All Entries in the "Quarterly conference calls" Category
Quarterly Conference Call for members May 9
Join us this week for the ACDIS Quarterly Conference Call.
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 prichards@cdiassociation.com 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.
Quarterly membership call slated for May 9
Don’t miss the May quarterly conference call for ACDIS members.
Dear ACDIS Member,
Our next quarterly conference call is scheduled for Thursday, May 9, from 1-2 p.m. ET. To access the call, dial the toll-free number that was emailed to you. It will also prompt you for a password (guest code). If you have not received your password via email, please contact ACDIS Members Services Specialist Penny Richards at prichards@cdiassociation.com.
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 will have a few ACDIS Advisory Board members on the call as well. We encourage your comments, thoughts, and questions during the call.
We want your ideas and questions!
If you have a question to ask, or suggestions for discussion on the upcoming call, please e-mail me at bmurphy@cdiassociation.com. Conference calls are a great way to ask a question, air any and all 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.
Q&A: Coding ‘hepatic encephalopathy’ as a secondary condition
Have a question you’d like ACDIS experts to answer? Email mvarnavas@cdiassociation.com
Q: What are the pros/cons of coding ‘hepatic encephalopathy’ as a secondary condition? For example, here is a clinical scenario that happened at our facility: A patient is admitted for pneumonia and the history and physical (H&P) states the patient has a ‘history of Hepatitis C with encephalopathy controlled with Lactulose, current grade 0 (zero).
In the opinion of the ACDIS Advisory Board members, is it compliant to code the Hepatitis C as with encephalopathy?
Donna Wilson: If a patient is admitted with viral hepatitis and also has hepatic encephalopathy, do not code hepatic encephalopathy (572.2) as a secondary diagnosis. Hepatic encephalopathy/coma is included in the code for the viral hepatitis (see AHA Coding Clinic for ICD-9-CM, 2007, 2nd Quarter, p. 6.)
Robert Gold: My concern is that the name of the code is “with coma.” When the patient is awake, alert, and not comatose, and therefore not being actively treated for coma, much less active delirium from hepatic encephalopathy (i.e., patient is stable on benchmark lactulose), do not code “with coma” just because the patient is under standard treatment—he doesn’t have it now. This is a Recovery Auditor target.
Sylvia Hoffman: I agree with Donna. It would be inappropriate to code the encephalopathy. The Coding Clinic referenced also states if a patient is admitted with viral hepatitis and also hepatic encephalopathy, do not list hepatic encephalopathy as a secondary diagnosis. Hepatic encephalopathy/coma is included in the code for the viral hepatitis.
Donald Butler: Although I find the logic of the question very seductive, I’ve finally realized how to perhaps express why I have not been comfortable with this concept for a while. Coding for a chronic condition that is under control with treatment, etc., is one thing (i.e., end-stage renal disease [ESRD], congestive heart failure [CHF], etc.). The nuanced difference for me on this particular item is that coding the hepatic encephalopathy would be capturing the acute manifestation of the chronic problem (i.e., the underlying liver disease) that is not currently present but which the patient had previously. Encephalopathy is (per the National Institute of Neurological Disorders and Stroke) a global brain dysfunction, and the patient described in this scenario does not have that. One would not consider coding acute pulmonary edema or acute CHF in an ESRD patient is who stable and compliant with their treatment regime.
Secondly, although there is a non-essential modifier for hepatic encephalopathy (acute), it still suggests that the intent is for an acute problem. Furthermore, there is no index entry for chronic hepatic encephalopathy, and clinically I’m not sure such a condition exists. There are better ways to capture the treatment focused on the chronic liver condition, especially if the liver disease is advanced to the point of chronic failure.
Editor’s Note: This question was submitted for the ACDIS quarterly conference call of February 14, 2013, and were answered by Donna Wilson, RHIA, CCS, CCDS, Robert Gold, MD, Sylvia Hoffman, RN, CCDS, CCDI, CDIP, and Donald Butler, RN, BSN, of the ACDIS advisory board.
ACDIS membership quarterly conference call Thursday, February 14
Happy Valentine’s Day from ACDIS. Join the Quarterly Conference Call Thursday, February 14.
Our next quarterly conference call is scheduled for Thursday, February 14, from 1-2 p.m. ET. To access the call, ACDIS members have been provided a toll-free number via email. If you have not received this email please contact ACDIS Member Services Director Penny Richards at prichards@cdiassociation.com or by phone at 781-639-1872, ext. 3423.
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 have a question to ask, or suggestions for discussion on the upcoming call, please e-mail me at bmurphy@cdiassociation.com. Conference calls are a great way to ask a question, air any and all 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.
Reminder: Quarterly Conference Call tomorrow
Quarterly conference call tomorrow.
The next ACDIS Quarterly Conference Call is scheduled for Thursday, November 15, from 1-2 p.m., ET. ACDIS members have received e-mail regarding how to access the call. If you have not received instructions, please contact Member Relations Specialist Penny Richards at prichards@cdiassociation.com.
Think beyond inpatients when conducting medical record reviews
Review the entire medical record. Consider starting from the point of admission
Consider new Noridian observation vs. inpatient flowchart
CDI specialists should review the overall quality of medical record documentation from the day a patient comes into the ER—regardless of whether that patient ultimately ends up in observation, as an inpatient, or elsewhere.
“Quality of care is not segregated into buckets,” says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI an Independent Revenue Cycle Consultant from Madison, WI and a member of the ACDIS advisory board.
CDI specialists often focus exclusively on inpatient admissions and exclude other reviews due to lack of opportunity to “move the DRG.” Some CDI programs have a rule of thumb of waiting 24-48 hours after admission before reviewing the chart, in order to allow sufficient time for clinical staff to perform a review of studies and workup.
But Krauss says CDI specialists looking to stay on the cutting edge of regulatory trends should rethink this mindset. Quality of documentation includes the entire universe of documentation in the chart, whether that’s observation, inpatient, ambulatory care, and even areas like home health and physical therapy.
“It doesn’t matter where it is, or how it’s paid. It’s how it’s documented,” Krauss says.
Given the increased scrutiny of observation services, records for observation patients are a good place to focus additional CDI efforts.
Noridian Administrative Services LLC, a Medicare Part A contractor for 11 states, recently issued this helpful Inpatient vs. Observation flow chart, an invaluable tool for CDI specialists looking to expand their value to their hospitals.
“We (CDI specialists) should have this checklist in our heads when we conduct reviews. If the history of present illness is
Join us Aug. 16 for the Quarterly ACDIS Conference Call.
poor, or there’s no chief complaint, or the physician’s ER documentation is not adequately describing the patient’s acuity, for example, we need to go back to the doctor,” Krauss says. “We should be thinking along these lines.”
Krauss cites the example of a CDI specialist whose work clarifying the documentation results in a shift of principal diagnosis from chest pain to gastroenteritis or costochondritis. His or her work goes for naught if the chart is audited six months later and is either denied due to a lack of medical necessity, or the hospital has to spend significant money making the case that the patient was appropriately admitted.
“The ramifications of just having the diagnosis in the chart without the facts is tremendous—conclusionary statements don’t go a long ways these days,” he says. “I like to use this flowchart as a mindset—we should be emulating the processes described in this flowchart during our reviews. We’re not serving as case managers, who look at what’s in the chart—we’re looking as CDI specialists at what is missing.”
A review of all record types will likely require a change in the mindset of most CDI specialists—and, more challenging, a change in the mindset of administration who have been sold on a certain idea of what a CDI program is (inpatient/DRG focus only). But Krauss says it’s a battle worth waging.
“It’s not about how many records we touch, the quality of documentation is the bottom line. Without that buy-in from administration who pays your salary, it’s hard to change that mentality,” he says.
Editor’s Note: Reviewing charts that change from inpatient to observation will be a topic for discussion on the ACDIS quarterly conference call of Thursday, August 16: http://www.hcpro.com/acdis/quarterly_conference_calls.cfm. ACDIS members have received dial-in instructions via e-mail. A recording of the call will be posted soon.
A few post-call thoughts regarding post-operative pulmonary insufficiency and electronic queries
Quarterly Conference Calls offer members opportunties to network and share best practices..
Editor’s Note: During last Thursday’s ACDIS Membership Quarterly Conference Call the Advisory Board discussed documentation requirements for post-operative respiratory failure and post-op pulmonary insufficiency among other topics. These calls, which are free to ACDIS members, allow participants to pose a question and gain feedback and perspective from the Board and other peers. Typically, upwards of 200 people join the call.
The following post was submitted by Janie Brown, RN, CDI specialist, at The Indiana Heart Hospital in Indianapolis. Contact her at JBrown5@ecommunity.com.
ACDIS members can download a recording of this and all previous, archived editions of the call from the ACDIS website.
When I started the CDI program here at The Indiana Heart Hospital (TIHH) nearly two years ago, I was also looking for some direction regarding how to document and code for respiratory failure/post-operative pulmonary insufficiency. For me, the AHA’s Coding Clinic for ICD-9-CM guidelines were unclear. So, I worked with our pulmonary critical care physician, Franklin Roesner, MD, one of our cardiac surgeons Bob Shoemaker, MD, and our Senior Medical Records Coder Debbie Dinsmore, to develop some internal guidelines for the use of the diagnosis of post-op pulmonary insufficiency. The definition we used is “a decrease in normal pulmonary function due to trauma to the thoracic cavity and or surgical intervention.”
The guidelines we ask our physicians to consider are as follows:
- Has pulmonary/critical care medicine been consulted?
- Has the patient experienced increased oxygen requirements over time?
- Has the patient required frequent respiratory treatments over and above incentive spirometry more than 24 hours post-op?
- Are chest x-rays being frequently monitored?
- Are pleural effusions being monitored or treated?
I have been known to “swoop” down to the SICU when I see a nephrologists typing in “respiratory failure” on a post-op emergent cardiac surgery who remains on the vent at 0800 after returning from the operating room at 0300 to just gently say, “are you sure you want to say that?”
We are very aware of the dangers of overusing this diagnosis here at TIHH and I think the development of our own internal guidelines has greatly assisted us in staying on the straight and narrow. We do not tend to include this diagnosis unless respiratory issues continue to greatly affect the patient’s progress on post-op day three or four.
In reference to using all electronic medical records: TIHH is the only hospital in our network that is all electronic. When I started here, our training consisted of learning to leave paper queries. I had no place to leave a paper, so I was forced to talk to my physicians. That turned out to be the biggest blessing in disguise I have probably ever experienced.
In my opinion, whether you are using paper or a computer for documentation, there is absolutely no substitute for the face-to-face exchange of thoughts and information when seeking to attain accuracy and completeness in the medical record. My advice to any CDI specialist is to get out of the office and away from the desk and talk to your physicians face-to-face.
Quarterly Conference Call scheduled for May 24
The next Quarterly Conference Call is scheduled for Thursday, May 24, 1-2 p.m., ET. ACDIS members should have
Join us this week for the Quarterly ACDIS Conference Call
already received email instructions regarding how to access the call.
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 industry-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.
We want your ideas and questions!
If you have a question to ask or suggestions for discussion on the upcoming call, please e-mail ACDIS Director Brian Murphy at bmurphy@cdiassociation.com. Conference calls are a great way to ask a question, air 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.
If you cannot attend the call, a digital recording will be available for members to download on the ACDIS website.
Determining the benefit of flesh-and-blood CDI vs. computer-assisted coding
Don't fear advent of computer assisted coding.
I received an interesting question following the February ACDIS Quarterly Conference Call about the impact of new technology on the CDI profession. It read: “Do you think computer-assisted coding (CAC) will reduce or eliminate CDI jobs?”
Several members of the ACDIS advisory board formulated answers worth sharing (read a few of their comments in the April edition of the CDI Journal.)
Here’s how I feel about CAC. It can be a valuable tool in the box of a CDI specialist, like a hammer or saw, but it does not replace the CDI specialist. At times I too react to new technologies with skepticism and defensiveness, wondering if this or that new gadget will sound the death knell for my own job. But machines will never replace the human element.
In short, summarizing the sentiments of the ACDIS Advisory Board:
- As long as physicians require education as to why accurate, complete, and legible documentation is important, CDI will be here to stay.
- As long as doctors respond to a face instead of an electronic prompt, CDI will be here to stay.
- As long as medicine remains part art and part science, CDI will be here to stay.
In short, CDI is not going anywhere anytime soon. View these new technologies as a new and exciting challenge to master, not as an enemy to fear. What do you think about CAC and the impact it will have on CDI? Send me an e-mail with your thoughts.
Q&A: Code or query for clinical significance
Q:I am wondering about whether coders can use information the physician takes from test results and includes in the
We love to respond to your questions. Post yours in the comment section below.
history and physical (H&P). We recently had a situation where the H&P indicated under the studies section that “chest x-ray showed atelectasis,” or “EKG showed right bundle branch block (RBBB) with anterior fascicular block” etc.
Some of us believe that it’s okay to code the diagnosis, i.e., atelectasis, if the provider states that the testing “showed” the diagnosis. Others believe we cannot code the diagnosis as this is a lab/testing result and the provider could just be reading the results onto their H&P dictation.
However, I argued that since the provider is using this information to make decisions about care/testing/procedures and indicates the testing results in the H&P body, that makes it okay to code from this information. I realize you cannot go to the testing result itself and code from it directly. What are your thoughts?
A: Most of the time these kinds of findings are “incidental,” in other words, they may have no clinical significance. I think it’s important to investigate whether these “new” findings lead to additional interventions, medications, more workup, etc. If not, then I don’t feel they meet criteria for coding/reporting. Just because something is mentioned does not mean we should code it. If I review the record and don’t see a direct correlation between a documented diagnosis and orders for care, I query for the clinical significance of the diagnosis.
We are seeing more and more copying and pasting of diagnostic findings from diagnostic reports into physician notes with no further documentation of clinical significance, treatment plan, etc. So you must be very cautious on coding these or not. Be sure to query the physician to either confirm or rule out the findings.
Editor’s Note: This question was answered by Lynne Spryszak, RN, CPC, CCDS, and Sue Belley, M.Ed., RHIA, CPHQ, of the ACDIS Advisory Board following the February 16 ACDIS Quarterly Conference Call.
