All Entries Tagged With: "AHIMA"
AHIMA calls for CDI presentations
Could CDI be becoming a healthcare buzz word? It seems like everywhere I looked over the past few weeks healthcare documentation improvement specialists played a prominent role.
Remember I mentioned the Health Care Compliance Association’s upcoming CDI presentation at its Physician Practice Compliance Conference in Philadelphia? This week I heard about American Health Information Management Association’s (AHIMA) call for speakers for its June 2010 conference.
The AHIMA program focuses on CDI and coding and takes place in San Antonio, TX. Over the two-day speakers are expected to talk about CDI program challenges and best practices and explore the difficulties of communicating across CDI and HIM channels. According to the AHIMA release, the deadline for presentation proposals is Friday, October 23. For information, contact Kathy DeVault, RHIA, CCS, manager of professional resources at AHIMA at Kathy.DeVault@ahima.org.
Don’t worry the AHIMA program doesn’t overlap with the ACDIS 2010 annual show in Chicago — that’s June 3-4 (or 2-5 if you plan to attend the pre conference and take the CCDS exam). And not to repeat myself, but how great is it to watch the documentation improvement profession gain the credence it deserves from its sister organizations. Communicating a consistent message at a variety of professional organizations can help CDI illustrate its value to rest of the healthcare system in America.
To lead or not to lead: Forming compliant queries
“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”
~Hamlet, Act III, Scene I
Shakespear as CDI? Hummm. . .
I truly think that Shakespeare was a frustrated CDI nurse.
I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:
“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”
If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.
Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?
I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.
AHIMA to start CDI work group
Back in March, AHIMA sent out the call for volunteers to help establish a new work group on clinical documentation improvement. The initiative comes as part of the association’s e-HIM effort and aims to determine industry needs and CDI best practices, according to a release.
“We were overwhelmed with the number of people who wanted to volunteer,” says Kathy DeVault, RHIA, CCS, manager of professional practice resources at AHIMA in Chicago.
ACDIS Advisory Board members are among the list of volunteers. DeVault planned to notify participants and begin a series of weekly, work-group calls in early April but the influx of interest pushed the start date back slightly.
Recap of fifth quarterly conference call
The fifth ACDIS quarterly conference call took place Thursday, November 20. That’s right, folks, it was our fifth! That means we’ve just passed our one year anniversary. Thanks to all of you who’ve helped to grow this organization and make it the success it’s been so far. We certainly look forward to more successful programs and events as we move quickly through the holidays and on to the New Year!
Speaking of successes, we had a lively discussion regarding AHIMA’s September release of its brief on how to conduct appropriate physician queries. As ACDIS Director Brian Murphy pointed out during the call, ACDIS submitted comments to AHIMA regarding the brief prior to its final publication. Many ACDIS members offered their opinions and helped to guide the final version.
The brief provides a framework description of what CDI specialists do in the field and also expresses the simple fact of the growth of physician queries as a process in today’s healthcare world, said Lynne Spryszak, RN, coordinator of Clinical Documentation Management Program at Alexian Brothers Medical Center, Elk Grove Village, IL. The brief “is still what I’d consider more or less incomplete but it is an improvement over the original” drafts of the document, she said.
It’s important to remember that the AHIMA brief primarily targets HIM professionals, said Robert S. Gold, MD, CEO, DCBA, Inc., in Atlanta. Although all panel members agreed there was much to be gleaned from the content of the final brief for CDI/CDM programs.
Questions from Brian’s Mailbox
Brian Murphy (our beloved ACDIS Director) routinely gets loads of e-mail and as much as he would love to be able to answer each message or question personally, the sheer volume can be overwhelming. So…he’s tossed a few questions my way and asked if I could address them.
The following are a few questions from his “in-box”:
Q: Should we document verbal queries in the record? Should we include paper queries in the record?
A: This is a matter for your facility to decide with collaboration from the CDS, HIM, and compliance departments. Let’s see what AHIMA had to say about this issue in the recently revised query brief Managing an Effective Query Process:
“Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query will be a permanent part of the patient’s health record. If it will not be considered a permanent part of the patient’s health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subject to health record retention guidelines.”
So, there’s no hard and fast rule about this. Our facility does both. First, I’ll address the second part of the above question.
After the consultants leave…what now?
Hey, you CDS with new programs out there! How’s it going? Are you sailing along on the smooth seas of phenomenal MCC capture rates or are you stalled in the doldrums? Are you asking yourself the following question: “What do I do now that the consultants are gone?
Been there. Done that …twice, in fact! Are you finding that the people at your hospital who decided that a CDI program was a good idea are now saying things like “the CMI doesn’t seem much different” or “where’s the money they promised us”?
Don’t feel bad. You didn’t do anything wrong. You’re just feeling the pangs of aftermath: the training and support is over and now you’re alone and administration doesn’t even know what you do, exactly.
First, who do you report to? Someone who actually knows from a hole in the ground, or someone who wouldn’t know an MCC if it bit them? This isn’t a silly question. If the person making the decisions doesn’t know what you’re REALLY there for, it’s going to be hard to succeed and grow your program. So, invite this person to come to your team meetings and be sure to share your successes and tell him/her how much more you can do with their active support. [more]
AHIMA Takes Second Look at Revised Physician Query Practice Brief
Brian Murphy, director of ACDIS, asked me to say something about AHIMA’s decision to revise the Physician Query Practice Brief and provide some commentary on the first draft. While I’m unable to provide the complete text here I’ll try and paraphrase the sections that, in my opinion, still need some clarification and I’ll give some examples of the sections that I agree with.
The revised brief is presented in two sections:
- the first addresses current legal, regulatory and ethical issues, documentation, the query process
- the second part provides direction concerning compliance; specifically, auditing and monitoring and reporting and performance metrics
What the brief does not do is answer the all-time burning question “what constitutes a leading query?” or acknowledge that there is a difference between a nurse asking a physician a question (clinician-to-clinician) and a coder querying the physician. I feel that the “guidance” provided in the first draft does anything but guide.