Q: I have a question about the following query. If the response is B, can you still capture it as withdrawal?
Based on these indicators taken from the medical record, please clarify by documenting on this query form and/or in the progress note the condition being treated with a nicotine patch and nicotine gum in this patient referred to as a “smoker” in the history and physical documentation.
- Nicotine/tobacco withdrawal
- Prophylactic treatment of nicotine/tobacco withdrawal
- Unable to determine
- Other (please specify)
A: I like your query but, unfortunately, when treating something prophylactically, by definition we are preventing it from occurring. A condition that is being prophylactically treated should not be coded.
According to the 2016 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief, we only need to provide “reasonable options” in a query. “Reasonable options” are determined based on the clinical indicators present in the medical record and, sometimes, there is only one appropriate response based on the clinical indicators present.
We want the documentation to accurately reflect the true picture of what is going on with the patient during the episode of care that is under review, so if the patient is not experiencing withdrawals, and is only being treated prophylactically to prevent the withdrawals, that is what we want the documentation to reflect.
Here are some sample queries for this scenario:
Documentation indicates a 25-year history of smoking cigarettes. Patient admitted to unit after six hours in the ED. Nursing notes describe increased irritability and continued requests to be allowed to smoke. Vital signs indicate elevated heart rate and blood pressure readings as described by nursing notes. Upon admission telephone order obtained for nicotine patch. Please clarify the indication for nicotine patch.
- Nicotine/tobacco withdrawal
- Prophylactic treatment of nicotine/tobacco withdrawal
- Unable to determine
- Other (please specify)
You have ordered the application of a nicotine patch for this patient with a history of smoking cigarettes for 10 years. The H&P indicates a “habit of 2.5 packs a day”. Nursing documentation in the ED and admitting unit describe the patient exhibiting anger and threatened discharge against medical advice. Nicotine patch applied 2 hours after admission. Later nursing notes indicate the patient is presenting in much calmer manner and cooperative with plan of care. Please clarify the condition you are treating with the application of the nicotine patch.
- Nicotine/tobacco withdrawal
- Prophylactic treatment of nicotine/tobacco withdrawal
- Unable to determine
- Other (please specify)
Editor’s note: Sharme Brodie, RN, CCDS answered this question. Brodie is a CDI education specialist for ACDIS and HCPro in Middleton, Massachusetts. Contact her at email@example.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com.
Developing and executing new policies and processes has become second nature, for Robin Jones, RN, BSN, CCDS, MHA/Ed, system director of clinical documentation excellence at Mercy Health in Cincinnati, Ohio. In 2004, Mercy launched their CDI program at their Cincinnati facility, and rolled out similar programs over the next several years at their remaining organizations. In the early years, the program, which had nine employees, reported to site-based leadership in either HIM, quality, or case management.
In 2011, the program was restructured, and now CDI reports under the revenue cycle. Today, they have 97 frontline CDI specialists, supervisors, managers, an educator, and a senior analyst, who serve across 23 Ohio and Kentucky hospitals.
“This was a brand new concept for us,” says Jones. “However, we gained a great deal of momentum and were able to grow our program and our processes.”
As the program expanded, Mercy’s CDI program implemented several policies through collaboration with other departments, including a clarification escalation process, Jones says.
Obtaining buy-in for the clarification escalation process, for example, required vetting through many administrative levels. When approaching leadership with new policy or procedure, Jones says her team uses the following steps:
- Know the “why,” benefits, and risks
- Have the data to support your request
- Be persistent and ensure your organization understands the importance of what CDI professionals bring to the table
With Mercy’s clarification escalation process, knowledge deficit was the number one challenge. The first step towards resolving this issue was ensuring CDI and coding teams had a strong understanding of the process. They trialed some of the process ideas and fixed areas that didn’t work, says Jones. They also introduced an incentive program to keep staff motivated to learn and follow new procedures.
CDI identified the benefits and risks associated with their proposed processes, and worked closely with the coding department from initial conversations to post-implementation, Jones says. Ongoing discussions and evaluations ensure the process maintains effectiveness, which is not always the case, says Jones.
Earlier this year, the CDI team redefined the clarification process with shorter parameters for providers to respond to queries in order to ensure timely concurrent responses to clarifications. Physician champions and corporate leadership also became involved early on, giving physicians, mid-level providers, and executives an opportunity to provide feedback on the proposal.
“Communication keeps everyone informed,” says Jones. “Understanding what works and what doesn’t for each department we work with has been essential to our success.”
There was a great deal of pushback from providers and leadership initially because of the policy’s post-discharge hold process, Jones says. When Mercy’s CDI department submits a clarification that is not addressed on the front-end, CDI holds the chart on the back-end for a certain amount of time— five days for severities and 10 days for financials. This delays final billing and, in turn, reimbursement. So, the CDI department had to propose a compromise, adjusting the chart hold time to two days for severity clarifications and five days for financial-based clarifications.
“The goal is to make our CDI program a concurrent program, getting clarifications answered prior to billing, to decrease the number of delayed-not-final-billed charts on the back-end.”
For those programs looking to propose a new policy or procedure, know your stuff, says Jones. Be proactive and do your research. Engage other departments about the new concept or process and discuss how it might affect them, and how you can partner to ensure a smooth transition. This will enhance proposals to leadership because risks and solutions will have already been addressed.
“I really think CDI is a key ingredient in so many different areas of hospital operations,” says Jones. “If you come to leadership with a concept, a thorough analysis, and answers to anticipated questions, you’ll be well prepared to get policies and processes enacted.”
We’ve received lovely feedback from a large majority of ACDIS members regarding our website upgrade which debuted at the conference in May. The site looks a lot cleaners, provides a snapshot of materials quickly on its homepage, and also allows members to easily search for the topic or item needed at the moment.
ACDIS members have access to:
- The CDI Journal
- Surveys, White Papers, and Position Papers
- Resources such as sample job descriptions, policies and procedures, and sample queries
- Membership networking opportunities such as ACDIS Forum’s chat groups and the Quarterly Conference Calls
There’s also a ton of free materials located on the site that even non-members have access to–all you need to do is register for the content by clicking on the blue “Free Resources” box when you hit a locked screen. Items that are open to all include:
- email newsletter CDI Strategies
- CDI Week materials
- ACDIS Blog articles
- Certification information
- Certain videos and webinars under the Resources tab
- The Career Center and Local Chapter pages
- ACDIS Radio
Of course we want you to join ACDIS and become part of the community that’s already more than 5,000 strong. If you’re on the fence, however, please take a look at all the materials we provide, free of charge, to help you advance your career and perform the role of CDI specialist.
It is time for our last CDI Week Caption Contest. Here are the rules: post your (tasteful and respectful, please) suggested captions for the following picture. At 3 p.m. today, the ACDIS team will select a favorite to win a prize. We will announce the winner in the comments below so make sure to check back this afternoon to see if you’re our lucky winner!
As part of the sixth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Joy Coletti, MBA, RN, CCDS, system services director for clinical documentation improvement at Memorial Hermann in Houston, Texas, answered these questions on electronic health records. Contact her at Joy.Coletti@memorialhermann.org.
Q: How long has your facility been using electronic health records?
A: It was phased in at each hospital over a one to two-year timeframe in early 2000. Two of our smaller community hospitals took the lead with engaged physician champions.
Q: What role did you personally play in the transition? How big a role did the CDI team play?
A: CDI did not really play a role in initial EMR adoption, unfortunately, other than [providing input on] how physicians are electronically prompted when they have a query, and where those query responses reside in the EHR.
Q: What was the impetus for the transition initially (ICD-10? Government imitative?)?
A: HIPAA was likely a large factor in speeding up the transition. E-queries were implemented in 2010. By 2010 the EMR was more electronic than paper, but still a hybrid of the two.
Q: Can you describe the different systems you use for your EHR and e-Queries?
A: EHR is a Cerner platform, but also has Intelligent Medical Objects which allows us to search diagnoses. For e-queries, CDI specialist and coders software were developed by Meta Health, now part of Streamline Health.
Q: Has EHR use led to remote CDI capabilities?
A: Yes, but within each hospital. Records are reviewed from an office location rather than within the units. This has significantly improved productivity levels. Records can also be reviewed across hospitals for coverage capabilities when a CDI specialist is out of the office or when census is very high at certain facilities. I hired three regional float CDI specialists who support multiple hospitals remotely from their offices on one hospital campus. Each CDI float supports multiple facilities and provided backup coverage.
Q: What has been the biggest benefit from EHR implementation in your opinion?
A: Legibility of documentation, the ability for many disciplines to access the record simultaneously, remote access, and quicker order entry with fewer errors.
Q: What has the CDI team struggled with most in terms of reviewing records in the EHR and helping physicians with their documentation?
A: First, fragmentation of the EHR, which makes it challenging for physicians to “tell the patient’s full story” in an accurate and efficient manner. Providers sometimes produce a lot of copy-and-paste generated notes, which are challenging for CDI specialists and coders to follow and understand the patient’s story.
Second, there are no central diagnosis or problem lists managed by physicians that can be used by CDI specialists and coders.
Q: What advice would you give to CDI specialists who might be just starting EHR implementation or struggling through the process?
A: Continue to use paper queries until the EHR is at least 50% electronic, or at least a majority of history and physicals and progress notes are electronic. Once you transition to e-queries, while the health record is still hybrid, place a paper query “prompter” in the paper record to alert providers they have an electronic query, the basic steps for how to answer that e-query, and, of course, the CDI specialist’s name and contact information.
Q: What contingency plans are in place for when the power goes out or internet goes down? (you can skip this question if you want, I’m just curious in light of the flooding in LA and the fires in CA and knowing what happened in NYC after Sandy.)
A: Luckily, our back-up generators have always kicked in. All generators were moved out of basement level years ago due to the history of flooding in Houston area. Our IT emergency plans kick in when the EHR goes down and “all hands on deck” until the issue is identified and the EHR is back up and running. In the past, we were able to be back up within two hours.
It is time for our first CDI Week Caption Contest. Here are the rules: post your (tasteful and respectful, please) suggested captions for the following picture. At 3 p.m. today, the ACDIS team will select a favorite to win a prize. We will announce the winner in the comments below so make sure to check back this afternoon to see if you’re our lucky winner!
As part of the sixth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Susan Lapp, RN, MSW, a clinical documentation improvement specialist for Community Hospital, South, in Indianapolis, Indiana.answered these questions about interdepartmental collaboration.
Q: How often to get to collaborate with the coding team?
A: We’re a hospital-based network of several facilities, each facility has a CDI staff member. If someone is off, we can cover. We report up through case management and help with length of stay needs.
We each work as a team with a remote coder. We get used to each other’s work habits and patterns. We use a program called “Jabber” that allows us to share each other’s computer screens and chat. We meet once a month with all the coders and all the CDI specialists for group discussion and education. The CDI team also meets once a month.
We have an escalation policy that we can use if the coder and the CDI specialist disagree on an issue. The case gets bumped up to our managers and they get the final say. It’s a good process that allows us to not take it personally and lean on someone else with more experience for a determination.
Q: What type of other groups do you work with?
A: Our physician advisor was working on denials and identified malnutrition as a frequent cause of denials. So we reached out to dietitian and started working on guidelines for documentation. Once we had that in place we were able to go out and provide physician education.
Within the case management team, we spend a lot of time discussing what the principal diagnosis of the case should be. Sometimes what needs to be the principal diagnosis isn’t the diagnosis with the longest length of stay but that’s what the coding rules call for.
A couple months ago, there was a case (case description altered to protect HIPAA requirements) where an elderly gentleman wasn’t correctly taking his medication. He came in once for an overdose and was discharged and when he came back again for a similar situation shortly thereafter, I was able to get the case management team together to re-evaluate their discharge plans.
We disagreed about what the documentation seemed to indicate, so we brought the treating physician in and determined that the patient indeed wasn’t able to self-monitor the medications any more. They found placement for him and his elderly wife. I think this is a perfect example of what a positive effect we can have when we collaborate.
Q: Are you doing any work with other departments on quality measures or that type of reviews?
A: We automatically get notified if the same patient comes back within the 30-day window, so we review those records and identify any clarification opportunities. This helps with NSTEMI documentation and with quality.
We also always look to see if the condition is present on admission or if it’s a hospital acquired condition. If we’re not sure we query the physician.
Complications are another area related to quality that we look at. I don’t know why they can’t just write whether it’s an expected outcome or not. I’ve been in nursing for 39 years and I never thought they’d pay me for this type of work but it’s great. I want my patients to have the best treatment possible and I help the record reflect that.
Q: What advice do you have for others who may be wishing they could collaborate a bit closer with other departments?
A: Be comfortable with the resources you have and be willing to ask questions. I’m not a coder, I’m a nurse. I don’t know what my coders know, that’s why they’re coders. You have to know your limitations as well as your expertise. There might be a difference in opinion as to how you interpret two little words but that difference might mean a patient gets sent home when they really shouldn’t be.
I have enjoyed being an instructor for ACDIS and HCPro for almost three years, now. Having the opportunity to travel across the country and teach others about the CDI profession has definitely been a rewarding experience for me. Even though each Boot Camp covers the same material, each class is unique—the attendees change and bring with them different mix experience and goals.
As an instructor, the best possible outcome is to have everyone go back to their facilities with their newly-acquired knowledge and immediately start applying it. Some may go on to attend another Boot Camp or the annual ACDIS conference for further training and insights. Others contact us directly with questions they encounter when they return to their jobs.
But, for the most part, once they leave our class, they are capable of performing their jobs without us—in fact, I think that’s one of the best indicators that we’ve done our job well, when we’re not needed and our students flourish in their CDI positions.
Sometimes we hear from one our attendees “just because.” The other day, I received a one-of-a-kind “thank you” from a student that not only made my day, but made me remember why I wanted this job to begin with and why I continue to do it.
In my class, during the circulatory system modules, I use an analogy with a school bus to explain how an acute myocardial infarction (AMI) affects DRG assignment and principal diagnosis selection. So, this student sent me a personalized school bus figurine. This was absolutely the best thank you and I truly appreciate this student’s kind words and gesture.
I have had mentors and teachers that certainly changed my life. But, when you are the instructor, you don’t often think about how you could possibly affect someone else’s career. The shift to the CDI role is one of those career changes that can be wonderful or devastating, and it’s not always immediately apparent if the role is right for a particular person. I do my best as a teacher, as a mentor, to bridge the knowledge gap and equip my students with the information they need to take on this new career. This particular student wanted me to know the affect I had on her career and, in doing so, reminded me why I do what I do, and why I love doing what I do.
Editor’s note: Brodie is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact her firstname.lastname@example.org. For information regarding CDI Boot Camps offered by HCPro, visitwww.hcprobootcamps.com.
Those working in the CDI field in settings such as long-term care, home health, or inpatient rehabilitation have additional impetus thanks to the Improving Medicare Post-Acute Care Transformation Act of 2014 or IMPACT Act. The rule requires the submission of standardized data by Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs). Specifically, the IMPACT Act requires, among other significant activities, the reporting of standardized patient assessment data with regard to quality measures, resource use, and other measures.
“It starts at a basic level—connect providers and services with the same language,” says Terrence A. O’Malley, MD, a physician at Massachusetts General who spoke on the CMS Open Door Forum earlier this year.
The Act further requires that CMS develop and implement quality measures from domains such as:
- Skin integrity and changes in skin integrity
- Functional status, cognitive function, and changes in function and cognitive function
- Medication reconciliation
- Incidence of major falls
- Transfer of health information and care preferences when an individual transitions from an LTCH, SNF, HHA, or IRF
- Resource use measures, including total estimated Medicare spending per beneficiary
- Discharge to community
- All-condition risk-adjusted potentially preventable hospital readmissions rates
- At-risk entities manage the most complex patients
The government is getting out of the fee-for-service business, says O’Malley. “CMS cares about the total cost of care, they only want to pay for services rendered. Physicians and facilities are no longer just going to get more money simply by providing more care. Right now there’s no cost associated with poor outcomes so fee-for-service is going away and is being replaced by payment models that will require communication across the continuum.”
Documentation will need to accurately reflect the underlying drivers of the care the patient needs, depict a healthcare plan for that patient which can be easily transferable and communicative across settings and assist other departments with addressing the root causes of patient ailments.
“What’s the difference?” O’Malley asks. “Programs need to pay attention to the most expensive patients the 1-5%, a group that isn’t currently well managed by the current healthcare system.”
CDI specialists working in these settings, specifically IRF, will need to become familiar with the different chart review elements to ensure the medical record is complete, according to Andrea Johnson, RN, BSN, CCDS, CDI specialist at Carolinas Rehabilitation, who presented on the subject in a recent ACDIS webcast. She says the information in an acute IRF is much different than the traditional inpatient, acute care setting and CDI professionals will need to understand and pay attention to:
- Impartment groups (IGC)
- Etiological diagnoses—the problem that led to the impairment for which the patient is receiving rehabilitation. Comprised of ICD-10 codes and follows PAI coding guidelines.
- Comorbidities that affect a patient during or after admission, but not including the day before or day of discharge:
- Tiers 0, 1, 2, and 3
- ICD-10 codes
- UB-04 coding guidelines
Further, for Medicare reimbursement, at least 60% of cases an IRF admits must have one or more of the following conditions, says Johnson:
- Traumatic brain injury
- A neurological disorder such as Parkinson’s, MS, or muscular dystrophy
- Spinal cord injury
- Major multiple traumas
- Hip fracture
- Knee or hip replacement for both legs, or when the patient’s BMI is 50 or higher, or when the patient is age 85 or older
- Congenital deformity
The intention of the 60% rule for IRFs is to distinguish the IRF’s population of patients and the care that they receive from others in post-acute care facilities. Noncompliance with the 60% rule would result in a 2% reduction in Medicare reimbursement for the fiscal year. Worst-case scenario is revocation of IRF status. This would make the IRF ineligible to receive the higher-rated reimbursement from Medicare for the intensive services which are provided.
The new system will place a greater emphasis on social determinants which are currently outside the purview of the healthcare team. Furthermore, pay-for-performance reimbursement trends will force the healthcare delivery system to address the drivers of poor outcomes and improve patient health.
“This is the future of the accountable care community,” O’Malley says. “It takes more moving parts. It’s centered in the shared health information platform. All parts have to communicate with each other in real time. If you bring the care team together you can use the information to see how the system works as a whole. The world is changing for the better, particularly for those patients who have complex needs.”
Editor’s note: Click here to view the slide presentation from the Open Door Forum Call. Click here to read more about the IMPACT Act on the CMS website.
by James S. Kennedy, MD, CCS, CDIP
On July 27, I was interviewed by the director of ACDIS, Brian Murphy, regarding the documentation and coding of encephalopathy, which has highlighted the tremendous confusion in the compliant definition, documentation, and coding of altered mental status and its underlying causes. This interview and its accompanying slides are available at http://www.acdis.org/acdis-radio/encephalopathy.
The documentation and coding of encephalopathy wasn’t much of an issue until around 2007, when CMS designated the various encephalopathies (e.g., metabolic, toxic) as MCCs when they weren’t even CCs in the older CMS-DRG system.
Unlike unspecified heart failure which is not a CC or MCC unless the physician states that it is systolic (HFrEF) or diastolic (HFpEF) CMS allows unspecified or acute encephalopathy (ICD-10-CM code G93.40) to be an MCC while some of its descriptors (e.g., anoxic encephalopathy) are just a CC or nothing at all (e.g., G94, encephalopathy in diseases classified elsewhere).
The Greek etymology of the word “encephalopathy” means “disease of the brain,” much like how the word “myopathy” means “disease of the muscle,” “nephropathy” means “disease of the kidney,” and “neuropathy” means “disease of the nerve.” As such, one could construe any disease of the brain to be an encephalopathy, such as strokes, brain tumors, and the like. In fact, Dorland’s medical dictionary (available in 3M’s encoder) defines encephalopathy as “any degenerative disease of the brain.” These definitions, in my opinion, are too broad.
I prefer the definition in Adams and Victor’s Principles of Neurology, 10th Edition, that defines encephalopathy as a global brain dysfunction that has an underlying cause distinct from any other named brain disease (e.g., Alzheimer’s). It could be a general medical condition (e.g., metabolic encephalopathy), a poisoning (e.g., toxic encephalopathy), chronic liver failure (e.g., hepatic encephalopathy), diffuse anoxia, or the like that results in the diffuse brain dysfunction.
These, of course, would have to be defined, differentiated, and documented by the provider, emphasizing that they are separate, distinct, or overlying another underlying diffuse brain disease (e.g., Alzheimer’s). Similarly, the National Institute of Neurological Disorders and Stroke states that the hallmark of encephalopathy is an altered mental state.
There is a myriad of brain diseases, many of which have names (e.g., Alzheimer’s disease, Lewy body dementia, normal pressure hydrocephalus, and Jakob-Creutzfeldt disease) that are distinct disease entities whose labels describe the brain’s pathology and clinical manifestations. I personally believe that if the patient’s manifestations can be explained solely by a named brain disease, the term “encephalopathy” is integral to that named brain disease, given that the name is more specific than the term.
The ICD-10-CM Index to Diseases has similar examples, such as hepatic encephalopathy being classified as hepatic failure; in this circumstance, another code for encephalopathy would not be coded if the mental status abnormality is only due to hepatic failure.
Therefore, if encephalopathy is documented without linkage to any condition, a query is needed to determine its underlying cause. If it is due to a named disease not in the ICD-10-CM Index to Diseases under the key term encephalopathy, the underlying disease (e.g., UTI) is coded first, followed by G94 (other disorders of brain in diseases classified elsewhere), which is per the Excludes1 note for G93.4 (other and unspecified encephalopathy).
That’s not to say that a patient with a preexisting brain disease cannot have another superimposed process, which, if clinical indicators are present, should be defined, diagnosed, and documented by the physician. The ICD-10-CM Index to Diseases outlines many of these, such as toxic, metabolic, toxic-metabolic, hepatic, anoxic, and other types of encephalopathy.
Editor’s note: Kennedy, the president of CDIMD-Physician Champions, in Symra, Tennessee. He is a general internist and certified coder, specializing in clinical effectiveness, clinical documentation, and coding strategies. Contact him at 615-479-7021 or at email@example.com.
This article was adapted from the original published in Briefings on Coding Compliance Strategies. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.