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
- 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
- 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 email@example.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS.
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.
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 firstname.lastname@example.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.
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 email@example.com.
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:
- Clinically indicated
- 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 firstname.lastname@example.org.
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.
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.
“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.
“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.
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?
by Melissa Varnavas
Healthcare has often been referred to a both a science and an art. Nevertheless, the healthcare industry continues its hunt for proof of quality healthcare services to, as much as possible, remove the art portion of the art-versus-science debate. That’s why the March/April edition of the CDI Journal pulls from a range of experiences and expertise to examine the many ways CDI efforts touch quality measures.
As Congress continues working to dismantle the Affordable Care Act (ACA), a wide range of vested entities contemplate the future of government payment methods. Hospital value-based purchasing (VBP), part of the ACA, offers a number of incentives—both positive and negative—to more closely tie patient outcomes to reimbursement on a host of measures. VBP represents the most comprehensive government pay-for-performance program, but it’s easy to feel overwhelmed by its various components when also considering the myriad collections of quality-focused programs hospitals and physicians need to navigate.
Quality-tied payments and public reporting measures can seem like the multi-headed Hydra of Greek lore—no sooner has a CDI program focused on, and defeated, one serpent than two other initiatives pop into existence. CDI programs understand the need to expand record review efforts, now that CC/MCC capture isn’t their only documentation goal.
Cheryl Ericson, MS, RN, CCDS, CDIP, does a nice job of summarizing the shift in her “Note from the Advisory Board” on p. 6, and on p. 10, ACDIS Editor Linnea Archibald looks at the various components of CMS’ VBP efforts, including a review of hospital-acquired conditions and present on admissions indicators. These articles help illustrate the complexity of quality concerns.
These aren’t the only measures considered in this issue, either. Advisory Board member Sam Antonios, MD, FACP, SFHM, CCDS, offers three tips for programs to help improve outcomes in regard to readmission reductions on p. 8, and ACDIS member Bonnet Tyndall, RN, CCDS, provides readers with a case study of how her team implemented record reviews for mortalities on p. 19.
All these potential review targets can be daunting, but don’t be intimidated. Take a look through this edition of CDI Journal and note how many of these programs aim to capture some of the diagnoses already found on most CDI programs’ top 10 lists.
As ACDIS CDI Boot Camp instructor Allen Frady, RN, CCDS, CCS, says on p. 22, “times like these are exciting for us CDI nerds.”
Editor’s Note: Varnavas is the Associate Editorial Director for ACDIS, overseeing its various publications and website content. Contact her at email@example.com.
Time to take action
With the help of our hospital quality improvement (QI) committees, we can take action to restore the integrity of the discharge summary. Consider the following:
- Advocate timely completion of the discharge summary and overall chart, preferably within a week of the patient’s discharge. The Medicare Conditions of Participation require that the entire medical record be completed (i.e., signed, sealed, and delivered) within 30 days of inpatient discharge; some states, such as California, have stricter deadlines. Summaries must be performed within seven to 10 days if they are to be typed and signed prior to the 30-day deadline. Even with these generous deadlines, good patient care requires that we do our summaries as soon as possible.
- Insist that discharge summaries meet quality standards. Have the QI committee audit physician discharge summaries for at-risk conditions, such as pneumonia, myocardial infarction, and heart failure. Involve the coding manager or clinical documentation specialist to learn how the terminology used affects resource intensity or risk of mortality determinations. Follow up with a corrective action plan when deficiencies are found.
Thank you again for the efforts you take to ensure data quality. Please let me know of other topics you would like me to address in this column.
Editor’s note: This is the third part in a three-part series. To read the previous two sections, click here and here. Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.
By Laurie L. Prescott, RN, MSN, CCDS, CDIP
It has been 10 years since I turned the focus of my career to the practice of CDI. About a year ago, I found myself calling it a “profession.” I have been a proud member of the nursing profession for more than 30 years. In both my personal and professional life, I tried my best to represent my profession and demonstrate that nurses are highly competent, knowledgeable leaders in providing healthcare to patients. Nurses have been granted the privilege of witnessing and assisting others in their most intimate moments of life.
I never wanted to minimize the role of a nurse, nor misrepresent it in any way. I feel very much the same about the profession of CDI. We serve a very important role in our organizations in that we work to ensure our patient’s stories are told accurately and completely.
The profession of CDI encompasses a number of different titles, credentials and professions besides nursing, to include medicine and coding. And I am sure no matter how a person landed in CDI they too are as proud of their specific profession that started them off as I am of my nursing background. And I am sure, too, that most are also proud of the fact they are now a member of the CDI profession. (Read the recently released “CDI: More than a credential,” position paper from the ACDIS Advisory Board.)
Google the word profession and the definitions returned are all similar. Most state that a profession describes an occupation requiring specialized education, knowledge, training, and ethics. Members of a profession are expected to meet and maintain a common set of standards. Skills and knowledge are obtained through the process of lifelong learning and continuing professional development. Indeed, the ACDIS Code of Ethics reinforces that commitment to lifelong learning.
I was always taught that a profession must have a developed body of knowledge. The ACDIS Code of Ethics addresses this as well with the statement, “Clinical Documentation Improvement Professionals must advance their specialty knowledge and practice through continuing education, research, publications, and presentations.” It is up to each and every one of us to grow our body of knowledge.
So my question to you is—what have you done lately to represent your profession?
We all need to be leaders. That does not mean you have to speak at the national conference, or write articles and books, but it could mean becoming a leader within your own hospital organization or helping with your local ACDIS chapter.
When I was working daily in the CDI role, I spread the word of CDI in an activity I called the “CDI Road Show.” I took the road show to anyone, any department that invited me. (And even to some that did not extend an invitation!) I wanted everyone to know what we did because their support of those efforts could help foster our success.
I wanted to represent my profession well; meaning I tried to demonstrate competence, knowledge, and commitment to ethical practice in every activity and exchange performed. This commitment was as much for myself as it was for all the CDI specialists I worked with. If I presented as well prepared and knowledgeable to a provider, the next time that provider spoke to another team member he or she would understand the skills our CDI team brings to the game. If I could speak concisely to administration and communicate both the value of CDI and the needed resources, the administrative team would see all CDI staff as professionals, too.
And so, I encourage you to step up. Volunteer to serve on a committee. Start a “road show” of your own. Mentor a new CDI. Learn something new today.
Most importantly, walk strong and tall and demonstrate to the world the CDI professional that you are.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.
Nursing notes cannot be used for coding and billing purposes. This does not mean, however, that they’re worthless for CDI purposes. Often times, CDI specialists neglect reviewing this documentation because they know it can’t be coded. This is a mistake.
“Often times, it’s the nursing notes that will support queries for encephalopathy, delirium or other altered mental status conditions,” says Karen Bridgeman, MSN, RN, CCDS, CDI educator at the Medical University of South Carolina in Charleston.
While nursing notes can help with clinical indicators to support a query with patients of all ages, nurses’ documentation helps a couple of pediatric-specific diagnoses, for instance, thrush.
“One thing I’ve noted a few times is that nursing usually documents clinical indicators of thrush. The doctor orders Nystatin, but doesn’t document what he/she is treating,” Claudine Hutchinson, BSN, RN, CDI specialist at the Children’s Hospital at St. Francis in Tulsa, Oklahoma, says.
With sticky diagnoses such as malnutrition – an especially difficult diagnosis in pediatrics – nursing notes also often provide valuable information on the patient’s body mass index (BMI), height, and weight. Additionally, the nursing notes often provide clinical indicators to support clinical validity of an already present diagnosis of malnutrition, according to Laurie Prescott, RN, MSN, CCDS, CDIP, CDI education specialist at HCPro in Danvers, Massachusetts.
“Malnutrition in children is based, in part, on their failure to meet developmental milestones and deviations related to their z-score and the pediatric BMI scale,” Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BRL Healthcare in Middleton, Massachusetts, said in response to a question in CDI Strategies.
If the nursing documentation supports a diagnosis of malnutrition based on unique pediatric criteria, then a CDI specialist can use that information to support a query to the physician. Often, nurses record the information used to calculate BMI during the initial physical assessment.
Nurses also often document the present on admission (POA) status of pressure ulcers during initial assessments. Since pressure ulcers fall under the hospital-acquired conditions banner, it is vital to document their POA status. If a physician documents a pressure ulcer, check the nursing documentation for its status upon admission.
We work with our [providers] during rounds to be sure that POA status is documented for any pressure ulcers documented by nursing on the admission assessment,” Jackie Touch, RN, MSN, CCM, CDI specialist at CHOC Children’s in Orange, California, says.
Nursing notes can also provide a valuable education entry point for CDI specialists. “In some instances, it may be as simple as showing the physicians where they can access the nursing documentation. “The physicians did not know how or were unable to view the nursing flow sheets,” at Wake Forest University Baptist Medical Center before the CDI helped address the problem, says Melinda Matthews, RN, BSN, CCDS, manager of inpatient clinical documentation excellence at Wake Forest Baptist Health, which includes Brenner Children’s Hospital in Winston-Salem, North Carolina, in an ACDIS Q&A.
Even though coders cannot use the nursing notes for coding purposes, Prescott advises working the nursing documentation into your regular chart review process.
“[Nursing notes] often assist in understanding the patient’s baseline conditions, and often help us to identify any secondary diagnoses not mentioned in the provider’s initial assessment,” Prescott said in a response to a question in CDI Strategies.
Prescott also advises educating the nursing staff about the usefulness of their documentation in supporting clinical validation and identifying missing diagnoses and opportunities for clarification. The nurses can be a valuable asset in reaching CDI goals, so educate them accordingly, Prescott says.
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