Although many CDI program directors wish for national standards for calculating CDI productivity (e.g., a set number of new reviews and re-reviews per CDI specialist per day), “frequent regulatory changes and broad diversity within the industry prohibit a one-size-fits-all approach,” the ACDIS Advisory Board wrote in a White Paper released in December.
While that fact may be indisputable—new CDI staff simply cannot be expected to be as productive as those with multiple years’ experience and programs with expanded record review scopes cannot be expected to turn over as many records as those simply looking for a lone CC/MCC—CDI programs can take advantage of polling research conducted by ACDIS over the years to help establish baseline metrics and program goals.
For example, a 2014 ACDIS website poll indicated that productivity expectations ran the gamut:
- 32% review 1–10 records per day
- 25% review 11–15 records per day
- 18% review 16–20 records per day
- 13% review 21–25 records per day
- 6% review 26–30 records per day
- 6% review more than 30 records per day
The productivity survey conducted in association with December’s White Paper release found 85% of respondents review 6–15 new patient reviews—only 7% reviewed less and only 5% reviewed 16 new records or more per day.
Ultimately, judging from the data, the Advisory Board suggested that “16–24 total reviews per day (new reviews and re-reviews) is an average range for a CDI specialist, with 20 daily reviews being an acceptable goal to account for variability in review focus,” as noted later in the survey.
The latest survey out from ACDIS probes at a number of additional questions related to CDI physician query practices, including:
- Do you query for clinical validation, i.e., to confirm presence of a documented diagnosis lacking clinical support? To date, 85% of the more than 200 respondents do.
- Does your facility have standard query policies and procedures? More than 75% do.
- Does your facility have an electronic query system either as part of your EHR or another software system? Only 17% don’t.
The survey which will remain open through March 1, also asks important questions about query auditing and monitoring, resources used to craft query policies, and about respondents’ perceptions regarding the effectiveness of electronic systems.
As I often say, ACDIS thrives on membership participation and we need yours to ensure the data revealed in this 2017 physician query assessment represents the true benchmarks of our industry. Won’t you take a few minutes to share your thoughts?
Click here to take the survey. And thanks!
by Sherri Clark, BSN, RN-BC, CCDS, CCS, Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, and core member of the Tennessee chapter of ACDIS
The joint meeting of the Tennessee Chapter of ACDIS (Association of Clinical Documentation Improvement Specialist), THIMA (Tennessee Health Information Management Association), and THA (Tennessee Hospital Association) occurred on January 27. The meeting took place at the THA headquarters in Brentwood. The subject of the meeting was “The Impact of ICD-10 and Payment Reform on Clinical Documentation Improvement.” Four members of the core team of TN ACDIS chapter leaders (Sherri Clark, Kristie Perry, Cynthia Raymond, and James Kennedy, MD) and one chapter member (Kyra Brown) served on the planning committee for this joint meeting. Attendees were offered a number of hour-long presentations to choose from during the meeting, including:
- Managing Conflicting Guidelines in ICD-10–CM/PCS
- CDI, Coding, and Quality – The Three Legged Stool
- Payment Reform in TN – Health Care Innovative Initiatives
- Recovery Auditor Prevention Strategies: How to keep the predators away
- MACRA, MIPS, APMS: Why CDI is a critical ingredient of the alphabet soup?
- ICD-10-PCS and the Impact on CDI
- The Case for Category II Codes
- Hospital Improvement Network and other statewide databases: How are they used and the importance of quality data
- The Impact of HCCs on Physician Accountability
The meeting drew physicians, coders, CDI specialists, and executives from THA. The presenters for the meeting included members of ACDIS, AHIMA, THIMA, and the THA. ACDIS Director Brian Murphy attended the meeting, as did all of the TN ACDIS Chapter leaders—Sherri Clark, Kristie Perry, Cynthia Raymond, Judy Rochelle, and James Kennedy. The joint meeting qualified for six continuing education units for ACDIS and AHIMA.
Editor’s note: Clark is a Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, Tennessee. She has been an ACDIS member since the spring of 2008 (she even attended the first ACDIS conference that year!) and a chapter leader since 2011 when the chapter was formed. For information regarding upcoming local chapter events, visit the website or email Clark at SClark@mc.utmck.edu.
Editor’s Note: Over the coming weeks, we’ll introduce a few of this year’s speakers who are heading to the podium for the ACDIS 10th Annual Conference which takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager, HIM Consulting Services for United Audit Systems, Inc., who presents “Clinical Documentation Improvement – From Inpatient to Outpatient: Defining the different documentation, coding, and reimbursement requirements.” She has more than 25 years of experience in HIM serving as the senior director of HIM practice excellence, coding and reimbursement for AHIMA from 2008 to 2014.
Q: What made your company want to expand into the outpatient setting?
A: We noticed that it was the next natural progression in the CDI world. With hierarchical condition categories (HCCs), Medicare Access and CHIP Reauthorization Act (MACRA), risk adjustment, etc., it’s really a prime time for CDI. Where to start is the hard part. With inpatient documentation reviews, CDI professionals have a captive audience, so to speak. With outpatient, CDI programs need to look at all the different departments where physician documentation plays a role. On top of that, there’s the physician clinics. It’s very complex on how you move the well-oiled machine of inpatient CDI into the outpatient world – everything gets really muddied.
Q: What are three things attendees can expect from your session?
A: At the end of my session, attendees will be able to:
- Start to delineate what outpatient CDI looks like in the post-acute care setting. It’s not as simple as duplicating your inpatient CDI program
- How inpatient and outpatient CDI roles differ; and
- Some tools to build the framework for outpatient CDI. Your CDI framework could look very different and you need to do active discovery. CDI looks different in every setting based on where their needs are.
Q: Who should attend your presentation and why?
A: CDI specialists and anyone who’s involved with coding and CDI – CDI managers, finance side, directors, HIM directors, coding managers, coders, and even physicians! Essentially, it would be good for everybody. Anybody trying to figure out what outpatient CDI looks like should definitely attend. It’s like the transition to ICD-10 in that we need to think about how we eat the elephant one bite at a time. Outpatient CDI is a whole new elephant.
Q: What’s one tool no CDI professional should be without?
A: A CDI specialist should always have their communication skills. A CDI specialist is in a unique position because they live in the middle. They need to have a relationship with providers and then they also need that communication with coders.
Q: What are you most looking forward to about this year’s conference?
A: Networking! Last year, was the first year I was there as a vendor. It’s so fun to meet our clients. It’s great to put a face to a name!
Q: Fun question: what’s your favorite movie?
A: I’m kind of a sap, so I love PS. I Love you. I also really love Brian’s Song.
by Erica E. Remer, MD, FACEP, CCDS
Auditors target multiple conditions which for clinical validation denials (CVD). Personally, I found acute kidney injury (AKI) and malnutrition the most commonly defensible targets. On the other hand, I often agreed with auditors on their CVDs for pneumonia and urinary tract infections. Other frequent CVDs included sepsis, encephalopathy, and respiratory failure.
Certain diagnoses are susceptible to CVDs for the following reasons:
- DRG downgrade: Auditors target medical records with only one CC/MCC because doing so downgrades the DRG and results in less reimbursement.
- Empiric treatment: Providers start antibiotic therapy early for patients who present with signs of infection (e.g., fever, leukocytosis, altered mental status) on as they seek the infection’s source. Sometimes the physician cannot identify the source or the etiology of the disease turns out to be a different than originally expected. Clinicians also need to be careful to not propagate the original debunked diagnosis via copy and paste, so it gets wrongly coded.
- Documentation consistency: Physicians should document their medical decision making process throughout the patient’s stay. Best practice is to document when a diagnosis is initially considered (may be in uncertain format), when the diagnosis is definitively ruled in, and when the condition resolves. The physician should recap this information in the discharge summary. Only mentioning a diagnosis once in the medical record, while permissible, raises an auditor’s interest and begs the question of whether the condition really was present.
- Pursuant to a query: When providers need to be queried to make a diagnosis codable, and they agree without supplying any clinical support, a red flag goes up—and I mean like waving one in front of an auditor like a bull, and not just signaling peril up ahead.
Finally, auditors target diagnoses with uncertain or emerging clinical guidelines. Clinical guidelines change, but it takes time for medical practice to adjust (e.g., malnutrition, sepsis). If a guideline is not universally adopted (for example, discussions regarding the new Sepsis-3 definitions) some variability in medical practice is allowed. That doesn’t necessarily mean a provider is wrong if he or she does not follow the latest guideline. As long as the provider is within the acceptable range of practice, he or she just needs to demonstrate the clinical considerations of the case and the auditor should accept the diagnosis. If a provider deviates from clinical criteria or guidelines, he or she should document the mitigating circumstances (e.g., on beta-blockers, previous antibiotic therapy, contamination).
On the other hand, the provider needs to consider established guidelines. If the average, prudent similarly qualified practitioner wouldn’t call an asymptomatic deviation of sodium by 1 mEq/L, hyponatremia, neither should you.
Similarly, AKI has criteria of change within the previous 48 hours, or deviation from a baseline from seven days ago, but a provider could make a convincing argument that the patient’s serum creatinine (SCr) is always X and the acute derangement is likely to have occurred since the onset of symptoms 36 hours ago. It would be quite serendipitous to randomly have a baseline drawn within seven days of an index visit if AKI preceded hospitalization, wouldn’t it? However, if the SCr is only off by 0.1 mg/dL, you are hard-pressed to spin that as AKI.
While the coder may not really the arbiter of clinical validation, coders should be empowered to refer questionable records for a clinical review either by the CDI specialist, the attending, or a physician advisor/champion, and coders need to know which conditions are vulnerable and which clinical indicators to consider.
Absence of abnormal clinical indicators does not mean the condition is definitively not present; it means the encounter needs clinical review and the condition may require more documentation to support it.
Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at email@example.com. For the third part of this article, return to the blog next week!
By Darice M. Grzybowski, MA, RHIA, FAHIMA
For those still trying to straighten out their budgets and priorities for 2017, I thought it might be helpful to reflect on a few larger industry trends that may significantly change the the focus of our efforts related to health information management (HIM) and clinical documentation improvement (CDI).
Government and legislation: To say the 2016 presidential election may bring change is obviously an understatement. There will undoubtedly be significant movement in healthcare policy, but for now there is still significant work and in some cases, confusion, surrounding the ongoing implementation of accountable care organizations (ACOs), the Affordable Care Act (ACA), ICD-10-CM/PCS, Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payment System (MIPS), phase two of the Health Insurance Portability and Accountability Act (HIPAA) audit program, and other legislative initiatives.
New technologies and opportunities: Sometimes, the more things change, the more they stay the same. At other times, the speed of change in technology can be dizzying. Does everyone have a coding, EHR, CDI, and revenue cycle solution? How do these solutions enhance the integrity and efficiency of the EHR, CDI, and coding processes? We must work collaboratively with our vendors as our partners but never confuse our professional standards, use good judgment and ethics to strike a balance to select solutions that enhance our performance.
Personal and professional development: It is hard to predict if we’re ready for the changes that may come in a single year, let alone whether we’re ready to meet the opportunities and challenges that may come in the next 10 years or beyond. Advancing digital and mobile technologies, the growing role of artificial intelligence and natural language processing, telemedicine, and the long-term possibility of ICD-11 will shape the future of CDI and HIM in ways that are difficult to predict. Ongoing changes accentuate the need for advanced skills in clinical, coding, and documentation integrity not just to add multiple initials for various certifications onto one’s business card. We must recognize that we need continuous lifetime learning and specialized education to support new roles.
The start of a new calendar is a perfect time to draw your own personal road map and reevaluate what path that you choose to go down. And if you don’t like it, take a turn and readjust—you have the power to do that. Let’s look forward to a year of new possibilities, new leadership in our country, new technologies, and new personal and professional growth. Change can be good, but only if it’s done with the right goals in mind.
Editor’s note: This article was adapted from the original published in HIM Briefings. Grzybowski is the president of HIMentors, LLC, which specializes in HIM operations, education, best practices, EHR/EDMS implementation, CAC, and CDI coding consultation. For information, visit www.HIMentors.com or email info@HIMentors.com. Opinions expressed are those of the author and do not represent HCPro or ACDIS.
by Laurie L. Prescott, MSN, RN, CCDS, CDIP
I spend much of my time communicating with CDI managers and directors. They work tirelessly to develop and nurture CDI departments, focusing much of their time on training new CDI staff and evaluating the experienced CDI professionals in their care in order to identify areas of education need. Often CDI directors fight for funding to buy the newest software with the latest and greatest bells and whistles. I remember how excited I was to use the new encoder when I was a young CDI specialist. Now there’s computer assisted coding software, software that prioritizes and develops work lists, tracking software, query opportunity software, etc., etc.
This all sounds great, but I think such technology may also be a hindrance when training new staff.
Experienced CDI specialists often complain about the lack of critical thinking skills within the ranks of those new to the industry. I often hear that it is difficult to teach a new CDI staff person because “no one uses the books anymore.” I hear that new CDI staff simply follow the query leads fed to them from the software programs and that they are not thinking for themselves. Managers also complain that many of the more experienced staff seem to be “coasting in their retirement job,” don’t wish to engage with the medical staff or challenge the status quo, and have become overly dependent on the EHR and the software to direct their day-to-day activities.
Please don’t get me wrong, I love the technology we have at our fingertips, but we also must understand that we, the CDI specialists, should be directing the software and not the other way around. This technology is meant to be a tool that assists the living, breathing, thinking CDI specialists. We need to use the skills our experience and intellect bring to the table whether those abilities be regulatory or coding knowledge, clinical expertise, communication skills, or, more importantly, a collection of these talents.
We speak about software in our CDI Boot Camps all the time. In these discussions, I encourage new CDI staff to pick up a code book, and a DRG Expert, and work the chart the old-fashioned way. Many groan when I mention such prehistoric methods to practice CDI, but there is a method to my madness. To effectively work as a CDI and to use the technology to its utmost value, we need to understand the inner workings and decisions the software program was designed to make. We need to know when the software misses something or inappropriately identifies a diagnosis that does not exist.
Critical thinking is defined as an active process of applying, analyzing, synthesizing, and evaluating information. The Critical Thinking Community (http://www.criticalthinking.org/pages/defining-critical-thinking/766) describes it as “ entailing the examination of those structures or elements of thought implicit in all reasoning; purpose, problem, or question-at-issue; assumptions; concepts’ empirical grounding; reasoning leading to conclusions; implications and consequences; objections from alternative viewpoints; and frame of reference.”
My simplified definition is that critical thinking is “thinking about your thinking,” questioning all conclusions and working to ensure you interpret all the facts and evidence correctly.
Critical thinking has been a buzz word for years, especially in healthcare. Many go through the motions of the day, not taking the extra energy to actually think through the record and identify those opportunities requiring intervention. CDI professionals need to attack each day’s tasks with an active focus. We cannot simply depend on a computer program to do the job for us. If all it took was a computer program, no thinking, no experience no effort—we would not be such a hot commodity in the world.
Editor’s note: Prescott is the CDI education director for ACDIS. She serves as a full-time instructor for its various Boot Camps as well as a subject matter expert for the association. Prescott is a frequent speaker on HCPro/ACDIS webinars and is the author of The Clinical Documentation Improvement Specialist’s Complete Training Guide and co-author on the forthcoming volume regarding the role of CDI staff in quality of care measures. Contact her at firstname.lastname@example.org. This article originally appeared in CDI Strategies.
by Erica E. Remer, MD, FACEP, CCDS
Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes, retrospectively, that a patient was not really afflicted by a condition documented in the medical record and coded by the coder.
If a coder assigns a code for a condition not really present, and removing that code assignment results in a lower-weighted DRG, then it is reasonable for a payer to expect the overpayment back.
However, if the condition was indeed present, medical personnel invested time, energy, supplies, and other resources, the hospital is entitled to reimbursement. Therefore, it is not appropriate to remove a diagnosis which was genuinely present. It is also unfair to remove legitimate diagnoses, because this results in the downgrade of severity of illness and complexity of management, and falsely deflates the quality measures assigned for that patient’s care.
It has never been reasonable or compliant for a coder to infer medical conditions from clinical indicators, and it is not reasonable to expect a coder to decide that a condition doesn’t exist if the provider documented it.
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.
Although the provider’s statement may be sufficient to code a particular condition, it does not mean the condition indisputably exists.
The adage is, “if you didn’t document it, you didn’t do it.” But we all know that is not true. No physician documents every thought or action, and it would be absurd to expect them to do so. The dilemma arises when a physician documents a condition without giving adequate evidence as to what led him or her to make the diagnosis.
Concurrently, a documented diagnosis which is not really present could lead other healthcare providers down an erroneous path. Conversely, not providing clinical support for a valid diagnosis sets the stage for future denials.
The legal definition of the standard of care is managing a patient at the level at which the average, prudent, similarly qualified practitioner in a given geographic medical community, would be providing medical care under the same or similar circumstances. There are clinical guidelines and scores which may assist a clinician in making diagnoses, but prudent practitioners also bring their past experience, knowledge, and judgment into play.
Medicine is an art, not a science, and not every patient “reads the textbook.” Many patients’ lives have been saved by a clinician who followed his or her gut. Just because a patient doesn’t strictly meet clinical criteria, doesn’t preclude him or her from having the medical condition that an astute provider diagnosed.
Is there a standard of documentation similar to that legal definition of a standard of care? The purpose of patient record documentation is to foster quality and ensure continuity of care. It is clinical communication. The fallacy is that documentation needs to be expansive and long; it just needs to convey to the subsequent healthcare provider (as well as the coder, utilization/case manager, auditor, lawyer, etc.) what the provider was thinking and why.
What coders can do
Sensible, qualified, and experienced coders or CDI specialists may read documentation and have concerns that a diagnosis is not supported by the clinical indicators.
Do they just unfailingly code a documented condition because the Official Guidelines for Coding and Reporting say that the provider’s statement is sufficient, or do they query the physician? Which conditions are prone to this? What clinical indicators should they be considering? How does one broach this subject with the physician?
The ACDIS/AHIMA’s Guidelines for Achieving a Compliant Query Practice recommend generating a query when the health record documentation “provides a diagnosis without underlying clinical validation.” It notes that “the focus of external audits has expanded in recent years to include clinical validation review,” and instructs coders to follow CMS and Coding Clinic guidelines, and to “query the physician when clinical validation is required.”
The CMS Statement of Work for the Medicare Fee-For-Service Recovery Audit Program 2013 notes that “clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”
I concur that a certified coder who has identified a diagnosis which needs more clinical support does not have the ability to validate it, but has the skills to recognize the necessity for validation.
If your institution has CDI specialists, then you have someone with the appropriate credentials in place to generate a query. The physician is the one who performs the validation by responding to the query in the affirmative, and by providing their clinical evidence for the diagnosis in question.
Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at email@example.com. For the second part of this article, return to the blog next week!
Editor’s Note: This note originally appeared in the February 9, 2017, edition of CDI Strategies. Click here to see the original article.
Three months from now the ACDIS team will head to our biggest event of the year—our national conference. And in case you haven’t heard it’s a milestone…our 10th. A big number and once again we are bringing the networking, the learning, and the fun.
It’s hard for me to focus in on even as few as four or five sessions that I’m most excited about, but instead of reprinting the entire agenda I thought I’d focus in on my personal top 10 speakers at the 2017 ACDIS conference. Cue the drum roll…
- “AHA Coding Clinic update,” with Nelly Leon Chisen, RHIA: Get the latest updates critical to CDI directly from the source: Chisen is the Director of Coding and Classification for the American Hospital Association, publisher of Coding Clinic. You don’t get much more authoritative than this.
- “Denials and CDI: A Recovery Auditor’s Perspective,” with Barbara Brant, MPA, RN, CDIP, CCDS, CCS and Timothy J. Garrett, MD, MBA, FACEP, FACHE, CHCQM, CIC. Hear straight talk from an actual auditor and what they see in the industry from a denials perspective: Brant and Garrett are from Cotiviti Healthcare. I give these guys credit for coming out to inform and take a little heat!
- “Sepsis: 1, 2, 3—RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines,” with William Haik, MD, CDIP. This session by the dynamic Dr. Haik includes the evolving definitions of sepsis and acute respiratory failure, including calculation of P/F ratio. Even more important now that Sepsis-3 will be the new criteria for the Surviving Sepsis Campaign.
- “ACDIS Advisory Board panel: Past, Present and Future of CDI.” This session with representatives of the ACDIS Advisory Board offers an insider’s look at the CDI profession, including where it presently stands and how it must evolve. OK, a bit of nepotism here as I’ll be on panel :). But seriously, we’re up to a lot!
- “The Post-Acute Care Setting: Integrating CDI into Multiple Outpatient Settings,” with Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA and Beth Wolf, MD, CCDS, CPC. This session examines specific outpatient settings such as home health, hospice, outpatient infusion centers, and clinics with employed providers, each with inter-related requirements for documentation, coding, and billing. They have some great ideas on how to expand your CDI department beyond the acute-care hospital setting.
- “A breakdown of the AHIMA clinical validation brief,” with Tammy Combs, RN, MSN, CDIP, CCS, CDIP and Melanie Endicott, MBA/HCM, RHIA, CHDA, CDIP, CCS, CCS-P. Clinical validation can be a challenging task for both CDI and coding professionals, and representatives who contributed to the 2016 AHIMA practice brief “Clinical Validation: The Next Level of CDI,” will no doubt add some clarity for CDI professionals on this topic. I’m honored to have official AHIMA representation on our podium!
- “Clinical Validation and Denials Management/Appeals: An ALJ’s Perspective,” with Alicia Kutzer, BS, Esq. LLM. Hear from an Administrative Law Judge (ALJ) and former QIC employee who was integral in developing training materials and presentations for proper adjudication of Medicare appeals and defended claim denials at the reconsideration and ALJ levels of appeals. I expect an interesting look “inside the courtroom” if you will.
- “Measuring Clinician Engagement Utilizing a Validated and Reliable Survey Instrument Developed by a Professional Doctorate Candidate,” with Nicole Draper, RN, BN, MHA. Attendees will be inspired to develop or adopt the validated and reliable survey instrument presented during this presentation to assess clinician engagement in their CDI program. Data and results will be shared from this speaker flying in from Australia to present!
- “Getting to the Heart of Accurately Defining Cardiac Ischemic Syndromes,” with Garry Huff, MD, CCS, CCDS and Christopher M. Huff, MD. This session is presented by two physicians including a board-certified cardiologist who completed a fellowship in advanced interventional cardiology at The Cleveland Clinic. Getting real clinical while having some fun!
- (TIE!) Our Two Inspirational Keynotes—“Healthcare, Remixed,” with Zubin Damania, MD (aka., ZDoggMD) and “Josie’s Story: Family-Centered Approaches to Patient Safety,” with Sorrel King. Sorrel King is pure inspiration and has a tragic, real-life story to motivate you to make a change in your own life. Her message on patient safety will resonate with any CDI specialist who reviews Patient Safety Indicators or refers an issue to quality. As for ZDogg… the man is a legend and there is no one more “Vegas” than him. Get ready for Healthcare… Remixed.
Sure, this list is subjective but I know you won’t be disappointed with any of them. Keep in mind my list of favorites just scratches the surface! We have more than 50 sessions to pick from.
As for the location…I’m a big Vegas fan and I’ve been very impressed with the MGM Grand. It’s big (the largest single hotel in the United States with 6,852 rooms) it’s new (built in 1993, constantly refurbished, as recently as 2012) with outdoor pools, rivers, waterfalls, and home to a number of entertainment venues, nightly shows, and world-class restaurants. And it’s located right on the strip.
Yes, there is a walk to the conference space—that’s inevitable with spaces this big and conferences this size—but I can tell you that the walk is MUCH shorter than you may have experienced in 2016 in Atlanta. I hope you enjoy the warm weather and the unforgettable sights and sounds of one of the most memorable places on earth.
So please come on out to this big 10th anniversary celebration of our association, and:
- Be inspired
- Have fun
Just make sure to sign up prior to March 7, 2017 to take advantage of our early bird ($100 off) and ACDIS membership (additional $100 off) discounts.
The team and I hope to see you on the strip!
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. For today’s Q&A, we caught up with Cheryl Ericson, MS, RN, CCDS, CDIP, the manager of clinical documentation services with DHG Healthcare, who will present “Leveraging CDI to Improve Performance under Alternative Payment Model Methodology.” Ericson is recognized as a CDI subject matter expert for her body of work which includes many speaking engagements and publications for a variety of industry associations. She currently serves on the advisory board for ACDIS and its credentialing committee (CCDS).
Q: Could you tell me a bit about what makes Alternative Payment Models (APM) different for CDI?
A: Participation in voluntary APMs is very complex and requires a high level of commitment from the healthcare organization. More than 800 hospitals, however, are required to participate in the Comprehensive Care for Joint Replacement Model (CJR) and an additional 1,100 or more hospitals will be required to participate in the episode payment for AMI and coronary artery bypass grafts (CABG). Because participation is based on randomly selected Metropolitan Statistical Areas (MSAs) many hospitals may be unprepared for the impact. These models are retrospective so the hospital is paid as usual under the applicable MS-DRG, but following the completion of the performance year the hospital may be required to return some of their payment to Medicare or they may receive an additional payment. This type of model, like many of the outcome measures included in the mandatory value-based methodologies, require CDI specialists to look beyond the current episode of care. The mandatory quality programs, however, only use a 30-day timeframe. In comparison, an episode of care in the APMs extends 90 days beyond hospital discharge or the date of surgery.
Q: What are three things attendees can expect from your session?
A: Attendees can expect to learn:
- The difference between the mandatory value-based programs such as HVBP, HRRP, HACRP, and mandatory APMs
- A better understanding of the mandatory bundled/episode based payment methodologies
- Strategies to incorporate into the CDI process to accurately reflect organizational performance under the mandatory bundled/episode payment methodology
Q: What is one tool CDI professionals cannot live without?
A: A grouper that supports risk-adjustment efforts.
Q: In what ways does your session challenge CDI professionals to think outside the box?
A: As the fee-for-service population decreases, which was reliant on CC and MCC capture, CDI specialists need to understand and modify their efforts to reflect modern CMS reimbursement strategies to support organizational financial health.
Q: What are you most looking forward to about this year’s conference?
A: Like most, I enjoy reconnecting with friends. I have the added bonus of reconnecting with former ACDIS Boot Camp participants. It’s great to learn how people have advanced in their career as the CDI profession continues to grow!
Q: Fun question: What is your favorite candy?
A: Dove Promises dark chocolate with almonds. Yum!
By Laura Legg, RHIT, CCS, CDIP
CMS recently announced the award of a new round of contracts for the Medicare fee-for-service Recovery Auditors (RA). As the new round of RAs roll out, even the most experienced RA response team will need to understand the new challenges we face with CMS’ 2017 changes. Make every effort to ensure your teams are centralized, efficient and organized with excellent communication skills. Also, it is very important to educate your RA response team on changes to the RA rules. Following are a few tips to help you stay on top of the changes.
Compose complete medical records: Your facility should include all required documentation necessary to support each case. If a physician orders a test, make sure the order, results, and interpretation are all included with the medical record and are legible and easily found. Also make sure the discharge summary is as complete as possible. The discharge summary should accurately reflect all confirmed diagnoses and all care administered during the patient’s hospital stay without introducing new information.
Avoid EHR cloning: Cloning, or copy and paste, is being seriously addressed by CMS. RAs may be looking at progress notes for confusion among caregivers due to copy and paste overuse.
Focus on challenging inpatient diagnoses: What diagnoses and procedures challenge coders the most? Some tricky diagnoses are, but are not limited to, sepsis, respiratory failure, renal failure, congestive heart failure, pneumonia, spinal surgeries, and skin procedures. Make sure the medical record documentation support these diagnoses and that coders can easily identify the correct code assignment for them.
Follow RA websites: CMS requires RAs to keep an updated provider portal which includes a list of issues under review. This resource shows the issue name, type of review, provider type, status impacted, date posted and a detailed description of the issue. It is a good idea to build your internal audit plan around this list and the Office of Inspector General’s (OIG) work plan. CMS will require RAs to broaden their review topics and they must include all provider claim types and may include required reviews based on referrals from the OIG report.
Audit: Be sure that all diagnoses are coded to the highest level of specificity. Ensure that all medical documentation entries are consistent. Be sure internal auditors look at the same data elements reviewed by the RA including principal diagnosis, secondary diagnosis, procedures affecting or potentially affecting diagnosis-related groups, present on admission indicators, and discharge disposition codes.
Reduce denial rates—Under the new rules, additional documentation request (ADR) rates will be affected by your denial rate. More denials will result in more requests and denials still mean a lot of work on the provider end and a drawn-out appeals process. You can improve response rate and efficiency simply by following RA timelines and responding to record request appropriately. Takebacks due to lack of response to ADRs are more common that you think.
Editor’s Note: Legg is the director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. This article was adapted from the original published in JustCoding.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS.