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Note from the instructor: Reminiscing over 10 years in CDI

SharmeBrodie_May2017

Sharme Brodie, RN, CCDS

By Sharme Brodie, RN, CCDS

One of the wonderful things that time allows us is the ability to look back with an experienced eye and either learn from the past or at the very least have some fun with it.

I remember my first weeks as a CDI specialist as if it just happened. It was a  grueling hiring process and I was thrilled to have gotten the job. Looking back, I have no idea why I thought this would be a good step in my career. None of us knew at that time what we were doing and we had no idea what to expect from this new profession. [more]

Q&A: Coding mixed cardiogenic and septic shock

Have CDI questions?

Have CDI questions?

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below. [more]

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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TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

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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]

Note from the Instructor: Take a road trip this summer

road trip

Take a CDI road trip this summer!

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

I recently taught a CDI Boot Camp at a large, multi-site organization, with attendees coming from CDI, HIM, and quality departments from four different sites. We began the week discussing the Official Guidelines for Coding and Reporting, moving through each Major Diagnostic Category (MDC), and talking about concerns related to code assignment and sequencing.

This discussion was very much a review for the attendees who hailed from the CDI and coding departments. The quality staff, however, coming from a variety of roles related to core measures, patient safety indicators, inpatient quality reporting, and hospital value-based purchasing, had continuous lightbulb moments.

One individual literally hit the side of her head and said, “This explains so much. How come we were not taught this before?”

After the first few days, I asked the quality department staff if they have ever told a coder or a CDI specialist that they “coded it wrong.” Almost every attendee raised their hand. I then asked the CDI specialists and the coders if they have ever been told they had coded a record incorrectly by an individual who had no understanding of coding guidelines. Every one of them raised their hands.

We discussed communications with providers, compliant queries, and practices of leading versus non-leading interactions when speaking to providers. Many of those who worked under the umbrella of quality spoke up to say that perhaps their discussions with providers had been leading. They never received education about how to compliantly query a provider for a diagnosis or how to query for removal of a diagnosis.

When we discussed sequencing new rules related to Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, I noticed the quality folks looking at each other and making faces. I stopped the class to ask what was wrong. They responded by asking when the change occurred. When I told them late last year—per guidance from AHA Coding Clinic, Third Quarter 2016—they all sighed and one expressed frustration about not knowing about the change earlier. They had been struggling to understand why admissions for COPD suddenly sky rocketed. One simple discussion answered a question they had been struggling with for months. And, as an added bonus, they learned why the coders were sequencing these diagnoses as they were.

As the week progressed, we talked about the specifics of a number of quality monitors—discussing what populations were included, exclusions, and the adjustments applied to organizations related to reimbursement. Now the coders and the CDI staff were asking why they hadn’t been taught this material before. They began to understand why the quality department was so concerned about the presence or absence of specific diagnoses. The quality staff were saying, “we need your help.” There was a purpose to this class: to knock down silos, learn from each other, and support each other.

I often describe our efforts as a group of individuals driving down a five lane highway. We have coders, CDI specialists, quality staff, case managers/utilization review staff, and denials management all traveling in their own lane. But, we are all heading to the same destination. We are all working to bring success to our organization. We wish to be recognized for the high caliber of care we provide, and consequently reimbursed appropriately for the resources we lend to that effort. Documentation is the key to this successful road trip. The providers are working to navigate safely on this busy highway with only the drivers to direct them.

As we travel down this road, we often swerve into each other’s lane. Often we are forced to swerve because the provider looks for guidance from us, assuming we understand the driver’s manual for the other cars on the road. If we do not understand every other driver’s role and their specific manual, we cannot support each other. We need to keep all our vehicles traveling in the same direction at a safe speed and ensure that as the providers try to cross the road we don’t run them down. It is confusing to providers if the CDI specialists instructs them one way and the denial management team tells them the complete opposite. Then they seek clarification from the quality coordinator and get a third interpretation of the “rules.” The providers are bound to give up and just navigate in the bike lane, never making any actual progress.

So, how do we learn to support each other? We need to step out of our comfort zones and spend some time with the other disciplines driving down that highway. We need to ask questions and answer other’s questions in return. We need to recognize that what we do affects the other’s work and work to support them. Large organizations often foster silos more than smaller organizations as they separate out the job functions more definitively. Often smaller organizations expect one person to wear a number of hats. Even though there are issues with overwhelming one individual, it also breaks down barriers.

Before you panic, I am not suggesting one person does it all. I am suggesting, though, that we intermingle a bit more, shadow different job roles, invite others to shadow us.

Take the road trip together—it’s more fun that way!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

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Guest Post: Relevant ICD-10 code proposals for CDI and coders

Allen Frady

Allen Frady, RN, BSN, CCDS, CCS

By Allen Frady, RN, BSN, CCDS, CCS

Editor’s note: The CMS ICD-10 Coordination and Maintenance Committee (CMC) met on March 7 and March 8 to discuss proposed code changes to ICD-10-CM and ICD-10-PCS. The committee is a federal committee comprised of representatives from CMS and the CDC’s National Center for Health Statistics (NCHS). The committee approves code changes, develops errata, addenda, and any other modification to the code sets. These code changes were discussed in hope of being amended in the 2018 code update, active October 1.

Among the many proposed changes to the code set, I noted 16 of particular interest to CDI specialists and coders. Remember, nothing is final until the September meeting of the CDC Coordination and Maintenance Committee(CMC), and of course, the CMS finalization.

AMI

Some of the most relevant talking points include possible changes related to heart disease. First, the CMC proposes reclassification of an unspecified acute myocardial infarction (AMI) to I21.9 AMI, including “unspecified myocardial infarction (acute) no otherwise specified (NOS).” Currently, “unspecified AMI” defaults to an STEMI. CDI specialists frequently prod physicians for additional specificity to ensure NSTEMI’s are not inadvertently reported as STEMI’s as it also affect quality standards.

Additionally, an unexpected proposal given the recent AHA Coding Clinic, First Quarter 2017, CMC proposes a new code I21.A1, Myocardial infarction type II (also called a Type II MI). Coding Clinic previously directed Type II MI to be coded as an NSTEMI. CMC’s proposal includes myocardial infarction due to demand ischemia and myocardial infarction secondary to ischemic imbalance as inclusion terms. The new proposed code would have a “code also underlying cause, if known” instructional note in the Tabular Index. Examples of precipitating events included in the proposal are:

  • anemia
  • chronic obstructive pulmonary disease (COPD)
  • heart failure
  • tachycardia
  • renal failure

There are, of course, other possible causes and the list provided is not intended to be comprehensive. This hopefully will circumvent the frustration CDI and coding professionals have had with the lack of an index entry for “Type II MI” for the last several years.

Other classifications of MIs exist. There are five in total and among the new code proposals for “other myocardial infarction type” specifies types 3, 4 and 5 as inclusion terms.

End-stage heart failure

Another interesting suggestion for the CDC comes from its recommendation for a new code for end-stage heart failure I50.84, to be used in conjunction with other heart failure codes. This represents potential for assignment to a higher level of severity within both the APR- and MS-DRG systems. There are also new inclusion notes for end-stage heart failure to be reported for the American College of Cardiology (ACC) stage “D” if the physician only writes “stage D heart failure,” it can be coded as end-stage heart failure. Furthermore, new inclusion terms direct the coder that diastolic heart failure and diastolic left ventricular heart failure include heart failure with preserved ejection fraction or with normal effusion. The same goes for systolic heart failure and the term reduced ejection fraction. Additional new codes related to heart failure include:

  • Acute right heart failure (I50.811) with an inclusion term of “acute ISOLATED RIGHT HEART FAILURE”
  • Biventricular heart failure (I50.82)
  • High output heart failure (I50.83)

I was somewhat unfamiliar with high output heart failure so for now, this reference from the National Institutes of Health will have to do:

“The syndrome of systemic congestion in a high output state is traditionally referred to as high output heart failure. However, the term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney. Many of the high output states are curable conditions, and because they are associated with decreased peripheral vascular resistance, the use of vasodilator therapy for treatment of congestion may aggravate the problem.” 

Surgical codes

The CMC proposed a number of updates related to surgical wound infections. There are several new proposals for obstetrics infection codes and there were also proposals for other wound infection codes, such as:

  • 41, infection following a procedure, superficial surgical site which accounts for a stitch abscess.
  • Deep incisional site under T81.42
  • Intra-abdominal abscess under T81.43
  • Slow healing surgical wounds, covered in the includes notes for T81.84, NON-healing surgical wounds per changes to the inclusion notes.

Additional recommendations

CMC has a few other suggestions CDI and coding professional need to note, such as:

  1. Moving late effects of cerebral vascular accident (CVA) from an Excludes I to an Excludes 2 category, which seems appropriate in light of Coding Clinic, Fourth Quarter 2016, p. 40, as well as the 2017 Official Guidelines for Coding and Reporting, advice to override the Excludes 1 note and code late effects when present in tandem with a new current stroke, anyway.
  2. A new code for immunocompromised status which includes terms for immunodeficiency status and immunosuppressed status, Z78.2. ICD-10 code Z78.21 covers immunocompromised status due to conditions classified elsewhere such as HIV or cancer, and Z78.22 immunocompromised due to drugs. In the past, immunocompromised status did provide for additional severity and it’s role in risk adjustment methodologies could expand.
  3. Proposed codes for the pediatric coma scale which could eventually provide some additional severity for cases with catastrophic neurological compromise. In this author’s opinion, these codes would be a welcome additional to pediatric hospitals seeking to properly adjust for their quality, outcomes and mortality metrics.
  4. Codes for nicotine dependence via electronic nicotine delivery systems (e-sigs, anyone?).
  5. Proposals for alcohol abuse, in remission. Also noteworthy, the term “Alcohol use disorder” seems to fall under the codes for alcohol dependence per newly proposed inclusion terms. The same proposals are provided for opioid abuse, in remission as well as cannabis, cocaine, sedatives, etc.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

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.