A Friday toast to lessons learned

Believe it or not there is an association for associations. And yes, Brian Murphy and I are soon to be members. Just as ACDIS provides a venue for CDI specialists to share best practices, the American Society of Association Executives (ASAE) and the Center for Association Leadership offers us helpful hints about how to help you. For instance, on the ASAE Blog “Acronym,” Brian Birch outlined a number of the valuable lessons he learned from his members.

I hope you can see where I’m going with all of this, my usual circular logic notwithstanding, since

'The Lesson' by Pablo Picasso. Don't we all have something to learn from one another?

what I’m hoping to convey is the power of circular learning. We all have something to learn from each other: The coder from the clinical experience of the nurse and the nurse from the regulatory understanding of the coder; the physician from the CDI specialist and CDI specialist from the specific knowledge of disease pathways locked away inside the mind of a physician.

So Mr. Murphy and I thought we’d put together a short list of items we learned from the members of ACDIS over the past few years. Things like:

• Once a nurse, always a nurse.
• Urosepsis is a four-letter word.
• Old physicians can learn new documentation tricks.
• Minutiae matters.
• It is easier to work with someone than for something.
• Be careful of the word acute.

And I think Brian Murphy and I learned the importance of the day-to-day work which CDI specialists pour their hearts into. As Mr. Birch wrote: “The best thing I have learned is that they are out there, professionals with strong minds and hearts who are just trying to make a better lives for themselves and their families.”

And so, a toast: To all the lovely lessons learned and all the casual teachers who have taken perhaps the briefest of moments to share their insights with me, their peers, and their coworkers. Please take a moment yourselves to post your own favorite lesson and give a shout out to the mentor who helped you most in the comment section below.

Supplement to October 2009 CDI Journal: Coding Clinic update

Hi ACDIS members, if you go to our CDI Journal home page you will find a special supplement to the October 2009 issue: A special report reviewing the important developments and guidance in Coding Clinic for ICD-9-CM, third quarter 2009. The source of the article is James Kennedy, MD, CCS, director of FTI Healthcare consulting and author of the Physician Queries Handbook.

In this article Dr. Kennedy breaks down the latest Coding Clinic as it pertains to CDI specialists, reviewing important sequencing considerations, query opportunities, and more. Going forward, ACDIS plans to make this a regular feature exclusively for our membership. Coding Clinic for ICD-9-CM is a vital component of every CDI specialists’ toolbox, and we hope you find the article useful.

If you have any feedback for Dr. Kennedy, please feel free to post it right here.

Take care,

Brian

CDIP at the crossroads

The field of clinical documentation improvement has rapidly expanded into a burgeoning profession with strong potential and long lasting value for all healthcare providers involved in the care of the patient. The importance of and necessity for complete and accurate medical record documentation reflective of true patient acuity, risk of morbidity and mortality, and readmission cannot be over emphasized. There is almost always an opportunity to improve clinical documentation in any medical record chart from both a resource intensive reimbursement standpoint and quality of care and clinical outcomes standpoint.

But just as the profession is gaining momentum and increased recognition in the business facet of healthcare, we have reached a crossroads and may be going down the wrong path.

For those of us who have been in the clinical documentation improvement arena for a long time, it is eye-opening to view the advertisements and promotional materials for clinical documentation improvement projects readily available at trade shows and appearing in prominent trade journals. The common promotional theme is increased reimbursement for the hospital, which is not surprising given the fact these clinical documentation improvement programs are marketed strictly on the basis of “reimbursement enhancement.”

Let’s not kid ourselves, every healthcare expenditure that is not direct patient care related must provide for a reasonable chance of return on investment, contributing to the organization’s financial performance in some for or fashion, whether it be additional revenue or at least cost avoidance. But there has been some talk in the industry that some firms have worked into their CDIP contracts a guarantee of specified amount of increased reimbursement for the hospital with the implementation of their programs. 

The aftermath

Clinical documentation improvement programs can be structured to meet the documentation requirements required in the health record to financially sustain the hospital from a financial accounting and quality of care reporting perspective. How the program is structured can dictate success or failure in the rollout and acceptance of the program by physicians and other ancillary service providers.

In speaking with a fellow colleague recently, I heard a valid concern that is worth mentioning regarding where the CDIS profession is now, and where it may be going. Once again it may be going down the wrong route. My colleague pointed out that in some instances, the clinical documentation improvement specialists appear to be focusing on reviewing the record solely for identification and documentation of “missed CCs and MCCs,” almost as if they were “CC/MCC scroungers.”

The very idea of CDIPs being promoted primarily as reimbursement mechanisms perpetuates and drives the ever-increasing viewpoint of CDIS as CC/MCC identifiers. In order to be directed down the right path, we need to stay attuned to the mission of the profession, which is to affect positive change in physician’s patterns of clinical documentation over the long term through provisions and actions of continued physician education. This relentless pursuit of physician clinical documentation education embraces a holistic approach with an emphasis upon the direct correlation between clinical documentation and the continued business financial viability of the both the hospital as well as the physician. A primary focus upon “getting that CC/MCC” documented in the record represents a very small cross sectional piece of what the CDIS can fundamentally contribute to a successful program.

Looking to the future

A recent article caught my attention, certainly an interesting thought to consider as we are at the crossroad of our profession. Clinical documentation improvement efforts are episodic with a bent toward reviewing individual records and utilizing the clinical query process in striving for complete and accurate clinical documentation. In an article that appeared in the July/August 2009 Journal of Hospital Medicine entitled “Transitions of Care Consensus Policy Statement,” the American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions.

Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. You may read a summary analysis of this policy census statement through this link.  http://hospital-medicine.jwatch.org/cgi/content/full/2009/1009/1?q=etoc_jwhospmed

There are seven consensus principles and standards for managing care transition as follows:

1. Accountability
2. Responsibility
3. Coordination of care
4. Family involvement
5. Communication
6. Timeliness
7. National standards and metrics

While each of these standards embraces elements of clinical documentation, the last standard above speaks greatly for the ability of the clinical documentation improvement specialists to jump into the fray of clinical documentation and fulfill a much needed role of assisting in the formulation and development of standardized communication formats for care transitions that can be used for accountability and continuous quality improvement. Minimal required information in the transition record that the CDIS can help facilitate include principal diagnosis and problem list, medication list reconciliation, identification of the coordinating physician/institution, patient’s cognitive status, and test results and pending test results.

Which way?

We are at the crossroads of our profession in CDI. Which direction we decide to take will guide the ultimate success and future of the profession. Decisions made today will certainly impact all of us tomorrow and well into the future.

Back from Boot Camp

If I’m looking a bit sore and stiff this week, it’s because I’m still recovering from our latest Clinical Documentation Improvement Boot Camp in Alpharetta, GA. No, no push ups or early morning runs were involved, just a lot of exercise for the mind.

I had the chance to attend the first 2 1/2 days of the four-day Boot Camp, and can honestly say I

There's no screaming at the CDI Boot Camp. We promise.

learned a lot from our instructor, Catherine O’Leary of CSG Solutions. Catherine has extensive experience as a nurse in medical/surgical intensive care, and her clinical knowledge and experience shines in the heart of the Boot Camp–a guided tour of the Major Diagnostic Categories (MDCs), including infectious diseases, the respiratory, circulatory, digestive, endocrine, and neuro systems, and much more. I learned more about “the left shift” and neutrophils than I ever did before, as well as coding/sequencing guidelines for sepsis.

Another strong point of Catherine’s background is her familiarity with the RAC program. She worked with several New York hospitals hard-hit by the RAC demonstration program, and has some great ideas to share for getting CDI specialists more involved with the RACs to prevent denials on a proactive basis.

The CDI Boot Camp is also a great place for discussions and networking with your colleagues. The goal of the CDI Boot Camp is to provide a small, classroom-like learning environment to teach the core skills and basics of the CDI profession. This small teacher-student ratio allows for a lot of dialogue with the instructors and each other. Many of our students took the opportunity to meet up for dinner and exchange business cards and phone numbers. I personally got to speak with several ACDIS members, including a few who I knew by e-mail signature only. It was a pleasure to be able to put real faces to names.

In summary, I hope all of our new CDI specialists, or CDI specialists in need of some additional training, make it out to a Boot Camp. And don’t fear the name: No sit ups and pull ups required, I promise.

Get the word out about CDI

Seasoned association members know the vital role such groups play in both policy and politics. One need look no further than the American Health Information Management  Association (AHIMA) and its role as one of the four cooperating parties which determines annual changes to the ICD-9-CM.

I recently noticed the Case Management Society of America’s (CMSA) call to action via the blog Case Management Mentor. CMSA drafted a proposal for legislation which would set standards for case management services. The proposal includes provisions covering staff qualifications, case management functions, authorized scope of services, payment of services, training requirements, quality management programs, and anti fraud and consumer protection practices.

Part of me (the independent, you can’t tell me what do, part) thinks legislating job descriptions might be a bit heavy handed. In the mix of all our congressional delegates must shove against that enormous stone wall of theirs I wonder how much momentum such efforts might add to the overall healthcare debate.

However, I concede the point that certain professional guidelines are well warranted. And, maybe more to the point of my blog post here is CMSA’s fairly straightforward encouragement for its members to reach out to their elected officials. To this point, I couldn’t agree more.

A newspaper friend drew this of me with the title "Varnavas for Something."

Now, I’m not one to make large contributions to candidates’ coffers. And I am not one, truth be told, to even post a sign on my lawn for my mayoral pick (Go Mayor Bill Scanlon!). However, I wholeheartedly enjoy ongoing dialogue with my elected officials. Maybe that makes me slightly geeky, but I think it is a total gas to listen to Congressman John Tierney’s open forums at the local library, to chat with him over coffee, and weigh in on a variety of interests and worries I share with my friends and neighbors.

As a CDI professional, you really have a unique perspective and insight into the current status of healthcare in America. When a teacher from the next town complains bitterly about her hospital bills you can explain how your documentation improvement efforts help reduce billing mistakes and improve patient care. When a physician complains about government interference in his practice of patient care you can explain all the ways simple documentation mistakes make such oversight necessary.

Just as you incorporate documentation improvement education into your healthcare community you can carry it outwards to the larger community—to your elected officials and neighbors, too. It would be a shame not to share your CDI insight with those who could benefit from it.

Okay, time to get off my soap box. Let me know what you think.

Query questions linger regarding renal failure

Robert S. Gold, MD

If you weren’t at the ACDIS 2009 annual conference you missed Robert S. Gold’s (MD, founder and CEO of DCBA, Inc., in Atlanta, GA) presentation regarding renal disease documentation for clinical indicators.

Physicians don’t explicitly document acute renal failure—a major complication/comorbidity, making it difficult for coders and CDI professionals due to the lack of pertinent clinical details contained in the medical record. Similarly, chronic kidney disease coding and billing frequently suffers the same fate due to lack of documented specificity and risk stratification.

Jennifer Avery, CCS, CPC-H, CPC, CPC-I

Physicians who think they’ve established a link between diabetes and chronic renal failure, in fact failed at the task simply because they haven’t documented this connection clearly enough to satisfy coding guidelines.

ACDIS has a number of resources for CDI specialists struggling with this issue. Members can find Dr. Gold’s 2009 presentation slides on the Forms & Tools Library along with a number of sample query forms and suggestions.

There’s also a number of related articles available to ACDIS members including:

• Case study: When to query for presence of acute renal failure
• Tip: Put on your clinical hat first, coding shoes second
• Use kidney key-words to sooth your documentation troubles

Also don’t miss Dr. Gold’s upcoming audio presentation Renal Failure Coding and Querying: Understand the Clinical Perspective Friday, October 23, 2009, 1 p.m. (EST) with Jennifer Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist with HCPro, Inc. and lead instructor for Certified Coder Boot Camp®—Inpatient Version.

Talk about documentation catches, simple mistakes cause profound costs

Sometimes documentation mistakes caught by CDI professionals are the simple ones. Like an incorrect date. I recently came upon this news brief from New York Injury News which outlined the trials of HIV patient who lost his coverage due to inaccurate documentation of a blood-test date.

You find vital information in the medical record everyday. Tell us about some of your 'best find' stories.

As compassionate people living day-to-day it’s easy to vilify the insurance company for dropping a sick person from its coverage rosters, or point the finger at the patient for not keeping better tabs on his or her clinical and coverage information. Yet CDI professionals well know the costs of seemingly simple mistakes. This particular case ended up costing the insurance company, Fortis, $10 million for inappropriate denial of healthcare coverage and added untold difficulties to a young man’s life.

Well, I know that CDI specialists catch these seemingly simple mistakes all the time. So here’s a special request to ACDIS Blog readers—wouldn’t it be nice to receive recognition for those otherwise unseen documentation catches you make everyday? Send me your funniest, most heart wrenching, or simply ‘best catch’ documentation stories by the end of October. We’ll run them by our editorial panel and pick the best to publish. E-mail  me at mvarnavas@cdiassociation.com.

Much ado about the flu vaccine

You probably know all the pros and cons of getting the yearly flu vaccination far better than me.  I’ve been inundated with propaganda from both sides of the argument—to get the flu shot or not (yes, I’m struggling to avoid another Shakespeare reference). In fact, just this morning someone sent me a clip from a Fox News video of a physician stating the vaccine for H1N1 is deadlier than the disease. It listed nine reasons not to get vaccinated.

In the interest of self-disclosure I have not (to my knowledge) ever received the flu shot. It is offered here as a benefit of my employment. They even offer them on-site. But I never get one. I’m not

Alien tripod illustration by Alvim Corréa, from the 1906 French edition of H.G. Wells' "War of the Worlds".

sure why. I guess I believe in the wives tales—that the shot makes some people sick. And, besides if H.G. Well’s virus helped humans defeat an alien race, I could withstand a little sniffle in favor of the greater good of planet Earth. (Yes, I am that strong.)

In the fall of 2009, however, we’re not just talking about the annual incarnation of the seasonal flu that receives its share of the—vaccinate, don’t vaccinate—hype. This year receiving an inoculation for the seasonal flu and the potential pandemic of H1N1 “swine flu” seems more important than ever.

Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) urges healthcare facilities to require staff vaccinations for flu.  The group made its recommendation August 31 as predictions from a presidential panel suggested that half of all Americans may be infected with the H1N1 virus during the upcoming flu season.

Just this week Indiana and Tennessee became the first to offer the H1N1 shots. At the end of September the swine flu swept through Austin, TX.

Rates of healthcare provider vaccinations for the simple seasonal shot, however, hover at the 42% mark, a rate that has not budged much in the last decade, according to the APIC. The Centers for Disease Control and Prevention, as well as APIC, recommend that all healthcare workers in direct contact with patients get a flu vaccination to keep patients safe.

My husband, a special education teacher here in Massachusetts, gets his vaccinations every year religiously. My elderly relatives to do too. For some reason I’m still not sold.

Let me know you feel about this season’s various flu threats.  Tell me about any flu-type challenges you see specific to CDI specialists regarding complications, documentation, and/or simple staffing considerations. If you have already had to deal with an H1N1 case, I’d love to hear from you.

Most of all, stay healthy.

To read more about required flu vaccination for healthcare workers, go to HealthLeadersMedia.com. (There’s an interesting Blog post from my friend and co-worker Gienna Shaw that shows how one hospital engaged its staff in a video about the importance of the H1N1 flu shot. It’s really cute. Definitely worth a watch.)

Don’t forget to read the CDC’s “flu facts,” too. They may seem like simple common knowledge but they’re always worth a quick review.

Oh, and I just got this in my e-mail inbox from CMS!

Flu Season is upon us! CMS encourages providers to begin taking advantage of each office visit to encourage your patients with Medicare to get seasonal flu shots. Flu shots are their best defense against combating flu this season. And don’t forget—health care workers also need to protect themselves.

Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient as a part B benefit. No deductible or copayment/coinsurance applies. Note that influenza vaccine is NOT a Part D covered Drug.

For more information about Medicare’s coverage of the seasonal influenza vaccine and its administration, as well as related educational resources for health care professionals, please go to  the CMS Web site. For information on Medicare policies related to H1N1 influenza, please go to www.cms.hhs.gov/H1N1 on the CMS Web site.

OIG gets proactive in 2010 Work Plan

Hospital readmissions, adverse events, and issues related to the American Recovery and Reinvestment Act of 2009 are some of the highlights of the 2010 OIG Work Plan.

“These are relatively new issues so this is pretty proactive on the OIG’s part,” says Steve Miller, JD, chief compliance and privacy officer at Capital Health in Trenton, NJ.

In previous years, many of the OIG’s planned reviews were on topics that have been around for awhile.

“They’re getting a jump on these newer issues right away,” Miller says. This is a good move, he adds, because newer issues tend to present a higher opportunity for errors.

While CDI specialists need not drill down into the nuances of the OIG investigations they do need to be aware of the implications of those governmental efforts on their day-to-day documentation improvement efforts.

For example, the OIG says it’s going to look into coding and documentation changes under the Medicare Severity Diagnosis Related Group (MS-DRG) system, as recommended in a March 2005 MedPAC report. Essentially, the OIG says its going to examine coding trends and patterns to determine whether specific MS-DRGs are vulnerable to potential upcoding.

According to ACDIS’ sister publications’  analysis of the Plan, in 2004, CMS implemented an edit to reject subsequent claims for beneficiaries whom the hospital readmitted on the same day. According to the Medicare Claims Processing Manual, if a same-day readmission occurs for symptoms related to or for evaluation or management of the prior stay’s medical condition, the hospital is entitled to only one DRG group payment and should combine the original and subsequent stays in a single claim. In 2010 the OIG plans to test the effectiveness of this edit and determine the extent of oversight of readmission cases.

“It’s interesting because this is an issue that is getting more attention from CMS this year,” Miller says. In fact, in April, CMS announced a pilot program “Care Transitions” to focus on eliminating unnecessary hospital readmissions.

Sure, some people think the pile of paperwork that constitutes the Plan makes for good bedtime reading (zzzzzzzzzzzzzzzz) a brief examination of its Table of Contents under CMS on page v can give a snap shot of any potential hot topics your facility compliance officer may be thinking about.

Q&A: Coding from NP documentation

Question: If a CDI specialist puts a sticker in the chart and a nurse practitioner (NP) signs it, can the coder code that diagnosis legally?

Answer: ICD-9-CM guidelines allow code assignment from a NPs documentation so it is important that you seek a compliant policy. I would suggest that you seek the NP scope of practice specific to your state. Although most states have similar scopes of practice, they can differ. I would suggest that you meet with your compliance department to create a facility specific policy regarding the NP scope of practice, and seek medical staff approval on the policy.

A sticker in the chart however is larger source of concern. It is not considered a valid part of a medical record and coding staff cannot report from something that is not part of the legal medical record. Additionally, signing your note as a method of agreement is not clinically valid data entry by a provider of medical care.  There is not enough documented proof that the person did anything other than sign (without reading) the note, and that kind of “validation” would not be supportable as a clinical decision.  A physician who signs the progress note of a medical student or nurse is not a substitute for the physician’s entry of the same verbiage in the medical record and will not stand under legal scrutiny. 

(Robin Holmes and Robert Gold of the ACDIS advisory board answered this question)