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CDI at Bat

The outlook wasn’t brilliant for the CDI that day:
The chart stood unattended, with one hour left to stay,

Even the best documentation specialists strike out once in a while.

Even the best documentation specialists strike out once in a while.

And then when Dr. Cooney didn’t chart, and Dr. Barrow did no more,
A pall- like silence fell upon the patrons of the floor.

A straggling few got up to go in deep despair. The rest
Clung to the hope which springs eternal in the breast:
They thought, “If only Dr. Casey could get a whack at that,
We’d put up even money now, with Dr. Casey at the bat.”

There was ease in Dr. Casey’s manner as he stepped into his place:
There was pride in Dr. Casey’s bearing and a smile lit Dr. Casey’s face.
And when, responding to the query, he lightly doffed his hat,
No stranger on the ward could doubt ‘twas Dr. Casey at the bat.

The usual sneer had fled from Dr. Casey’s lips; his teeth clenched in rage:
He pounded with cruel violence his pen upon the page.
And now the nurse she holds the query, and now she lets it go,
And now the air is shattered by the force of Dr. Casey’s NO!

Oh, somewhere in this favored land the sun is shining bright,
The band is playing somewhere, and hearts are light,
And somewhere men are laughing and little children shout;
But there is no joy at the hospital – mighty Dr. Casey had struck out.

Breaking documentation bad habits

A documentation specialist and I were doing rounds on a unit one day when we ran into a physician who left a query unanswered.

The CDI whispered in my ear:

“I query him about this condition all the time and he usually writes it but I don’t get why he won’t write it without being asked first.”

The physician’s response was simply  “out of sight, out of mind.” After a lengthy discussion regarding long standing documentation habits, we realized that this physician wasn’t being non-compliant or difficult—he truly needed the constant reminders. He had developed a pattern of dictation he reverted to whenever looking at a patient’s chart and was in a time crunch.

So this begs the question, how do we change documentation habits and patterns? Do we have any real hope of changing them at all?

For many CDI specialists posting queries is not enough to change a physician’s documentation behavior. Probably the best answer to this question is to keep clinical documentation information  in front of physicians. Constant reminders through informational/educational opportunities that are updated monthly can be very beneficial. The format needs to be applicable to the physicians and can vary from hospital to hospital. I caution that once you establish a format be consistent in your approach.

Possible strategies include:

  • monthly newsletters
  • posters and flyers in the physician lounge
  • cue cards that can be easily carried in a pocket and presentations at meetings

But probably the most beneficial method for providing support for documentation that reflects the severity of illness of the patient is for a CDI specialist to be visible on the units when the physicians are on the units. I can’t stress enough the need for personal one-on-one time with the physicians on the floor, the importance for a CDI specialist to be “in their face.”

Pick a CDI topic of the month and go with it. The information needs to remain simple and to the point so you don’t lose the interest of the physician. Again, time is money in their mind so they tend to be more accepting when you get straight to the point. And don’t be afraid to recycle what you’ve used in the past, as reinforcement of new habits is also very beneficial in supporting clear and consistent documentation.

To lead or not to lead: Forming compliant queries

“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”

~Hamlet, Act III, Scene I

Shakespear as CDI? Hummm. . .

Shakespear as CDI? Hummm. . .

I truly think that Shakespeare was a frustrated CDI nurse.

I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:

“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”

If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.

Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?

I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.

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Third time a charm for New England Regional group of CDI specialists

minuteman-statue

Last Thursday Patty Spry and the New England Regional CDI specialists’ group invited me to come out to Emerson Hospital in Concord, MA to attend their third quarterly meeting. It was a great way to spend the afternoon. I live only 45 minutes down the road from Concord so it was an easy drive, though as I told the meeting attendees I hadn’t been to Concord since a middle school field trip to Minute Man National Historic Park.

Spry did a great job organizing the event. She sent out directions and an agenda in advance of the meeting, and each attendee received a few pages of handouts, including some sample physician education posters. There was coffee, soda, and cookies at the rear of the room, which are always appreciated.

I thought a particularly nice touch to the meeting was an anonymous salary survey which you could fill out when you checked in. Just something to keep in mind as an idea for members hosting their own meetings.

It was a great turnout of 30+ attendees. I went on first to speak about the new Certified Clinical Documentation Specialist (CCDS) exam as well as our recent national conference. The group then talked about ongoing challenges and solutions at their own individual facilities.

Spry says that the main benefit of the New England Regional group is the networking it provides. Said Spry:

“The group provides us with a great support network.  So many of these CDI Programs are new and the CDS can feel isolated in this new position.  We talk about difficulties encountered.  The issues are not unique to just one hospital and everyone is willing to share their experiences.  We also share educational background and work experiences. 

 “Everyone did an in-depth personal introduction and spoke about their individual programs.  They mentioned current problems they encountered and looked for support from the group. We all spoke so much that we didn’t get to address the entire agenda (like SIRS and CHF)!”

The winner of the door prize was Kathy McDiarmid from Beverly Hospital. Kathy will recieve a free ACDIS or HCPro audio conference of her choice. Congratulations Kathy!

The group is planning its next meeting in October. If you’re a new CDI specialist in the New England area and would like to get more involved, send Spry an e-mail at PSpry@emersonhosp.org.

Take care,

Brian

TIA, D-Dimer physician query Q&A

Q: Our CDI program is a little over a year old and we do not have a physician advisor/champion. One of my difficulties is I find myself trying to diagnose the patient and then trying to write a query in an attempt to obtain a specific diagnosis. For example, a physician documents in his progress note that the patient’s D-Dimer is elevated much above her normal level and her syncope could be related to this.

It is possible that the patient has had a transient ischemic attack (TIA), but how do I write this query as to not offend the doctor or look like I am diagnosing the patient? Previously, I have written the query as follows: “Please relate the syncope to the med diagnosis when the workup is complete (i.e., TIA, other).”

A: An elevated D-Dimer is a nonspecific test that may point to thrombosis and, in the setting of syncope, does not point to any one disease. Know that a TIA rarely results in syncope unless it involves the posterior (basilar) circulation, which is very uncommon. A pulmonary embolus usually has an elevated D-Dimer and can result in syncope; however the symptoms would be dramatic. Given that D-Dimer and TIA have little direct correlation with each other, the physician would be frustrated but not offended by this question.

I would suggest the following:

Determine whether your hospital has access to any electronic internal medicine references that you can use to learn of the clinical indicators of certain conditions (i.e., TIA, stroke) so that, when you see these indicators, you remember the reference (you can say that “I saw this in Harrison’s Textbook of Medicine”, for instance) and you can query for the clinical significance of that indicator.

You can also use these references to learn about certain laboratory tests or medications so that you can ask open ended questions about them (i.e., “Please indicate for what condition the following pharmaceutical was prescribed; Please indicate the clinical significance of the temperature of 102, WBC of 18,000, and hypotension in the setting of the patient you described to be toxic appearing”). Note that I did not lead the physician as to what to say.

Regarding your question, I would have queried the physician in one of the following manners:
Please indicate the clinical significance of the elevated D-Dimer level of ________ in this patient with syncope.

In light of the elevated D-Dimer, the other laboratory studies, and your history and physical examination, please indicate in your progress notes and discharge summary the likely cause of this patient’s syncope. Hospitals are allowed to code “possible, probable, suspected” diagnoses when written or dictated at the time of discharge (e.g., the discharge summary).

You may also create multiple choice query forms for the common situations that you run into.

Editor’s note: James S. Kennedy, MD, CCS, director for FTI Healthcare in Atlanta, GA answered this question in the April issue of the ACDIS publication the CDI Journal.  Check back soon at the HCMarketplace to learn more about the upcoming publication of the Physician Query Handbook authored by Kennedy and his colleagues at FTI.

AHA quotes CMS ‘No RAC med-neccessity reviews till next year’

According to a May 28 article in the AHA News Now newsletter CDI specialists need not worry about medical necessity reviews from Recovery Audit Contractors at least until next year.
During the three-year RAC demonstration, 32% of all claims denials were for medical necessity. A CMS-study however showed the California demonstration RAC had a 40% error rate when it examined medical necessity denials of inpatient rehabilitation facility claims, the AHA article states.

AHA’s senior associate director for policy Rochelle Archuleta says the CMS analysis validated the healthcare industries concerns about RAC auditor’s ability to interpret physician judgment.

Latest ACDIS conference call available for download

For those who missed it, the latest ACDIS quarterly conference call (held last Thursday, May 28) is now available for download on our quarterly conference call page. Follow the link to the page and click the link to listen in.

Seven members of the ACDIS advisory panel were on the call with over 160 members of the association. We discussed benchmarking CDI programs, reporting complications from surgery, and much more.

As a reminder, these calls are a free service of your membership in ACDIS.

Take care,

Brian

Collect daily data to show CDI program growth

There are several resports you can use to justify your CDI program’s return on investment, writes5975_large Colleen Garry, RN, BS, in The Clinical Documentation Improvement Specialist’s Handbook. Discussing concrete data and results will also reveal areas of strength as well as areas that need improvement. Garry suggests running the following reports on a daily basis:

  • Productivity levels
  • Number of completed reviews
  • Number of queries sent to physicians
  • Physician response rate
  • Closeout time for concurrent/retrospective reviews
  • Discharge-not-final-billed report retrospective query turnaround time

Identiying measurable criteria and being able to effectively mine your data represents one of the most important aspects of an effective CDI program. As soon as you’ve uttered the mantra “if it wasn’t documented, it wasn’t done,” follow up with another mantra: “if you can’t measure it, you can’t improve it.”

Be aware, however, that the number of queries you need to submit to physicians may fluctuate—in fact, you may want to see the number of queries on a particular topic decrease as a measure of your CDI program’s success. But that doesn’t mean you’re educational efforts will make the CDI program obsolete. 

“As the level of detail, specificity, and clinical interpretation increase, the role of the coding professional and [CDI professional] will change. . . ” writes Gary. “Most physicians are data driven individuals. . . As you report positive results, other clinicians will want to participate in the program.”

Florida ACDIS meeting scheduled for June

Doesn't Tampa General look beautiful?

Doesn't Tampa General look beautiful?

The second Florida ACDIS meeting will be held on June 19, 2-6 p.m. at Tampa (FL) General Hospital. This meeting will concentrate on the future of Florida ACDIS and the role of Clinical Documentation. Darlene Shelffo, manager of CDI at TGH will unveil our new Florida ACDIS Web site.

 

There may be a few more surprises as well with the first ever election of officers. Members will be contacted by e-mail. Look on the ACDIS Web site for more information and updates. Mark your calendars and don’t be left out!

 

ACDIS conference photos posted

Believe it or not, I’m still jet-lagged from our whirlwind trip to that desert oasis. My husband and I planned to fly out of Vegas on Sunday

Here's a shot of ACDIS Director Brian Murphy before one of the sessions started.

Here's a shot of ACDIS Director Brian Murphy before one of the sessions started.

 but our flight was delayed due to some engine trouble. We missed our connection flight in Cleveland and had to spend the night there. So we arrived back in Boston on Monday. . . Better late than never!

Hope you’re all back in the swing of things. If you’re on Facebook I’ve posted a few photos from the trip on the ACDIS group page. There’s more on the way. These are just the ones I took with my little digital. If you have any please post them, too. If I took one of you and neglected to label you, please tag your photo to help us put “names to faces” as Mr. Murphy says. We’ll be compiling a photo page to publish in the next CDI Journal.