Summary of Wisconsin February meeting

The Wisconsin Chapter of ACDIS held its Winter Chapter Meeting on Saturday, February 18^th in Wauwatosa, with 45 members in attendance.  The keynote speaker was Dr. Jessica Whitley, a currently practicing hospitalist who also operates an active clinical documentation educational practice geared towards physician-to-physician education.  Dr. Whitley presentation, titled “A Clinical Perspective on Chart Review and Diagnoses Assignment from a QIO Reviewer’s Perspective” reinforced concepts of clinical validation of diagnosis selection through use of an actual case study resulting in alternate principal diagnosis selection.  Other presentations included “CDI’s Impact on the Recovery Audit Contractor Initiative-Capitalizing Upon Our Strengths to Minimize Hospital Financial Exposure,” and “You Don’t Know About Principles of Multiple Significant Trauma is What You Don’t Know!”

The WI ACDIS Chapter’s next monthly teleconference is scheduled for March 29^th and plans are being made to organize a Fall Meeting. Contact Glenn Krauss at glennkrauss@earthlink.net for additional information about chapter activities.

Refresh your awareness of combination codes

The JustCoding.com Virtual Summit for ICD-10 takes place next week.

Coders have been seeing more and more combined procedures in recent years in the CPT^® Manual. For example, in 2011, AMA combined CT of the abdomen and CT of the pelvis into a single code. So the thought of combination codes for diagnoses shouldn’t be that scary.

Some of the combinations will make life easier. In ICD-10-CM, coders will only need one code to report type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema instead of three in ICD-9-CM. The single ICD-10-CM code includes the type of diabetes mellitus, the body system affected, and the specific complications affecting that body system.

Some of the combinations may come as a surprise, though. Codes in categories T36–T65 are combination codes that include substances related to adverse effects, poisonings, toxic effects and underdosing, and external causes (e.g., T39.011A, poisoning by aspirin, accidental [unintentional], initial encounter).

Combination external cause codes identify sequential events that result in an injury, such as a fall that results in striking an object (e.g., W01.111A, fall on same level from slipping, tripping, and stumbling with subsequent striking against power tool or machine, initial encounter).

Start now by reviewing some of the categories with combination codes: diabetes, coronary artery disease, pressure ulcers, and poisonings and adverse effects. Review the documentation you currently have and try coding the record in both ICD-9-CM and ICD-10-CM. That will help you determine what’s missing, then share that information with physicians.

You can even start querying them for the additional information now. Hopefully, they will be in the habit of documenting the additional information by the time October 1, 2013 rolls around.

Editor’s Note: This article first published on HCPro’s ICD-10 Trainer blog. The JustCoding.com Virtual Summit for ICD-10, two tracks of courses regarding the new coding systems, begins tomorrow February 29 through Friday, March 2. ACDIS will be “virtually” present and available to chat with participants throughout the Summit.

Incorporate awareness of transfer DRGs into CDI record review efforts

CMS never met a dollar it didn't want back.

CMS never met a dollar it didn’t try to recoup. So we have RACs and HACs and stacks of regulatory requirements that take many, many healthcare dollars to manage. The post-acute care transfer DRGs are but one example.

(RACs, of course, are Recovery Audit Contractors which the government recently renamed Recovery Auditors or the Recovery Audit Program. And I’m sure you all know that HACs stands for hospital acquired conditions.)

For the uninitiated, post-acute care transfer DRGs exist because CMS doesn’t want to pay the hospital the full freight if the patient receives follow-up care somewhere else, and it ends up having to pay the another facility or healthcare agency (such as home health) as well. When the program began, 10 DRGs were designated as transfer DRGs; that list has since expanded to 273.

You can download the current list here.

Why do you need to know about transfer DRGs?

The CDI specialist is one of the few people who has at least a general idea of where the DRG is going to land before the patient is discharged. As you know, every DRG is attached to both an arithmetic length of stay (A/LOS) and a geometric length of stay (G/LOS). The A/LOS is the average LOS of patients within that DRG, including transfers and long-stay outliers. The G/LOS is the national mean length of stay for that DRG, except for transfers and long-stay outliers. The A/LOS is used for calculating outlier payments, while the G/LOS determines the transfer DRG payments. If you don’t have a good idea of the DRG before you transfer the patient or discharge the patient with services, your facility’s number crunchers could have an unpleasant jolt at reimbursement time.

When a patient is transferred to another facility or home with services after staying fewer days than the transfer DRG’s G/LOS, the post-acute care transfer DRG rule kicks in. Instead of receiving the full DRG reimbursement (relative weight multiplied by the hospital’s blended rate), a per-diem rate applies. The per-diem rate is the DRG reimbursement divided by the G/LOS. The hospital will receive twice the per-diem rate on day one and the per-diem rate every day thereafter up to the full DRG reimbursement.

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Maybe, possibly, definitely: Stay informed regarding ICD-10 delay

Which countdown to ICD-10 calendar will you use?

On February 14, CMS acting administrator Marilyn Tavenner told American Medical Association (AMA) meeting attendees that CMS would “reexamine” the timeline for ICD-10-CM/PCS implementation. Tavenner offered no details, just the vague possibility of potential reconsideration.

The healthcare industry jumped with the news.

American Health Information Management Association (AHIMA) immediately published a release urging healthcare professionals to move forward with their ICD-10 implementation and training plans, and downplayed the announcement, pointing its vague language.

“This is a promise from CMS to examine the timeline, not to change it,” said Dan Rode, MBA, CHPS, FHFMA, vice president for advocacy and policy at AHIMA, in the release. “But government officials are sending mixed signals that many in the healthcare community will interpret as a reason for delay.”

The AMA celebrated.

“The timing of the ICD-10 transition could not be worse for physicians as they are spending significant financial and administrative resources implementing electronic health records in their practices and trying to comply with multiple quality and health information technology programs that include penalties for noncompliance,” wrote Peter W. Carmel, MD, AMA president in a February 16 release. “Burdens on physician practices need to be reduced—not created—as the nation’s health care system undertakes significant payment and delivery reforms.”

The very next day, February 15, HHS Secretary Kathleen Sebelius said “the federal government will delay for an unspecified time the implementation date for the ICD-10 diagnostic and procedural coding system,” HealthLeaders Media reported.

Specifically, the HHS release stated that the agency “will initiate a process” to delay the ICD-10 implementation date for “certain health care entities.”

And that was pretty much it.

The rest of the release reiterates that the provider community feels burdened by the ICD-10 implementation, but also reiterates the importance of the move to ICD-10 because it will “provide more robust and specific data that will help improve patient care.”

Meanwhile, CMS confirmed to ACDIS’ parent company HCPro Inc., that the agency will use the rulemaking process when revisiting the ICD-10 implementation timeline; a process known to be lengthy, a process that does not always furnishes an expected result (meaning after the rulemaking CMS may just decide to keep the implementation date firm).

So multiple experts from ACDIS Advisory Board members to AHIMA directors repeated the refrain,; “Stay the course with ICD-10 implementation.”

I’m on their side.

In a phone conversation earlier this week, an ACDIS member told me that she was glad to hear CMS delayed ICD-10 by two years. Two years, she said.

Of course, I asked where she got her information and she cited some reputable sources which, on closer examination, actually said nothing of the sort.

All this commotion—all this maybe, possibly, definitely thinking about it—may ultimately cause serious difficulties for those in the midst of ICD-10 implementation plans. The possible delay could cause facility administrators to pull back the purse strings on training funds. Programs could decide to delay important technology purchases to save money since the implementation date isn’t imminent.

Meanwhile, we hear how far behind facilities actually are in their ICD-10 planning. CDI staff (according to a recent survey) say they do not even know if a ICD-10 implementation committee is meeting at their facility or what will be expected of them as the coming change draws near. Possibly postponing the actual “go-live” date only adds to facility procrastination on these issues.

The more advanced facilities have already evaluated their staffing needs in terms of CDI specialists’ concurrent record reviews and coding needs. These facilities have already budgeted for additional employees and charted a course for staff member training beginning with anatomy and physiology. Even more advance programs have already begun reviewing their top MS-DRGs for documentation improvement opportunities related to ICD-10.

History may prove me wrong (especially as rumors also abound about HHS opting to skip ICD-10 and jump directly to ICD-11!) but I remain convinced that ICD-10 implementation is inevitable and that the sooner facilities prepare themselves the better.

CDI specialist orientation (more CDI Talk inspiration)

One of the repeated conversation themes on CDI Talk is how to orient a new staff member (within an existing program), or how a small program can start its own CDI efforts and train its own staff. Parallel to those conversation threads are participants’ real hunger for more avenues and sources of education.

Let’s look at some of ACDIS’ online poll data to set the stage:

• July 2011: How many total years of professional experience do you have in healthcare (CDI, plus other)?
• 20 years or more, 60%
• November 2009: How long did it take you to get up to speed as a new CDI specialist?
• 3 to 6 months, 32%
• 6 to 12 months, 34%
• June 2011: How long do you think it takes to achieve an “expert” level of proficiency as a CDI specialist?
• 2 years, 35%
• 3 years, 22%.

And here’s one  final on-line poll data point to help me answer the question as to whether CDI managers are actually providing enough training to new staff members:

• January 2011: How long is your training period for new CDI specialists?
• 12%, 2 weeks
• 22%, 30 days
• 30%, 31 to 60 days
• 20%, 61 to 120 days
• 12%, approximately 6 months
• 3%, less than 6 months

It seems to me that those who indicated that it takes six months or more to get up to speed need more training than what I commonly consider necessary as part of orientation.  This data suggests that what is these new CDI specialists need is more of a mini-college training program.

Obviously there is a rather significant challenge—how to provide the level of knowledge and training along with the

(Image via Homeclick) It is a sink that is made so fish swim in it. Get it? Sink or swim.

appropriate mentoring to actively promote and support the new CDI specialists so they can succeed. Of course, there is always the consultant option which proves to be relatively expensive. Plus, a ‘mature’ program should not need to rely on such an expensive option for new staff orientations. At the opposite end of the spectrum is the ‘sink or swim’ method.

Thankfully, home grown and self-supported possibilities exist to constitute a middle ground between these two options. At the very least, facilities should implement an orientation or mentoring process where the experienced individual’s guidance can make a huge impact.

I believe the biggest challenge facing those hoping to implement a CDI orientation program comes from a lack of targeted, written learning resources. I consider one of the largest draws for ACDIS membership stems from the need for learning, resources, and accessibility to a community of knowledgeable and supportive peers. ACDIS provides such a community, with a quickly growing resource base. (If you’re a member, you ought to know. If not, go look at every part of the ACDIS home page).

In addition, ACDIS offers a few helpful handbooks and guides that can be re-purposed for orientation, such as:

• The 2012 CDI Pocket Guide
• The CCDS Exam Study Guide
• The CDI Specialists Handbook, second edition
• The Physician Queries Handbook

Furthermore, the only independent (i.e., not part of a consulting package) seminar I’ve found is HCPro’s CDI Boot Camp. While the total cost (fee, travel, hotel) may be prohibitive for many there is also the online version as an option. Again, a mature CDI program ought to be able to handle at least some of the orientation process internally.

Even with the valuable resources of ACDIS, some holes in new staff orientation remain. AHIMA and AHA’s Coding Clinic for ICD-9-CM provide further guidance, but even those resources do not cover everything. Several major elements of an orientation program are not addressed by the resources mentioned.  Just to get started, how about:

• Creating a tool that outlines in detail basic competency and knowledge expectations for the novice CDI specialist. This tool should also list areas for mid-level and advanced achievements to give new CDI staff a set of expectations for continued professional growth. There are some examples in the Forms & Tools Library, in the policies and procedures section (search for “staff orientation checklist), but not at the detail I envision.
• Curating a collection of vital subject articles and references. (Review the CDI Journal archives, the ACDIS Blog, and the Helpful Resources links just to get started on this collection. Add in other professional organizations and their publications such as the National Institutes of Health, AHIMA, AMA, and others and this would be a one-stop database of useful CDI knowledge.)
• Creating an outline of topics that the new CDI specialist needs to master before achieving their initial competency. Further, this outline ought to provide enough detail and referenced sources to serve as a complete training program guide.
• Sources would likely include the books and articles mentioned immediately above, along with sections of widely accepted texts such as coding guidelines, Faye Brown, and medicine texts like the Merck Manual.

Before starting to collect all those articles and tools, though, I should probably determine the basic elements of an orientation program! Below I’ve listed a few resources online which discuss this, including:

• The five key elements of a good orientation program
• The Community Tool Box: Developing Staff Orientation Programs
• Making New Employee Orientation a Success

After reviewing these, I must confess that my definition of orientation varies from those discussed above.  Still, several points are important to keep in mind to successfully bring a new staff member up to speed in the CDI world:

• Provide structured, purposeful training
• Offer a straightforward sequence of topics or activities to enable learning
• Give new staff members a written agenda complete with goals and measurable objectives
• Provide ongoing, two-way feedback and evaluation
• Supply appropriate resources and support
• Actively integrate the new person into the team
• Celebrate and welcome the individual and his/her accomplishments as they gain proficiency in their new role
• Pair new staff with an experienced mentor and provide oversight of their engagement
• Offer engaging, interactive, as well as some self-directed education

However, as mature and professional learners, CDI specialists must be responsible and accountable for their education and success.

Honestly, for a new or developing program that has to add or replace staff, the right consultant is worth the money.

At some point CDI programs need to be able to hire new staff and train them in-house. Creating a comprehensive training program does require a lot of effort and maybe it is work that some of you have already done?  If so, why duplicate work? Let’s see if we can compile a  “best of” list of what program components others have found successful and create a tool that we can share. Post your information here to the blog, e-mail me, or contact Associate Director Melissa Varnavas mvarnavas@cdiassociation.com

Q&A: Resolving the case load, productivity question

We love to respond to your questions. Post yours in the comment section below.

Q: For a newly trained CDI specialist, what is the approximate number of reviews (both concurrent and follow up) one should expect him/her to be able to handle per day? I recall from the CDI Boot Camp that the starting number was about 10, but I can’t remember how many new versus follow-up cases CDI staff should expect to review. I assume that the base number of 10 records increases as the weeks goes on, right?

A: From my experience, a newly hatched CDI specialist working solo should be able to review about 10 cases/day for the first few weeks. I typically give a new person just one unit to cover, which would mean that on Monday she/he would have about 5-10 new admissions from the weekend (depending on the size of the unit –for example, our units were about 20 beds each) plus their re-reviews. Thereafter that person could have two or three new admits per day which would make about 10 or so total reviews.

After a month, I would add a second unit, thereby doubling the reviews from 10 to 20. A full assignment for my reviewers was four units. I tried to give people similar clinical units to cover so there might be some overlap. For example, whoever covered the cardiovascular intensive care unit (CVICU) would also cover the post-coronary artery bypass graft (CABG) units. That way,

if she didn’t get to review the CVICU record that patient would eventually be hers in the CABG unit and she could review the case then.

As the manager I really scrutinized the number of admissions on each unit (from a data perspective) so that everyone’s assignments were about equal and that everyone had similar query-opportunity units. This way the CDI specialist could not only learn different areas and become more professionally versatile for the benefit of the hospital but enable him/her to build additional physician relationships and a broader understanding of conditions based on the range of physician perspective.

At the six-month mark a CDI specialist would assume a full assignment. Again, as a manager, I understood that it would still be a while before he/she was able to identify documentation improvement opportunities with 100% ability. Our program had processes for prioritizing reviews as well as clearly defined query follow-up policies. Our physician response rate goal was 100% and our policies and processes were designed to make that happen.

My team only had documentation responsibilities, however. We did not perform utilization review, case management, or other measures. If these additional tasks are added to a CDI specialist’s to-do list, I would recommend you adjust your program’s expectations accordingly.

If you have utilization review tasks also included in your CDI duties, and find it inhibiting your ability to follow-up on outstanding CDI reviews, track the number of cases that you are unable to review or follow up on for one-to-three months. This ensures you have data to support your position—that the additional role of utilization review hampers your ability to effectively complete CDI reviews of the records.

Your data should also show potential lost opportunities such as reductions in captured severity of illness/risk of mortality scores, DRG change, missed queries, etc. so that you can show how the lack of complete record review negatively affects the facility and patient care.

Editor’s Note: This article first appeared in the February 16 edition of CDI Strategies. For additional information regarding productivity metric for CDI specialists see also:

• Survey: Production expectations for reviews, re-reviews
• CDI Productivity Benchmarks (A CDI Talk topic)
• Q&A: Productivity measures for CDI specialists
• Additional thoughts on CDI staff productivity
• Metrics ideas and thoughts
• Q&A: Maintaining CDI productivity under the SOI/ROM system
• Chart reviews: Best practices from three perspectives

Pretending to be someone you’re not

Don't use someone else's name unless you've asked permission first.

A posting for the ACDIS job board actually came in twice within a minute. So, naturally I called the contact person listed and asked if the hospital actually wanted the job posted twice; maybe there were two openings available or something like that.

The contact had no idea what I was talking about. He didn’t know ACDIS from his elbow!

Talk about confusion… me explaining about the Association and the job board, him claiming he hadn’t sent the posting… me telling him the reply address in the in-coming post e-mail was his e-mail address… him explaining how the position wasn’t supposed to be posted outside the hospital.

It took a few minutes for the two of us to get onto the same page. After some digging around on his end, he called back to say one of his colleagues submitted the posting and used his name and e-mail address as the contact. Mystery solved. Job posted. Everyone’s happy.

What’s the point, you ask? Be careful if you use someone else’s e-mail information to make an announcement or solicitation. Let them know you’re doing it. Spare your colleague the possible embarrassment of not knowing their information is out in the public for the reason you used it. I caught Mr. Contact completely off guard and I’m sure he was embarrassed. As it turns out, the person who submitted the post thought Mr. Contact was notified in advance. He was not.

I’m glad this one red-flagged me to call and ask about the duplicate mail. It might have been worse if an applicant said they saw the job the ACDIS board and he didn’t know it was posted there. Or worse still if the job had been filled in house—we’d have people from applying for a non-existent job, wasting their time and hopes; and have wasted that facility’s staff time handling unnecessary applications.

So, my advice is to take that extra moment to be sure everyone’s on board before you take an action that brings your facility into the public eye.

Take 10 steps to refresh your documentation review process

Ensure your CDI programs examines patient records "door-to-door."

I recently had occasion to stop and think about how I approach a chart for a clinical documentation review. For me, it has become an almost instinctual process, so I found it instructive to examine my process in a more systematic manner. With that in mind, I thought I would share my perspective on how to approach a review.

I recommend a review methodology that goes from door-to-door: beginning with the ED record and ending with the discharge summary. As you review the chart, think about the disease processes you see. If you are an RN CDI professional, think about this just as if you were taking care of that patient on the nursing unit. Consider how these disease processes interrelate and affect that patient’s care. Now you need to make that clinical picture fit the regulatory requirements through compliant, codeable language.

Step 1: Review the ED physician record. Note presenting signs and symptoms, lab values, medical history, and the ED physician’s impression, as well as the reason why the patient is being admitted. Note any diagnostics or procedures performed in the ED. Don’t forget this part of the admission, because you might be using the ED record as the basis for an attending query, such as acute respiratory failure for a dyspneic patient intubated in the ED.

Step 2: Look for the physician’s document of the patient’s history and physical (H&P). Use the same review strategy you used for the ED record. Determine if the physician has a clear idea of the principal diagnosis. Identify if the physician is waiting for additional diagnostics or consults. Take note of any gaps in the documentation. Can each diagnosis be coded completely based on the documentation? How firm is each diagnosis—are there diagnoses that are noted as rule out, probable, possible, cannot confirm, etc.?

Make note of those diagnoses so that you can follow the progression of each diagnosis as the patient receives inpatient care. You don’t want a diagnosis to drop off without resolution. Ensure that there is enough clinical information in the chart at this point to support the diagnoses the physician chose. With an understanding of how principal diagnosis is determined, what do you think the principal diagnosis is at this (albeit early) point? Also identify any early, potentially relevant secondary diagnoses. If the H&P is missing, make yourself a note to keep looking for it. If consults have been ordered, or you are expecting a consult to be ordered, make a note to look for the reports. Do you see a clinical picture without a diagnosis that might require a query?

Tip: Remember that when the chart is coded, the H&P and the discharge summary are going to carry the most weight.

Step 3: Look at vital signs and intake and output (I&O). Vital signs can give a strong clue in many cases as to just how sick your patient might be. You definitely need to note abnormals. I&O can help you if you’re looking for signs of acute renal failure due to dehydration, for instance. Determine if there are there any clinical conditions you might associate with the abnormal vital signs, such as a post-operative fever. Do you have enough supporting documentation to ask the physician if he or she suspects clinically significant atelectasis? Remember that when you evaluate for sepsis, fever is one of your SIRS indicators.

Step 4: Review labs and radiology reports. If there are abnormal findings, consider the clinical significance of those findings for the patient’s care. If the physician hasn’t addressed the abnormal findings in his or her documentation, make a note of those findings and follow the patient’s progression in future tests. As a CDI specialist, you may note a clinical progression based on those test results. Coders cannot code directly from labs or radiology reports, so if there is evidence of something clinically significant to report, query the physician. For instance, a patient with documentation of a subdural hematoma, mental status changes, and a decrease in their Glasgow coma scale may have had a brain MRI indicating mass effect and a midline shift. In this case you would probably query the physician regarding possible brain compression.

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‘Stay the course’ despite suggestions that CMS may delay ICD-10 implementation

HHS confirmed its intent to re-examine the ICD-10 compliance deadline during a proposed “rule making,” session the agency announced in a press release yesterday, Thursday February 16. The release came following a statement HHS Secretary Kathleen G. Sebelius made during a presentation to the American Medical Association (AMA) meeting on Tuesday, February 14. The AMA previously announced its intention to oppose the ICD-10 implementation timeline. The group sent a letter voicing its opposition to Speaker of the House John Boehner in January, according to FierceHealthIT.

In the release, Sebelius says “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

“Since the AMA announced its intention to try and delay the implementation of ICD-10, this news does not come as a total surprise,” said Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro, Inc., in Danvers, MA. “Providers are expected to comply with meaningful use, transition their practices to the 5010, and implement EHRs in their office. When you consider that providers are also facing a decrease in their reimbursement rates it is no wonder that they feel that their backs are against the wall.”

That said, providers have had plenty of advance notice, Spryszak noted. CMS announced the conversion to ICD-10 in January of 2009, giving them nearly five years to plan.

Until further information becomes available on the exact nature of the delay, providers should continue to push forward with their implementation efforts, according to industry experts.

“Even if they do delay ICD-10, especially for physician practices, this should not deter the infrastructure redevelopment to accommodate ICD-10’s likely implementation in whatever time frame they do implement it, be it six, 12, 18, or 24 months from their previously announced date of October 1, 2013,” said James S. Kennedy, MD, CCS, managing director of FTI Consulting in Brentwood, TN.

The rest of the world is already using ICD-10, Kennedy explained, and will likely transition to ICD-11 soon, while the United States is still using ICD-9. “Change is necessary if we are to develop a robust database of our patients’ illnesses and treatments as to better measure outcomes and efficiency. While ICD-10 is not perfect—nothing is—we should not let the need for perfection be the enemy of the common good. Procrastination is not the solution,” Kennedy said.

Guidance on documentation requests, queries, and late entries in the record

Lynne Spryszak, HCPro’s CDI Education Director, was one of several speakers offering great information during yesterday’s ACDIS members’ Quarterly Conference Call. She mentioned a November 2011 CMS publication about documentation requests that can have a direct impact on provider requests. Here is the link:

http://www.cms.gov/manuals/downloads/pim83c03.pdf

Lynne also provided more information from the Medicare Benefit Manual:

3.3.2.5 – Late Entries in Medical Documentation

(Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11) This section applies MACs, CERT, Recovery Auditors, and ZPICs, as indicated.

“A provider may discover that certain documents were misfiled or needed to be filed in the medical documentation during the process of responding to an ADR. Providers are encouraged to add to the medical record or notes file all relevant documents that were created at the time of service or within a few days of the date of service.

“The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the query responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO and State Agency.”

Thank you, Lynne!