Open letter to the President

Editor’s Note: The following is a mock letter, an editorial expression representing my response to President Barack Obama’s speech before elected officials on Wednesday, September 9, 2009.

Dear President Barack Obama, and esteemed and honored elected officials,

I write to you not in any official capacity related to my position as the associate director for the Association of Clinical Documentation Improvement Specialists (ACDIS) but rather as a citizen who is a firm believer in the cause these healthcare professionals represent.

Perhaps you have heard of clinical documentation improvement (CDI), perhaps not.  As a profession, CDI is relatively young. ACDIS itself is merely two years old. Hardly even a toddler. But the physicians, nurses, and coders who consider themselves CDI specialists are making great strides to help their facilities. Many of them save their programs millions in otherwise lost revenue annually. But while saving money represents a positive outcome from their venture it is not their mission.

These professional men and women crossed barriers of experience, reached out to each other to meet a singular goal–to improve patient care. They know that once all parties involved begin to speak the same language, dialogue begins to take place. They take the clinical knowledge of the physician and translate it into the complex languages of the healthcare coding and billing world.

The government already parses data collected by coders for all manner of initiatives. No doubt with an increased emphasis on electronic medical records an avalanche of information will be available to improve patient care, cut healthcare expenses, and seek out fraud and abuse in healthcare spending.

But none of these worthwhile initiatives will matter if the basic information written in the patient’s medical record by the physician cannot be correctly and compliantly translated into the coding and billing payment structure.

Physicians just want to take care of their patients. CDI helps them do just that.

The current struggle over healthcare reform appears to most Americans unending, the battle unwinable. And as you must realize those who vehemently seek to improve their current station will do just that. Just ask our ACDIS membership. I do not write this letter to say that the efforts of clinical documentation improvement specialists will solve all of the American healthcare system’s ills. This letter is written merely to inform you that they are out there working hard to do what they can to help.

Sincerely,

Melissa J. Varnavas

New article of the month: Complications of surgery

Hi ACDIS members, there’s been a lot of talk regarding complications of surgery during our quarterly conference calls. In response, we worked with Dr. Robert Gold of DCBA, Inc. and the ACDIS advisory board, and Mario Perez of J.A. Thomas & Associates, to bring you a new article of the month on the subject.

Please click here to view the article or visit our main page.

As a reminder, you can find an archive of previous articles of the month (as well as many other articles and links) on our helpful resources page.

Take care,

Brian

HACs set for October 1: Are you ready?

When a hospital-acquired-condition (HAC) is not present on admission (POA), and it is the only complication/comorbidity (CC) or major CC (MCC) on the claim, the case will group to a lower-weighted Medicare Severity DRG (MS-DRG). That means less reimbursement for your hospital.

“It could have a financial impact on the hospital’s bottom line,” says DeAnne W. Bloomquist, RHIT, CCS, a coding and compliance consultant and the president of Mid-Continent Coding, Inc., in Overland Park, KS.

The following eight HAC conditions take effect October 1:

1. Foreign object retained after surgery. Codes 998.4 (foreign body accidentally left during a procedure) and 998.7 (acute reaction to a foreign substance accidentally left during a procedure) denote this HAC.
2. Air embolism. Code 999.1 (air embolism to any site, following infusion, perfusion, or transfusion) denotes this HAC that refers to a condition in which air inadvertently passes through an open blood vessel.
3. Blood incompatibility. Code 999.6 (ABO incompatibility reaction) denotes this HAC.
4. Stages III and IV (decubitus) pressure ulcers. Code 707.23 indicates a stage III decubitus ulcer, and code 707.24 indicates a stage IV decubitus ulcer.
5. Falls and trauma. This includes fractures, dislocations, intracranial injuries, crushing injuries, and burns. The following codes denote this HAC:
   • Codes 800–829: Fractures
   • Codes 830–839: Dislocations
   • Codes 850-854: Intracranial injuries
   • Codes 925–929: Crushing injuries
   • Codes 940–949: Burns
   • Codes 991–994: External causes (i.e., heat, air pressure, light, frostbite)
6. Catheter-associated urinary tract infections (UTI). Code 996.64 (infection due to indwelling urinary catheter) denotes this HAC.
7. Vascular catheter-associated infections. Code 999.31 (infection due to central venous catheter—catheter-related bloodstream infection, not otherwise specified) denotes this HAC.
8. Mediastinitis after coronary artery bypass graft (CABG). Code 519.2 (mediastinitis) and a CABG procedure code from the 36.10–36.19 range denote this HAC.

For more information on HACs, visit www.cms.hhs.gov

To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com.

To read the complete article ” Don’t let HACs cut into your bottom line“, visit the ACDIS Web site’s Helpful Resources section.

Chicago CDI Boot Camp sold out

That’s the good news and the bad news, I’m afraid.

On the good news side of the scale we place the fact that 32 people—that’s right, 32 people—registered for the four-day CDI Boot Camp being held at the Marriott Courtyard in Chicago/Schaumburg September 28 through October 1. The number of registrants speaks to the intensity of the educational needs of the profession as well as to the dedication of CDI professionals.

Of course, on the bad news side of the scale we place the fact that the Chicago program is, in fact, sold out. So anyone in the area who had hoped to register but was perhaps waiting for last minute approval from their director or other supervisor missed out, I’m afraid. We hope that if you’re in Chicago and did get shut out of the Boot Camp, you’ll be able to take some solace in the fact that the 2010 ACDIS conference will be held in the Windy City June 3rd and 4th, with the pre-conference coding essentials program and post-conference CCDS exam.

Just one more item to tip the scale to the positive. (I like to leave things primarily on a positive note, if possible.) Just because the Chicago program is closed doesn’t mean there won’t be other learning opportunities. The Atlanta, GA, program taking place at Hyatt Place October 12-15, still has multiple open slots. Just a note on that, the early bird hotel room rate ends on September 18, so if you are interested you might want to mention that to the powers that be.  And the Boot Camp taking place at the Hilton Phoenix Metro Center in November from the 2nd to the 5th also has multiple slots open.

We are in the planning stages for the 2010 Boot Camp schedules now so if you want a session to come to your neighborhood, give us a shout. We hope everyone who attends the Chicago intensive has a great time and learns a lot.

Get all the information on anemia documentation

I’m just sticking my foot into a wicked pile of super sticky unknown substance by bringing this topic of ‘acute blood loss anemia’ back up. But there’s been so much back and forth with our own ACDIS Advisory Board to iron out the details published in this week’s CDI Strategies, that I was quite surprised when one of our readers e-mailed shortly after publication to ask another question based on the brief.

Another question? I thought we couldn’t possibly write anything more on the topic! Well, I was wrong. Our friend from Washington, DC, asked: “If  ‘precipitous drop in hematocrit’ is documented, must the baseline be known? What are the parameters and is it facility specific?”

So I’m throwing the whole thing out here  to blog land. Please help me by posting any (and all) information you might have regarding how you approach physicians with queries for anemia.

Update physician education with tips from ACDIS members

A newcomer to the ACDIS group page on Facebook asked recently how to keep physician engagement in clinical documentation improvement high as CDI programs begin to mature.

To be sure, there’s always an initial excitement regarding new programs and the potential they hold for improvement. Sometimes, however, that energy begins to fade. Reading Tina Lewis Simpson’s comment I was reminded of a HealthLeaders Web cast, 5 Ways to Hospital-Physician Quality: Goals, Incentives, Dialogue, Infrastructure, Data, in which Rebekah Wang-Cheng, MD, FACP, medical director for clinical quality at Kettering Medical Center in Dayton, OH, offered several strategies to facilitate physician communication. Consider the following techniques to improve physician education and awareness of your CDI program:

• Educate one-on-one, face-to-face, in real time. When addressing a particular problem with physician documentation, don’t wait, says Wang-Cheng. Use a specific case that happened within the past day or two to illustrate your point.
• Educate in groups. Go where physicians gather, Wang-Cheng says. Offer education sessions during quarterly medical staff meetings, or specialty meetings
• Show data. CDI specialists constantly gather data, benchmark and report this data back to the physicians. When physicians see how appropriate documentation affects patient care and the overall mission/wellbeing of the facility they will be more likely to understand the mission behind your position.
• Walk in their shoes. Shadow a physician for a day to observe the pattern of their care. That way you’ll have a better understanding of the physician’s work flow. Armed with understanding you can adjust your query process to fit their needs as well as your own.
• Say, “Thanks.” If a physician is responsive to your inquiries, praise him or her for their helpfulness. Take your appreciation a step further, says Wang-Cheng, by sending him or her a thank you note to their home so they can show their family. “There’s nothing better than to be able to say to a spouse: ‘Look, someone said something nice about me.’”
• Start at the top. Approach physician leaders in various disciplines. This type of influence will help you “spread and sustain the education,” Wang-Cheng says.
• Listen as much as you talk. Emphasize with the physicians. Realize they have difficulties, both professional and personal, too. Don’t be afraid to admit ignorance but be sure to ask for their assistance when you do.
• Make the physician lounge a welcoming place. A CDI specialist may not have direct involvement regarding the physical location and ambiance of the physician lounge, but he or she can use the lounge as a way to get the word out about the CDI program. Visit often and leave specific, small tokens of appreciation from time to time.

Those interested in additional tips to gain physician support may want to click on Sylvia Hoffman’s blog posts, at right, including: Spring ideas to woo physician support and KISS method applies to CDI physician education, too.

Furthermore, thanks to North Cypress (TX) Medical Center Director of Clinical Documentation Improvement Mike Alcorn, LVN, there are some sample e-mail physician education packages available in our Forms & Tools Library. Read how he created his physician education strategy in CDI Strategies.

If you have any tips or innovative suggestions for how to spice up the physician education component for the more advanced CDI programs please post ‘em here. We love to hear what you’re up to. Besides what’s working for you may help solve a problem for someone else.

Six steps to start a CDI program successfully

1. Get leadership support from the start: Show those in the C-suite (The CEO, CFO, CIO, etc.) the impact of CDI programs. Obtain cost estimates from companies who help set up CDI programs. Convey the bottom line in financial terms. Show how better documentation more accurately reflects severity of illness and the patient population, resulting in increased reimbursement and better patient care.

2. Form a planning group: Include finance, medical records, care management, quality improvement, medical staff, and nursing. Communicate with other CDI programs and peers to learn what worked best for them and what didn’t work at all.

3. Determine CDI needs: Consider a neutral third party to conduct an inpatient coding and documentation audit, evaluate current query processes, and update query policies and procedures. Based on your audit findings and industry research, determine the staffing and organizational needs of your CDI program. Ask:

• Should your program be housed under HIM or finance or case management?
• How many full time staff members will you need?
• Will your organization support the addition of a physician advisor/champion?

4. Present to leadership: Explain your proposed program specifications and budgetary needs to the facility management. Make your presentation simple and effective. Where possible, combine anecdotal information with hard data. Present your data clearly and effectively. Use Power Point presentations and graphs when possible.

5. Hire appropriately: Take your time during the hiring phase. Be selective. Do not compromise your program needs to fit the capabilities of the candidate. Involve the CDI manager, HIM, and a multidisciplinary team in the interview process. Keeping the right person means hiring the right person.

6. Earn staff member support: This can come from a physician champion as well as from your own ongoing educational efforts. Conduct presentations with groups of physicians, attend their staff meetings, and ask for their input. Similarly, build solid working relationships with nursing team members and coders to analyze queries.

Physician buy in for E/M services

From the Documentation Guideline for E/M Services (Centers for Medicare and Medicaid Services):

To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or established. The Physician must then uses the presenting illness as a guiding factor to determine the extent of key elements of service to be performed. The key elements are:

• History
• Examination
• Medical decision making

History:  The physician must determine the type of history. Is it Problem focused, Expanded focus, Detailed, or Comprehensive.

Exam: The examination may involve several organ systems or a single organ system. The extent of the exam performed is based upon clinical judgment, patient history and the nature of the presenting problem. The type of exam must be determined to be:

• Problem focused
• Expanded focus
• Detailed
• Comprehensive

Medical Decision Making: Medical Decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. A number of options must be considered.

• The number of possible diagnosis and or management options
• The amount and /or complexity of medical records, diagnostic tests and /or other information that must be reviewed and analyzed.
• -The risk of significant complications, morbidity, and/or mortality as well as co morbidities associated with the patient’s presenting problem, the diagnostic procedures and /or the management options.

The level of decision making must be determined to be:

• Straightforward
• Low Complexity
• Moderate Complexity
• High Complexity

Some important points that should be kept in mind when documenting level of risk are:

• Comorbidities/Underlying disease
• Surgical or invasive diagnostic procedures ordered, planned or scheduled.
• Surgical or invasive diagnostic procedure performed.
• The referral for or decision to perform a surgical or invasive diagnostic procedure.

When counseling and/or coordination of care dominates the patient encounter (more than 50%), time is considered the key or controlling factor for a particular E/M service. Presenting problems that affect level of risk include:

1. Minimal: Minor problems such as colds, insect bites, etc.
2. Low:  Two or more self limiting problems such as well controlled hypertension, dontrolled diabetes, cystitis, allergic rhinitis, or simple sprain.
3. Moderate: One or more chronic illness with mild exacerbation or progression, or two or more stable chronic illnesses. An undiagnosed new problem such as a lump in the breast counts as a moderate problem. Also the presence of an acute illness with systemic symptoms such as pylonephritis, pneumonia, colitis, or brief loss of consciousness is also a moderate problem.
4. High: One or more chronic illness with severe exacerbation, progression or side effects of treatment. Acute or chronic illnesses or injuries that pose a threat to life or bodily function, such as multiple trauma, acute MI, pulmonary emboli, severe respiratory distress, acute renal failure, seizures, TIA, CVA, or sensory loss.

The gem in the E/M billing system is that in order to bill for the appropriate level of service, the physician must document appropriately. Physicians cannot be billing for a higher presenting problem with 60 minutes of counseling time when the diagnoses is urosepsis with diabetes, and chest pain. The codes will simply not substantiate the higher billing! Make your physicians aware of the rules.

CCDS recertification web pages up

Hi ACDIS members, for those who have achieved their Certified Clinical Documentation Specialist (CCDS) certification, please note that we now have informational web pages up regarding recertification. You can find them by clicking on our certification tab, and then clicking the recertification link in the upper right-hand corner of the page. I’ve also included a direct link here.

Recertification occurs every two years from the date on which you passed the CCDS exam, and is accomplished by submitting 20 CEUs and a certification maintenance fee. Recertification is critical because it ensures that you stay up to date on the latest regulatory updates, trends, and updates to this ever-changing profession. We will accept all CEUs relevant to the profession (i.e., attending AHIMA, case management, or other related conferences, submitting nursing CEUs, attending inpatient coding seminars, etc.).

More information on the type of CEUs we will accept, and on calculating your CEUs, can be found on our recertification pages.

If you have any questions don’t hesitate to contact me.

Thanks,

Brian

bmurphy@cdiassociation.com

NC ACDIS Meeting Scheduled August 28,2009

NC Regional ACDIS Meeting will be hosted by Novant Health at

Friday, August 28, 2009

10 a.m. to 2 p.m.

Presbyterian Hospital – Multipurpose Room

200 Hawthorne Lane

Charlotte, NC 28204

Topic of Discussion: Pneumonia and current Treatment  Modalities

Cost- $10 – payable at door (cash only)

Light Breakfast and lunch provided

All NC Documentation Specialists Welcome & Encouraged to Attend.