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Pressure Ulcer Coding and Staging

Does it sometimes seem like wound and pressure ulcer documentation is a movable feast? I’ve spent a lot of time scrutinizing wound documentation lately in anticipation of the new pressure ulcer codes being implemented October 1st and sometimes I can hardly believe what I’m seeing.

I’ve seen wound care flow sheets where vascular or diabetic ulcers are incorrectly documented with a stage (which should only be assigned to pressure ulcers) and I’ve seen pressure ulcers go from stage I to stage III or from stage III to stage I between one shift and the next. [more]

POA: Episode II

episode_2_jedi_knight3Preface to the following: You won’t find a more staunch advocate for ethical behavior in the documentation compliance profession than me. I firmly believe that documentation compliance is all about quality, specificity, and the behaviors and processes that support those aims.

However, we all also know that when it comes to implementing new initiatives it’s the bottom line that makes the decisions. That being said…

Once upon a time in a galaxy far, far away there existed an entity known as CMS, sometimes called the Empire. The Empire controlled everything in its purvue, including hospital reimbursement.

Last year the Empire passed a new law called “Present on Admission (POA)”. All the citizens who reported to the Empire lived in fear of this new law but the first year passed without any significant battles.

Episode 2:
I suspected (as I’m sure you all did) that once the Empire announced that it would exclude payment for hospital-acquired conditions, it was only a matter of time before the commercial carriers followed suit. Guess what? It happened.


After the consultants leave…what now?

Hey, you CDS with new programs out there! How’s it going? Are you sailing along on the smooth seas of phenomenal MCC capture rates or are you stalled in the doldrums? Are you asking yourself the following question: “What do I do now that the consultants are gone?

Been there. Done that …twice, in fact! Are you finding that the people at your hospital who decided that a CDI program was a good idea are now saying things like “the CMI doesn’t seem much different” or “where’s the money they promised us”?

Don’t feel bad. You didn’t do anything wrong. You’re just feeling the pangs of aftermath: the training and support is over and now you’re alone and administration doesn’t even know what you do, exactly.

First, who do you report to? Someone who actually knows from a hole in the ground, or someone who wouldn’t know an MCC if it bit them? This isn’t a silly question. If the person making the decisions doesn’t know what you’re REALLY there for, it’s going to be hard to succeed and grow your program. So, invite this person to come to your team meetings and be sure to share your successes and tell him/her how much more you can do with their active support. [more]

How to make a CDIS

While those of us at ACDIS are already working as CDIS there are nurses and coders out there who e-mail me and ask how to become a CDIS so I thought I’d write about what I look for when I’m hiring someone.  FYI, folks, opinions ahead. [more]

AHIMA Takes Second Look at Revised Physician Query Practice Brief

handsBrian Murphy, director of ACDIS, asked me to say something about AHIMA’s decision to revise the Physician Query Practice Brief and provide some commentary on the first draft.  While I’m unable to provide the complete text here I’ll try and paraphrase the sections that, in my opinion, still need some clarification and I’ll give some examples of the sections that I agree with.

The revised brief is presented in two sections:

  1. the first addresses current legal, regulatory and ethical issues, documentation, the query process
  2. the second part provides direction concerning compliance; specifically, auditing and monitoring and reporting and performance metrics

What the brief does not do is answer the all-time burning question “what constitutes a leading query?” or acknowledge that there is a difference between a nurse asking a physician a question (clinician-to-clinician) and a coder querying the physician.  I feel that the “guidance” provided in the first draft does anything but guide.


ACDIS Conference I: Highlights

caesarsWhat can I say about our first ACDIS conference that will adequately describe the excitement and satisfaction I felt to be surrounded by so many of my peers? 

I had been looking forward to this time ever since the dates had been announced.  When I walked out of the airport to catch the hotel shuttle, saw the palm trees (photo-op!) and felt the warm weather (thank you Lord, for 80 degrees after a Chicago winter) I knew I wasn’t “in Kansas anymore”.

From the time that I walked into the marble-floored lobby of Caesar’s Palace until I left to return home every hour was packed with experiences that I won’t soon forget.  I arrived late Wednesday morning, the day before the conference started, so that I would have time to check into the hotel and get my bearings.  [more]

CDI Talk: When in Doubt, Call a Friend

discussionIf you haven’t joined in the discussions taking place on “CDI Talk” you’re missing out on a wealth of information.  Some of the recent discussion topics (to name only a few) have been: query forms, BMI,  querying for decubitus ulcers, POA, RACs, to name just a few.

You don’t have to be an expert to join in; in fact, questions from new Documentation Specialists are often trigger the most lively discussions!  One topic from 3/26 titled “What DRG would you assign” received 25 responses!  This topic was a great example of how CDIS see situations differently and the supporting arguments presented were well thought out and detailed. [more]

RAC – Who and What are They and Why Should I Care?

While we’ve been busy working our fingers to the bone performing our chart reviews CMS has been diligently working to come up with ONE MORE THING that will ultimately involve CDI Specialists: the RAC program.

The RAC (Recovery Audit Contractor) program is an outcome of section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). As part of this Act Congress directed the Department of Health and Human Services (DHHS) to conduct a 3-year demonstration program using Recovery Audit Contractors (RACs) to detect and correct improper payments in the Medicare FFS program.

In addition, in section 302 of the Tax Relief and Health Care Act of 2006 (TRHCA), Congress required DHHS to make the RAC program permanent and nationwide by no later than January 1, 2010. [more]

What challenges are you facing? Let’s hear from you

Sometimes it’s difficult to find the time to write a post, but I have a good excuse:  I’m busier now than ever since MS-DRGs rolled around. Our CDI team has been developing new query templates, searching out obscure secondary diagnoses and has beenhot on the trail of substantiating conditions present on admission. Sound familiar? [more]

Welcome to CDI Blog

I’m honored to be asked to write the first post for our soon-to-be-famous CDI Blog! There are so many wonderful people involved with the ACDIS, many whom I’ve met over the phone and many over the internet. The internet is really a great tool: it allows us to communicate instantly and directly with one or many, share our ideas and it’s a wonderful venue for building our community: that of Clinical Documentation Specialists.

What we do is hard to explain to outsiders.  It involves the ability to read a patient’s chart, understand their diagnosis and treatment plan and to identify whether the documentation in the record, once translated into ICD-9 codes, will paint an accurate picture of their inpatient stay.  Our efforts impact a facility’s public quality ratings, affect physician profiles, and determine the revenue a hospital receives. [more]