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Book excerpt: Defining clinical documentation and coding standards in the revenue cycle, integrating real-time auditing, part 2

Lamkin_Elizabeth

by Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit every open chart and query providers to obtain clarifications and additional documentation when needed.

Placing CDI staff on the clinical units to audit chart documentation in real time and personally interact with physicians and other clinical staff, often helps with education effectiveness as well. The CDI specialist can query the physician to explain why the documentation does not meet criteria or does not really tell the story of the patient’s condition.

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Summer reading: Defining documentation and coding standards in the revenue cycle, part 1

Lamkin_Elizabeth

Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules. A facility’s revenue cycle plan should define the necessary education on documentation, when and how this education will be delivered, and how compliance with education will be reported.

It is difficult to hold physicians and other medical staff accountable for applying the rules if they are not educated on what the most current rules require. Physician engagement increases if education includes why documentation is so important and why it must be done correctly while the patient is still in the hospital. Physicians normally do not receive formal education or training on documentation to meet regulatory and coding criteria in their training programs or through continuing education; therefore, it is up to the hospital to stay current on regulations and documentation rules and to provide training to physicians.

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Summer Reading: Physician Education Discussion Scenarios

LauriePrescott_May 2017

Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example: The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids. For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Could you identify a probable etiology for her pneumonia? The physician responds, “It is probably due to aspiration.” The CDI specialist thanks the physicians and asks, “Could you please clarify that possible cause-and-effect relationship in the record?” She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”  Jane should then document this verbal query and the results as part of the CDI notes for this account. [more]

Summer Reading: Stepping out on your own

LauriePrescott_May 2017

Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

‘Flying solo’

After a few trial runs, new CDI specialists should be given the opportunity to review records on their own. Before composing any queries during this initial stage, the manager or mentor should review a draft of the query proposed and provide feedback to identify any additional opportunities and compliance concerns, as well as to save the fledgling staff member from any potential physician ire due to a misplaced query.

Such feedback should reinforce concrete rules of the CDI road and should be supported by official rational from governing bodies such as AHA Coding Clinic for ICD-10-CM/PCS, Official Guidelines for Coding and Reporting, ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, or in-house policies and procedures.  Of course, mentors and managers should offer their expert opinions and tips on how to practice effectively, as well. This feedback should also offer the new staff member an opportunity to voice questions and concerns, and accelerate the learning process. This step in the process can continue until the new staff member and the preceptor agree that the new CDI specialist is functioning well independently and is comfortable “flying solo.”

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Summer Reading: A letter to new CDI staff

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

Dear Clinical Documentation Improvement Specialist,

I remember my first day as a new CDI staff member very well. I had been through an extensive interview process—three interviews, a written test, and a meeting with the consulting firm that trained me. At the time, all I understood was that I was going review records and help medical staff meeting documentation needs. After more than 20 years of nursing experience, and time spent as a nursing school clinical instructor and in management, staff development, and healthcare compliance roles, I figured this would be an easy jump for me. It was a jump that felt like I had leapt right off a cliff.

I spent my first day training with two inpatient coders and the consultants. These two ladies were an interesting pair. One had been coding for more than 25 years, and I concluded she could diagnose most disease processes better than a number of physicians I knew. The second was new to the inpatient process, having coded in outpatient and clinic settings for a few years. We were implementing a new CDI program. Everyone looked to me to make this program a success. I soon understood this was much more of a challenge than I ever imagined.

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Summer Reading: Tips for preparing for the CCDS exam

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

Once you have met the two-year minimum work experience requirement required to sit for the Certified Clinical Documentation Specialist (CCDS) credential exam, it’s time to study. Start by reviewing CCDS Exam Candidates Handbook for information on applying to sit for the exam as well as the process for taking the test. The following are a few additional tips that many successful candidates have used to earn their certification:

  • Discuss with peers and supervisors
  • Join a study group
  • Visit the CCDS discussion board on the ACDIS Forum
  • Start studying early like a few months prior to sitting for the exam
  • Review a new content area each week
  • Spend extra time studying areas where you feel less confident
  • When reviewing practice questions multiple times, make sure you understand the concept and don’t just memorize an answer
  • Take a day or two to prepare your mind and body for the exam
  • Get a good night’s sleep and eat a good meal before taking the exam
  • Leave plenty of time to arrive for the exam

Once you are set to begin the exam, take a deep breath, exhale, and let your knowledge and experience guide you through successful completion of the certification.

Editor’s note: This article is an excerpt from the “CCDS Exam Study Guide,” by Fran Jurcak, MSN, RN, CCDS. To read more about certification, visit the ACDIS website, here.

 

Summer Reading: New CDI staff exercises to perfect the review process

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

Shadowing staff

Often, the first step in becoming comfortable with the CDI record review process comes from simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your facility, reach out to ACDIS via its CDI Forum or local chapter events. Consider calling nearby facilities, asking for their CDI department manager. Many CDI specialists willingly open their doors to those just starting out. If your CDI manager is willing (or has connections of his or her own), perhaps you will be able to shadow a neighboring facility to get a better idea of how different CDI programs function as well.

Many CDI program managers ask candidates to do this during the interview process so both parties better understand the basic competencies and expectations of the job. Other program managers gradually introduce new CDI specialists to the process by shadowing experienced specialists at least once per week for a set number of hours or records per day. Other programs may require new staff members to jump into the reviews as soon as possible. [more]

Book Excerpt: CDI’s role in inpatient-only procedure documentation

Mackaman_Debbie

Debbie Mackaman, RHIA, CPCO, CCDS

By Debbie Mackaman, RHIA, CPCO, CCDS

Connect CDI, utilization review, and case management before the patient is discharged

When a procedure converts to an inpatient-only procedure during the surgery, the documentation process may get a little more complex. Analyze what happened during the procedure itself. If the inpatient-only procedure is performed on an emergency basis, it’s likely the admission order was not obtained prior to the procedure. The outcome for the patient will determine the next steps. If the patient expires, no further action is required by the registration or operating room staff. The coding and billing teams take over resolution of the case.

If the patient does not expire, the surgeon should confirm the type of surgery originally scheduled and the reason for the needed change to the inpatient-only procedure. He or she should do so before the patient leaves the postoperative area. The care team needs to make a determination regarding the admission of that patient. Under current CMS guidance, the three-day payment window may apply in this scenario. The case should be held for billing purposes until a thorough post-discharge review can be completed.

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Book Excerpt: CCDS exam format

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

The CDI specialist role is complex and multidisciplinary, suitable for clinically knowledgeable professionals who are proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals and objectives. These professionals possess knowledge of healthcare and coding regulations, anatomy, physiology, pharmacology, and pathophysiology. Furthermore, such professionals possess the valuable ability to engage physicians in dialogue and educational efforts regarding how appropriate clinical documentation benefits patient outcomes and the overall well-being of the healthcare system.

Therefore, the CCDS exam content stems from:

  • Analysis of the activities of clinical documentation specialists in a wide range of settings, hospital sizes, and circumstances
  • Input from ACDIS member surveys
  • Input and research of the CCDS advisory board comprised of experienced clinical documentation specialists

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Book Excerpt: Listen to the butterflies

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CDI Field Guide to Denials Prevention and Audit Defense

By Trey La Charité, MD, FACP, SFHM, CCDS

CDI professionals need to take seriously those fluttering feelings found in the pit of the stomach when anxiety arises.

Experienced coders often have what may feel like to the uninitiated as a sixth sense about compliant code assignment. Such professionals employ the breadth and depth of their experience to apply a wide range of coding guidelines to a particular scenario. So when the coding team expresses concern about a medical record’s final coding summary, wise CDI professionals take heed. Likewise, as a CDI professional’s experience grows and he or she becomes familiar with the coding system, common claims denials, and Recovery Auditor targets, they too will develop some degree of extrasensory auditor perception.

Overtime, coders and CDI professionals come to know problematic areas. Facilities that neglect to harness this level of expertise miss a tremendous opportunity to prevent denials before they’re issued.

As a wise man once said, “If it doesn’t pass the smell test, don’t code it.”

When such situations arise, CDI program administrators should take every effort to appease those butterflies.

For example, the 2013 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Process included an addendum recommending facilities develop a query escalation policy. The samples offer suggestions for CDI and coders to bring questions of clinical validity to a manager or steering committee for review.

Many CDI programs also create a reconciliation policy to handle any discrepancies between CDI and coder opinions regarding documentation and coder of a particular medical record. Effective programs establish collaborative methods of communication between the two departments, allowing both teammates the opportunity to ask each other questions and share information supporting their opinions. When unable to reach consensus, the case may get bumped to the coding/HIM manager and CDI manager/director to discuss or for the final determination.

Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS.