop-up. However, we live in the real world with real patients and real money. So any irregularities created by the inherent current imperfections will affect real claims.”
Although it is beyond the scope of the Advisory Board to offer definitive regulatory advice on how to code these procedures, it did acknowledge that discrepancies exist and plans to raise this issue to regulatory authorities.
Tomorrow, Wednesday, August 19, from 1-2 p.m., ET, our own CCDS Coordinator Penny Richards, CPC-A, joins Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer and Fran Jurcak, MSN, RN, CCDS, for a free, 60-minute webinar exploring the most frequently asked questions regarding the Certified Clinical Documentation Specialist (CCDS) credential and examination process. During the call, the panel will discuss:
- How to apply
- How to prepare for the exam
- What resources are available for study
- Re-certification processes
In addition to the agenda, speakers will be answering questions live. To register, visit “CCDS FAQ: Everything You Need to Know About Taking the ACDIS CCDS Certification Exam.”
Quarterly Conference Call
ACDIS members can dial-in to a free topic-focused telephone conference call with leaders and Advisory Board members this Thursday, August 20, from 1-2 p.m., ET. This quarter’s agenda includes:
- Pulling past medical history forward from EHR for CDI purposes
- Ethics and ethical CDI practices
- The role of the physician advisor in CDI
- Your Q&As
We want your ideas and questions!
If you have a question to ask the ACDIS advisory board, or general suggestions for discussion on the upcoming call, please e-mail Associate Director Melissa Varnavas at email@example.com.
Conference calls are a great way to ask a question, air any and all CDI concerns, or gather input on a policy or procedure at your hospital. ACDIS members have access to this and all the Quarterly Conference Calls Archives on our website www.acdis.org. While we cannot guarantee your question or discussion point will be addressed on the call, we will try to work in as many as possible.
Please note that due to heavy call volume, we recommend that you dial in 10 minutes early. Dial-in instructions were set to ACDIS members via email this week. If you are an ACDIS member and did not recieve your instructions, call our customer service department by no later than 11 a.m. on the day of the live call at 877-240-6586 or email firstname.lastname@example.org
We look forward to talking with you then!
The next ACDIS Quarterly Membership Conference Call is scheduled for Wednesday, August 27 (note: not typical Thursday), from 1 to2 p.m. Eastern. Dial-in instructions will be sent to ACDIS members this week (please check your spam filters and email permissions to ensure you receive important information from ACDIS about your membership benefits). If you are an ACDIS member and do not receive your dial-in instructions, contact Member Services Specialist Penny Richards at email@example.com.
These quarterly calls are a means for ACDIS members to network with one another and to discuss any CDI-related issues. We encourage your comments, thoughts, and questions during the call. If you have a question to ask the ACDIS advisory board, or general suggestions for discussion on the upcoming call, please email firstname.lastname@example.org.
Please note that due to heavy call volume, we recommend you dial in 10 minutes early.
The next ACDIS quarterly conference call will be held on Thursday, May 29, 1-2 p.m. ET. Please note that due to heavy call volume, we recommend that you dial in 10 minutes early. Among other subjects, discussion will include the following topics:
- CDI beyond reimbursement: Medical necessity (special guest Glenn Krauss with reference to Novitas Solutions: E/M Service: Face-to-Face Documentation; and the following .ppt: Medical Necessity.
- Implementing electronic queries (special guest Michael McKelvey)
- Querying for hyponatremia in the setting of hyperglycemia
- Including physician “teaching” in queries/functional quadriplegia
- Obesity/BMI as a secondary DX
- Meditech and queries
- Clinical vs. coding guidelines
These calls are offered as a means for ACDIS members to network with one another and to discuss any clinical documentation improvement related issues. We will have a few ACDIS Advisory Board members on the call as well. Conference calls are a great way to ask a question, air any and all CDI concerns, or gather input on a policy or procedure at your hospital. While we cannot guarantee your question or discussion point will be addressed on the call, we will try to work in as many as possible. Note that we cannot answer questions relating to specific code assignment (i.e., which code to assign in a given clinical situation). However, questions about diagnosis sequencing, DRGs, ICD-10 preparedness, etc. are welcomed.
If you are an ACDIS member and did not receive your dial-in instructions please email Penny Richards at email@example.com at least one-hour prior to the start of the program.
The ACDIS Quarterly Membership Conference Call is scheduled for Thursday, Feb. 20, from 1-2 p.m. ET. Dial-in instructions for ACDIS members were sent out this week.
Our next quarterly conference call is scheduled for Thursday, November 21, from 1-2 p.m. ET. To access the call, please dial the toll-free number that was emailed to you.
If you did not receive the email dial-in information please email Penny Richards at firstname.lastname@example.org at least one-day prior to the call.
Due to heavy call volume, please dial in 10 minutes prior to the start of the program. These calls are offered as a means for ACDIS members to network with one another and to discuss any clinical documentation improvement related issues.
We will have a few ACDIS Advisory Board members on the call as well. We encourage your comments, thoughts, and questions during the call. If you would like to submit a topic or question for discussion please email ACDIS Director Brian Murphy at email@example.com
ACDIS members are invited to participate in a Quarterly Conference Call taking place, Thursday, Aug. 22, 1-2 p.m. (EST). Dial-in instructions were sent via email to ACDIS members. If you are an ACDIS member but did not receive your dial-in instructions please email firstname.lastname@example.org for information.
Please note that due to heavy call volume, we recommend that you dial in 10 minutes early.
These calls are offered as a means for ACDIS members to network with one another and to discuss any CDI related issues. We encourage your comments, thoughts, and questions, as ACDIS Advisory Board members will provide feedback during the call. If you would like a particular topic discussed email ACDIS Director Brian Murphy at email@example.com.
Q: I enjoyed listening to the ACDIS quarterly conference call in May. Someone on the call stated they have a physician response rate of 95%. That caused me to wonder what the typical time frame for physician response might be; ours is 48 hours after discharge. I have heard some facilities give two weeks and some give up to 30 days, so I am wondering if there is some standard there
A: Different facilities structure their programs differently. Many have no policy in place regarding expectations related to the timing of the physician’s response. That said, the most successful programs do set expectations typically of about 72 hours, and indicate on the query form, itself, that a response is expected within that time frame.
The goal is to have a high query response rate within that 72 hour time frame. In other words, there is a difference between an organization with a 95% response rate where the queries are closed within 72 hours and one that has a 95% response rate, but the queries are left open indefinitely. Best practice would be to resolve any open query before billing.
Few organizations will hold a claim for 30 days pending a query response, which can result in a re-billing situation if the query response changes the DRG assignment. An effective CDI department can positively impact bill hold times as they work to resolve open queries so the record is complete for coding within days of discharge. Most organizations have a bill hold goal of three to five days. Be sure to address how long a query can remain “open” or awaiting a response within your CDI program policies and procedures.
One of the most important aspects of tracking physician responses is to determine which physicians need extra support and education regarding the importance of CDI efforts. An internal escalation process (such as the samples recently published in the CDI Journal) may be another way to address habitual non-responders. Be sure to get hospital and physician leadership support for your deadlines and share them with the medical staff.
Also, you need to know if your organization voids those queries that no longer impact the DRG. For example, if a CDI specialist leaves a query for a CC but a different CC was coded, that query would be “voided” in some organizations. Then, when calculating your response rates you’d also have to void or remove those queries from the calculation so rather than a non-response counting against the query rate, that particular query would be removed from the equation. Additionally, some organizations “close” a CDI query and “open” a coder query when a patient is discharged if their coding department then follows up on the query so that can impact response rates as well by lowering the CDI response rate.
As you can see, there are a lot of factors to consider when calculating a query response rate so it is difficult to compare organizations without knowing how long queries can remain “open” awaiting a response and what query resolution processes are in place. Remember the value of the CDI department is in issuing queries to clarify incomplete, vague or missing documentation so query resolution should be a prominent task within the CDI role.
ACDIS members are invited to participate in a Quarterly Conference Call taking place today, Thursday, May 9, from 1-2 p.m. (EST). Dial-in instructions were sent via email to ACDIS members. If you did not receive your dial-in instructions please email firstname.lastname@example.org for information.
Today’s agenda includes a discussion of how one hospital implemented an electronic health record and computer assisted coding in conjunction with CDI input, as presented by special guest Mark Dominesey, a presenter at the 2013 ACDIS conference.
It also includes a discussion of record reviews for quality metrics associated with APR-DRGs, presented by ACDIS Advisory Board member Sue Belley. You can download a few slides Belley plans to present on the call here: www.hcpro.com/content/291981.ppt.
In addition, advisory board members will address member questions regarding renal failure, seizure documentation, capturing patient mortality documentation, and will also answer live questions from participants.