Editor’s Note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we spoke with Barbara Brant, MPA, RN, CCDS, CDIP, CCS, a senior consultant with Cotiviti Health Care, presenting “CDI Specialists: Impact Potential in the Audit Process.” Since 2005, she has been involved in the development, implementation, and auditing of CDI programs. Brant has assisted health systems with ICD-10 Gap Analyses and created ICD-10-CM educational materials for specialty physician groups. Currently, she provides training and clinical support for DRG auditors. She lives in Camp Hill, Pennsylvania with her husband Marty.
Q: What do you think CDI specialists’ biggest misconceptions about the Recovery Auditor program are?
A: There are really three main misconceptions:
- Denials are determined without complete review of the documentation
- Recovery Auditor’s only look for “gotcha” errors
- CMS Recovery Audit programs are performed to only take back
Q: Recovery Auditors are not at the top of anyone’s best friend list in healthcare, but what important purpose do they serve?
A: The goal of any audit is to identify problematic issues. The purpose of CMS’ Recovery Auditors is to identify and prevent improper payments. Therefore, Recovery Auditors serve a purpose by encouraging healthcare providers to work for solutions to correct identified problems, stabilize provider revenue cycles, and ensure accurate payments for payers.
Q: What are three things attendees can expect from your session?
A: The three things that attendees can expect are
- To understand that Recovery Auditors perform very comprehensive reviews of all documentation provided.
- To obtain knowledge that the guidance for recommended reimbursement changes (higher or lower) is based on extensive peer-reviewed research of best-practices, clinical consensus data and Official Coding Guidelines.
- To use information from this session for improved denial data due to CDI performance improvements.
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: To encourage use of retrospective audit data to concurrently improve problematic documentation
Q: What are you most looking forward to about this year’s conference?
A: Interaction with colleagues and to stay updated on CDI’s expanding roles within the revenue cycle
Q: Fun question: what’s your favorite movie?
A: A Christmas Story – a perfectly imperfect loving family!
The third reason that the discharge summary is more important than the H&P is that, given that the ICD-10-CM principal diagnosis establishes the foundation for the diagnosis-related group (DRG) essential to cost-efficiency measurement, we must be crystal clear what condition we determined (after study) to be the reason for which we wrote the inpatient order, how the diagnostic approach or treatment evolved, why the patient had an unexpectedly long length of stay, or why he or she consumed additional resources. If two or more reasons qualify, coders can pick a higher-weighted code if it is supported by the documentation. For more information on principal diagnosis selection, read this related article.
For example, a woman presents with pancreatitis, and the diagnostic workup determines that it is due to gallstones. In MS-DRGs, if the ICD-10-CM code for gallstones is sequenced as the principal diagnosis instead of the ICD-10-CM code for acute pancreatitis, almost double the resources are allocated to that admission. The coder, however, may not choose the gallstones as the principal diagnosis unless the discharge summary shows, beyond a shadow of a doubt, that the circumstances of admission, the diagnostic approach, and the treatment rendered support the gallstones as the principal diagnosis. This may require that we overtly document how the admission was not only to treat the patient’s acute pancreatitis, but also to determine its underlying cause. Under most circumstances, a cholecystectomy would be performed during that hospitalization; however, if the surgery is delayed, an overt discussion on the reason for the delay can help a coder understand why the gallstones could still qualify as a principal diagnosis, even without surgical treatment.
We have the same situation with atrial fibrillation and decompensated systolic or diastolic heart failure. Atrial fibrillation as a principal diagnosis is higher-weighted than heart failure when they coexist. Unless we discuss how the patient’s atrial fibrillation contributed to the patient’s decompensation and demonstrate that it influenced the diagnostic approach and treatment rendered (assuming it did), the coder may be less secure in sequencing atrial fibrillation as a principal diagnosis, however.
Last, but not least, the discharge summary is the only part of the inpatient medical record in which we may document uncertain, probable, likely, suspected, or still-to-be-ruled-out diagnoses, and from which a coder may code those diagnoses as though they existed. Physicians and coders cannot apply this rule on outpatient facility or physician claims. It is only allowed for inpatient facilities. Not only does this affect DRGs, it also factors into the hierarchical condition categories (HCC), and affects our cost efficiency under value-based purchasing and other CMS initiatives.
For example, the physician admits a due to chest pain. After a diagnostic workup, the physician determines the pain is noncardiac and discharges the patient home on a proton pump inhibitor. The DRGs for noncardiac chest pain are lower-weighted than those for heartburn or gastroesophageal reflux disease. Unless we state in our discharge summary that the chest pain was likely due to these conditions necessitating the use of the proton pump inhibitor, the coder must use chest pain as a final diagnosis. It doesn’t help to only state these clinically valid possibilities in the H&P, progress note, or consultation report; someone must clearly cite them in the discharge summary if they are to be reported.
In another example, a patient is admitted with pneumonia whereby all diagnostic studies are negative. Based on the definitive antibiotics prescribed, what organism does the treating physician think likely caused the patient’s pneumonia? If the patient received a full course of vancomycin, might the physician think the pneumonia was due to MRSA? The coder cannot code this thought, however, unless the physician puts it in the discharge summary.
Most HIM professionals agree that physicians procrastinate completing their discharge summaries. Physicians often delegate the task to individuals who may not have the proper insight into the patient’s condition, such as medical students, house staff, or nurses. These summaries often lack underlying causes, complicating factors, and consequences that affect resource utilization and severity of illness. They may not resolve conflicting information provided by various consultants. The result is a subpar summary, which in turn leads to poor data quality.
Editor’s note: To read part 3 of this article, come back to the blog next week! Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.
By Brian Murphy
These days it seems sepsis is constantly in the news. Hardly a day passes where the efficacy of some new life-saving drug is being advocated or disputed, a sepsis DRG downgraded, or Sepsis-2 versus Sepsis-3 definitions debated. We’ve also had some major recent news from the likes of the Surviving Sepsis Campaign.
CDI specialists inhabit a world in which they need to navigate three sets of reporting requirements: Sepsis-2, Sepsis-3, and SEP-1, the latter from the National Quality Forum measure for public reporting of sepsis.
How can CDI specialists make sense of it all? I recommend reading our most recent ACDIS White Paper, “Where are we now with sepsis?”
The paper covers in detail the multiple issues around this tricky diagnosis, from the problems inherent in administrative versus clinical data, to systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock prior to the new Sepsis-3 definitions in 2016, and the definitions post Sepsis-3. The article also includes a nice bulleted summary and takeaways for your CDI department and medical staff.
Special thanks for principal authorship go to ACDIS advisory board member Sam Antonios, MD, FACP, SFHM, CPE, CCDS. Though primary authorship goes to Antonios, the entire ACDIS advisory board reviewed the work prior to publication.
To download the new White Paper, click here.
I would also encourage any of our ACDIS members who haven’t been by our resource pages in a while to check out all our White Papers and Position Papers. We’ve been publishing some helpful guidance of late, and more is on the way.
I hope this paper proves helpful in your continued mission of clinical accuracy in the patient chart.
If you have suggestions for topics you’d like to see the advisory board address, please let me know via email at firstname.lastname@example.org.
If at all possible, CDI programs should review all hospitalizations in a facility for documentation improvement opportunities. And all charts truly means every chart, including every insurance product, regardless of reimbursement mechanism (i.e., by MS-DRG or per diem), including the no-insurance and charity cases. The reason for this directive is multifaceted. First, reimbursement certainly is not the only purpose of a CDI program’s efforts. Even if a particular payer reimburses on a per-diem (per-day) basis or by a different DRG system (i.e., APR-DRGs), meaning there may not be any reimbursement benefits to improved documentation, CDI efforts still offer significant gains.
In particular, every payer employs some form of risk adjustment methodology to compare the outcomes of care between different providers. In other words, a facility’s providers look better to an insurer if they achieve the same results as a competing facility’s providers but do so caring for sicker patients.
Second, the need for a particular patient’s hospitalization must be justifiable. It doesn’t matter how many high-dollar diagnoses a CDI professional identified in the medical record if the payer – be it Medicare or private insurer – denies the claim. The sicker the patient is – both in fact and on paper – the harder it is for an auditor or a payer to justify that the patient should never have been admitted at all or that the patient should have been cared for in observation as opposed to being admitted as an inpatient.
If a CDI program is understaffed and simply does not have the resources to review all charts, program goals should evolve such that more than just the Medicare cases are reviewed. In other words, a CDI program should not be reviewing only Medicare patients.
If a CDI program reviews only Medicare cases, the government and the Office of Inspector General (OIG) believe that hospitals preferentially targets Uncle Sam’s coffers. Don’t increase your facility attractiveness to those who are looking for additional targets. By reviewing all payers, facilities set the precedent that increased reimbursement from CMS is not the only goal of a CDI program.
Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS.
Editor’s Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Jeff Morris, RN, BSN, CCDS, the supervisor of clinical documentation improvement (CDI) at University of South Alabama Health System in Mobile, Alabama, who is presenting “CDI in Obstetrics and Gynecology: A Roadmap to Program Development and Success.” Morris has 20 years of nursing experience in adult critical care, medical-surgical/telemetry, and emergency department (ED). Morris was the first CDI specialist hired at USA Children’s and Women’s and now has five years of experience in CDI. He is an active member of ACDIS and is an Alabama ACDIS Chapter leader.
Q: Could you tell me a bit about the why your facility developed its CDI program?
A: Initially, our organization hired CDI specialists to be liaisons between our coding and provider staff to provide documentation education related to ICD-10 specificity. With numerous ICD-10 delays, we transformed from a non-traditional program to a traditional program and added additional staff members.
Q: What are three things attendees can expect from your session?
A: Let me give you a list:
- Determine the need for CDI reviews of OB-GYN records at an individual facility and begin implementation of such a program
- Become familiar with Official Guidelines for Coding and Reporting and AHA Coding Clinics specific to the OB-GYN patient population
- Identify strategies for program success, program maintenance, and metrics to monitor
Q: What is one tool a CDI professional cannot live without?
A: The CDI Pocket Guide, it’s an invaluable resource that all CDI specialists should have.
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: I am happy to be co-presenting this session with Beverly Lambert, RN, BSN, our main CDI contact in the OB/GYN patient population at our organization. OB/GYN is a patient population most CDI programs do not review. There are many documentation nuances that are very specific to this patient population, but there are also commonalities.
Q: What are you most looking forward to about this year’s conference?
A: I am most looking forward to the networking and collaboration that occurs between CDI professionals during these few days. I always leave the conference refreshed and full of new ideas to bring back and implement at my facility.
Q: Fun question: What is your favorite breakfast food?
A: French toast. We have a place in town that has awesome bananas foster French toast!
Tara Bell, MSN, RN, CCDS, CCM, manager of CDI and utilization review services at United Audit Systems, Inc. (UASI) of Cincinnati, worked in CDI for more than 13 years and in nursing for more than 24. For the past several years, she’s gone above and beyond helping the South Carolina ACDIS Chapter balance its books as its former treasurer and now as its vice president.
Bell and her husband Allen have been married for 23 years and have two Maltese fur babies, Merlot and Miller (although she’s not divulging the back story about how they got their names). The duo takes their puppies with them everywhere. They even bought a camper to keep them close during vacations. “They love to ride the jet skis, paddle boards, and even kayak,” says Bell. “They really do think they are little humans.
ACDIS Blog: What did you do before entering the CDI field?
Bell: I worked on neurology and cardiac surgery floors, and neonatal intensive care unit with the preemies (babies). I eventually moved into the world of case management and utilization review (UR) at a national worker’s compensation carrier. I had various jobs during my time there. I worked as a UR nurse in their call center for precertification. I also worked as a telephonic case manager, and then transferred to an onsite/field case manager. This involved working with catastrophic and traumatic work injuries. I met so many wonderful people and learned an enormous amount in dealing with these injuries, follow up care, home modifications, etc.
ACDIS Blog: Why did you get into this line of work?
Bell: It was a natural progression for me from case management into CDI. A local facility advertised an opening for a CDI specialist. They were launching a new CDI program from the ground up. I weary of all the traveling required with field case management (my trusty Honda and I covered two to three states), so I thought I would see what this CDI stuff was all about. I truly had no idea what I was actually going to be doing in the job when I interviewed, but knew I would give it my all and make it work.
This was in 2004 and we were in the 10% of facilities in South Carolina that would have a CDI program. As it happened, they placed the CDI folks in the same department as the UR team. During my first month or two on the job, I actually functioned as a UR nurse. We were waiting for official training from a vendor/contractor to start and with my past experience I could help the UR team.
It has been the best decision I ever made. I was able to be part of launching the CDI program and eventually went on to supervise the program. My department director was a true visionary and knew the value of SOI/ROM when everyone still focused only on capturing one MCC and CC. She was a great mentor and so much of who I am now as a leader is due to her.
I love being able to use my nursing education and background to put the pieces of the puzzle together. I am a stronger nurse due to my involvement in CDI and the pathophysiology knowledge it takes to decipher a chart
ACDIS Blog: What has been your biggest challenge?
Bell: My biggest challenge has also turned into my biggest reward. I was presented with an opportunity to leave my “safe place” and join UASI toward the end of 2013. I had been involved with CDI at that point for almost 10 years at the same facility. I took the leap of faith, while also leaving behind the people who had mentored me all those years.
It has been a great challenge learning and growing within the consulting and staffing world. However, it has been my greatest reward. I am able to collaborate with best and brightest CDI programs across the nation while also developing and growing our own CDI staff. It has been a very rewarding and gratifying experience.
ACDIS Blog: How has the field changed since you began working in CDI?
Bell: I remember when simply COPD was a CC, is that not crazy to think of now? We had DRG, not MS-DRGs. The CDI world has really grown up over the last 13 years. CDI professionals have gained more respect within the industry and I am proud to be part of this profession.
There is much more of a network and educational opportunities for us to continue our learning. This was not the case in 2004 and I really developed a strong relationship with our coding team for guidance. I still believe in CDI/coding being a true team for success.
ACDIS Blog: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on CDI Talk or through ACDIS?
Bell: I learn something new and exciting every year at the national ACDIS conference. I remember meeting one of my now teammates on the South Carolina ACDIS Chapter in Nashville a few years back. We were on the same shuttle from the airport and realized we were both from SC. She was speaking on the pediatric population and it was a wonderful presentation.
Last year, I enjoyed Cheryl Ericson so much on ACDIS Radio that we invited her to speak at an joint SC/NC ACDIS chapter meeting.
ACDIS Blog: What piece of advice would you offer to a new CDS?
Bell: Not to be discouraged by a physician who is not onboard with CDI. See it as a challenge to educate that physician, to show him or her that CDI can be their ally, not their enemy.
Also, by all means, research for knowledge. Reach out to the ACDIS website, blogs, local chapters, and members. Read through Coding Clinics when they are published. All the knowledge that you gain makes you a stronger and more confident CDI professional.
ACDIS Blog: If you could have any other job, what would it be?
Bell: This goes back to what made me want to become a nurse. I would be involved/help manage a pet rescue. I support one locally and would love to be more involved if time allowed. I always tease my family and friends and tell them if I won the lottery I would set one up. A friend of mine who is also a CDI specialist would help me run it. She loves animals as much as I do. There are so many animals that need our help and simply want love.
ACDIS Blog: What was your first job (what you did while in high school)?
Bell: I worked at a department store, Belk. I was hired on during Christmas season working in gift wrapping. That was a crazy time for sure. I remember waking up at night dreaming of wrapping presents. I eventually moved out to the floor and worked in children’s apparel. We received a discount, so I believe most of my pay check when right back to the store for clothes I kept buying.
ACDIS Blog: Can you tell us about a few of your favorite things:
- Vacation spots: The panhandle of Florida, the beaches are so beautiful. Myrtle Beach in the winter, Lake Hartwell on the South Carolina/Georgia state line.
- Hobby: Reading, hanging out at the lake, boating, paddle boarding. I also love to visit local vineyards which are popping up all around us.
- Non-alcoholic beverage: Coffee for sure in the mornings, I’ve got to have the caffeine.
- Foods: I am still a teenager at heart. Pizza, chicken fingers, buffalo chicken dip…
- Activity: Anything to do with the sun and warm weather. I am definitely a southern girl at heart. No cold weather for me, please.
Probably the most onerous duty physicians have is the preparation of the inpatient discharge summary, especially after a long or complicated hospital stay. To be frank, I hate doing discharge summaries. I’ll find every reason to put them off. If I look at the current medical records delinquency list, I’m not the only one who has DCSAS, or discharge summary avoidance syndrome (which, by the way, does not have a code in ICD-10-CM). I’m sure you know someone similarly afflicted.
Given my unfortunate condition, I force myself to promptly and completely perform my discharge summaries—and there’s no better motivation than the realization that CMS and other payers are moving us from fee-for-service to what they call a quality- or value-based reimbursement system, as described by HHS Secretary Sylvia Burwell last December in a post on the Health Affairs Blog. I believe that Dr. Tom Price, Donald Trump’s new HHS Secretary, shares the same agenda.
Our success with these inpatient quality and value measurements is largely predicated on how well, and how timely, we organize and assemble our discharge summaries. While the admitting history and physical (H&P) is crucial for good patient care and utilization review, in ICD-10-CM/PCS-based coding and quality measurement, the discharge summary is even more important.
Why is the discharge summary more important than the H&P? There are several reasons.
First and foremost, receiving physicians look to the discharge summary to understand what inpatient diagnoses and treatments the patient obtained. Physicians are now accountable for preventing readmissions; thus, a well-constructed discharge summary will guide physicians at a skilled nursing facility or an outpatient clinic in continuing that diagnostic or treatment plan and keeping the patient out of the acute-care hospital. As such, the summary should be completed on the day of discharge and contain all acute and pertinent chronic diagnoses addressed, treatments administered, and consequences anticipated so the receiving physician can quickly understand the patient’s condition.
Second, the discharge summary represents the hospital’s final diagnostic statement of what the physician believes caused the patient’s symptoms. This is essential to assigning complete and precise ICD-10-CM codes, which factor into severity and risk adjustment. Sadly, ICD-10-CM coders are not allowed to clinically interpret the record to assign codes—they can only use the words we write or dictate.
Unless we continue to document acute diagnoses and underlying causes as they are diagnosed (e.g., documenting when established, documenting to say whether the diagnosis is better or worse, and finally documenting in the discharge summary), the coder cannot confidently assign all the ICD-10-CM codes to describe how sick our patients are.
Editor’s note: To read part 2 of this article, come back to the blog next week! Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.
Last week on the blog, we provided readers with a list of fun indoor activities to keep you busy when you’re not in the conference. If hiking and adventuring are more your speed, though, the Las Vegas area offers a wide range of attractions for you as well.
Below is a list of suggested activities for the outdoor enthusiast. Enjoy!
To read our list of indoor activities, click here.
- Red Rock Canyon National Conservation Area: Red Rock Canyon National Conservation Area, located 20 miles from Las Vegas Strip, allows visitors to hike, picnic, and view plant and animal life under 3,000-foot-high red rock formations. It’s open daily 8 a.m. to 4:30 p.m. Learn more at http://www.redrockcanyonlv.org/.
- Valley of Fire: The Valley of Fire is a 35,000-square-mile state park, named for the magnificent red sandstone formations formed from great shifting sand dunes during the age of the dinosaurs more than 150 million years ago (Mesozoic Era). These brilliant sandstone formations can appear to be on fire when reflecting the sun’s rays. It is located in the Mojave Desert approximately 58 miles northeast of the Las Vegas. Learn more at valley-of-fire.com/.
- Boulder City: Boulder City is located about 20 miles outside Las Vegas (and on the way to the Hoover Dam). You’ll find great restaurants, shopping, and antique stores. Learn more at bcnv.com.
- Hoover Dam: No trip to the area is complete without a stop at the Hoover Dam. The damn holds back the waters of Lake Mead and straddles the border between Nevada and Arizona. You can take a bus tour from the Strip. Learn more at vegas.com/attractions/near-las-vegas/hoover-dam/.
- Ghost towns: There is a way to step back into the Silver State’s astonishing past. Dotting the vast landscape of Nevada are countless ghost towns, and while indecipherable ruins and tumbleweeds mark some, others are surprisingly intact. Either way, these remarkable places are portals into a Nevada of old and certainly worth a wander. Learn more at lvlg.com/lasvegas/attracts/ghstwns.htm.
Q: I’m having problems determining the correct coding guidelines for chronic obstructive pulmonary disease (COPD) and pneumonia. Have the guidelines changed regarding COPD and pneumonia? Do you now have to code the pneumonia as a COPD with a lower respiratory infection?
A: Yes, the AHA’s Coding Clinic for ICD 10-CM/PCS, Third Quarter 2016, discusses an instruction note found at code J44.0, chronic obstructive pulmonary disease with acute lower respiratory infection requires that the COPD be coded first, followed by a code for the lower respiratory infection. This means that the lower respiratory infection cannot be used as the principal diagnosis. We would assign code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) as the principal diagnosis, followed by an additional code to identify the lower respiratory infection.
If the patient has an acute exacerbation of COPD and pneumonia, we would assign both codes J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) and code J44.1 (chronic obstructive pulmonary disease with acute exacerbation). Per the instructions, either code may be sequenced first and it should be based on the circumstances of the admission, followed by a code to identify the infection, such as code J18.9 (pneumonia, unspecified organism).
CDI specialists and/or the coding staff need to clarify the type of infection to ensure the proper code assignment. There does seem to be some concerns regarding classifications of lower respiratory infection. Per the Coding Clinic, acute bronchitis and pneumonia are both included in code J44.0 (lower respiratory infections). Influenza, on the other hand, is not included in code J44.0 because it is considered both an upper and lower respiratory infection.
Additionally, the type of pneumonia needs to be clarified. For example, aspiration pneumonia (code J69) is not classified as a lower respiratory infection, but as a lung disease due to the external agents. To assign the appropriate code in the case of aspiration pneumonia, we would need to know the external agent, i.e. milk versus vomit.
Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at email@example.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.
Physician support in the CDI decision-making process from the CDI program’s inception helps physicians see beyond the immediate obligation of documentation to the greater good such documentation provides.
Physicians, as a group, tend to have similar personality traits. For example, physicians are:
- Educated, so give them definitions
- Scientists, so give them data
- Proud, so illustrate how they rate against their peers
- Results oriented, so give them a goal
Many argue that the best form of physician education is physician involvement. The earlier physicians get involved in CDI development, the greater their investment becomes. At the CDI program’s inception, medical staff leadership or the facility’s chief medical officer (CMO) typically join the CDI steering committee to set overall goals from the program and expectations for physician response, involvement, and training. Physician investment in CDI at the highest levels trickles down through the physician ranks and encourages the involvement of the entire medical staff in day-to-day documentation improvement activities.
Many programs hire a physician advisor to act as a mediator between medical staff and CDI professionals. If your program has a physician advisor, tap into his or her experience. He or she often plays an important role in identifying CDI targets and providing both group and one-on-one education.
Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.