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Guest Post: Discharge summary critical to hospital data quality and pay-for-performance, part 1

James S. Kennedy

James S. Kennedy

Probably the most onerous duty physicians have is the preparation of the inpatient discharge summary, especially after a long or complicated hospital stay. To be frank, I hate doing discharge summaries. I’ll find every reason to put them off. If I look at the current medical records delinquency list, I’m not the only one who has DCSAS, or discharge summary avoidance syndrome (which, by the way, does not have a code in ICD-10-CM). I’m sure you know someone similarly afflicted.

Given my unfortunate condition, I force myself to promptly and completely perform my discharge summaries—and there’s no better motivation than the realization that CMS and other payers are moving us from fee-for-service to what they call a quality- or value-based reimbursement system, as described by HHS Secretary Sylvia Burwell last December in a post on the Health Affairs Blog. I believe that Dr. Tom Price, Donald Trump’s new HHS Secretary, shares the same agenda.

Our success with these inpatient quality and value measurements is largely predicated on how well, and how timely, we organize and assemble our discharge summaries. While the admitting history and physical (H&P) is crucial for good patient care and utilization review, in ICD-10-CM/PCS-based coding and quality measurement, the discharge summary is even more important.

Why is the discharge summary more important than the H&P? There are several reasons.

First and foremost, receiving physicians look to the discharge summary to understand what inpatient diagnoses and treatments the patient obtained. Physicians are now accountable for preventing readmissions; thus, a well-constructed discharge summary will guide physicians at a skilled nursing facility or an outpatient clinic in continuing that diagnostic or treatment plan and keeping the patient out of the acute-care hospital. As such, the summary should be completed on the day of discharge and contain all acute and pertinent chronic diagnoses addressed, treatments administered, and consequences anticipated so the receiving physician can quickly understand the patient’s condition.

Second, the discharge summary represents the hospital’s final diagnostic statement of what the physician believes caused the patient’s symptoms. This is essential to assigning complete and precise ICD-10-CM codes, which factor into severity and risk adjustment. Sadly, ICD-10-CM coders are not allowed to clinically interpret the record to assign codes—they can only use the words we write or dictate.

Unless we continue to document acute diagnoses and underlying causes as they are diagnosed (e.g., documenting when established, documenting to say whether the diagnosis is better or worse, and finally documenting in the discharge summary), the coder cannot confidently assign all the ICD-10-CM codes to describe how sick our patients are.

Editor’s note: To read part 2 of this article, come back to the blog next week! 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. 

 

 

Conference Update: Things to do in Las Vegas, part 2

ACDIS Conference Corner

ACDIS Conference Corner

Last week on the blog, we provided readers with a list of fun indoor activities to keep you busy when you’re not in the conference. If hiking and adventuring are more your speed, though, the Las Vegas area offers a wide range of attractions for you as well.

Below is a list of suggested activities for the outdoor enthusiast. Enjoy!

To read our list of indoor activities, click here.

  1. Red Rock Canyon National Conservation Area: Red Rock Canyon National Conservation Area, located 20 miles from Las Vegas Strip, allows visitors to hike, picnic, and view plant and animal life under 3,000-foot-high red rock formations. It’s open daily 8 a.m. to 4:30 p.m. Learn more at http://www.redrockcanyonlv.org/.
  1. Valley of Fire: The Valley of Fire is a 35,000-square-mile state park, named for the magnificent red sandstone formations formed from great shifting sand dunes during the age of the dinosaurs more than 150 million years ago (Mesozoic Era). These brilliant sandstone formations can appear to be on fire when reflecting the sun’s rays. It is located in the Mojave Desert approximately 58 miles northeast of the Las Vegas. Learn more at valley-of-fire.com/.
  1. Boulder City: Boulder City is located about 20 miles outside Las Vegas (and on the way to the Hoover Dam). You’ll find great restaurants, shopping, and antique stores. Learn more at bcnv.com.
  1. Hoover Dam: No trip to the area is complete without a stop at the Hoover Dam. The damn holds back the waters of Lake Mead and straddles the border between Nevada and Arizona. You can take a bus tour from the Strip. Learn more at vegas.com/attractions/near-las-vegas/hoover-dam/.
  1. Ghost towns: There is a way to step back into the Silver State’s astonishing past. Dotting the vast landscape of Nevada are countless ghost towns, and while indecipherable ruins and tumbleweeds mark some, others are surprisingly intact. Either way, these remarkable places are portals into a Nevada of old and certainly worth a wander. Learn more at lvlg.com/lasvegas/attracts/ghstwns.htm.

 

Q&A: Coding guidelines for COPD and pneumonia

Q: I’m having problems determining the correct coding guidelines for chronic obstructive pulmonary disease (COPD) and pneumonia. Have the guidelines changed regarding COPD and pneumonia? Do you now have to code the pneumonia as a COPD with a lower respiratory infection?

A: Yes, the AHA’s Coding Clinic for ICD 10-CM/PCS, Third Quarter 2016, discusses an instruction note found at code J44.0, chronic obstructive pulmonary disease with acute lower respiratory infection requires that the COPD be coded first, followed by a code for the lower respiratory infection. This means that the lower respiratory infection cannot be used as the principal diagnosis. We would assign code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) as the principal diagnosis, followed by an additional code to identify the lower respiratory infection.

If the patient has an acute exacerbation of COPD and pneumonia, we would assign both codes J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) and code J44.1 (chronic obstructive pulmonary disease with acute exacerbation). Per the instructions, either code may be sequenced first and it should be based on the circumstances of the admission, followed by a code to identify the infection, such as code J18.9 (pneumonia, unspecified organism).

CDI specialists and/or the coding staff need to clarify the type of infection to ensure the proper code assignment. There does seem to be some concerns regarding classifications of lower respiratory infection. Per the Coding Clinic, acute bronchitis and pneumonia are both included in code J44.0 (lower respiratory infections). Influenza, on the other hand, is not included in code J44.0 because it is considered both an upper and lower respiratory infection.

Additionally, the type of pneumonia needs to be clarified. For example, aspiration pneumonia (code J69) is not classified as a lower respiratory infection, but as a lung disease due to the external agents. To assign the appropriate code in the case of aspiration pneumonia, we would need to know the external agent, i.e. milk versus vomit.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.

 

Book Excerpt: Physician engagement from the start

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

Physician support in the CDI decision-making process from the CDI program’s inception helps physicians see beyond the immediate obligation of documentation to the greater good such documentation provides.

Physicians, as a group, tend to have similar personality traits. For example, physicians are:

  • Educated, so give them definitions
  • Scientists, so give them data
  • Proud, so illustrate how they rate against their peers
  • Results oriented, so give them a goal

Many argue that the best form of physician education is physician involvement. The earlier physicians get involved in CDI development, the greater their investment becomes. At the CDI program’s inception, medical staff leadership or the facility’s chief medical officer (CMO) typically join the CDI steering committee to set overall goals from the program and expectations for physician response, involvement, and training. Physician investment in CDI at the highest levels trickles down through the physician ranks and encourages the involvement of the entire medical staff in day-to-day documentation improvement activities.

Many programs hire a physician advisor to act as a mediator between medical staff and CDI professionals. If your program has a physician advisor, tap into his or her experience. He or she often plays an important role in identifying CDI targets and providing both group and one-on-one education.

Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

 

Radio Recap: Brundage discusses denials and physicians communication

ACDIS radio

ACDIS radio

Editor’s Note: Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group, LLC, in Redington Beach, Florida, presented on the January 11, 2017, installment of ACDIS Radio. The title of the program was “Denials and effective physician communication.” This Q&A was developed from conversations during that session. Should you have any questions regarding the material, please reach out to Brundage at DrBrundage@gmail.com.

Q: Have you encountered denials based on “Late Entry” where CDI query response was received after discharge?

A: This is a technique by the auditor to deny a reasonable diagnosis. The CDI team can query the physician up to the time of the final coding. Getting the query response and therefore clarification of the documentation and/or diagnosis in the official medical record allows the diagnosis to be coded and included in the final coded record. This should be accomplished no later than 30 days post-discharge.

Q: There are many primary care physicians who round in hospitals and flat out say that they don’t care about CDI, they’re not interested, or they refuse to hear education. How do we get through to them?

A: Leverage the influence of your physician advisor and/or chief medical officer to encourage them and share the value of CDI efforts with the rest of the medical staff. This helps both the facility and the physicians with value based care, length of stay (LOS) metrics, cost per case, case mix index, as well as CC/MCC capture and DRG shifts. Improving these aspects, in turn, help the physician in optimizing severity of illness (SOI) and risk of mortality (ROM) metrics. CDI also helps with the various measures included in CMS’ value based purchasing. Physicians who have managed Medicare patients (we all do at this point), benefit from record reviews focused on specificity related to the capture of diagnoses for hierarchical condition categories(HCC) as well.

Q: Can the CDI team do anything to help prevent short-stay denials?

A: Ask the medical director to review the chart of the denied claim to determine if the medical necessity of inpatient admission was met. If the medical director or CDI physician advisor believes medical necessity was met, have him or her reach out to the auditor over the phone for a peer-to-peer conversation before drafting an appeal letter. We get 89% of soft denials approved at the peer-to-peer level, but this number falls off dramatically if you allow these to become full denials that require an appeal letter. Your physician advisor can call and get these overturned with a collegial conversation much easier than a letter can.

Q: Do you have any recommendations on appealing a denied diagnosis due to clinical indicators, but in the discharge summary it states “possible” or “probable” and treatment was the focus of diagnosis?

A: Review for the clinical criteria to support the diagnosis documented in the medical record. Remember the CMS 72-hour payment window allows 72 hours of outpatient data to support your inpatient diagnosis. For example, the emergency department (ED) (an outpatient setting) documentation may support the inpatient diagnosis made at the time of admission. Fight denials of conditions that were present in the ED, but improved at the time of admission. These are valid diagnoses according to the CMS 72-hour payment window.

In addition, review the record to see if the following conditions for a secondary diagnosis were met:

  • Clinically evaluated
  • Therapeutically treated
  • Necessitated a diagnostic test or procedure
  • Increased length of stay (LOS)
  • Increased nursing care or monitoring

 

Conference Q&A: Manchenton digs into surgical CDI

Manchenton

Cheryl M. Manchenton, RN, BSN, CCDS

Editor’s Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Cheryl M. Manchenton, RN, BSN, CCDS, senior inpatient consultant/project manager with 3M Health Information Systems, overseeing CDI programs, who will present “Anatomy of an Operative Note: A CSI Analysis of Operative Notes Gone Bad.” Manchenton specializes in workflow design, program management, quality metrics, and performance. She is responsible for the 3M quality services and quality services training materials and hosts the 3M CDI Management Roundtable. Manchenton is a guest for ACDIS Radio on the March 22 at 11:30 a.m. EST. She will be providing a brief preview of her conference presentation that you won’t want to miss! To register for ACDIS Radio, click here.

Q: What’s the biggest challenge you encountered in your experience with surgical CDI programs?

A: The biggest challenge is lack of timely operative notes or detailed daily progress notes. In other words, minimal documentation by surgeons including a comprehensive list of chronic conditions.

Q: What are three things attendees can expect from your session?

A: Our session will be at minimum entertaining. Attendees can expect us to share very common pitfalls with operative note templates, strategies for collaborating to improve and results of effective collaboration.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: Instead of complaining about who’s fault something is with poor documentation, coding or quality metrics, I hope our session will show attendees some creative ways to actually improve.

Q: What are you most looking forward to about this year’s conference?

A: Collaboration!

Q: Fun question: What is your favorite animal and why?

A: I love otters. They work hard but play hard too. They know how to make work fun.

 

Book Excerpt: Documenting the discharge process

Birmingham_Jackie

Jackie Birmingham, RN, BSN, MS, CMAC

By Jackie Birmingham, RN, BSN, MS, CMAC

Editor’s note: For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition, by Jackie Birmingham, RN, BSN, MS, CMAC. This excerpt originally appeared in Revenue Cycle Advisor, here.

Whether writing a note, completing a flow sheet, or entering information in an electronic record, a discharge planner is capturing data: facts related to actions, reactions, and decisions. For the purposes of this example, a discharge planner is writing the story about the planning that occurs to prepare for a patient’s transition to the next level of care.

Information entered into the medical record describes the final discharge plan for the patient. Organizations implement documentation policies to guide discharge planners regarding what the medical record must include.

The Conditions of Participation (CoPs) require documentation of the assessment or evaluation of a patient’s discharge planning needs. CDI specialists can use the following CoPs (c) Standard (c) to ensure the minimum evaluation topics are documented including

  • “Admitting diagnosis or reason for registration;
  • Relevant comorbidities and past medical and surgical history;
  • Anticipated ongoing care needs post-discharge;
  • Readmission risk;
  • Relevant psychosocial history;
  • Communication needs, including language barriers, diminished eyesight and hearing, and self-reported literacy of the patient, patient’s representative or caregiver/support person(s), as applicable;
  • Patient’s access to non-health care services and community-based care providers; and
  • Patient’s goals and treatment preferences”

The list above reflects the minimum standards. Discharge planners should use this list as a tool to audit a sample of patient charts to determine whether their hospital meets these minimum requirements. After completing an audit, compare the findings to the facility’s documentation policy to determine whether it addresses all necessary elements. Use this activity as an opportunity to identify potential quality improvement initiatives. Although this list aims to aid in assisting in patient discharge needs, CDI specialists can look to these notes to identify additional documentation improvement opportunities or for evidence supporting the need for a physician query. Additionally, CDI specialists should be aware of the wide variety of documentation required throughout the patient’s care, what each documentation requirement’s purpose may be, and the parties responsible for ensuring the accuracy of those documents.

 

Guest Post: The CDI buzz about CMI: What your facility metrics mean

What's your case-mix index?

What’s your case-mix index?

Jocelyn Murray

Jocelyn Murray

By Jocelyn E. Murray, RN, CCDS

There’s no question of the financial sustenance facility case mix index (CMI) provides. An elevated CMI level indicates an increased severity (or acuity weight) in surgical and life sustaining levels of medical care. Facility budgets are formed around the CMI, it is the acuity weight representing the average facility case and therefore reflects upon reimbursement. It makes perfect sense that this marker is a strong point of reference in the financial revenue department and a CFO focus. CMS.gov gives the following description of the CMI:  the average DRG weight relative weight calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.

We know our financial leaders focus on the CMI on an ongoing basis, but is it a true indicator of our CDI operational assessment and program productivity?

In my opinion, the CMI is a good tool to compare area hospital performance at a similar acuity level for medical and surgical care. We know a comparable facility with a much lower CMI can be a direct reflection on missed documentation and lower acuity weighted diagnostic codes. CDI intervention then consists of a provider education plan to improve documentation and capture the severity. Pre-billed audits ensure the acuity is also captured in final coding. Both are standard elements of the CDI process and program interventions.

It can also be a useful tool to help identify how outpatient CDI focus programs in the ED, short-stay surgery, and observation practice levels help ensure CMI accuracy. The DRG for a patient admission that does not meet medical necessity, indicates the patient’s care could have been provided on an outpatient basis. It could also have a critical impact on the CMI.

The lower weight CMI, as reflected by the DRG in this case, is tossed into the bucket as part of the calculated averaged acuity level for the site. One or two occurrences of low CMI weighted inpatient cases may not be a concern, but a handful of cases would certainly have a detrimental overall effect.

In my first years of CDI program implementation, the facility had a significant drop in the CMI over a couple of months during the summer. I dug into the metric further and discovered the top two acuity case surgeons in both neuro and orthopedic were away on vacation. A significant drop in surgeries occurred, and a small number of high-acuity procedure cases were performed and made available in the in that period’s calculation. Of course, the surgeon’s absence had nothing to do with our CDI program productivity efforts. And yet, the CMI drop was brought to my attention by the chief financial officer (CFO) who questioned the cause as CDI productivity. Together, we reviewed my identified findings and took the opportunity to bring forward critical information to the leadership team. The CMI changes had no reflection on the CDI program impact in the absence of surgical caseloads available during that time period.

CDI programs (CDI) are working at more advanced levels in 2017 and need to focus on understanding how their CMI metrics are effected and how the program responds. One key performance of the CDIP is identification of the root cause with any metric change.  Only then can you can establish a responsive goal and develop an individualized action plan for intervention.

In my case, a report identified the absence of two key surgeons and the effects of their absence on revenue for the facility. It was then up to the executive leadership and chief medical staff to strategize on how to prepare, plan, and focus actions for this type of revenue impact in the future.

Editor’s Note: Murray is a senior CDI consultant, HIM services, at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. She has expertise both in program assessment and enhancement to improve the quality, productivity, and effectiveness of CDI programs within an organization. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.  Contact her at jocelyn.murray@comforcehealth.com.

 

 

Note from the Director: CDI success requires more than a credential

Which credential/certification/licensure makes for the best CDI specialist? RN? RHIA? MD?

If you answered all of the above—or none of the above—you’re on the right track, according to a new Position Paper written by the ACDIS Advisory Board published on the ACDIS website.

To be blunt, no licensure or credential can identify whether someone will succeed as a CDI specialist. Not even ACDIS’ own Certified Clinical Documentation Specialist (CCDS) certification can guarantee that. We do, however, require anyone who sits for the CCDS exam to have two years of experience as a CDI specialist, so we feel good about the competency of our CCDS-credentialed professionals. CCDS holders must understand the basic core competencies and have demonstrated their skills in the field already.

But is that person a guaranteed fit with your culture?

Is that person dependent on an encoder or other computer assisted coding/natural language processing (CAC/NLP) tool that your hospital does not have?

There are many other factors that make up a good CDI specialist. As the new Position Paper explains, these factors include:

  • Effective verbal and written communication
  • Self-directed with an ability to work independently to complete the work at hand
  • The ability to think critically
  • A commitment to lifelong learning

The new Position Paper also notes that a strong clinical foundation is a must for any CDI specialist, and hiring an RN, MD, or an RHIA with strong clinical acumen will certainly fulfill that requirement. But, it’s no guarantee of success as the paper states:

“Credentials do not guarantee whether one will succeed as a CDI professional. Credentials merely identify the body of knowledge in which that person was originally trained. Prior bodies of knowledge certainly assist one’s success, and credentials and/or licensure provide identification of one’s stated profession and their level of education or achievement, but they do not ensure CDI competence. There is a number of necessary skills that cannot be ensured or captured by a credential.

It always comes down to the person. Why should CDI be any different?

If you’re wondering whether a Position Paper represents ACDIS’ official stance on an issue, you can find the answer here. Our recently published “Hierarchy of Authority” explains the order of significance of our published articles. ACDIS Positon Papers are peer-reviewed and represent the consensus opinion of the advisory board. We hope you find “ACDIS’ ‘Hierarchy of Authority’ of published articles” helpful as you navigate our website.

Editor’s note: This article originally appeared in CDI Strategies. Brian Murphy is the director of the Association of Clinical Documentation Improvement Specialists. Contact him at bmurphy@acdis.org.

Radio Recap: Technology and its impact on CDI

26596_ACDIS-Radio-logo

ACDIS Radio

As with all aspects of the medical field, new technology shifts CDI. Sam Antonios, MD, FACP, SFHM, CCDS, a board certified internist and CDI and ICD-10 physician advisor for Via Christi in Wichita, Kansas, shared his thoughts on technology’s effects on CDI during the November 29, 2016, ACDIS Radio broadcast.

At his own facility, Antonios deploys new technologies, which gives him a unique perspective on implementation. “Technology needs to be viewed as something that is happening and cannot be ignored. It will influence and it will shape the future,” Antonios said. “We’ve gotta embrace it and learn to live with it. But not only that, learn how to [leverage] it as a competitive edge because there is a large and vast need for that type of skill set,” Antonios advised.

The typical workflow for CDI staff at Via Christi goes something like this: reviewing charts, recognizing opportunities, and sending queries to providers and physicians. Technology influences the way all these steps happen, according to Antonios.

Technology also changes the physical location of the CDI professionals within the hospital, according to Antonios. When paper charts were the norm, CDI specialists had to physically be on the floor of the facility. Now, they can work from their offices in the facility or even from home. While this shift improves things like commute time and efficiency, it can have a negative effect on CDI/physician relationships, Antonios warned.

The relationships between CDI specialists and physicians are important. Because of this, Antonios said that all parties need to be more intentional. Relationships can erode under this new system. “There’s gotta be strategies that compensate for that remote work. Otherwise, over the long run, those relationships are at risk. Those relationships are very critical to get the query back, for education, and for training for some of the residents,” Antonios said.

As far as Natural Language Processing, Antonios said that his facility is in stage two. The logarithms for the Natural Language Processing are getting a lot better in his opinion. In the next stage, the systems will not only pick up on words but also start to detect intent and underlying meanings. This could totally change how a CDI professional conducts the review process. As it stands right now, the Natural Language Processing systems are “hit or miss” for CDI professionals, according to Antonios.

Physician-facing Natural Language Processing could advance the CDI process even further. If the system made suggestions to the physician as they created and updated their records, it could limit the number of queries and speed up the CDI process. “I suspect that we’ve got three-to-four years to really see it mature,” Antonios said.

Although the advent of new technologies has many benefits, Antonios did acknowledge some potential drawbacks. Copy/past errors pose one of the biggest problems with electronic health record technology. The computer cannot tell what pieces of the record have been copy/pasted and therefore it can miss mistakes and opportunities for a query. It’s the “one thing that keeps tripping up all Natural Language technology,” Antonios admitted.

Sepsis detection presents another potential pitfall. Over the last month, Antonios’ facility tried to fine-tune the algorithm for sepsis detection. “We are still in the early stages of making sure that technology is as close to predictive prognostication such as a human being,” Antonios said. In some cases, the technology may have increased sepsis detection, but the mortality rates did not change.

CDI specialists “need to pay attention” over the next few years as Antonios foresees all facilities moving to completely electronic documentation. CDI staff need the skills to guide the physicians in optimizing their documentation. “I think of the CDI role now as a little bit of a hybrid to be similar to an informaticist’s role. [CDI specialists need to] become super users,” Antonios advised.

With all the new technologies, Antonios said that “no one in the hospital is better positioned to be at the elbow of physicians guiding them through best practices in documentation than a CDI.”

Editor’s Note: ACDIS Radio is a bi-weekly, free, webinar featuring ACDIS Director Brian Murphy with case study presentations and interviews with some of the CDI industry’s most cutting-edge practitioners. Tune in every other Wednesday at 11:30 a.m. ET. Register at https://acdis.org/acdis-radio. To review the remote CDI poll on the ACDIS website, click here. For more information on remote CDI, read this “Ask ACDIS” and this article. The February 2016 Quarterly Conference Call also featured a discussion of remote CDI, and this article offers some rational for remote positions.