RSSAll Entries Tagged With: "clinical documentation"

Note from the CCDS Coordinator: Over the Y92.838 and through the Y92.821 to Grandmother’s Y92.01 we go

Penny

CCDS Coordinator Penny Richards

By Penny Richards

Ah. Thanksgiving. While the ACDIS team will be out of the office for the Thanksgiving holiday and Black Friday, we know that the opportunities for mishaps requiring medical attention are far too plentiful to mention. We wouldn’t want to leave you without ACDIS’ guidance in this trying time, so here is a short list of codes that might prove helpful to the on-duty clinical documentation specialist. [more]

Book excerpt: Unexpected CDI effects

Trey La Charité, MD, FACP, SFHM, CCDS

Trey La Charité, MD, FACP, SFHM, CCDS

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

No new hospital initiative operates in a vacuum. And there is no way to anticipate every consequence of your CDI program. Even with the best intentions, there will be downstream consequences to navigate.

Let’s start with the first place your program’s effects will be noticed: the medical records department. If you didn’t know, your medical records department maintained a Discharged Not Final Billed (DNFB) or Discharged Not Final Coded (DNFC) list before the advent of your CDI program. [more]

Q&A: Acute pulmonary insufficiency

Have CDI questions?

Have CDI questions?

Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (PSI) if it’s failure. 

A: Our process is to review the chart and see if it meets clinical evidence for additional specificity such as acute respiratory failure. If it does not, does it meet clinical evidence for acute respiratory distress (now that there is a new code for that condition)? If it does not, then our CDI teams would not query. If it does meet the criteria, we would add all the relevant information from the record on the query and ask the physician if, in his or her medical opinion, the documented acute pulmonary insufficiency could be further specified. [more]

Note from the Instructor: Is your CDI program stagnating? Get out of the rut and fast!

AllenFrady_May2017

Allen Frady, RN, BSN, CCDS, CCS, CRC

By Allen Frady, RN, BSN, CCDS, CCS, CRC

The basic tenant of learning CDI is learning how MS-DRGs work, and the tiered structure of CC and MCC levels. That is the first step, to be sure, but it is not the final destination. In the new era of quality based reimbursement, there are a number of growth opportunities. And yet, I believe many (if not most) CDI programs are either missing completely or performing poorly in meeting them. In the age of bundled DRGs, 30-day readmissions, hospital acquired conditions, Medicare Advantage Plans, patient safety indicators, quality reporting, and mortality rankings, if you find yourself having a harder and harder time justifying the value of proper documentation to your chief financial officer, take another look at the current state of affairs. [more]

Note from the Associate Editorial Director: Consider the peer audit

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Associate Editorial Director Melissa Varnavas

By Melissa Varnavas

Back in 2015, 40% of ACDIS Radio listeners (of the October 28, 2015, broadcast) indicated their CDI program had an established query auditing process in place. Another 29% said they had some type of query review practices established but they only informally or occasionally take the time to examine the efforts of CDI specialists.

ACDIS has long advocated for some type of regular query practice audit and review—be that driven by the CDI program manager or director or peer-to-peer amongst the CDI team. Donald A. Butler, RN, BSN, then the CDI manager at North Carolina facility authored a White Paper regarding the auditing process and provided an in-depth PowerPoint presentation regarding the benefits back in 2012. In 2013, a number of professionals described the importance of such reviews and pulled the lid off for a glimpse inside their own processes in a CDI Journal article. [more]

Book excerpt: Peer review to ensure compliant query practices

Start your weekend with some CDI reading!

Start your weekend with some CDI reading!

By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS

Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and collaboration, and objective evaluation of the performance and effectiveness of individual CDI staff members as measured against your facility’s policies and priorities.

According to AHIMA’s “Managing an Effective Query Process” “Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes.” [more]

Q&A: Tracking denials

denials poll

Did you know 55% say CDI is involved in the denials management and appeals process?

Q: When looking at denials timelines, what information should be noted?

A: There are many critical time elements to capture during the denial appeals process. It is recommended that you add these to your denials database. If that is not possible, an alternative spreadsheet or database should be developed. The first date to track is the date that the denial or remittance advice (zero or underpayment) was received. The amount of time allowed to file your appeal will vary from payer to payer. When tracking timelines, it is important to note the: [more]

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

Brian-Murphy

ACDIS Director Brian Murphy

Part 4 (click here to view part 1, click here to view part 2, and click here to view part 3)

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America. In Part 2, I detailed the facts of the case. Part 3 looked at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI. Part 4, discusses recent developments of the case.

Since I wrote my initial three parts of the developing case of UnitedHealth Group, Inc. vs. the United States of America there has been a huge development on the legal front. Round 1 of the case of UnitedHealth Group, Inc. vs. the Unites States of America is over, and the decisive winner (at least in the matter of one complaint filed by the DOJ) is United. [more]

Guest post: Compliance risks abound in HCCs

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Let’s discuss the compliance risks CDI and coding professionals need to address related with hierarchical condition categories related to the MACRA.

Coding must be based on provider documentation, not what is entered on a superbill or computer software. ICD-10-CM code assignment is based solely on a provider’s documentation in the legal medical record, according to the 2017 ICD-10-CM Official Guidelines and Coding Clinic, Fourth Quarter, 2016, pp. 147–149. The problem is that many physicians document one way in their notes and then pick an ICD-10-CM code in their billing software or superbill that would not be assigned if one applies ICD-10-CM coding conventions based on the provider’s documentation.  [more]

Note from the ACDIS Editor: CDI Journal focuses on reimbursement concerns

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ACDIS Editor Linnea Archibald

By Linnea Archibald

Though any CDI specialist will tell you this profession isn’t about money, a facility’s reimbursement can certainly be affected by CDI professionals’ work. Because of this undeniable fact, we’ve dedicated the November/December edition of the CDI Journal to the multi-faceted world of reimbursement.

Within the newest edition’s pages, you’ll find valuable information covering reimbursement topics such as using PEPPER data for denial defense and tracking CMI metrics. You’ll also get a glimpse into the non-reimbursement fueled world of PPS-exempt cancer centers. [more]