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TBT: 2017 Conference Committee member shares session insight

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Faisal Hussain, MD, CCDS, CDIP

By Faisal Hussain, MD, CCDS, CDIP

It was a real privilege to serve on the 2017 ACDIS Conference Committee, even though it involved a lot of hard work, and tough decisions regarding the selection of speakers and award winners.

One of the sessions that caught the interest of the entire committee concerned objectively measuring providers’ clinical engagement. What made this session even more special was the fact that the presenter, Nicole Draper, RN, BN, MHA, DH-C, was responsible for putting together one of the first CDI programs in Australia.

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TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

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TBT: Six steps to help you join the CDI ranks

Editor’s note: This article originally appeared on the ACDIS website in November 2015. To read the original article, click here.

There is a lot of discussion about how to be a good CDI specialist, but as the profession grows and facilities look to hire new CDI team members, many more people are looking to get into the field.

A few months ago, we received an email asking us what we would recommend to CDI hopefuls. After combing through our resources, consulting with our Boot Camp instructors and Advisory Board members, and interviewing working CDI specialists, here are six simple steps to help you set your feet on the CDI career path.

1. Learn as much as you can

When Shiloh A. Williams, MSN, RN, CCDS, CDI specialist (now CDI program manager) at El Centro Regional Medical Center in Holtville, California, initially applied for a CDI position, she knew nothing about CDI, coding, or the revenue cycle. She did a Google search before her interview and read up on DRGs, codes, and common diagnoses. Her research, coupled with her prior nursing experience and clinical knowledge, won her the position.

“I scoured the ACDIS website for information, ideas, and best practices,” Williams says. “Now that I’m doing the job, I am constantly turning to ACDIS resources for staffing and department metrics.”

Regardless of the field or position, any candidate who learns as much as possible about the role and company prior to sitting for an interview will have a distinct advantage. You may not have hands-on experience as a CDI specialist, but that doesn’t mean you can’t learn as much as possible about the field.

Review the materials on the ACDIS website—much of it is free—and take lots of notes. Read the ACDIS Blog and the CDI Strategies e-newsletter for timely tips and news updates. The ACDIS Helpful Resources page and ACDIS Radio are also fantastic free options to learn about the field and the industry.

It’s also a good idea to look through CDI job postings to see what facilities are looking for in terms of knowledge and experience. Some noteworthy topics to research include:

  • DRG basics
  • ICD-10 codes
  • How to read a medical record and research a chart
  • Hospital quality initiatives

2. Attend a local chapter meeting

If you have a local chapter in your area, call or email the leadership and ask if you can attend a meeting. This is a great opportunity to network with local CDI specialists, learn about the job from working professionals, and discuss timely topics and issues relevant to the field.

Networking may also lead to potential mentorship and job shadow opportunities that you wouldn’t have otherwise. Williams relied heavily on her mentors early in her CDI career.

“I was able to work alongside Marion Kruse, a well-known clinical documentation improvement and Medicare expert,” she says. “My passion for my work was fueled by her knowledge and expertise.”

Check the Local Chapter page on the ACDIS website for more information and meeting schedules.

3. Job shadow CDI staff

If you have a CDI program at your facility, ask the program staff if you can shadow them for a day to learn more about the work they do.

If your facility doesn’t have a CDI program, reach out to neighboring hospitals and see if their program would host you for a morning or afternoon.

Job shadowing is one of the most important things a prospective CDI specialist should do before applying for a job in the field, says Mark LeBlanc, RN, MBA, CCDS, director of CDI services at the Wilshire Group, and former ACDIS Advisory Board member.

“It’s a great opportunity to watch a CDI specialist work, ask questions, and see the work in action,” he says.

“It’s also a chance to see how you have to interact with staff on the floor. You need to be outgoing, and you have to be able to speak to all different levels of professionals, from providers to coders, so you can get things done.”

Also take advantage of other networking opportunities, such as reaching out to members of the ACDIS Advisory Board. “The board would definitely be willing to spend a few minutes with someone to talk about CDI,” LeBlanc says.

4. Analyze your skills

Typically, the most important attributes for a top-notch CDI specialist are extensive clinical knowledge and awareness of disease processes and complications, comorbid conditions, medical coding, and Medicare reimbursement.

A balance of clinical expertise and coding knowledge makes a candidate ideal, says Bonnie Epps, MSN, RN, CDI director at Emory Healthcare in Atlanta.

“I think [CDI] work would be easier if we all were proficient in coding,” says Epps. “If someone is interested in CDI, they should try and learn something about what coding is and why it’s important.”

Those with clinical backgrounds wishing to enter the field need to understand that CDI specialists have little to no contact with patients. Although their clinical acumen will definitely be put to use, they will no longer have any sway over the patients’ day-to-day care.

CDI work is based solely on what is written in the clinical documentation. For former bedside nurses, this requires a novel way of thinking and a willingness to learn new skills, Epps says.

“[An applicant] should be able to pick up the skills to read the chart, analyze the chart, and learn the coding rules and language,” says Epps. “You must be willing to learn these things and think in new ways.”

Communication skills (both written and verbal), imagination and creativity, and analytical and problem solving skills are also a must.

“You have to be willing to work with others and collaborate,” says Epps.

5. Train yourself

Programs typically train new CDI specialists for three to six months through in-house mentoring, job shadowing, and formal classroom learning. They often send new staff members to a CDI Boot Camp and/or have consulting training available.

However, if you are serious about getting a job in the field and want to expand your knowledge, it may be a good idea to sign up for an online learning program or a CDI Boot Camp on your own time. You’ll receive a comprehensive overview of the job and required knowledge, which will make you a more competitive applicant for prospective employers.

If you would like to work on training yourself, here are some helpful resources:

LeBlanc says prospective CDI specialists should also brush up on their anatomy and physiology— especially important with the advent of ICD-10.

6. Apply for the job

You’ve done the research. You’ve decided the job is a good fit for your personality and skill set. Maybe you’ve even job shadowed a CDI specialist or networked with CDI professionals at a local event. Now it’s time to apply for the job. There are plenty of facilities out there that will hire new staff even if they do not have CDI experience. Highlight any related training and skills in your resume and during interviews.

Keep in mind, you do not need to have the Certified Clinical Documentation Specialist (CCDS) credential to become a CDI specialist. The CCDS represents a mark of distinction for those who have been working in the field for a number of years. In fact, you must be a working CDI specialist for at least two years before you can sit for the exam. CDI career path.

Conference Corner: #TBT ACDIS conference through the years

Can you believe we’re just a couple days away from the 10th annual ACDIS conference? As we prepare for this monumental anniversary celebration, the ACDIS team is getting a bit nostalgic. Take a look at these pictures from the last nine years of ACDIS conference. We can’t wait to see you in Las Vegas!

10th Annual ACDIS conference by Slidely Photo Gallery

TBT: CMS offers video on ICD-10 coding for diabetes

Check out this video from CMS from last year. How has your facility changed its documentation improvement efforts around diabetes and how have the recent ICD-10-CM/PCS coding updates, Official Guidelines for Coding and Reporting, and new recommendations from Coding Clinic affected those efforts?

Let us know in the comment section. It’s a concern lots of CDI specialists struggle with.

TBT: Pediatric efforts offer new CDI opportunities

Starting a pediatric CDI program? Read how.

Starting a pediatric CDI program? Read how.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article “Pediatric efforts offer new CDI opportunities” which originally published in the October 2013 edition.

“We’re seeing more and more children’s facilities starting CDI efforts,” says ACDIS Advisory Board member Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. “The largest growth comes from multi-hospital systems that already have CDI programs in place. They see the potential of expanding to their affiliated children’s facility.”

With roughly 500 children’s facilities in the nation, Gold sees both the probable benefit and difficulty inherent in such CDI expansion. Children’s hospitals do not have Medicare patients—the typical starting point for traditional, short-term acute care hospitals, he says. In fact, most are paid on a contract basis related to a certain percentage of the actual charges of the care provided “so there was little financial incentive for children’s facilities to implement CDI,” he says.

Furthermore, children’s facilities do not have the external scrutiny that adult hospitals face. Where typical healthcare facilities turn to HospitalCompare,  HealthGrades, and other public quality report cards, children’s programs have few options, says Gold. He notes that Parents Magazine publishes an annual “Top 10” list, but that it is based on anecdotal data from its subscribers and research. So it can be difficult to persuade administration to expand CDI efforts based on physician ego, or quality scores either.

At the Medical University of South Carolina (MUSC) in Charleston, Karen Bridgeman, MSN, RN, CCDS, CDI specialist, started building the case for expansion by examining data from the University HealthSystem Consortium and National Association of Children’s Hospitals and Related Institutions. This data allowed MUSC to compare benchmarks regarding patients’ severity, mortality, and facility case-mix index (CMI). They took the 25 top and bottom DRGs and divided them into two categories—high-volume, low reimbursement and low-volume, high reimbursement—for Medicaid, Blue Cross, and commercial payers.

The data suggested that a higher level of clinical complexity existed than was being depicted in the medical record, Bridgeman says. Asthma and bronchitis, seizures, and neonatal care fell into the high-volume, low yield bucket; that cardiothoracic conditions and Level III neonatal ICU fell into the high-yield, low volume bucket; and that chart review of pediatric patients could help with respiratory failure, cystic fibrosis, sickle cell, and chemotherapy documentation improvement.

“We found the physicians writing respiratory distress, but that just wasn’t clear enough to determine whether it was an shortness of breath or a respiratory failure,” Bridgeman says. “Sepsis and shock weren’t being documented at all.”

TBT: Live focus group insights from the 9th Annual ACDIS Conference

The 2016 ACDIS Conference general session

The 2016 ACDIS Conference general session

Just as clinical coders transitioned to home-based offices in the early 2000s, many CDI specialists are now seeking greater flexibility in the workplace. During the 2016 Annual ACDIS Conference in Atlanta, TrustHCS sponsored a focus group with 15 CDI directors, managers, and supervisors who shared their thoughts on the evolution of the CDI industry.  Here are five items I took away as areas to watch in the coming year.

  1. CDI programs are expanding:

New venues for CDI programs include: all payers, outpatient, rehabilitation, observation, second and third Medicare reviews, value based purchasing and core measures, mortality reviews, PSI/complications, and pediatrics. The barrier to these expansion plans is the ongoing shortage of trained, qualified staff, and funding for implementation, which leads to the second discussion topic—CDI outsourcing.

  1. CDI outsourcing ahead:

While most participants preferred to hire and train their own CDI specialists, the group concurred that CDI outsourcing is becoming increasingly necessary to fill staffing gaps. Needs included weekend and vacation coverage, and growing demand for more CDI reviews as part of their program expansions.

The pros and cons of outsourcing through staffing agencies versus a full-service outsourcing company were discussed and four must-haves were identified:

  • Only qualified CDI specialists need apply: The agency or outsourcing company must fully vet, audit, and test CDI specialists. Performance results should be made available for review and substantiated through CDI staff auditing and testing prior to the engagement.
  • Onboarding support required: Along with the quality of the candidate, the onboarding of CDI support staff should also be provided by the agency or outsourcing company with an overall plan of how the onsite leadership team will collaborate with remote staff. Specific attention must be paid to documentation, coding, and physician nuances of each individual facility.
  • Staff audits necessary: The agency or outsourcing company should also audit their own staff, rather than ask the facility to review CDI staff performance. CDI outsourcing must save management time—not increase the CDI director’s workload.
  • Technology enablement essential: The focus group voiced that any outsourced CDI specialist—through an agency or full-service firm—must have ready access to technology. The outsourced CDI specialist depends on technology to assign a DRG, review cases remotely, and communicate queries electronically. Outsourced CDI programs need to be able to efficiently operate the facility specific software or have technology available to them to seamlessly join the workflow occurring in-house. CDI directors are encouraged to ask about technological capabilities or familiarity with systems before entering into any type of outsourced CDI arrangement.
  1. More CDI reporting needed: While most of the CDI programs began with a focus on reimbursement, they are quickly shifting to a focus on quality outcomes. Providing good reporting and analytic support is a major need for most, if not all, participants in the focus group. Current systems were noted as missing key capabilities for data reporting and analytics for CDI performance.
  1. Understanding the reporting structure:Most of the CDI programs represented during the focus group are housed in the HIM department—or at a minimum, report to the HIM director. The participants agreed the HIM department was the best fit for their CDI efforts because of the availability and access to patient records and HIM’s mutual goals. However, other organizations are finding success with CDI reporting through quality or case management. Outsourced CDI firms need to understand the differences that accompany various reporting structures.
  1. Remote CDI workforce emerges: We know the coding industry works well in a remote setting. Would remote CDI be a viable option for healthcare facilities thriving in a remote environment today? Here is what the focus group said:
  • Remote CDI specialists require a fully implemented EHR system.
  • Only certain functions are recommended for remote CDI—including case ID, case reviews and queries. A blended approach is best practice.
  • Remote staff could rotate—with at least one day a week spent onsite at the hospital/health system/care location.
  • There must always be at least one onsite CDI lead or liaison to communicate with physicians, coders and other departmental teams.
  • High-quality standards must be maintained throughout the program—including for remote staff.
  • CDI programs must be well established before attempting a remote program.

Editor’s note: Amber Sterling, RN, BSN, CCDS, director of CDI services at TrustHCS, wrote this article about a focus group hosted during our 2015 event. ACDIS is currently looking for speakers to apply to present at our 10th Annual ACDIS Conference in Las Vegas. Click here to learn more about the application process, and to apply.

 

TBT: Leveraging CDI staff in EHR implementation effectively

AHIMA releases recommendations for data governance

Program managers need to be wary of so-called mission creep and the tendency to lean on the CDI department as a panacea for all emerging documentation troubles.

Back in October 2015, ACDIS Director Brian Murphy joined Douglas B. Fridsma, MD, PhD, FCP, FACMI, from the American Medical Informatics Association and Steven J. Stack, MD, from the American Medical Association on the stage for a Luminary Healthcare Panel discussion during the American Health Information Management Association (AHIMA) annual convention in New Orleans.

During the discussion panelists offered their insight into how electronic health records (EHR) affect the business of healthcare and the act of caring for patients themselves.

“It’s not just about the problems we’re facing now but how healthcare will be delivered in 10 years,” Fridsma told the audience at the time, while Stack outlined the AMA’s efforts to leverage data to help reduce deadly diseases related to diabetes and referenced overall population health.

While data can help with these national and even global healthcare initiatives, Fridsma cautioned against adding data for data’s sake.

Today, the conversation regarding the value of electronic health record systems continues.

“…[T]he industry’s thought leaders have a duty and a charge to acknowledge the inherent limitations of technology for certain applications,” wrote past-ACDIS Advisory Board member Robert S. Gold, MD, CEO of DCBA Inc., on February 24, on the Healthcare Financial Management Association (HFMA) blog.

“There is a still a disconnect between what data does and how it affects patient care,” Murphy told the panel that day back in October.

For their part, CDI professionals understand how different data elements affect each other and how different, previously siloed, departments need to use the same basic data—physician documentation—to illustrate a wide-variety of outcomes from financial to quality to healthcare research, he said.

“Obtaining that clear record requires a team effort between coding, HIM, informatics, quality, physicians. We, as an association, have long supported the idea that those coming to the CDI role need to have specific qualifications [which include] the individual’s capability to effectively interrogate the medical record for clinically significant clues of a specific diagnosis, plus the ability to communicate amongst various professional types,” Murphy said.

Members of the ACDIS Advisory Board broached the topic of EHR benefits during the February 18 ACDIS Quarterly Conference Call, discussing how clinical documentation improvement professionals could positively affect physician documentation within the electronic health record and improve the accuracy of the information captured.

Some facilities actually employ CDI specialists as EHR “super users” training them first and engaging their assistance in helping physicians get up to speed on the new systems. That’s the case at Mercy Health in Cincinnati, Ohio, according to Robin Jones, RN, CCDS, BSN, MHA/Ed, Corporate System Director, Clinical Documentation Excellence, who reached out to ACDIS following the Quarterly Conference Call to share her story.

Having CDI super users “…allows the CDI specialists to provide training for the physicians, engage in dialogue about the program, and become an ally for the physician when they are struggling with order entry,” Jones says. CDI queries get posted to a “sticky note” located on the main access page in the EHR so it’s the first thing the physician sees when they enter a particular patient’s record. Furthermore, Mercy’s physicians have customized worklists that allow them to see at a glance patient charts that have a clarification/query which “allows for prioritization and forethought when assessing the patient and knowing that a response is needed,” Jones says.

As with all areas of potential CDI expansion of duties, however, program managers need to be wary of so-called mission creep and the tendency to lean on the CDI department as a panacea for all emerging documentation troubles.

In October 2013, ACDIS released a position paper on Electronic health records and the role of the CDI specialist. In it, the Advisory Board cites the positive outcomes associated with EHR implementation but also warns against now common problems such as:

  • copying and pasting information from the previous days’ notes
  • extensive drop down menus unrelated to the patient condition
  • “note-bloat” which carries forward non-pertinent information taking the physicians’ focus off the necessary clinical concerns

The position paper discusses each of these concerns (and a few others) while addressing the various roles and expectations of CDI specialists in helping to resolve these difficulties.

As Murphy stated last October, all data begins with documentation. It’s the CDI specialist’s job to make sure that documentation is as accurate as possible to tell the true story of the patient’s condition.

How are you handling EHR implementation at your facilty? Have you developed policies and procedures around your EHR and eQuery workflows? Let us know in the comments section or email ACDIS Associate Editorial Director Melissa Varnavas at mvarnavas@acdis.org.

TBT: Set learning goals for CDI growth

Regulatory changes make CDI and coding accuracy more important than ever

Work as a team to set goals for CDI.

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. Alternatively, we’ve flipped the theme around, going back into our archives to highlight some salient tid-bit worthy of second look. This week, we looked at an article from the January 2014 CDI Journal “Collaborative approach works best when new staff start” 

When Northern Westchester Hospital in Mount Kisco, New York, hired two new CDI nurses, Kerry Seekircher, RN, CCDS, documentation specialist supervisor there, followed a training path which used her own experiences as an overarching guide for the new team.

The 233-bed facility hired a consultant who trained the team for two weeks, providing an overview of CC/MCC basics, DRG definitions, and coding guideline lessons.

Meanwhile, Seekircher pulled information from materials on the ACDIS website, downloaded items from its  Forms & Tools Library, and incorporated various AHIMA physician query practice briefs into her own training material handbook. She crafted query exercises, compliance quizzes, and learning objectives for the team. She also outlined a series of goals, which defined what the new staff members should expect to understand at the three-month, six-month, one-year, and two-year marks. (Read the sample goals, which you can adapt to your facility’s needs, on pp. 12–13, of this edition of the CDI Journal.)

“Coming from bedside nursing and coming from multiple years of clinical experience, there is a desire to feel reliable in the role, a need to feel like you can immediately do everything and understand everything,” Seekircher says. “But that simply isn’t a realistic expectation for a new CDI specialist. You cannot be at the two-year mark when you’ve only been in the role for three months.”

Such an outline of expectations was “long overdue,” she adds. “I know that we are going to need additional training resources as time goes on. We need to illustrate those goals and set timelines associated with them in order to make sure the resources are available to help us meet those goals.”

Now three months into their roles, the new staff members have begun querying on their own.

TBT: Redefining what “advanced” means

Have a question that is troubling you and your team? Ask us!

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. Alternatively, we’ve flipped the theme around, going back into our archives to highlight some salient tid-bit worthy of second look. This week, we looked at outtakes from a 2014 CDI Journal article “Expanding CDI efforts: Redefining what ‘advanced’ means.” The following individuals also offered their insight for the article but were not included in the Journal at the time due to space considerations.

“An advanced CDI program is one in which the CDI professionals are certified in both coding and CDI. They supplement this expertise with a sound foundation of clinical knowledge of disease processes and possible treatments,” says Ann-Marie Carducci, RN, CCS, CPC, CPHQ, CPUR, senior director of utilization management at Montefiore Medical Center in the greater New York City area.

Advanced CDI programs also need to recognize the potential to raise the standards of clinical documentation improvement to include documentation in the medical record by all caregiver disciplines, including physicians and advanced nurse practioners, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CDI, C-DAM, director of enterprise solutions for ZirMed in Louisville, Kentucky.

“They need to make sure [the medical record] accurately reflects all of the elements necessary to meet the challenges inherent in the transformation of the current healthcare delivery model,” Krauss says.

CDI specialists should also reach out to their case management counterparts, particularly in light of confusion and changing regulations associated with the 2-midnight rule, and medical necessity requirements associated with inpatient admissions, says Donna D. Wilson, RHIA, CCS, CCDS, CPHM, senior director at Compliance Concepts, Inc., in Wexford, Pennsylvania.

“CDI specialists can move DRGs all day long but without a [medically necessary inpatient admission] the claim is subject to full denial of the entire inpatient stay,” she says.

Similarly, progressive CDI programs might look to analyze records for “super specialty” areas such as pediatric neurosurgery or cardiovascular surgery, or complicated repetitive surgeries with multiple diagnoses, or multiple trauma, says Wendy DeVreugd, RN, BSN, PHN, FNP, CCDS, MBA, director of case management and clinical social work at the University of California Irvine Health.

Even though these patients don’t typically have government insurance (Medicare/Medicaid), having excellent documentation by a physician in all payer records helps with public reporting results, DeVreugd says.

When contemplating “advanced” CDI efforts, first consider reviewing all payers, not just Medicare, agrees Wilson. “Most ‘infant’ CDI programs begin with Medicare payers to determine the return on investment, so reviewing all payers seems to be a logical next step for most hospitals,” she says.

Expanding beyond government payers can lead to a host of other expansion ideas, says DeVreugd. When she worked at Kindred Healthcare, a long-term acute care setting in California, such a shift caused the team to look at quality and mortality reports. Before its CDI program implementation, Kindred had one of the highest mortality scores in the state but after CDI efforts took root the system’s patients reported better than expected mortality.

This shift in expected-to-observed mortality rates also affects how physicians come to see CDI, says DeVreugd.

“Once we get more advanced in how we tell the story of CDI program’s effect on quality, revenue, and physician profiling, and patient outcomes, we’ll see greater support from the physician community,” DeVreugd says.

Wilson also recommends expanding into quality-related measures. “Realize that the role of CDI goes beyond reimbursement by enhancing documentation to reflect the true severity of illness and risk of mortality of the patient and help CDI staff understand the importance of quality indicators such as present on admission and hospital acquired conditions [HAC] which will allow for accurate reporting of the hospital’s external public reporting data,” she says.

Advanced CDI programs must be metric driven, collecting data which supports the complete return on a facility’s investment in CDI efforts, says Timothy N. Brundage, MD, CCDS, principal of Brundage Medical Group, LLC, in St. Petersburg, Florida. Mature CDI programs also have extensive and intensive physician education including direct physician-to-physician CDI education, Brundage says.

“We have overcome the physician buy-in problem by using physician documentation report cards with education which includes documentation created directly by the provider being educated. We remain in compliance by using discharged and post-bill patient charts for education and not for re-billing purposes,” he says.  

An advanced CDI program’s focus goes beyond the direct financial effects of code assignment and DRG reimbursement and “recognizes CDI programs’ effect on the organizational health and wellbeing on multiple levels,” says Laurie L. Prescott, RN-MSN, CCDS, CDIP, director of CDI education for ACDIS/HCPro, in Danvers, Massachusetts.

Advanced programs recognize how documentation effects medical necessity, clinical validation, CMS quality metrics (Hospital Value Based Purchasing, HAC Reduction program, Patient Safety Indicators etc.) and provider and organizational profiling. “Advanced CDI is ever changing, adjusting to new initiatives as CMS and private payers increase their focus to pay for performance versus fee for service,” she says.