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Call for 2017 Conference Poster Presentations Now Open!

2017 Poster Presentation application period open through December 15!

2017 Poster Presentation application period open through December 15!

ACDIS is excited to announce that it is accepting applications for poster presenters at its 10th Annual Conference, to be held May 9-12, 2017, at the MGM Grand Hotel in Las Vegas.

This is a great opportunity for hospitals and other CDI professionals to promote their CDI programs and share them with a national audience. Posters may describe an innovative program process or department expansion, a CDI success story, or an obstacle your team overcame. Posters may not promote a product or service.

If you are interested in presenting a poster, click this link to submit your idea: http://app.keysurvey.com/f/1084930/5a39/

The deadline to apply is December 15, 2016.

Here are some key details you need to know:

  • We have room for 40 posters.
  • The 2017 Conference Committee will review all applications and select those chosen for presentation. All applicants will be notified of the Committee’s decision by the first week in January.
  • Presenters will be given a $200 discount off their conference registrations. If the poster is presented by a team the discount will apply to one member.
  • Presenters must be able to spend one hour with their poster during a dedicated poster viewing time. Presenters who do not particulate in the session hour will be billed for the $200 discount. The date and time of the presentation session will be announced at a later date.
  • We will approve one application per facility (unless space permits additional posters).
  • Maximum poster size requirements have CHANGED. Posters may be NO WIDER than 36 inches and NO HIGHER than 48 inches. Posters exceeding these limits will be turned away and the presenter will be billed for the $200 discount.

We look forward to hearing from you with your poster idea!

Guest Post (Part 3): Complying with definition changes

James S. Kennedy

James S. Kennedy

Note: This post is part three of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

by James S. Kennedy, MD, CCS, CDIP

For those who have been reading along with my columns regarding sepsis documentation and coding challenges, allow me to suggest the following strategies to assure a balance of compliance :

  • Standardize the definition and documentation of severe sepsis first. Recovery Auditors (RAs) will be looking for records with sepsis codes that do not have R65.20 or R65.21 as a secondary diagnosis as to deny these codes and DRGs. So CDI specialists should work with medical staff to establish standardized definitions; this could incorporate any or all of the following three criteria:
    1. Change in SOFA score of 2 or more, which means that a new PaO2 of <60 on room air, or a Glasgow Coma Scale of 13 could, by themselves, generate the two points needed to qualify for an acute organ dysfunction. The physician would have to document what the organ dysfunction is, which may not necessarily be an organ failure, given that ICD-10-CM uses the word “dysfunction” rather than “failure” in justifying R65.20, severe sepsis. I suggest this be part of a standardized emergency department assessment template or admission order involving an infection, which means we must reprogram our electronic health record (Epic, Cerner, Meditech, McKesson) to systematize their capture.
    2. A lactate level of 2 mEq/L or more due to an infection. If the coder requires an organ dysfunction to go with R65.20, the physician would have to document tissue hypoperfusion for which no ICD-10-CM code is in the index to diseases. I suggest coding I99.8, other disorder of circulatory system.
    3. Any of the criteria described in SEP-1 (which can include a lactate level of 4 mEq/L or more to define septic shock). Note that SEP-1 documentation or order templates must be reviewed in light of what is needed for ICD-10-CM, given that these are signed by a provider, they may be used for coding purposes.

No matter what criteria you use, be sure to coordinate it with your quality and CDI/coding staff so if a physician documents “severe sepsis” or “septic shock,” the SEP-1 algorithm can be implemented. Also, be sure that physicians explicitly link organ dysfunctions to sepsis or preferably use the word “severe sepsis” so R65.20 is not inadvertently missed by the coders. As mentioned above, coders and CDI specialists should work closely with quality to ascertain if any of these organ dysfunctions in the setting of sepsis represent severe sepsis prior to claim submission. Here are my suggestions as to how to handle the current situation:

  1. Develop a facility-wide definition for sepsis without organ dysfunction. As you see above, many physicians in the United States do not believe that organ dysfunction is required to diagnose a patient with sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, you must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding purposes so that when it is documented by a provider, this statement can be used to disprove the RA’s denials. These will be handy if you are appealing beyond the first level.
  2. Remind the RA that the ICD-10-CM guidelines is part of HIPAA and that coding is based on provider documentation, not the RA’s interpretation. I’m sure that all of our contracts with private-payers state that we will comply with federal law, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign ICD-10-CM codes based on provider documentation and that Coding Clinic, First Quarter 2014, pp. 16-17, states that “the official guidelines are part of the HIPAA code set standards.” We don’t want RAs to violate HIPAA or our contracts with payers, do we? This may require that a hospital attorney or compliance officer weigh in, given that RAs have been known to deny codes based on provider documentation.
  3. Be on the lookout for Coding Clinic advice clarifying this issue.  Coding Clinic for ICD-10-CM/PCS addressed some aspects of this in its fall 2016 publications for the third and fourth quarter. In addition to this advice, you may wish to submit your own cases to Coding Clinic advisors to see how they comment.

Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version.

A Note from the CCDS Coordinator: Congratulations to our 3,500th CCDS holder!

The 3,500th CCDS holder Jamie Brown and her two children—daughter, Kaitlyn, age nine, and son Cody, age seven.

The 3,500th CCDS holder Jamie Brown and her two children—daughter, Kaitlyn, age nine, and son Cody, age seven.

A couple of weeks ago, the 3,500th person to hold the CCDS certification passed the exam. We are delighted to introduce you to Jaime Brown, BSN, RN, CCDS, a CDI specialist at Ochsner Health System at Jefferson Parish, Louisiana. Please join us in congratulating her on this tremendous accomplishment!

Before becoming a nurse, Brown had a career as a commercial loan underwriter for a major financial institution before obtaining her bachelor of science in nursing. She worked in oncology for seven years and has been in CDI for three years.

“CDI has been an awesome professional opportunity,” says Brown. “I have had the opportunity to increase my clinical knowledge, learn the financial side of healthcare, and be a part of the formative years of this unique profession all while having the flexibility to be there for my children when they need me.”

Brown has two children—daughter, Kaitlyn, age nine, and son Cody, age seven. She enjoys her free time trying new restaurants and catching up with family and friends.

ACDIS: Why did you get into this line of work?

Brown: I was looking for a change and saw the job posting. It peaked my curiosity because it was the “business” side of nursing.

ACDIS: What has been your biggest challenge?

Brown: The biggest challenge for me is that there is usually not a straight answer to a question. Each admission is different and no two clinical scenarios are the same.

ACDIS: What has been your biggest reward?

Brown: The biggest reward has been seeing the financial and quality impact I can have through my chart reviews. It’s always nice to query for the only MCC on a record or clarify something with a provider so that their record is accurate. Although I am not at the bedside, I can still make a difference. I also feel like I have learned more from a clinical aspect in the last three years in CDI than I did in my seven years at the bedside.

ACDIS: How has the field changed since you began working in CDI?

Brown: When I started in CDI, we were still in ICD-9. Most people had not heard about CDI. We worked strictly with inpatient records. Today, we code in ICD-10. Other medical professionals have heard about our role and providers are looking to expand our role. My employer now has an additional program specifically for reviewing ambulatory records. (Click here to learn more about that program.) I can only imagine where CDI will be in another three years.

ACDIS: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on CDI Talk or through ACDIS?

Brown: One of our primary responsibilities as CDI professionals is to educate providers. When I started, I often wondered if we would ever educate them enough to the extent that we would be out of a job. I have learned rather quickly that CDI will always be in demand because the rules are so complex and there are always new providers to train. If you miss a query opportunity, it is a learning opportunity.

ACDIS: What piece of advice would you offer to a new CDI specialist?

Brown: There is a learning curve in this job like none other. Just when you think you understand the concepts, you will be faced with a situation that makes you question your new found understanding. Confidence and understanding come with time. Be patient.

ACDIS: If you could have any other job, what would it be?

Brown: I would love to be a personal financial advisor, managing everyday household finances. I love a spreadsheet and have serious organizational skills. I make a spreadsheet for just about everything, including vacations!

ACDIS: What was your first job (what you did while in high school)?

Brown: I was a store clerk at Afterthoughts Boutique in high school. I pierced ears and sold jewelry and hair accessories.

ACDIS: Can you tell us about a few of your favorite things:

  • Vacation spots: Chicago and Florida beaches
  • Hobby: Dining at new restaurants–there are always new places to try in New Orleans
  • Non-alcoholic beverage: Diet Coke
  • Foods: Boiled crawfish and steak
  • Activity: Hanging out with my kids and friends

Thoughts from the field: Expert thinking

Don't sweat it, share your expertise with the CDI community.

Don’t sweat it, share your expertise with the CDI community.

I was looking through old drafts of blog posts and came upon some notes from ACDIS blogger Linda Renee Brown. She wrote that sometimes CDI professionals look for expert advice and that once they identify it, they follow it to the letter. But “What’s an expert?” she asked, and went on to quote an old teacher who broke the term down into its component parts stating that a “ex is a has-been and a spurt is a drip under pressure.” Clearly the teacher (and Brown) meant that anyone can self-describe as an expert but its up to us as individuals to do the extra research and ensure that the advice provided is actually sound.

In clinical documentation, as in any professional field, there exist any number of possible expert resources from which to draw advice and information. Programs instituted on the advice of a consulting firm may have benefited from its initial education and training. Those with extensive electronic health records and eQuery systems no doubt learn from the expertise of its designers and staff as well as the technological tools and resources available within the system.

All types of other experts also exist. The person who hired you, perhaps. The co-worker who offered you a kind word and simple advice which resonates even today. The coder who continues to lend you an ear as you try to decipher the latest recommendations from Coding Clinic.

Yes, even various publications can provide a certain amount of expertise. Coding Clinic of course serves in this role, as the AHA represents one of the four cooperating parties governing code assignment. So, too, does AHIMA and it’s publications, similarly due to its participation on that four-corporation governing body as well as its more than 75 year legacy representing the health information management field.

And, of course, we believe that ACDIS provides expert advice as well. It is the only association totally focused on the daily activities of those working to ensure the complete integrity of the medical record. That’s not why I believe ACDIS’ advice equals sound advice, however. Actually, I believe the strength of the education, insight, interpretation, and analysis provided to its members comes directly from the collaborative nature of the association itself. We depend on the input and opinions of our members. We bring those thoughts and ideas forward in a number of ways, through the Journal, ACDIS Radio, our quarterly conference calls, and more. We encourage your feedback and suggestions on those items and we continue to grow and reassess the state of the profession through your eyes.

As Brown wrote in her notes, “if you’ve been working in CDI for any length of time and you’ve allowed yourself—and have been allowed—to think for yourself and act for yourself and make judgments based on what you know in your core to be right, you don’t need an expert. You are headed in the right direction.”

Whether you’re looking for advice on a particular topic or have an opinion, thought, or CDI success story reach out to your peers here or via the ACDIS Forum. By sharing our expertise we all benefit.

Thanksgiving mishaps? There’s an ICD-10 code for that!

It's Thanksgiving! Time to celebrate all the ICD-10 codes you (hopefully) won't actually encounter this holiday.

It’s Thanksgiving! Time to celebrate all the ICD-10 codes you (hopefully) won’t actually encounter this holiday.

As we prepare for the Thanksgiving holiday with family and friends and give thanks for all of our blessings, it is important to be ready with appropriate codes to accurately document any holiday mishaps.

Here’s a short list to help you quickly and efficiently communicate the information required to file a complaint claim:

For incidents with a fresh (live, not saucy) turkey:

  • W61.42 Struck by turkey
  • W61.43 Pecked by turkey
  • W61.49 Other contact with turkey

For general kitchen and meal prep actions:

  • Y93.G1 Activity, food prep and cleanup
  • Y21.2 Undetermined event involving hot water
  • Y93.G3 Activity, cooking and baking

For dealing with obnoxious Uncle Leo who insisted on pushing his way to the dessert table:

  • Y04.2 Assault by strike against or bumped into by another person

For your mother-in-law’s criticism of the lumpy gravy (which we know was not lumpy):

  • Z63.1 Problems in relationship with in-laws

For activities post-meal to work off effects of R63.2 Polyphagia (overeating):

  • W21.01 Struck by football

For Friday morning:

  • W72.820 Sleep deprivation

Editor’s note: The ACDIS office will be closed for the Thanksgiving holiday and will reopen on November 28. Please send along your most common documentation improvement opportunities either in the comment section or via email to mvarnavas@acdis.org.

Local Chapter Update: Photos from the Illinois ACDIS meeting

Illinois 2

Members of the Morris CDI department hosted the October event!

The Illinois ACDIS meeting took place Thursday, October 13, at Morris Hospital. They shared a few photos with us from their event—check them out and join us in congratulating them on a successful meeting! If you have photos from a recent chapter meeting or event, please e-mail them to us! For more information about upcoming events visit the Local Chapter pages on the ACDIS website!

Illinois 1

Thanks for a great meeting from the Illinois Chapter leaders!

Guest Post (Part 2): Solving the documentation difficulties for sepsis-3

James S. Kennedy

James S. Kennedy

Note: This post is part two of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

by James S. Kennedy, MD, CCS, CDIP

In developing a CDI strategy for dealing with new sepsis-3 criteria, remember three environments by which we must consider disease terminology and supporting criteria. One cannot talk about sepsis, severe sepsis, or septic shock documentation without considering the environment in which such documentation is to be interpreted.

Clinical language
Physicians use a language in direct-patient care that communicates (easily translates) well with other physicians. Every physician knows what “urosepsis,” “unresponsiveness,” and “neurotoxicity” is; however, ICD-10-CM does not recognize these terms for coding purposes, thus we ask physicians to use different words so coders can assign the correct coding conventions.

Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) is a clinical language; so is sepsis-3. ICD-10-CM is not.

Not all physicians embrace sepsis-3, thus some may wish to label a patient has having sepsis even if they don’t have organ dysfunction, which makes clinical sense to them.

Coding language
In a landmark article published in the Journal of AHIMA in 2014, Sue Bowman, senior director of coding policy and compliance for AHIMA in Chicago, Illinois, makes it very clear that ICD-10-CM is not for clinical care but for administrative purposes.

“The standard vocabulary afforded by SNOMED CT supports meaningful information exchange to meet clinical requirements, Bowman says. “ICD-10-CM and ICD-10-PCS, with their classification structure and conventions and reporting rules, are useful for classifying healthcare data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous,” she wrote.

Sepsis-3 amends clinical language only; however, for coding purposes we must still document using ICD-10-CM’s language, which still recognizes sepsis without organ dysfunction and sepsis with acute organ dysfunction (severe sepsis) and is based on the individual physician’s criteria.

Core measure language
Defining cohorts with core measures, such as SEP-1, is an abstraction based on clinical criteria and not necessarily based on what a physician writes.  For example, the definition of severe sepsis and septic shock is completely different in SEP-1 than Sepsis-3. We must remember, however, that in 2017, if a physician documents severe sepsis and R65.20 is coded, that record will be held accountable for the SEP-1 core measure even if it doesn’t meet the SEP-1 criteria. View this regulation here.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at jkennedy@cdimd.com.

Local Chapter Update: Wisconsin ACDIS meeting covers cardiology in-depth

Wheaton Franciscan in Wauwatosa

Wheaton Franciscan in Wauwatosa hosted the October WI ACDIS Chapter meeting.

The Wisconsin ACDIS Chapter met Saturday, October 15, at Wheaton Franciscan in Wauwatosa and featured a full day of speakers and networking.

The presentations were all given by members of the chapter and were well-received by attendees, who came from across Wisconsin and neighboring states.

While each presentation was equally informative, one in particular stood out to attendee Susan M. Burke, RN, CCDS, CDI specialist at Edward Hines Jr. Veterans Administration Hospital in Illinois. The session focused on cardiology, specifically arrhythmias, Takotsubo cardiomyopathy (broken-heart syndrome), and stenting. The two speakers, one of which was a cardiac nurse, used diagrams and interactive visuals to demonstrate blockages, including left bundle branch block (LBBB), specifically where they originate.

“It is one thing to know it from reading,” she says, “and another to see it in a schematic that makes perfect sense and creates links in the minds of the audience members—and this did.”

The presentation also included pictures of Takotsubo, demonstrating how it got its name and how it appears radiographically in the catheter lab. The research that has been done linking Takotsubo to other disease entities was completely unknown to Burke, who has been a nurse for more than 30 years.

“Though it may sound simplistic, I can tell you that having a good grasp of cardiology is not as easy as other body systems,” she says. “Hearing and now having a visual in my head helps me in my practice. I think the same could be said for most nurses and coders.”

Editor’s Note: For information about upcoming chapter events, visit the Local Chapter page on the ACDIS website and click on your state. Additionally, the CDI Strategies weekly publication includes an ongoing listing of upcoming events.

Q&A: Community-acquired pneumonia

Q: How do we determine if a patient’s pneumonia is community acquired or not? What documentation should we look for to support this?

A: To be honest, any type of pneumonia can be acquired in the community. However, physicians often use the term “community acquired” to signify a simple pneumonia. Simple pneumonia is usually easily treatable, although the term is somewhat self-limiting. The diagnosis causes unique problems for CDI specialists.

In general, simple pneumonia cases would not and should not be admitted to the hospital for inpatient status. They could be admitted, however, if they have a number of other medical problems that further complicate the care of their pneumonia, or are becoming acute themselves—for example, a congestive heart failure (CHF) patient getting fluid overloaded, a diabetes patient with an out-of-control blood sugar level, or a very elderly patient who also has a urinary infection and has now become confused.

We certainly would not want to make a blanket statement that any patient admitted to the hospital probably has a gram-negative or complex pneumonia. But, oftentimes, the pneumonia by itself does not support the admission.

“Atypical” is a term used by physicians to describe a unique presentation of pneumonia that has its own set of chest x-ray findings, history, and treatment requirements. Generally, atypical pneumonia is usually caused by one of the organisms classified as a complex pneumonia for DRG assignment purposes. Unfortunately, the term “atypical” codes to one of the simple pneumonia types.

Interestingly enough, “hospital acquired” and “healthcare acquired” are almost always written when the physician is attempting to describe a more complex pneumonia, resistant to treatment, in a patient who has a higher acuity illness. Unfortunately, these terms code to simple pneumonia classifications, too. Physicians are almost always surprised (and often disagree) with these phrases being classified as “simple.”

For this reason, what I teach CDI specialists to ask for the specific organism, and to either document that organism as either confirmed or suspected at discharge. Getting the exact organism is not always possible. Nevertheless, physicians need to document their assessment based on the same clinical evidence that caused them to treat that patient in one manner versus another.

For CDI specialists, the moral here is that when physicians document “atypical,” “hospital-acquired,” and “healthcare-acquired” you may need to craft a query, so providers don’t get an inappropriate downgrade.

Furthermore, CDI specialists may need to query the physician regarding patients sick enough to be admitted to the hospital for community-acquired pneumonia, particularly if the physician did not include any additional documentation regarding comorbidities. It may be that the patient actually has sepsis, or reveal a more specific causative organism which changes the classification to a more complex pneumonia.

Worst case scenario, a reassessment of the utilization procedures may need to occur if a large population of simple pneumonias is actually being admitted with no complications, no co-morbidities, no risk factors, and they genuinely do have simple gram positive type pneumonias.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.

Guest Post (Part 1): Documentation and coding challenges abound for sepsis-3

James S. Kennedy

James S. Kennedy

Note: This post is part one of four, excerpted from an article originally published in JustCoding. Click here to read the original. The comments and opinions represent those of Kennedy

by James S. Kennedy, MD, CCS, CDIP

There are a number of coding compliance challenges with sepsis-3 and with sepsis or severe sepsis in general. In this article, I’ll review my top four concerns.

First, sepsis-3 states that patients with an infection meeting the new sepsis criteria should be coded as R65.20, severe sepsis. This is impossible in the United States, given that ICD-10-CM code R65.20 can only be assigned if the physician documents “severe sepsis,” not sepsis alone, or if the physician documents that an acute organ dysfunction is associated with sepsis, though many coders fail to assign R65.20 when these links are made. Its apparent that the sepsis-3 authors are not familiar with Coding Clinic for ICD-10-CM/PCS, the Department of Justice, or our friendly neighborhood recovery auditors (RA).

Secondly, ICD-10-CM still has a multitude of codes for sepsis without organ dysfunction (e.g., A40-A41). The 2017 ICD-10-CM Official Guidelines for Coding and Reporting states that “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. It states:

The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” (Emphasis added.)

Recent advice from Coding Clinic supports the concept that if an individual physician documents sepsis using his or her own criteria (that may differ from sepsis-3 or that of a RA), coders are obligated to code it. Therefore, if a physician documents sepsis, can we still defend the coding of an A40-A41 code if there is no documented organ dysfunction? I believe that the Guidelines and Coding Clinic say that we can, even if the RA doesn’t like it.

Thirdly, the ICD-10-CM table instructions for code R65.20, severe sepsis, tell us to use an “additional code to identify specific acute organ dysfunction.” If a physician documents severe sepsis based on the sepsis-3 criteria of a lactate over 2 milliequivalent per liter (mEq/L), or sepsis-3’s changes in the Glasgow Coma Scale, what is the organ dysfunction that should also be coded or queried for? Without an organ dysfunction documented and coded, a RA may claim that the severe sepsis code is invalid.

Finally, in my own personal review of the CMS 2015 MedPAR, approximately 45-55% of MS-DRGs 871 or 872 (septicemia or severe sepsis) do not have a code for severe sepsis, yet a number of patients have acute organ dysfunctions present on admission which I believe should have been linked to the patient’s sepsis to render the severe sepsis code.

RAs look at sepsis DRGs without R65.20, severe sepsis, or R65.21, septic shock, as opportunities to take money away from facilities who coded sepsis (e.g., A40-A41) as present on admission and sequenced it as a principal diagnosis without an additional R65.20 or R65.21 code. To take these records out of the RA data mining pool, CDI professionals must make every effort to query providers if the clinically valid indicators of organ dysfunction due to sepsis are present but the record does not have the documentation interpreting these indicators as to report R65.20 and R65.21 and their associated organ dysfunctions. This effort, however, must be coordinated with the SEP-1 or quality manager, given that any coding of R65.20 or R65.21 subjects the record to the SEP-1.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at jkennedy@cdimd.com.