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Weekend Reading: Essential query requirements

Essential CDI Guide to Provider Queries

Essential CDI Guide to Provider Queries

Taking into consideration the various requirements governing the capture of healthcare data, CDI programs can easily itemize the basic elements needed for compliant queries.

Query forms should be vetted and approved by the organization and should be tracked or documented in some manner. They should not be written on sticky notes or other slips of paper that may run the risk of being discarded or discounted.

The growing adoption of electronic medical records and CDI software has made it easier for CDI professionals to ensure all necessary query elements are present. Nonetheless, CDI staff must understand what these elements are. Because it must meet the basic tenets of information exchange, the query form should include the following:

  • Patient name or identification number
  • Admission date and/or date of service
  • Health record or account number
  • Date the query was initiated
  • Date the query was closed
  • Name and contact information of the individual initiating the query
  • Name and contact information of the physician responding to the query
  • Statement of the issue in the form of a question, along with clinical indicators specified from the chart

In addition to ensuring compliance, these elements allow CDI staff to track and monitor the number of queries being initiated, who is initiating them, the number of queries being answered, and who answered them.

Tracking provides data that can be used to show program value and physician involvement. Conversely, the data can be used to swiftly recognize any problematic trends with a CDI specialist or provider, which is critical for process improvement and remediation efforts.

Editor’s note: This excerpt was taken from the Essential CDI Guide to Provider Queries, written by Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS.

Career Center: This week’s new job postings

career-centerThe new ACDIS Career Center allows you to upload your resume anonymously, browse open positions and sign up for alerts about new jobs specific to your criteria. If you’re looking to hire, we have job posting options (discounted for ACDIS members) as well as the ability to browse our resume database. Click here to learn more.

Here are the latest job postings:

Product Spotlight: With CDI growing to encompass both inpatient and outpatient procedures, don’t get overwhelmed

mcf_2016_265x265The mission of a CDI department may be financial- or quality-based, and the scope of CDI continues to expand as hospitals identify documentation gaps that affect their processes. But while goals may change, one matter is certain: the mission of CDI must be clearly defined for a department to reach its goal.

At the 2016 Revenue Integrity Symposium, expert speaker Laurie L. Prescott, MSN, RN, CCDS, CDIP, will discuss how to define a departmental mission and how to avoid diluting CDI’s impact by trying to do it all during her session While You Are in the Record …: How to Prioritize the Many Hats of CDI.

But that is not the only topic being discussed at this year’s conference. 2016 Revenue Integrity Symposium brings together training on Medicare billing and compliance, case management, revenue integrity, coding, CDI, and patient status, helping attendees ensure compliance and accurate billing and reimbursement across the revenue cycle. Covering all areas of revenue cycle professionals’ expanding roles, the 2016 conference has something for everyone.

Speakers will cover topics such as the 2-midnight rule, IPPS and OPPS updates, chargemaster maintenance, denials management, payer audits, ICD-10 code updates for 2017, clinical documentation improvement, value-based purchasing, and utilization review.

The full agenda is now available to download. Register today to take advantage of early bird pricing.

Q&A: CKD relationship

Ask your CDI question in the comment section.

Ask your CDI question in the comment section.

Q: The coders at my facility have stated auto linking congestive heart failure (CHF), hypertension (HTN), and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” HTN. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record. I referenced the Coding Clinic, Fourth Quarter 2008, which states that unless a causal relationship exists between the heart condition and the hypertension—and the physician documents this relationship in the record—each condition requires its own code, and if the documentation does not make that link, an HIM/coding professional must code the two conditions separately.

I understand that ICD-9 Coding Clinics may not apply in ICD-10, but I cannot find any updated guidance. Our coders are going by the Coding Clinic, First Quarter 2016, which still uses the phrase “due to.”

A: I know of no updated instruction that allows heart disease and hypertension to be an assumed relationship. We teach that the provider must clearly state the heart disease is due to (related to, secondary to, etc.) the hypertension.

Of course, the relationship between CKD and hypertension is a combination that can be assumed if found to be present.

For the patient that has the trifecta—is hypertensive, and has heart failure and kidney disease—we still need the provider to clearly state the relationship between the heart disease and the hypertension.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.

What part of your ACDIS membership means the most to you?

Rebecca Hendren

Rebecca Hendren

by Rebecca Hendren

Recently, ACDIS celebrated an exciting milestone as we welcomed the 5,000th member to our association. Our profession has grown enormously in the last decade—and so has ACDIS—and we are thrilled that, as our rosters grow, we are able to expand the amount of educational offerings we provide and the networking opportunities members can enjoy.

The occasion of the 5,000th member got me thinking about members both old and new. Some of you have been members for many years, and have seen ACDIS grow and expand. Others have only recently joined, and may still be poking around the website trying to determine what materials will be most useful for you.

I would love to hear which part of your ACDIS membership means the most to you and what you find most valuable. What can’t you live without? Is it the bimonthly CDI Journal, filled with analysis of the latest regulatory developments and best practices for CDI challenges? Is it the discount on the annual conference? Or is it the ACDIS Forum, which you can log in to at any time, day or night, and ask your peers how they handle a situation?

Please drop me a note at rhendren@acdis.org and let me know.

Your comments will help us as we plan ways to enhance membership and help everyone make the most of the many benefits this close-knit community offers.

Some of your responses may also help me with the most fun part of my role with ACDIS, which is that to develop new education and training products that will help CDI professionals and their organizations stay up-to-date on changing requirements, train new CDI professionals, or help educate providers and others on the importance of documentation integrity. I look forward to hearing from you!

Weekend Reading: Six steps to hospital reimbursement calculations

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Determining a hospital’s individual base rate or reimbursement is a complicated process best left for the hospital chief financial officer (CFO). However, a quick description may better illustrate how the IPPS works. CMS describes the following steps on its website at www.cms.hhs.gov/AcuteInpatientPPS.

Step 1

Hospitals submit a bill to their Medicare fiscal intermediary (FI) for each Medicare patient they treat. The FI is a private insurance company that contracts with Medicare to carry out the operational functions of the Medicare program. Based on the information provided on the hospital’s bill, the FI categorizes each case into an MS-DRG, which determines how much payment the hospital receives.

Step 2

The base payment rate is a standardized amount that is divided into a labor-related and non-labor-related share. CMS adjusts the labor-related share by the wage index applicable to the area where the hospital is located. The non-labor-related share is adjusted by a cost-of-living factor. This base payment rate is multiplied by the MS-DRG’s RW to determine reimbursement for each individual patient encounter.

Step 3

If CMS recognizes the hospital as serving a disproportionate share of low-income patients, the facility would receive a percentage add-on adjustment for each case paid through the IPPS. This percentage varies depending on several factors, including the percentage of low-income patients served. CMS applies the adjustment to the MS-DRG base payment rate, plus any outlier payments received.

Step 4

CMS pays an add-on amount to approved teaching hospitals for indirect medical education. This additional payment varies depending on the ratio of residents to beds under the IPPS for operating costs and according to the ratio of residents to average daily census under the IPPS for capital costs.

Step 5

CMS also provides an additional payment for cases that include technologies that meet the new technology add-on payment criteria.

Step 6

On occasion, CMS may consider a specific patient’s stay as an abnormal situation. Such patients consume a considerable amount of facility resources. CMS identifies these as outliers and increases payments for such situations to protect the hospital from large financial losses due to unusually expensive cases. CMS adds all outlier payments to the base payment rate to determine the final reimbursement payment for the hospitalization.

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.

Website Update: Demo video available now

The ACDIS website recently got a complete makeover, and there are a ton of new features that you may not be aware of. Last week, the ACDIS team got together and hosted a complimentary webcast “tour” of the new site—and we published the recording in case you missed it!

ACDIS still includes all the membership benefits you’ve come to love: access to surveys, benchmarking reports, and white papers; quarterly conference calls on hot CDI topics with the ACDIS Advisory Board; the CDI Journal publication; and the “CDI Talk” group—now called the ACDIS Forum for networking with your peers.

But now it also includes:

  • Access to a new career center in which members can post job openings
  • An improved layout and better search functionality, making content easier to find
  • Expanded pages for local chapter leaders and their members
  • Updated ACDIS Radio archives
  • Expanded resources

Click here to view the website demo video.

 

Guest Post: Clinical Documentation Specialist Survey

Take this survey!

Take this survey!

Who doesn’t want to help out a struggling student? Michelle Gordula is working towards her Health Information Administration degree at Stephens College in Columbia, Missouri, and reached out to us for help. Her senior seminar project is all about the collaboration of CDI specialists, coders, and other HIM professionals, and she’s conducting a survey as part of her research. Responses are due by Friday, June 24, 2016.

To complete the survey, copy and paste the following into a word document and follow the instructions. E-mail responses to micgordula14@gc.stephens.edu.

1. What is the highest degree or level of school you have completed?

☐High school graduate or equivalent  ☐Associate degree  ☐Bachelor’s Degree

☐ Master’s Degree  ☐ Doctorate Degree

 2. How long have you been working as a Clinical Documentation Specialist?

☐ Less than 1 year ☐ 1-5 years  ☐6-10 years ☐More than 10 years

3. To each of the statements below, please mark the box applicable

  Strongly Agree Agree Neutral Disagree Strongly Disagree
I am confident of my chart reviews.
My chart reviews are useful to those who perform chart audits.
I have a good understanding about the role of a Coder on chart reviews.
I have a good understanding on the importance of reporting codes accurately.
Feedback from Coders regarding DRG assignment is beneficial to me.
Feedback from Coders regarding code selection for Principal Diagnosis is beneficial to me.
Feedback from Coders regarding code selection for CC/MCCs, are beneficial to me.
Collaborative chart reviews with Coders are beneficial to me.

Tip: ‘Temporary pause’ in reviews of denied two-midnight rule claims

New detail on the 2-Midnight rule for inpatient admissions could come with a new proposal.

CMS ordered BFCC-QIO contractors to reexamine all claims they denied since October 2015.

On June 6, CMS posted a message on saying that it ordered BFCC-QIO contractors to reexamine “all claims they denied in their medical review process since October 2015 to make sure medical review decisions and subsequent provider education are consistent with current policy. The current pause will allow time for the BFCC-QIOs to conduct these re-reviews.”

Ronald Hirsh, MD, FACP, vice president of the revenue-cycle solutions for Accretive Health’s regulations and education group, says he expects “a very short suspension” of the reviews.

Hirsch lists seven points hospitals need to know about the two-midnight rule:

  1. The basics of the rule have not changed since it was introduced. Patients with an expectation of two, medically necessary, midnights in the hospital or who spend two, medically necessary, midnights in the hospital should be admitted as inpatients.
  2. Determining medical necessity for hospital care involves physician judgment. Physicians should be documenting the factors that make treating patients in a doctor’s office or at a nursing facility unsafe.
  3. Medicare pays hospitals to provide services seven days a week. If hospitals keep patients an extra day because they do not offer a test or service on a weekend or holiday, that is not a medically necessary day.
  4. Do not use the outcome of a case to retrospectively review a short stay. Hospitals should only use the information available at the time of the admission decision to determine whether the right status was chosen.
  5. Every inpatient admission that spans less than two midnights—unless it was an inpatient-only surgery, death, or transfer—should be reviewed prior to billing to ensure the correct status was chosen.
  6. Hospitals that aggressively admitted high-risk patients with an expected short stay prior to the two-midnight rule can now expect a markedly higher observation rate under the rule.
  7. Do not leave patients on observation status for periods of time longer than two midnights. If patients have medical necessity for hospital care, admit them. If they do not, send them home.

Editor’s note: This post was originally published by HealthLeaders Media.

A Note from the Instructors: The value of the CCDS credential

Prescott_Laurie_webby Laurie Prescott, RN, MSN, CCDS, CDIP

Those working in the healthcare field really value their credentials. The letters after a person’s name open many professional doors for an individual. When I worked as a nursing manager, if an applicant held AACN certification that simple fact told me I had likely had an individual who possessed the experience, knowledge, and competency to perform the desired position. I am very proud to now as the CDI Education Director at ACDIS to work for an organization that offers a credential which the majority of employers understand communicates competence and experience in the role of CDI.

The Certified Clinical Documentation Specialist (CCDS) credential is seen as the industry’s preeminent credential within our profession. Many organizations have identified this as a requirement for employment and it has become a valuable credential to have following your name.

Because of its value, we get many requests by individuals to waive or lower the work experience requirements. Many question how to get the experience when they cannot qualify for the job without the credential. However, this credential represents much more than passing a test—it communicates to the world the fact you are a competent leader in the profession of CDI. It tells employers you have both book and practical knowledge, the ability to critically think your way through a medical record review and understand how to impact your organization’s health. It says you understand the many aspects of the role and possess the skills to ensure success. The credential is one you should be proud to list after your name. It has value.

Over the last few months, I have worked with other amazing volunteers who contributed s to the revision of the CCDS exam. (Learn more about the CCDS Exam Committee on the ACDIS website.) I never appreciated how much time, thought, energy, and passion is involved in writing an exam.

We spent much time working to define the prerequisites for this exam, as we understand competence within this role is acquired with experience. The learning curve in this role is one that is not easily accomplished no matter the professional route you traveled. We must have an understanding of anatomy, physiology, pharmacology, regulatory and compliance, coding practices, hospital reimbursement, CMS quality measures, and so much more. We must possess strong communication skills, a thick skin, persistence, an ability to investigate and research as well as the ability to think through our record reviews critically. We must work independently and also possess strong team building skills.

That is a great deal to ask of any one person, but that is role of a CDI specialist.

Of course, the CCDS credential does not guarantee that every holder will be a model employee or a perfect fit for your facility but what it does communicate—not only to potential employers but to yourself as well—that you have reached a level of competency within the role.

If you are the person wondering how you can get hired when you do not qualify to sit for the exam, understand that there are a number of other skills that you already bring to the table. Sell these skills and demonstrate self-direction in learning the body of knowledge needed for the role. Be patient—the credential will follow as you grow in your competency as a CDI specialist. And when you can finally add CCDS after your name, be proud of what those letters communicate.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.