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 firstname.lastname@example.org. 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.
Editor’s Note: Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group, LLC, in Redington Beach, Florida, presented on the January 11, 2017, installment of ACDIS Radio. The title of the program was “Denials and effective physician communication.” This Q&A was developed from conversations during that session. Should you have any questions regarding the material, please reach out to Brundage at DrBrundage@gmail.com.
Q: Have you encountered denials based on “Late Entry” where CDI query response was received after discharge?
A: This is a technique by the auditor to deny a reasonable diagnosis. The CDI team can query the physician up to the time of the final coding. Getting the query response and therefore clarification of the documentation and/or diagnosis in the official medical record allows the diagnosis to be coded and included in the final coded record. This should be accomplished no later than 30 days post-discharge.
Q: There are many primary care physicians who round in hospitals and flat out say that they don’t care about CDI, they’re not interested, or they refuse to hear education. How do we get through to them?
A: Leverage the influence of your physician advisor and/or chief medical officer to encourage them and share the value of CDI efforts with the rest of the medical staff. This helps both the facility and the physicians with value based care, length of stay (LOS) metrics, cost per case, case mix index, as well as CC/MCC capture and DRG shifts. Improving these aspects, in turn, help the physician in optimizing severity of illness (SOI) and risk of mortality (ROM) metrics. CDI also helps with the various measures included in CMS’ value based purchasing. Physicians who have managed Medicare patients (we all do at this point), benefit from record reviews focused on specificity related to the capture of diagnoses for hierarchical condition categories(HCC) as well.
Q: Can the CDI team do anything to help prevent short-stay denials?
A: Ask the medical director to review the chart of the denied claim to determine if the medical necessity of inpatient admission was met. If the medical director or CDI physician advisor believes medical necessity was met, have him or her reach out to the auditor over the phone for a peer-to-peer conversation before drafting an appeal letter. We get 89% of soft denials approved at the peer-to-peer level, but this number falls off dramatically if you allow these to become full denials that require an appeal letter. Your physician advisor can call and get these overturned with a collegial conversation much easier than a letter can.
Q: Do you have any recommendations on appealing a denied diagnosis due to clinical indicators, but in the discharge summary it states “possible” or “probable” and treatment was the focus of diagnosis?
A: Review for the clinical criteria to support the diagnosis documented in the medical record. Remember the CMS 72-hour payment window allows 72 hours of outpatient data to support your inpatient diagnosis. For example, the emergency department (ED) (an outpatient setting) documentation may support the inpatient diagnosis made at the time of admission. Fight denials of conditions that were present in the ED, but improved at the time of admission. These are valid diagnoses according to the CMS 72-hour payment window.
In addition, review the record to see if the following conditions for a secondary diagnosis were met:
- Clinically evaluated
- Therapeutically treated
- Necessitated a diagnostic test or procedure
- Increased length of stay (LOS)
- Increased nursing care or monitoring
If you’ve ever read one of our Position Papers, White Papers, a Note from the Board in our bi-monthly CDI Journal, or listened to an ACDIS Quarterly Conference call, then you know what a crucial role the ACDIS advisory board plays in the leadership of our association.
That’s why we need you, our ACDIS members, to take a few minutes out of your day for a very important duty: Voting for our next group of board members.
ACDIS advisory board members serve a voluntary, three-year term. Members of the board write articles, answer member questions, review conference materials, set direction for our CDI Practice Guidelines committee, and more.
Read more about our board members and their responsibilities on the ACDIS website by clicking here.
This year, seven finalists have stepped up to run and volunteer their time and energy. They deserve to have our members make an informed choice and cast their votes. Out of the seven nominees, the four with the most votes will be elected by popular vote of the ACDIS membership, for terms effective April 2017 through April 2020.
This vote by our membership is an important responsibility and we hope you take a few minutes to fulfill it.
View our voting page (open to ACDIS members only) here.
How to vote
- First, log onto the website with your username and password. You must be an ACDIS member in good standing. If you have forgotten your username/password, please write or call our customer service team: email@example.com, or 1-800-650-6787.
- Go to our voting page by clicking here.
- Read through the candidates’ bios/qualifications and reasons they are running, and then write down your top four votes.
- Click the yellow “vote” button.
- Our voting tool requires you to rank the candidates. Your top choice should be ranked number one, your second choice number two, etc. on down through number seven. If you’d like, you can just rank your top four candidates.
- Click the gray “vote” button. It will ask you to you review your choices.
- Once you are satisfied, click “confirm” and you are done. Our website only allows you to vote once.
You have two weeks to cast your ballot; voting opens today, Thursday, March 16, and closes end of day Friday, March 31.
Thank you for your attention to this important matter!
Yes, the ACDIS 2017 Conference is sure to keep you busy, provide valuable education, and great networking opportunities, but make sure you leave some time to enjoy the Las Vegas area.
When you first think of a week in Las Vegas, you likely think of slot machines, shows, and parties. But, a number of alternative activities in the area are real crowd pleasers, too. Below is a list of some excellent museums and indoor attractions in the Vegas area.
Make sure to check back on the blog next week for some outdoor activities, as well
- Neon Museum: The Neon Museum is dedicated to collecting, preserving, studying, and exhibiting iconic Las Vegas signs for educational, historic, arts and cultural enrichment. The Neon Museum campus includes the outdoor exhibition space known as the Neon Boneyard. Learn more at neonmuseum.org.
- The Mob Museum: The Mob Museum presents a bold and authentic view of organized crime’s effect on Las Vegas history, as well as its unique imprint on America. It presents real stories and actual events of mob history via interactive and engaging exhibits that reveal all sides of the story about the role of organized crime in the U.S. Learn more at themobmuseum.org.
- The Linq and the High Roller: The Linq is a hotel and outdoor shopping district featuring a curated array of unique shops, restaurants, bars, and entertainment experiences, anchored by the High Roller, the world’s tallest observation Ferris wheel. Learn more at https://www.caesars.com/linq.
- The National Atomic Testing Museum: The National Atomic Testing Museum is a science, history, and educational museum focused on the story of America’s nuclear weapons testing program at the Nevada Test site. Located only 1.7 miles from the strip, it’s a quick trip to this history focused museum. Learn more at http://nationalatomictestingmuseum.org/.
- Madame Tussauds: No list of Vegas activities would be complete without a reference to Madame Tussauds. It is one of the most famous wax museums in the country for good reason. It’s located less than a mile from the strip and there is a public transport bus that will take you straight there if you want. Learn more at https://www.madametussauds.com/las-vegas/en/.
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 Cheryl M. Manchenton, RN, BSN, CCDS, senior inpatient consultant/project manager with 3M Health Information Systems, overseeing CDI programs, who will present “Anatomy of an Operative Note: A CSI Analysis of Operative Notes Gone Bad.” Manchenton specializes in workflow design, program management, quality metrics, and performance. She is responsible for the 3M quality services and quality services training materials and hosts the 3M CDI Management Roundtable. Manchenton is a guest for ACDIS Radio on the March 22 at 11:30 a.m. EST. She will be providing a brief preview of her conference presentation that you won’t want to miss! To register for ACDIS Radio, click here.
Q: What’s the biggest challenge you encountered in your experience with surgical CDI programs?
A: The biggest challenge is lack of timely operative notes or detailed daily progress notes. In other words, minimal documentation by surgeons including a comprehensive list of chronic conditions.
Q: What are three things attendees can expect from your session?
A: Our session will be at minimum entertaining. Attendees can expect us to share very common pitfalls with operative note templates, strategies for collaborating to improve and results of effective collaboration.
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: Instead of complaining about who’s fault something is with poor documentation, coding or quality metrics, I hope our session will show attendees some creative ways to actually improve.
Q: What are you most looking forward to about this year’s conference?
Q: Fun question: What is your favorite animal and why?
A: I love otters. They work hard but play hard too. They know how to make work fun.
By Jackie Birmingham, RN, BSN, MS, CMAC
Editor’s note: For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition, by Jackie Birmingham, RN, BSN, MS, CMAC. This excerpt originally appeared in Revenue Cycle Advisor, here.
Whether writing a note, completing a flow sheet, or entering information in an electronic record, a discharge planner is capturing data: facts related to actions, reactions, and decisions. For the purposes of this example, a discharge planner is writing the story about the planning that occurs to prepare for a patient’s transition to the next level of care.
Information entered into the medical record describes the final discharge plan for the patient. Organizations implement documentation policies to guide discharge planners regarding what the medical record must include.
The Conditions of Participation (CoPs) require documentation of the assessment or evaluation of a patient’s discharge planning needs. CDI specialists can use the following CoPs (c) Standard (c) to ensure the minimum evaluation topics are documented including
- “Admitting diagnosis or reason for registration;
- Relevant comorbidities and past medical and surgical history;
- Anticipated ongoing care needs post-discharge;
- Readmission risk;
- Relevant psychosocial history;
- Communication needs, including language barriers, diminished eyesight and hearing, and self-reported literacy of the patient, patient’s representative or caregiver/support person(s), as applicable;
- Patient’s access to non-health care services and community-based care providers; and
- Patient’s goals and treatment preferences”
The list above reflects the minimum standards. Discharge planners should use this list as a tool to audit a sample of patient charts to determine whether their hospital meets these minimum requirements. After completing an audit, compare the findings to the facility’s documentation policy to determine whether it addresses all necessary elements. Use this activity as an opportunity to identify potential quality improvement initiatives. Although this list aims to aid in assisting in patient discharge needs, CDI specialists can look to these notes to identify additional documentation improvement opportunities or for evidence supporting the need for a physician query. Additionally, CDI specialists should be aware of the wide variety of documentation required throughout the patient’s care, what each documentation requirement’s purpose may be, and the parties responsible for ensuring the accuracy of those documents.