All Entries Tagged With: "education"
Dazed and confused? Or Encephalopathy?
Altered mental status, dementia, or encephalopathy: What’s really going on with your elderly patient that presents with confusion?
The typical scenario is the elderly patient with some minor dementia, who has been living fairly independently, who is described as being more confused than usual. A work up does not indicate any acute neurological conditions but the patient is admitted with altered mental status. Further work up often reveals an underlying infection or metabolic condition. After treatment of the underlying concern, the patient’s mental status returns to baseline and the patient is discharged back to their usual living arrangements.
Don't let dementia documentation confuse you.
The resources consumed in treating this type of patient often include a head CT, neurological consult, neurological checks, EEG, sometimes even a bed in the intensive care unit. But if the physician only documents altered mental status or dementia and not a type of encephalopathy, the true severity of illness of the patient may not be accurately reflected.
So what is encephalopathy?
As defined by the National Institute of Neurological Disorders and Strokes, National Institutes of Health, encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent, metabolic dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation) chronic progressive trauma, poor nutrition, or any reason for lack of oxygen or blood flow to the brain.
The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include tremors, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.
Coding Clinic provided a definition in the first quarter of 1988 (pages 3-4):
New e-learning courses open to ACDIS members
In my spare time, I am a creative writing student at a low residency program. Essentially, that
Not an actual sample.
means I’m taking a correspondence course on how to be a better writer. Every month I mail off a packet of papers. My adviser takes out her colored pens, marks them up, and sends them back. It is a little intimidating. I trust you share my “red pen” fears. But I graduate in January (hooray), and hopefully these writing lessons have made the Blog, e-newsletter, and other publications more enjoyable for you.
Sometimes, however, I catch myself wishing for a simpler way, something more akin to our own ACDIS online learning library. As far as I know though there are no writing CEUs for assistant association directors. But if you happen to be in the market for a convenient way to collect CEUs for coding, case management, or CCDS certifications, ACDIS can help.
Just last week we posted two new e-learning courses: one on hospital acquired conditions and another on present on admission. These new programs join sessions on 2009 IPPS MS-DRG update, understanding and applying the 2009 ICD-9-CM codes, inpatient coding: physician queries, and major complications/comorbidities.
Since I won’t be earning CEUs for writing this blog post, I’ll be jumping online in the coming weeks to tackle the ACDIS e-learning offerings myself. I promise to post my progress to all of you here. Feel free to place your bets now on how I’ll do.
If you’ve taken any of our courses please let us know what you think. ACDIS plans to add roughly four new courses every year and we’d love your feedback about what to concentrate on in 2010.
A Friday toast to lessons learned
Believe it or not there is an association for associations. And yes, Brian Murphy and I are soon to be members. Just as ACDIS provides a venue for CDI specialists to share best practices, the American Society of Association Executives (ASAE) and the Center for Association Leadership offers us helpful hints about how to help you. For instance, on the ASAE Blog “Acronym,” Brian Birch outlined a number of the valuable lessons he learned from his members.
I hope you can see where I’m going with all of this, my usual circular logic notwithstanding, since
'The Lesson' by Pablo Picasso. Don't we all have something to learn from one another?
what I’m hoping to convey is the power of circular learning. We all have something to learn from each other: The coder from the clinical experience of the nurse and the nurse from the regulatory understanding of the coder; the physician from the CDI specialist and CDI specialist from the specific knowledge of disease pathways locked away inside the mind of a physician.
So Mr. Murphy and I thought we’d put together a short list of items we learned from the members of ACDIS over the past few years. Things like:
- Once a nurse, always a nurse.
- Urosepsis is a four-letter word.
- Old physicians can learn new documentation tricks.
- Minutiae matters.
- It is easier to work with someone than for something.
- Be careful of the word acute.
And I think Brian Murphy and I learned the importance of the day-to-day work which CDI specialists pour their hearts into. As Mr. Birch wrote: “The best thing I have learned is that they are out there, professionals with strong minds and hearts who are just trying to make a better lives for themselves and their families.”
And so, a toast: To all the lovely lessons learned and all the casual teachers who have taken perhaps the briefest of moments to share their insights with me, their peers, and their coworkers. Please take a moment yourselves to post your own favorite lesson and give a shout out to the mentor who helped you most in the comment section below.
Chicago CDI Boot Camp sold out
That’s the good news and the bad news, I’m afraid.
On the good news side of the scale we place the fact that 32 people—that’s right, 32 people—registered for the four-day CDI Boot Camp being held at the Marriott Courtyard in Chicago/Schaumburg September 28 through October 1. The number of registrants speaks to the intensity of the educational needs of the profession as well as to the dedication of CDI professionals.
Of course, on the bad news side of the scale we place the fact that the Chicago program is, in fact, sold out. So anyone in the area who had hoped to register but was perhaps waiting for last minute approval from their director or other supervisor missed out, I’m afraid. We hope that if you’re in Chicago and did get shut out of the Boot Camp, you’ll be able to take some solace in the fact that the 2010 ACDIS conference will be held in the Windy City June 3rd and 4th, with the pre-conference coding essentials program and post-conference CCDS exam.
Just one more item to tip the scale to the positive. (I like to leave things primarily on a positive note, if possible.) Just because the Chicago program is closed doesn’t mean there won’t be other learning opportunities. The Atlanta, GA, program taking place at Hyatt Place October 12-15, still has multiple open slots. Just a note on that, the early bird hotel room rate ends on September 18, so if you are interested you might want to mention that to the powers that be. And the Boot Camp taking place at the Hilton Phoenix Metro Center in November from the 2nd to the 5th also has multiple slots open.
We are in the planning stages for the 2010 Boot Camp schedules now so if you want a session to come to your neighborhood, give us a shout. We hope everyone who attends the Chicago intensive has a great time and learns a lot.
Update physician education with tips from ACDIS members
A newcomer to the ACDIS group page on Facebook asked recently how to keep physician engagement in clinical documentation improvement high as CDI programs begin to mature.
To be sure, there’s always an initial excitement regarding new programs and the potential they hold for improvement. Sometimes, however, that energy begins to fade. Reading Tina Lewis Simpson’s comment I was reminded of a HealthLeaders Web cast, 5 Ways to Hospital-Physician Quality: Goals, Incentives, Dialogue, Infrastructure, Data, in which Rebekah Wang-Cheng, MD, FACP, medical director for clinical quality at Kettering Medical Center in Dayton, OH, offered several strategies to facilitate physician communication. Consider the following techniques to improve physician education and awareness of your CDI program:
- Educate one-on-one, face-to-face, in real time. When addressing a particular problem with physician documentation, don’t wait, says Wang-Cheng. Use a specific case that happened within the past day or two to illustrate your point.
- Educate in groups. Go where physicians gather, Wang-Cheng says. Offer education sessions during quarterly medical staff meetings, or specialty meetings
- Show data. CDI specialists constantly gather data, benchmark and report this data back to the physicians. When physicians see how appropriate documentation affects patient care and the overall mission/wellbeing of the facility they will be more likely to understand the mission behind your position.
- Walk in their shoes. Shadow a physician for a day to observe the pattern of their care. That way you’ll have a better understanding of the physician’s work flow. Armed with understanding you can adjust your query process to fit their needs as well as your own.
- Say, “Thanks.” If a physician is responsive to your inquiries, praise him or her for their helpfulness. Take your appreciation a step further, says Wang-Cheng, by sending him or her a thank you note to their home so they can show their family. “There’s nothing better than to be able to say to a spouse: ‘Look, someone said something nice about me.’”
- Start at the top. Approach physician leaders in various disciplines. This type of influence will help you “spread and sustain the education,” Wang-Cheng says.
- Listen as much as you talk. Emphasize with the physicians. Realize they have difficulties, both professional and personal, too. Don’t be afraid to admit ignorance but be sure to ask for their assistance when you do.
- Make the physician lounge a welcoming place. A CDI specialist may not have direct involvement regarding the physical location and ambiance of the physician lounge, but he or she can use the lounge as a way to get the word out about the CDI program. Visit often and leave specific, small tokens of appreciation from time to time.
Those interested in additional tips to gain physician support may want to click on Sylvia Hoffman’s blog posts, at right, including: Spring ideas to woo physician support and KISS method applies to CDI physician education, too.
Furthermore, thanks to North Cypress (TX) Medical Center Director of Clinical Documentation Improvement Mike Alcorn, LVN, there are some sample e-mail physician education packages available in our Forms & Tools Library. Read how he created his physician education strategy in CDI Strategies.
If you have any tips or innovative suggestions for how to spice up the physician education component for the more advanced CDI programs please post ‘em here. We love to hear what you’re up to. Besides what’s working for you may help solve a problem for someone else.
Don’t cut out ‘excisional’ when considering debridement queries
This is one case when you can't 'cut it out.'
Recently a client contacted me regarding a surgeon who asked the coding department to stop querying him about excisional debridements. His comment was that all his debridements are excisional. He’s a surgeon and he cuts. Bottom line. So please stop pestering him with the queries.
As most of us know, this clearly isn’t enough to code a record and has been the reason for a significant number of concurrent and retrospective queries across country in many, many hospitals. The simplest solution, of course, is for the physician to use the words excisional debridement but as we all know, that simple solution doesn’t always translate into simple reality.
What the client wanted to know was if they could make the assumption based upon his comment, that whenever he documented debridement, that he meant excisional and code to excisional. Again, I believe most of us would say that the documentation doesn’t indicate excisional and needs further clarification. So how do we get the documentation and not irritate the physician?
In an attempt to help clear the water surrounding the word “excisional,” many coding departments and documentation teams have made attempts to develop policies and procedures for clarifying this procedure. This became especially important with Recovery Audit Contractors (RACs) and other auditing agencies focusing on this specific procedure. Add to the mix the increasing number of elderly patients that are admitted with wounds that require care and then the number of non-excisional methods of treating these wounds. Clearly there is much to consider.
So what’s the best approach? Of course education is important. Physicians must understand the importance of their documentation and how a single word (or lack thereof) impacts the severity of illness, risk of mortality, and reimbursement. Communication of coding guidelines and definitions becomes an important function of a documentation improvement team.
Whether through queries, newsletters, posters or presentations, it is important for a documentation team to recognize the need for an ongoing method to provide support and resources to healthcare providers regarding documentation. We need to help providers learn the vocabulary that best represents the diagnosis and care they provide to the patient. Making assumptions or creating policies that allow for ambiguous interpretation of documentation will only create other problems.
So, clearly this particular surgeon needs to understand that if he performed an excisional debridement then he needs to document “excisional debridement.” Providing him with the information that defines an excisional versus non-excisional debridement is also important. Hopefully, once this information is shared, he will understand the need to include the appropriate words in his documentation. If not, that leaves the query process as an important part of the documentation process.
In answer to the question of whether it’s okay to eliminate queries for excisional debridement if the physician documents just debridement, only the provider knows the depth to which he or she cut and therefore it becomes the responsibility of that healthcare provider to document accurately and appropriately. I know this answer doesn’t necessarily make a CDI specialist’s day, but look at the bright side; it’s another opportunity to have a conversation with a physician and spread the word of complete and consistent documentation!
Examine secondary health data for documentation motivation
I’ve been hearing a lot lately about the perennial question of how to get to good ‘ole physicians to “buy-in” to the CDI system. Like my fellow blogger Sylvia Hoffman asks, “How do you get an old dog to perform new tricks?”
One way (and it seems like the government’s pretty keen on this method too) gaining popularity is another aphorism—the good ‘old carrot and stick. If physicians keep proper documentation they score better on a number of rating systems. If they don’t they (and the facilities they work for) get hit with RACs, MACs, poor ratings, decreased reimbursement, you name it. With so much incentive to improve documentation techniques you’d think it’d be a “no-brainer” wouldn’t you?
Here are four sites to keep your eye on when tracking quality trends.
HealthGrades: HealthGrades provides ratings and profiles of hospitals, nursing homes, and physicians to consumers, corporations, health plans and hospitals.
Health Care Cost and Utilization Project (HCUP): A family of healthcare databases and related software tools and products made possible by a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ).
The Leapfrog Group: The Leapfrog Group is an initiative driven by organizations that buy healthcare who are working to initiate breakthrough improvements in the safety, quality, and affordability of healthcare for Americans. Organizations voluntarily report certain data requested by Leapfrog, which is then published on the Leapfrog Web site.
Premier Hospital Quality Incentive Demonstration: The demonstration involves the Centers for Medicare and Medicaid Services (CMS) partnership with Premier Inc., a nationwide organization of not-for-profit hospitals, and will reward participating top performing hospitals by increasing their payment for Medicare patients.
Take advantage of opportunities for personal growth
A clinical documentation improvement (CDI) specialists’ focuses on educating physicians on the
Take advantage of educational opportunities where ever you find them.
merits and material benefits of complete, accurate, and effective medical record documentation on the practice of medicine. The CDI specialists’ goal is to affect positive change in physician’s documentation. CDI specialists also help the physician understand and appreciate his/her role in clinical documentation as a proactive and defensive strategy to meet the tough business economic climate challenge of healthcare.
In order to affect positive change and be successful in the role of CDI, the specialist need to view the duties and responsibilities inherent to the position through the eyes of a businessperson. Just as physicians are business people who happen to choose medicine as their line of business, CDI specialists’ are business people who happen to choose documentation improvement as their line of business.
As a businessperson, the CDI specialists has the responsibility of expanding and continually building upon his/her business skills through personal investment in tools and education as a strategy in becoming more proficient and effective in the business of CDI. It is incumbent upon the CDI specialist to maintain relevancy in clinical medicine through reading of the medical literature such as JAMA, New England Journal of Medicine, subscribing to Journal Watch publications, Mayo Clinic Proceedings, and other daily newsletters.
Other considerations include subscribing to the Harvard Business Review or Influence without Authority, and investing the time to refresh skills in negotiation and communication through coursework at a local college or adult education class.
A successful and competent CDI specialist will recognize the need for continual education beyond learning the basic CDI crash course taught and promoted by many consulting companies. The likelihood of success of a CDI program rests primarily on the CDI specialist, recognizing the value and worth of proficient business skills as a foundation for the delivery of physician clinical documentation education of long lasting benefit and use to both the institution and the physician.
Quite frankly, there is more to CDI than leaving clinical queries on the record in hopes of the physician answering the query. A CDI specialist can control his/her own destiny through development and honing of business, communication, and negotiation skills.
Let the opportunities begin.
ACDIS launches CDI Boot Camps
You’ve just been named the director of your hospital’s new clinical documentation improvement
For a four-day crash course in CDI try an ACDIS Boot Camp
(CDI) program and have the lucky opportunity to hire a handful of new staff. The skill set for this profession is diverse and nuanced. Once you find and hire the perfect candidate you still need to provide detailed education about the levels of expectations associated with their new career.
At the risk of sounding like an infomercial, I’ll come right out and say that these new “Boot Camps” can help. The CDI Boot Camp focuses on:
✓ Medical record review and physician query techniques
✓ MS-DRGs and reimbursement under the IPPS
✓ ICD-9-CM coding rules and regulations
✓ CDI program benchmarking and compliance initiatives
It’s a classroom setting course that discusses how to assess undocumented diagnoses based on clinical indicators; how to implement a step-by-step process for a thorough review; how the IPPS system works and how specific, accurate documentation determines hospital payment; how vital ICD-9-CM coding knowledge is to the overall CDI practice and compliance effectiveness of the facility; how to assess and query physicians regarding problematic diagnoses such as congestive heart failure, sepsis, renal disease, and encephalopathy, to build clinical skill-sets and medical record recognition
Phew, there’s a ton of other information that’s being covered during the four-day course. For more information about the CDI Boot Camp, download the .pdf of the brochure, contact Customer Service at 800/780-0584 or e-mail bootcamps@hcpro.com. ACDIS members save $150 off the registration fee.
It takes a hospital. . .
A recent hospital audit of 300 medical records turned up some not too surprising facts about physicians. The doctors are still not documenting appropriately, their handwriting is illegible, and the discharge summaries are inadequate.
Recent changes in CMS regulations have made certain wording and diagnosis linking imperative for hospital coding and reimbursement. The new rules are confusing and complicated. Certain words need modifiers, certain diagnosis must be linked to their causative agents, other conditions must be rated as acute, exacerbated, or unstable.
Old dogs need to learn new tricks.
There is an old expression that “You can’t teach an old dog new tricks.” I am starting to wonder if this shouldn’t also include physicians. I work in the Clinical Documentation Improvement office and we strive to educate physicians on the nuances of clinical documentation. This recent audit indicates that we still have a lot of work to do.
I attended parochial school my entire life and I spent most of my formative years having to stay after school for poor penmanship. I still have terrible handwriting and I missed out on a lot of fun. This only goes to explain why I cannot criticize someone for having poor handwriting. The new computer era is upon us and with the advent of electronic medical records it also may be a mute point. I do not give penmanship classes.
However, like that old dog, the problem may be that seasoned physicians are too old to learn new techniques for documenting patient care. Perhaps we need to start educating the physicians sooner, when they are still in medical school.
The problem may be the lack of incentive. Perhaps the physicians need some sort of pay for performance to entice them to change their old habits.
Or the problem may be that hospitals need more upper management support for their CDI departments. Perhaps a series of speeches given by the CEO would get everyone motivated.
The problem may be a lack of educational resources. Perhaps hospitals should invest in teaching tools and educational literature.
The problem may be everything mentioned above and then some.
Clinical documentation teams across the country are working diligently to educate physicians and improve documentation. Blaming the CDI department for the deficiencies of the physicians, will not correct the problem. Secretary of State Hilary Clinton said “it takes a village to raise a child,” cribbing from an old African proverb. Well, maybe it takes a hospital to educate a physician.