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Note from Associate Editorial Director: Quotes of note

Melissa Varnavas

Melissa Varnavas

by Melissa Varnavas

As a young journalist on deadline, I stared down a blank white computer screen as the clock ticked toward midnight, pondering an exposition regarding my home town’s complicated municipal budget. In the end, I settled on introducing the article with a quote from Theodore Roosevelt. “Nothing in the world is worth having or worth doing unless it means effort…”

As the article devolved into a collection of quotes from city councilors, my editor at the time simply titled the piece “Beverly Budget Debate: Quotes of Note.”

While not exactly one of my more shining journalistic moments, it is true that certain quotes, like that of Roosevelt’s, reverberate through time, echoing with the truth of the sentiment they express. It’s probably the reason so many ACDIS members include famous quotes in their email signatures.

I love the one from hockey player Wayne Gretzky that ACDIS member Tracy Boldt, RN, BSN, CCDS, CDIP, system manager for CDI at Essentia Health in Duluth, Minnesota, uses in her signature: “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.” The 2016 CDI professional of the year award winner Karen Newhouser played off Gretzky’s quote in her acceptance speech, encouraging those in attendance to use the resources available to them to stay informed about changes in healthcare reimbursement and their effect on CDI efforts.

Another of my favorites related to the CDI profession has long been Mark Twain’s: “The difference between the almost right word and the right word is really a large matter. ’Tis the difference between the lightning bug and the lightning.” Don’t call it congestive heart failure if it’s actually acute-on-chronic diastolic heart failure.

Musing on this, I asked the ACDIS team to put on their thinking caps and come up with a few themselves. Both ACDIS Director Brian Murphy and ACDIS CCDS Coordinator Penny Richards stuck with a writerly theme and the importance of thoughtfully chosen words to convey a message.

Murphy chose John Cheever’s: “A page of good prose remains invincible.”

Richards chose Emile de Girardin’s: “The power of words is immense. A well-chosen word had often sufficed to stop a flying army, to change defeat into victory and to save an empire.”

“Not to mention invited in the auditor or caused claims to be denied,” she added.

ACDIS Editor Linnea Archibald pointed to a quote from Henry Wadsworth Longfellow: “It takes less time to do a thing right than to explain why you did it wrong,” as evidence of the importance of educating physicians on proper clinical documentation habits. Those physicians who take the time to heed CDI professionals’ advice, she says, ultimately end up saving time by getting the documentation correct to begin with.

ACDIS Associate Director of Membership and Product Development Rebecca Hendren chose a quote from Jane Austin, tweaking the details a tad. “It is a truth universally acknowledged, that a physician in possession of poor documentation must be in want of a CDI specialist.” We’ll leave it to you to look up the original wording.

ACDIS Educational Director Laurie Prescott couldn’t settle on just one. Her favorites include:

  • “Good words are worth much, and cost little,” by George Herbert
  • “I like good strong words that mean something,” by Louisa May Alcott, in Little Women (like acute, chronic, and acute on chronic, Prescott added)
  • “It’s always a bit of a struggle to get the words right, whether we’re a Hemingway or a few fathoms below his level,” by Rene J. Cappon (which is why you have CDI specialists to assist you, Prescott joked)

We’re sure you have your own favorites, too. Feel free to share them with us or better yet, why not play this game with your CDI team and post your quotes near physician’s documentation stations and around your CDI department as a fun way to provide a little additional insight into the importance of CDI.

After all, as Aristotle said, “The aim of CDI is to represent not the outward appearance of things, but their inward significance.”

Editor’s note: Varnavas is the Associate Editorial Director of ACDIS. Contact her at mvarnavas@acdis.org.

Guest Post: Your CDI team’s role in pneumonia value-based outcomes, part 2

Shannon Newell

Shannon Newell, RHIA, CCS

by Shannon Newell, RHIA, CCS

Pneumonia as a principal diagnosis

Consider the following case studies.

Case study 3: A patient with history of chronic obstructive pulmonary disease (COPD) presents to the ER with complaints of a low-grade fever of 99.8, and shortness of breath for two days with intermittent minimal wheezing. Chest x-ray is positive for a left upper lobe infiltrate. The patient’s white blood cell count is 10,000, lactic acid is 0.8, pulse is 88, and respiratory rate is 22 breaths per minute with a pulse oxygen level of 96% on 2 liters. The patient is admitted with COPD exacerbation and community-acquired pneumonia. The patient is started on IV antibiotics for treatment of the community-acquired pneumonia and receives bronchodilators every four hours without IV Solu-Medrol for treatment of the COPD. The patient’s condition improves, and in four days the patient is discharged on oral antibiotics. Documented diagnoses: Community-acquired pneumonia and COPD exacerbation. Pneumonia, unspecified organism is coded as the principal diagnosis. Both pneumonia and COPD exacerbation are clinically supported as principal diagnosis options. ICD-10 classification instructions require that patients with COPD with acute lower respiratory infections have COPD sequenced as the principal diagnosis. The correct selection of COPD as the principal diagnosis with pneumonia as a reported secondary, POA diagnosis would exclude the discharge from the readmission and mortality outcome cohorts.

Sepsis as a principal diagnosis: The inclusion of pneumonia as a secondary, POA diagnosis does not include a discharge in the outcome cohorts. This rule of thumb is typically true: Only cases with a principal diagnosis of pneumonia will “count.” There is one exception, however, and that is the reporting of pneumonia as a secondary, POA diagnosis when sepsis is reported as the principal diagnosis.

If sepsis is reported as the principal diagnosis and pneumonia is reported as a secondary, POA diagnosis, the discharge will be included in both the readmission and mortality outcome cohorts. In such cases, if—in addition to the secondary diagnosis of pneumonia—severe sepsis is present and reported as a secondary, POA diagnosis, the discharge is excluded from the cohort.

The evidence-based definitions adopted for use will impact how sepsis/severe sepsis codes are reported and, in turn, will impact performance for the pneumonia mortality and readmission outcomes.

Case study using the Sepsis-2 definition

  • Scenario:
    • A patient is admitted with pneumonia not elsewhere specified, with multiple clinical indicators of a systemic infection (temperature 102; respiratory rate 28 breaths per minute; white blood cell count 18,000 uL; pulse 120 beats per minute; lactic acid level 2.4 mmol/L).

The patient’s blood pressure, mental status, platelet count, bilirubin, and renal function are all within normal limits, and there is no evidence of delayed capillary refill.

  • Principal diagnosis:
    • Sepsis—if documented—would be reported as the principal diagnosis. (If not documented, a query would be recommended given the multiple clinical indicators of a systemic infection.)
    • Pneumonia would be reported as a secondary, POA diagnosis.
  • Pneumonia mortality/readmission cohorts:
    • The patient would be included in the cohorts.
    • An opportunity to exclude the discharge from the cohorts exists if Sepsis-2 criteria are used and severe sepsis is documented. (If not documented, a query would be recommended using the following clinical support: lactic acid level greater than the upper limits of laboratory normal (1 mmol/L).)

Case study using Sepsis-3 definition

  • Scenario:
    • Same as case study with the Sepsis-2 definition above.
  • Principal diagnosis:
    • If the Sepsis-3 definition is used, the clinical indicators in this patient do not meet sepsis definition requirements. This is because the elevated lactic acid level is not part of the Sequential Organ Failure Assessment score defining sepsis.
    • The principal diagnosis would be pneumonia. Sepsis and severe sepsis would not be reported.
  • Pneumonia mortality/readmission cohorts:
    • The patient would be included in the cohorts.

Discharge status of “against medical advice”

Whenever “against medical advice” is reported as the discharge status, that discharge is excluded from both the mortality and readmission cohorts. CDI teams typically focus on accuracy of discharge status due to its impact on accurate MS-DRG assignment and payments.

Editor’s note: This article was previously published in the Revenue Cycle Advisor. To read the first part of this article, click here. Newell was previously the director of CDI quality initiatives for Enjoin, but is now retired. Should you have any questions regarding this article, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

 

Conference Corner: Shipping out to Vegas!

If you’ve ever felt that your luggage always ends up too heavy, taking a trip down to the loading dock to see the pallets shipping out to the 10th annual ACDIS conference in Las Vegas would certainly make you feel better about your bag.

pallet fun

Linnea Archibald (left) and Penny Richards (right) joining in on the packing fun.

Though we already extended our thanks to the internal staff who make the ACDIS conference possible, the team putting this conference together deserve another round of applause. On Tuesday, the office management team finished packing up the pallets to ship to the conference. CCDS Coordinator Penny Richards and ACDIS Editor Linnea Archibald ventured down to the loading dock to see the process in action and were thoroughly impressed.

On the dock were five pallets ready to go onto the truck – each wrapped in cellophane and jam packed with ACDIS supplies. Here are a few of the items making the trek to Vegas:

  • More than 2,000 tote bags with goodies included
  • More than 2,000 event agendas, exhibit hall floor plans, program guides, and exhibitor directories
  • Close to 50 signs and posters
  • Office and setup supplies such as batteries, clips, box cutters, calculators, envelopes, extension cords, first aid kits, pens, scissors, and more
  • More than 600 pieces of pre-con materials
  • Book store merchandise
  • The ACDIS Achievement Awards

There’s no way the ACDIS conference would be as spectacular without the many staff members working behind the scenes. When you arrive at the conference, look around and imagine packing all that in your roll-around suitcase!

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The pallets packed and ready to go!

Guest Post: Your CDI team’s role in pneumonia value-based outcomes, part 1

Shannon Newell

Shannon Newell, RHIA, CCS

by Shannon Newell, RHIA, CCS

The selection of a principal diagnosis, secondary diagnosis, present on admission (POA) status, and discharge status on each claim determines whether a pneumonia discharge will be included in Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program measures. And effective CDI reviews can capture this documentation.

Pneumonia as a principal diagnosis

CMS includes any discharges with the principal diagnosis of pneumonia (including aspiration pneumonia) in the mortality and readmission outcome measures. Some of these discharges are excluded for various reasons, for example, discharges with a reported discharge status of “against medical advice” are excluded from both measures. The final group of included discharges is referred to as the “cohort.”

Consider the following case studies.

Case study 1: A patient is admitted with pneumonia and acute respiratory failure requiring BiPAP with admission to the ICU along with IV antibiotics for treatment of the underlying pneumonia. Two principal diagnosis options exist–acute respiratory failure or pneumonia. Coding guidelines permit the selection of either option as the principal diagnosis. Today’s CDI teams typically select the option that results in the highest MS-DRG relative weight. Based on current MS-DRG relative weights, the pneumonia would result in the MS-DRG with the highest relative weight, and if it is selected, the discharge would be included in the readmission and mortality outcome cohorts.

Case study 2: A 65-year-old white male with known AIDS is admitted with pneumonia related to his underlying AIDS. Only the pneumonia is addressed during the hospital stay. Based on ICD-10-CM Official Guidelines for Coding and Reporting, AIDS/HIV infection (B20) would be reported as the principal diagnosis, and the HIV-related condition, pneumonia, would be reported as an additional diagnosis. The reporting of AIDS (B20) as principal diagnosis would remove the patient from the pneumonia readmission/mortality cohorts.

Summary

Performance on the CMS 30-day pneumonia readmission and mortality measures adjusts payments received for the Medicare and commercial patient population. By promoting and adopting evidence-based definitions; associated documentation requirements; accurate selection, sequencing, and assignment of POA status; and accurate reporting of discharge status, the CDI team plays a vital role in data integrity for claims-based quality measures.

Editor’s note: This article was previously published in the Revenue Cycle Advisor. Come back to the ACDIS Blog next week for the second part of the article. Newell was previously the director of CDI quality initiatives for Enjoin, but is now retired. Should you have any questions regarding this article, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

 

Conference Corner: Thanks to our internal staff!

ACDIS_1292(5-24-16)

Staff answer questions and work at the ACDIS booth

The days are winding down to the long awaited 10th annual ACDIS conference. Next week, more than 30 members of our HCPro and BLR teammates will make their way to the airport to support the ACDIS community during the largest conference we have ever conducted—with more than 1,500 paid attendees, 50 exhibitors, upwards of 300 exhibitor attendees, and more than 90 speakers and presenters.

In addition to the core ACDIS team, dozens of people lend their time, energy, and innumerable talents. When put all together, they produce the thriving conference we will experience in Las Vegas. We hope you’ll join us in thanking our staff members who make the conference possible.

While it would be nearly impossible to name every single person who contributed in some way, we’re going to give it our best shot:

Shannon Storella and the entire events team: Shannon is our fearless leader throughout the conference, from the planning stages to the live event. She keeps us all in line and helps the event run as smoothly as possible.

Kathy Wilson does an amazing job holding the entire event together working between the various departments as well as with the hotel staff and conference center management to ensure everything stays inline. The conference wouldn’t be as successful (or fun) without her!

Our conference presenters have gotten to know Wendy Walsh (or W2, as she sometimes signs her emails) very well over the past six to eight months. She is our conference producer, helping guide the speakers from the planning stages of their presentations through to execution at the actual conference. She keeps track of speakers’ presentations, makes sure their travel arrangements are set, ensures their presentations meet ANCC continuing education requirements, and a host of other tasks required to keep the sessions full of quality information. She helps prepare our room moderators to produce the best session experience possible.

Maggie Gagnon does a fantastic job both behind the scenes leading up to the conference and throughout the conference to generally ensure that the entire event runs smoothly.

Jess Carbone is the brain behind our ACDIS conference App, adds messaging, uploads materials, and trains the rest of the ACDIS staff on how to use the App. We love seeing the attendees interact through the app and post updates from the sessions.

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Staff working at the registration desks

Mary Ann Genovese, Kerry Neenan, Jennifer Hollis, and the rest of our exhibit hall support staff do a great job working with exhibitors and organizing floor plans, and assisting and directing attendees during the conference.

Andrea Kraynak, Stephen Andrews, Nicole Votta, Rebecca Hendren, Linnea Archibald, Sharme Brodie, Allen Frady, Shannon McCall, and Wendy Walsh: These lovely people will be our room moderators for our five session tracks, making sure the sessions ran as smoothly as possible. They’ll let you know where the bathrooms are, ask you to silence your cell phones, and remind you to use the microphones to ask your questions at the close of the session. They will keep the rest of the conference group updated via the App on interesting quotes and tidbits from each presentation as well.

Sheila McGrath, Erin Smith, Sarah Devlin, Melissa Varnavas, Penny Richards, and everyone in the ACDIS booth will be available to explain the various books, pocket guides, newsletters, and other products available to help CDI programs train their staff and grow. In between sessions, the booth will be open to attendees who wish to make a purchase or ask a question, and they will be ready and eager to help.

Mary Ann Genovese, Kerry Neenan, Jennifer Hollis, and the rest of our exhibit hall support staff do a great job working with exhibitors and organizing floor plans, and assisting and directing attendees during the conference.

Melissa Ketelsen (in customer service in our Tennessee office), Shannon McCall, Dave Garvey (both onsite) and our registration folks make the registration process run so smoothly, and for answering attendee’s questions, fixing or replacing badges, and providing support throughout the conference.

Casey Thomas, Mike Mirabello, Matt Sharpe, Mollika Sun and AnnMarie Lemoine do a fantastic job organizing ALL of the pieces here in the office that gets shipped to the conference! Their efforts ensure that we have everything we need to run a successful event onsite.

The list goes on, and surely we’ve still left off a few names! It takes a huge group of people to make the conference as spectacular as it always is. The conference wouldn’t be what it is without the effort of each and every person on this team.

Note from the Associate Director: Learn from the best around in CDI

R_Hendren

Rebecca Hendren

By Rebecca Hendren

One of the tasks I enjoy most in my role as the ACDIS associate director of membership and product development is getting to interact with our book authors and CDI Boot Camp instructors. Many of these talented professionals have been involved in CDI longer than they’d care to admit, but through that experience have developed a keen insight into advancements in the industry along with a desire to share that knowledge with ACDIS and with the larger clinical documentation improvement community.

Once a year, at the ACDIS national conference, we also get to see their expertise in action as they share pearls of wisdom in one of three pre-conference events.

This year, CDI Education Director Laurie Prescott, MSN, RN, CCDS, CDIP, CRC, and Shannon McCall, RHIA, CPC, CCS, CCS-P, CPC-I, CCDS, CEMC, CRC, director of the HCPro suite of coding Boot Camps, bring a two-day version of their risk-adjustment record review and coding program.

If you never been in a class with these two, trust me, it’s a blast. I know. I know. As the associate director of membership and product development, I’m supposed to tell you that—but I mean it. As someone who comes from neither a clinical or coding background, diving into something as complex as coding guidelines’ application to CMS-Hierarchical Condition Category (HCC) methodology is more than intimidating but these lovely ladies do a tremendous job of providing detailed instruction on the individual HCCs and opportunities for improved documentation with clinical scenarios to demonstrate how these concepts can be incorporated into CDI practice.

As an ACDIS staff member, I’m particularly lucky because I get to bounce around to a number of different sessions. So, I’m also looking forward to catching up with two of my favorite CDI people Richard Pinson, MD, CCS, and Cynthia Tang, RHIA, CCS, co-creators of the beloved CDI Pocket Guide. They’re teaching a pre-conference event designed to help CDI programs break down departmental silos into a collaborative, cohesive team. It’s called “Building a Best Practice CDI Team,” and throughout the program Pinson and Tang will explore the importance of understanding how your medical staff thinks and learns—and adjusting CDI efforts accordingly.

“A successful CDI team is based on engagement of medical staff obtained through effective communication,” says Pinson. “For example, physicians often respond to education using evidence-based literature and consensus guidelines. By collaborating with your team, you will find the methods that work.”

Over the course of the past year, I’ve also had the distinct pleasure of being able to work with Trey La Charité, MD, FACP, SFHM, CCDS, medical director of clinical documentation integrity and coding for UT Hospitalists at the University of Tennessee Medical Center (UTMC), as he crafted not one but two books—The CDI Companion for Physician Advisors and The CDI Field Guide to Denial Prevention and Audit Defense. That’s in addition to the volume, The Physician Advisor’s Guide to Clinical Documentation Improvement, that he co-wrote with James S. Kennedy, MD, CCS, CCDS, CDIP, president of CDIMD-Physician Champions.

I know how beloved both doctors La Charité and Kennedy are within our community and know how much people love their pre-conference deep-dive into essentially everything a CDI physician advisor needs to know to help CDI programs flourish. The second day of this preconference event includes a second track case study featuring Erica E. Remer, MD, FACEP, CCDS, and Kelly Skorepa, BSN, RN, CCDS, corporate manager of clinical documentation integrity for University Hospitals Health System in Cleveland. I’ve heard Remer speak during ACDIS Radio programs, so I’m interested in learning more from her as well.

If you’re already signed up for one of these pre-conference events, I’m sure you’re as excited as we are. If you’re still on the fence about whether these extra courses will meet your CDI program’s educational needs, check out the agendas on the ACDIS website or feel free to reach out to me to learn more.

Editor’s note: Rebecca Hendren is the associate director of membership and product development at ACDIS. If you have any questions, please reach her at rhendren@acdis.org.

Guest Post: It begins and ends in Patient Safety

Jocelyn Murray

Jocelyn Murray, RN, CCDS

By Jocelyn E. Murray, RN, CCDS

My CDI journey began at a level one trauma and teaching hospital in New Mexico. I accepted a permanent recruitment position and relocated out west. I shifted my career role from case management into CDI Implementation. There, I reported directly to the Chief Safety Officer, a well-respected medical professor for the university.

The CDI program (CDIP) implementation focus at the university hospital was on patient safety. How else would I be enticed to change scope of practice? I wanted to continue my nursing mission and help insure quality patient care. The CDIP aimed to:

  • Identify documentation omissions
  • Capture unexpected postoperative events
  • Clarify if the events were inclusions of care or unexpected outcomes
  • Identify any adverse effects during the patient encounter

The CDIP focused on improved quality by means of safety and risk identification linked to inpatient care. We provided lunch-and-learn sessions for insight to the medical and surgical provider teams. The forums reviewed quality and safety findings, provided documentation education and launched a query process as part of the CDI review to obtain documentation clarification necessary. The CDI specialist acted in a liaison role to utilization review (UR)/case management, quality, and nursing, and raised awareness of the identified untoward events that occurred during inpatient care. The CDIP brought awareness to the multidisciplinary team and new processes of documentation capture were established. New processes of identification for early intervention were also an indirect result of the awareness.

It’s now eight years later, and CDIP expansion led to a nationwide implementation of necessary CDI software tools, the improvement in financial impact tracking and reporting, capture of secondary comorbid (CC/MCC) diagnoses, and recognition of APR-DRG severity of illness/risk of mortality (SOI/ROM) indicators. All actions assisted in the practice’s more accurate capture of patient acuity and identifying the severity of care provided.

Nevertheless, the CDIP role in quality and safety recognition has never faltered. Quality documentation and Value-Based Purchasing (VBP) data transparency kept a light on patient safety, and the lost revenue impact associated has now been identified. Patient safety indicator (PSI) reviews remain a key component of CDIP practice for documentation excellence. PSIs have a critical impact on practice performance and the identity of PSI exclusions can protect facilities from financial loss. A wide variety of agencies offer public reports comparing both hospitals and physicians, allowing the savvy patient to choose only the safest, highest rated medical and surgical care. Does your program have a clear picture of the report and what impact it makes?

The impact of imprecise documentation with inaccurate coded data is measurable. Consider a random consultant audit of 14 facility records, four of the records identify likely inaccurately coded cases triggering established PSIs. The inaccuracy carries an error weight of greater than 28% on both the practice and provider quality statistics and corresponding revenue impact. CDIP PSI audits are critical; they increase compliance adjustment and the ROI. CDI specialists with quality training insight recognize the key diagnostic terms required to accurately clarify untoward event documentation in a safety audit. The list includes some of the following:

  • Inclusion
  • Exclusion
  • Clinically indicated
  • Necessary
  • Required
  • Inherent
  • Routinely expected

Patient safety queries and documentation integrity education will bring focus towards a greater understanding of the impact these specified diagnostic terms hold. A diagnosis identifying the condition as part of the post-operative and medical care will then also prevent a coded error.

In addition, PSI exclusions, as noted in the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Enhanced Version 5.0 reference, provide insight into diagnoses that do not meet PSI definition if combined with other acuity indicators. To learn more about quality and safety documentation and reporting, click here. You’ll find great material for provider education as well.

Editor’s note: Murray is a senior CDI consultant for HIM services at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. Advice provided is general. Contact Murray at jocelyn.murray@comforcehealth.com.

 

Conference Corner: Make time to check out the Poster Session at the Conference in Las Vegas

By Penny Richards, CCDS Coordinator and Member Services Specialist

2016 Poster Session

2016 Poster Session

Along with a dizzying number of education sessions at the ACDIS Conference in Las Vegas next month will be the annual Poster Session. These science fair-style presentations allow a selected group of your colleagues to present their CDI team and facility’s challenges and success stories, condensed onto a poster. Posters will be on display throughout the conference in the Exhibit Hall.

Presenters will be on hand during the morning break on Thursday, May 11, (10:15 to 11:15 a.m.) to talk to you about their poster and answer your questions. You’re sure to come away from the Poster Session with great ideas to incorporate into your CDI program to help build your own success story.

2016 Poster Presenters

2016 Poster Presenters

Here is a list of topics you’ll find at this year’s Poster Session:

  • CDI Report Card: Physician CDI Education
  • How to Avoid a Query Initiative: Educating the Physicians
  • Implementation of the Stop Sepsis Collaborative
  • CDI 2.0: Education for the Newer CDI
  • CDS Competency Validation
  • Putting the PSI in CDI
  • Key Chart Reviews Using SharePoint
  • Improved SOI and ROM Documentation
  • Provider Perspective on Charting Compliance and Query Success
  • Pediatric Malnutrition
  • CDS Coverage and Query Delivery
  • Remote CDI Challenges and Solutions

    Browsing the posters

    Browsing the posters

  • Shared Note Query in EPIC
  • Growth and Success at Tidelands Health System
  • Building a Successful CDS Team
  • Finding Data Hidden in Obstetrics and Prenatal Records
  • Career Ladder: Review Assignments by Units
  • A Retrospective Denials Review
  • Strategies to Improve Provider Query Response Rates
  • Out DRG Analysis and Review Taskforce (DART).
  • Our successful CDI/HII (Health Information Integrity) Remote Team
  • Transition from Traditional CDI Practices to Innovative CDI Practices
  • Shift from Regional to a System Approach to CDI
  • CDI in the Rehab Setting
  • Physician Engagement with TEMPO Board Rounds
  • MS-DRG Groupers Assigned to the MDC 24
  • Revitalizing a CDI Program to Promote Orientation of New Staff
  • Daily CDI Huddle: Team Meeting
  • Oncology Documentation: Improving SOI and ROM
  • Development and Implementation of a CDI Ladder
  • Impact CDS Impact on Quality Reporting and Documentation Accuracy
  • From Failing to Exceeding Goal in Three Months
  • Financial Impact of CDS in Critical Access Hospitals
  • Candyland: A Fun Look at CDIs and Physicians Engagement
  • Complications of Care: A Retrospective Review

You will find a list of all of the posters in your conference bag so you can make notes of which topics you find particularly interesting for follow up after the conference.

We will take photos of each poster and put them on the ACDIS website after the conference. We will also post a one-page description written by the presenter, including their contact information, so you can reach out for more helpful information about their topic.

Maybe you will present your success to conference attendees in 2018!

Book Excerpt: Understanding basic types of denials

Twist_Tanja

Tanja Twist, MBA/HCM

by Tanja Twist, MBA/HCM

You can’t manage what you don’t understand. So, the first step in any effective denials management program is to develop an understanding of the what constitutes a denial, as well as the different types of denials and their contributing causes.

Capture and categorize denials by their specific reason and dollar value, to deep dive into the type(s) of services being denied, the type of claim, the physician, payer, department, person, or situation that caused the denial. Despite a large number of denial reason codes used throughout the industry, all of them generally tie back to a few basic denial types: medical necessity or clinical denials, and technical denials.

Medical necessity or clinical denials

Medical necessity or clinical denials are typically a top denial reasons for most providers and facilities. They are also known as hard denials, in that they require an appeal to request reconsideration. Denial reasons that fall under this category include:

  • Inpatient criteria not being met
  • Inappropriate use of the emergency room
  • Length of stay
  • Inappropriate level of care

The primary causes of medical necessity denials include:

  • Lack of documentation necessary to support the length of stay
  • Service provided
  • Level of care
  • Reason for admission

Providers must ensure physician and nursing documentation clearly supports the services billed and that the physician’s admission order clearly identifies the level of care. One of the most effective means of ensuring compliance is through the implementation of a CDI program,  either internally or outsourced to a qualified vendor. A successful CDI program facilitates the accurate documentation of a patient’s clinical status and coded data.

Implementing a successful CDI program is typically one of the most challenging pieces of the denials management process, but it is the most important for long-term success. First obtain the support of the executives and physician leadership within the organization and second, but equally important, identify a physician champion to serve as the liaison to the physicians, reviewing chart documentation, and providing feedback on how to prevent denials moving forward.

Technical denials

Any nonclinical denial can be categorized as a technical or preventable denial. Causes of technical denials can range from contract terms and/or language disputes or mistakes related to coding, data, registration, or, charge entry errors, and charge master errors. Other technical denials may be caused by claims submission and follow-up deficiencies and denials pending receipt of further information, such as medical records, itemized bills, an invoice for an implantable device or drug, or receipt of the primary explanation of benefits (EOB) for a secondary payer claim.

All healthcare claims need to be submitted in adherence with federal, state, and individual health plan requirements and all claims need to be submitted in a timely manner. Other claim submission errors can be caused by claims being sent to the wrong address or even the wrong payer. Technical denials are known as soft denials because they can usually be reprocessed by providing a corrected claim or other additional information to the payer.

Editor’s note: This article is an excerpt from HCPro’s new handbook in the Medicare Compliance Training Handbook Series, Denials Management, published in January 2017 and written by Tanja Twist, MBA/HCM. This excerpt originally appeared in the Revenue Cycle Advisor.

Conference Conversations: What are ACDIS speakers looking forward to most?

ACDIS 2017

ACDIS 2017

“It’s in Vegas. Need I say more?” jokes William E. Haik, MD, FCCP, CDIP, who presents “Sepsis: 1, 2, 3—RAC Attack!” on Day 1, in Track 1, at 1:45 p.m.

Hardly a week goes by without a mention of sepsis in the medical literature, whether peer-reviewed scientific journals or non-peer-reviewed medical publications. Recently, more evidence has surfaced that seems to support the importance of Sequential Organ Failure Assessment (SOFA) in the risk assessment of sepsis patients, according to a recent White Paper on the topic from the ACDIS Advisory Board. And there continues to be conflict between clinical language, coding language, and the language required by quality assessment programs. (Read the related White Paper on the topic on the ACDIS website.)

But Haik, a founding member of the ACDIS Advisory Board, has a knack for breaking complicated clinical and coding conditions into manageable pieces of information, providing concrete examples of what clinical indicators CDI specialists should look for in the medical record and how to best craft a query to convey the patient’s condition in codeable terminology. Just as he has a knack for a quick comeback and rich and hearty laughter.

“We arm wrestle during my talk,” he says. “Just kidding,” he adds. “In reality, I’m trying to get participants to think inside the box! I want to get everyone to think clinically as a physician would.”

Striking a serious tone, he adds that presentations on quality, hierarchical condition categories, and value-based purchasing represent topics of interest. “I’m really looking forward to expanding my knowledge,” he says.

He’s not alone. The 10th annual conference features many physician presentations including that of Ronald Hirsch, MD, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who presents on Day 2, Track 4, 11:15 a.m. to 12:15 p.m.

Hirsch knows how CMS’ regulations and guidance can confuse even the most astute clinician with its vague and often contradictory instructions. Nevertheless, these regulations affect everyone—doctor, patient, bedside nurse, case manager, CDI, billing and coding, even healthcare executives.

While his presentation “Medicare Regulation Update: Practical Application for CDI Professionals” promises to shed a light on this often opaque information, Hirsch is looking forward to learning just as much from his peers and other breakout sessions throughout the conference.

2016 pre-cons

2016 pre-cons

“With the breadth of courses available at the conference, I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference physician advisor Boot Camp. It will be an honor to hear from Erica Remer and James Kennedy, two of the most renowned physicians in CDI,” Hirsch says.

Fellow physician, Nicole Fox, MD, MPH, FACS, CPE, medical director of pediatric trauma and CDI at Cooper University Health Care in Camden, New Jersey “cannot wait to hear about other program’s successes,” she says.

Fox, who presents “Playing to Win: How to Engage Physicians in Clinical Documentation Improvement,” on Day 3, Track 3, from 11 a.m. to noon, says she’s particularly interested in ambulatory CDI as Cooper University plans for its next area of growth and expansion.

Just as Fox looks forward to hearing other people’s CDI success stories, she’s excited to share her own, too. “One of the strengths of our program is physician engagement,” she says. “Physicians are never taught how to document, so they struggle with this much-needed skill set and are often hesitant to ask for help.”

Cooper University’s CDI program, however, tracks a 100% response rate to its CDI department queries, a rate at least partially attributed to the peer-to-peer education Fox helped establish.

“I think one of the general challenges with physician engagement is not recognizing that the best way for physicians. There is no substitute for a practicing physician embedded in your CDI program who will proactively educate peers and handle any concerns that arise,” she says.

Cooper University also has a remote component to its CDI program. Past ACDIS Achievement Award winner Kara Masucci, RN, MSN, CCDS, and her manager Rebecca R. Willcutt, RN, BSN, CCS, CCDS who both work at Cooper University, join Boston Medical Center’s Lara M. Faustino, RN, BSN, CCDS for a panel discussion on Day 2, Track 2, at 9:15-10:15 a.m., for a panel discussion on remote CDI efforts.

General session networking

General session networking

Like Fox, Faustino’s looking forward to learning from industry experts and peers and, of course, “networking! I always enjoy learning from a variety of CDI professionals from across the nation and it always amazes me how very similar we are, or how vastly different we approach the same types of challenges.”

When Jeff Morris, RN, BSN, CCDS, now CDI supervisor at University of South Alabama Health System in Mobile, first started in the role it was as a liaison between coding and physician staff to provide documentation education related to ICD-10 specificity. With numerous ICD-10 delays, however, Morris transformed the program, added staff, and expanded into focus areas such as CDI in obstetrics and gynecology, which he’ll explore on Day 1, Track 5, at 3:45 p.m.

“I am most looking forward to the networking and collaboration that occurs between CDI professionals during these few days. I always leave the conference refreshed and full of new ideas to bring back and implement at my facility,” Morris says.

There’s a lot to get excited about this year, especially with the 10th anniversary festivities. What sessions are you looking forward to most? What’s your favorite part of the ACDIS conference every year?

Lunchtime

Lunchtime catch-ups