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Tip: Improving CDI-physician relationships

Experts agree that a collaborative healthcare environment leads to better patient outcomes and improved organizational success. Despite this, long-standing tensions between nurses, coders, CDI specialists, and physicians can be difficult to overcome.

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Note from the CCDS Coordinator: Is it time to recertify your CCDS credential?

ACDIS 522

CCDS Coordinator Penny Richards

by Penny Richards

In the next couple months, hundreds of CCDS holders will need to recertify their credential. Even those who’ve gone through the process may need a quick refresher. So, without further ado, here are some tips and hints to help you have a smooth recertification process.

You may recertify up to 60 days before your due date. Not sure when it is due? Look at the date on your certificate (the one you have framed and hanging on the wall, of course). Your recert is due every two years from the date you passed the exam. You can also email me (prichards@acdis.org) and I’ll check your due date in the CCDS database.

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Tip: Diversify your CDI education to keep staff engaged

Every CDI specialist knows how difficult it can be to set aside a whole hour or more for dedicated training and education. With productivity expectations and quotas, cutting out a sizable chunk of time for learning can be challenging. Diversifying CDI education tactics can help engage staff in more meaningful ways.

Though electronic health records (EHR) and technology sometimes complicate the CDI process in select ways, CDI managers and leaders can harness technology to increase educational reach. [more]

Q&A: Denial management teams

Have CDI questions?

Have CDI questions?

Q: What guidance do you have for building a denial management team?

A: As with any team, it is important to have the right players working together with identified roles and responsibilities established for each. The members of the denials management team should be representative of departments with a direct tie to the various types of denials. Include the following groups: [more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

Determine the underlying cause of the altered mental status

Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:

  • Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.

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Symposium Update: Early bird hotel discount ends August 17

outpatient logo

The ACDIS Symposium: Outpatient CDI is currently sold out!

There are only a couple more days left to get a discounted hotel room rate for the ACDIS Symposium: Outpatient CDI. Reserve your room by Thursday, August 17 to take full advantage of the discount. The symposium takes place from September 18-19 at the Hilton Oak Brook Resort and Conference Center in Oak Brook, Illinois.

When you book your hotel room by August 17, you’ll get the discounted room rate at the Hilton Oak Brook Resort and Conference Center for $159 (tax and fees not included). To book by phone, call 866-275-6295 and mention ACDIS.

Please note that the Outpatient Symposium is sold out. If you have registered and know you won’t be able to attend, please notify customer service to allow others into the event.

 

Note from the Associate Director: Announcing a new outpatient version of the CDI Pocket Guide

R_Hendren

Associate Director Rebecca Hendren

By Rebecca Hendren

Outpatient CDI is a fast-growing area of the profession. So, I’m excited to announce a new resource that will be an incredibly useful tool for those expanding to the outpatient arena. Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, authors of the CDI Pocket Guide, are currently finishing their work on a new version focused on Hierarchical Condition Categories (HCC): the 2018 Outpatient CDI Pocket Guide!

One of our guiding principles at ACDIS is to be at the forefront of changes in the industry. We want to provide our members with guidance, information, and resources they can turn to for education and clarification as they venture into new CDI focus areas. We’ve been publishing articles exploring the growing outpatient and ambulatory arena for several years now and will continue to do so as this segment of the profession grows and changes. We want to keep our fingers on the pulse of what’s going on and share that knowledge with our members.

We bring together leading thinkers in the profession who can share their expertise, whether through articles in the CDI Journal, innovative sessions at our annual conference or the new outpatient-focused ACDIS Symposium, or lively discussions in the ACDIS Forum.

I’m delighted that the trusted authors of the CDI Pocket Guide are equally forward thinking and partnered with us to develop a this new resource.

Please continue to let us know what information you need and what resources you would like ACDIS to offer. We really do listen to you and use your feedback to develop our editorial directions.

Editor’s note: Hendren is the associate director of membership and product development at ACDIS. Contact her at rhendren@acdis.org.

UnitedHealth Group, Inc. versus the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian Murphy

By Brian Murphy

The work of a CDI professional can at times seem isolating and unimportant. Does it matter if a query gets answered? When we educate physicians and tell them what they document matters, are they listening?

Then a case comes along and demonstrates not just that the CDI profession does matter—but that it matters a lot.

That point was driven home to me while reading a May 16, 2017 court document, United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., in which the Department of Justice (DOJ), alleges that UnitedHealth artificially increased Medicare Advantage (MA) reimbursement/Hierarchical Condition Category assignment by mining for non-supported diagnoses that were not documented/reported by the physician or through chart documentation.

The case is a qui tam—a lawsuit brought forward by a private individual. The plaintiff is Benjamin Poehling, the former Director of Finance for UnitedHealthcare Medicare & Retirement (and its predecessor Ovations), which was the group at United that managed its MA plans and its Medicare Part D prescription drug programs.

The lawsuit seeks to recover more than $1 billion under the False Claims Act. The total damages sought are unspecified but it’s a large case with a lot at stake.

This case has received quite a bit of coverage, too, from big newspapers like the New York Times and popular healthcare websites like Beckers Hospital Review and HealthLeaders Media.

There is a lot more to this case than this 103-page court document, though. In addition to Poehling’s case (filed in February 2017), another whistleblower, James Swoben, a former employee of Senior Care Action Network Health Plan and a consultant to the risk-adjustment industry, came forward with similar allegations in March.

In a very recent development, UnitedHealth Group’s lawyers are seeking to get the case dismissed, claiming that they are not required to validate the accuracy of diagnostic data submitted by healthcare providers.

I need to reiterate that, at this point, the claims asserted against UnitedHealth Group are only allegations and there have been no determinations of liability. It remains to be seen whether the case will even reach court.

However, the case ultimately resolves, it’s a very interesting, real-world, big-dollar example of the business of healthcare, raising the question of who is ultimately responsible for the accuracy of submitted diagnoses to Medicare (coders, CDI, administrative contractors, physicians?). It calls into question the oft-repeated adage that coders must code what the physician documents. It brings into even greater prominence the process of clinical validation, for which ACDIS recently released a new white paper.

Reading through these articles and the original court document, I thought to myself, if only UnitedHealth Group had a robust, compliant CDI process in place, this suit could have been prevented. More than anything, United States of America vs. UnitedHealth Group Inc. is confirmation that your work as a CDI professional matters, and that the broader CDI profession matters.

I plan to share my thoughts on this case in a series of blog posts here and I welcome your thoughts and commentary.

Editor’s note: To read the summary of the case, visit the DOJ website by clicking here. To read the court document in its entirety, click here. Brian Murphy is Director of the Association of Clinical Documentation Improvement Specialists (ACDIS). He can be reached at bmurphy@acdis.org.

 

 

Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

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Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.

Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at www.nejm.org/doi/full/10.1056/NEJMcps1603154. [more]