If you just can’t get enough of former ACDIS CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, consider joining her and fellow speakers Deborah Hale and John Zelem for the 2015 Medicare Compliance Forum in Charleston, South Carolina, October 27-28.
The 2015 Medicare Compliance Forum addresses the ever-changing reimbursement landscape and has six tracks to choose from (three each day), covering Medicare billing and compliance, as well as challenges facing case managers, clinical documentation improvement specialists, utilization review professionals, and more. Here’s a look at the CDI-related sessions being offered.
Document, Document, Document: Enhance Documentation to Drive Meaningful Data
Cheryl Ericson, MS, RN, CCDS, CDIP
Providers need more than just being told to “document” because not all documentation in the medical record is created equal. Most medical records contain pages and pages of words, but much of this text is repetitive and doesn’t translate into meaningful codes, which in turns fails to support medical necessity. This session will take a look at when documentation has meaning by exploring the general concept of medical necessity and its relationship to coded data.
Is Your Readmission Problem Really a Documentation Problem?
Cheryl Ericson, MS, RN, CCDS, CDIP
This session will present an overview of the impact of coded data on CMS quality initiatives, which are also known as pay-for-performance. Participants will be introduced to the CMS quality initiatives of the Hospital Value-Based Purchasing Program, the Healthcare-Acquired Condition Reduction Program, and the Readmission Reduction Program, and how CDI efforts can support accurate reporting of these measures based on administrative data. Key documentation issues associated with the CMS quality initiatives will be presented.
Clinical Documentation Improvement and the Quality Mandate
Deborah K. Hale, CCS, CCDS
Value-based purchasing (VBP) is an important step to revamping how healthcare services are reimbursed in the Medicare program, and it is emerging in the commercial insurance market. Clinical Documentation Improvement for risk adjustment and accurate representation of the patient’s precipitating factors are critical to financial and marketing success. This session will demonstrate Clinical Documentation Improvement targets for risk adjustment and for achieving success with VBP initiatives.
The Role of CDI and the EHR in Supporting Medical Necessity
John Zelem, MD, FACS; Cheryl Ericson, MS, RN, CCDS, CDIP
CDI specialists are often tasked with reviewing the medical record to ensure documentation is comprehensive. However, the use of EHRs can minimize the utility of the health record as documentation often becomes generalized and repetitive. CDI specialists and coders face challenges associated with organizational implementation of meaningful use (e.g., problem lists, computer physician order entry, and the ability of providers to copy and paste documentation). Explore some of the challenges associated with provider documentation resulting from the increased use of technology.
The majority of education CDI professionals offer to physicians and other clinical staff is provided informally. On-the-spot education while interacting with the medical staff on the unit, often saves the physician time and paperwork. It also often saves the CDI specialist from having to submit follow up queries, too. However, for this method to work the CDI staff needs to be available and visible to the medical team.
Often my most successful teaching moments took place on the elevator, in the stairwell, in the parking lot, or in the cafeteria. These opportunities are invaluable. Rarely, did an educational opportunity occur while I was at my desk.
If the physician approaches you, they are displaying a motivation to learn and an interest in your mission. A positive, competent response on your part will reinforce their perception of you as a resource and they will come back with more questions. If you are unsure of the right answer, be honest, and tell them you will research the answer. Always, follow up with a response in a timely manner.
I often found a conversation with one physician would be overheard by others and suddenly I would find myself with an audience of several physicians learning and sharing their thoughts with each other. For example, in posing a question to a hospitalist about the causal organism of a pneumonia may lead to a discussion about documentation of “probable” or “likely” diagnoses and the importance of following that documentation through to the discharge summary. Meanwhile, the resident two feet away was about to dictate the discharge summary in a similar case asks the CDI specialist if he got his documentation correct. One conversation can lead to another and learning can happen, even when you least expect it.
Examples of informal education include one-on-one conversations, topic-specific tips , newsletters, posters/fliers, pocket cards. Check out the ACDIS Forms & Tools Library for a host of donated materials to kick-start your efforts. The only limit is your imagination!
When I started learning how to be an educator, I quickly learned the saying “seven times, seven ways.” The idea being we need to hear information repeatedly and receive it in a variety of ways before we are able to learn and incorporate that information in our daily practice.
Consider querying for clarification between renal insufficiency and renal failure, where the physician reads the query and asks you to just tell him what he should write. I would not start explaining the differences within the code set applied to these two terms or enter into a lengthy conversation about why the specificity is needed. Instead, point out the clinical indicators relevant to the patient as compared to the diagnostic criteria established for acute renal failure. Ask the physician to clarify if the kidneys are exhibiting failure or insufficiency based on the established criteria.
Stick to the facts. Keep it simple. Keep it relevant to the specific patient at the moment of conversation.
In this scenario, the physician needed a quick explanation. But let’s apply our “seven times, seven ways” theory by later following up on that interaction with an educational mailer or documentation tip via email to the physician. This second round of information could further highlight the needed differentiation and why this added level of specification is important to support issues such as extended length of stay, severity of illness, or resource consumption. Other ways to provide education include hanging posters in the physician lounges or documentation areas. I once even threatened to place fliers on a physician’s windshield!
The point is, that you may not always have the time (or the physician may not have the time) to engage in one-on-one education but you can use your physician queries as the first step in a more prolonged, detailed education campaign. We need to build upon each educational opportunity to reinforce the teaching. Repetition can be very valuable.
Q: I am new to the CDI role and looking for suggestions as to how to work with the surgeons to help them beef up their documentation?
A: I smiled when I read your question, this challenge is not particular with you. Surgeons offer us a number of challenges. One of the reasons is that surgeons are reimbursed differently than other providers. When the primary care physician rounds on inpatient acute care patients they document their notes to assist with their E&M (evaluation and management) charges in mind. Depending on the extent of their assessment, the patient’s condition, and the amount of time the physician spends with their patient, the physician can submit a bill for the visit based on four levels. They will submit charges for every time they round on the patient.
When CDI professionals work with the primary care providers to improve their documentation it often can have a direct impact on their E&M levels as well. When we talk about how their documentation improvement efforts support their own billing as well as the hospital’s they can be more open to CDI efforts.
Surgeons are reimbursed differently. For example a surgeon performs a total hip replacement. He will be reimbursed one global fee which covers the pre-operative, peri-operative and post-operative care. Their documentation within the post-operative period does not directly affect their payment. They don’t have a tangible motivation to write a thorough post-operative note.
Now, I don’t want to put all surgeons in this category, as I have met many that offer excellent documentation starting with the pre-op history and physical. When I find a surgeon who documents well I will hold them up as a top performer and use examples from his documentation for others to see. Sometimes, a little peer pressure works wonders.
Another more tangible motivator, is to discuss severity of illness/risk of mortality (SOI/ROM). These measures are determined based on their documentation. Then discuss quality ratings and how patients, organizations, and even commercial payer contracts with providers are based on quality measures pulled from SOI/ROM data.
No surgeon wants bad ratings for everyone to view on the internet. Explain that your efforts as a CDI not only will improve reimbursement for the organization (which consequently buys new operating room equipment and pays for qualified staff to care for his patients) but also can effectively assist in increasing the SOI/ROM of his patients. So if his patients develop complications or die due to underlying comorbidities their level of SOI will demonstrate a patient who was at risk for such complications. There is much information on physician quality ratings on the internet to assist you in these discussions.
One of the most convincing reasons for establishing a concurrent documentation review program is the ability to discuss a patient’s record while the details of the patient’s case are still fresh in the physicians’ mind. Such interactions are as important for resolution of the medical record documentation as it is for providing ongoing education for the physician. Not surprisingly then, many experts encourage facilities to maximize opportunities for verbal interactions between the CDI team and the physician staff, whether it is on the patient care unit or through meetings in the physician lounge. To do so, however, CDI specialists need to exhibit a unique set of interpersonal skills. the CDI specialist must be both positive and professional in his or her interactions with physicians but they must also be able to interpret the physician’s body language at the time of the discussion and be able to weigh and recall a particular physician’s communication preferences over time. Such skills may be summarized by the colloquialism “know your audience.”
For example, Dr. Smith may respond well to e-mail communication but become visibly uncomfortable, aggressive, or reclusive when approached on the floor of a nursing unit. Conversely, Dr. Adams consistently ignores written queries left in the medical record and does not return phone calls. Approach him during his routine rounds, however, and he will answer multiple CDI questions happily.
Beyond understanding the physician’s preference for type of communication, the CDI specialist must also be aware of the personality type of the physician. A process-orientated physician, for example, may respond positively to a CDI specialist who explains how his or her documentation in the medical record translates through the HIM department, billing, and, ultimately, reimbursement and quality data reporting. A results-orientated physician, however, would see such discussions as a waste of time, preferring to understand how the process will affect him or her directly, instead. The ability of the CDI staff member to not only be aware of these different dynamics, but also to adjust their queries and education accordingly can appease wary physicians and earn physician support for the CDI program overall.
There are only so many hours in a day. And only so many minutes to explain the complicated process of coding and reimbursement to a less than eager room full of physicians. In an hour-long session, Bryan P. Hull, MD, site lead for ICD-10 enterprise project and assistant professor of medicine at Mayo Clinic Hospital in Phoenix found he spent 30 minutes or more talking about the definition and purpose of the DRG system—over and over again.
“I knew there had to be a better way to do this,” says Hull.
Hull began researching online tools for video creation and came upon VideoScribe which essentially animates PowerPoint presentations making it seem as though someone has been videotaped hand drawing the presentation.
With a solution in hand, he just needed a story-line for his presentation and support from his CDI teammates, which he readily received.
“Some people stay up late at night thinking about the meaning of life,” Hull states at the outset of the five minute video, as an artist’s hand quickly sketches a cartoon image of a Greek philosopher. “Other people think about the possibility of life on other planets,” he adds as the artist colors an alien head in a thought bubble. “But in care management, other things keep us up at night; things like clinical documentation improvement.”
The video goes on to describe the role of documentation in quality reporting and the role of the CDI specialist in helping physicians capture that documentation. Hull provides two case examples of patients with pneumonia and walks through the different conditions, demonstrating how variables such as home oxygen, COPD, and other conditions affect the patient’s severity of illness, length of stay, and the DRG assignment.
Now, Hull goes to the meetings, runs the video, and makes himself available to support the CDI team members. “We start the video and the physicians recognize my voice and laugh,” he says. “They really get a chuckle out of it. It opens the door to the CDI team to take over the presentation and drill down into more detailed documentation improvement initiatives.”
Mayo has played the video at all its Phoenix divisions and even at the enterprise-wide CDI conference held in the fall. Now, Hull envisions adding other videos focusing on DRGs 177, 178, 179, and turning them into a collection.
“We’ve gotten a lot of feedback from the providers regarding the videos. We can measure the difference, the improvement in the documentation overall. While that may not be due specifically to the video we know that our training matters.”
The American Medical Association (AMA) has pushed to defeat the ICD-10 code set transition since 2012. During its recent House of Delegates meeting, this November, the AMA reinforced its position that ICD-10 implementation should be delayed by two years. It initially put forth that resolution in June.
The AMA’s stance was a contributing factor in the implementation delay implemented in 2012–the one that pushed the “go-live” date from October 1, 2013, to October 1, 2014. That may not have been a great thing for physicians, according to Paul Weygandt, MD, JD, MPH, MBA, CCS, vice president of physician services for J.A. Thomas and Associates in Atlanta.
“The worst thing for physicians was that the AMA delayed ICD-10 by one year,” he told AHIMA Convention attendees in October. Why? Because it provided physicians a convenient illusion that the AMA could stop ICD-10 implementation again. And why should physicians bother understanding the documentation needs of ICD-10 if they think the change will never actually come to pass?
The question for CDI specialists is how to get physicians on board for ICD-10 when the AMA is not? Remind them that ICD-10 doesn’t change the way they practice medicine. They will still treat patients the same way they do now. We’re just asking them to document a little more specifically.
Physicians are likely documenting much of the necessary information already, such as laterality, because it’s good patient care. The physician wants to know where an injury occurred so when the patient comes back for a follow up, he or she is checking the correct area.
ICD-10 is also written in more clinical terms and less coder speak, which means docs will need to learn less than coders. For example, many pulmonologists already describe asthma as:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
ICD-10-CM now uses those terms.
For myocardial infarctions, physicians have been documenting STEMI and non-STEMI for years, Weygandt says. In ICD-10-CM, coders will be able to report it that way.
Don’t tell physicians what they need to document. Tell them what they aren’t documenting. Give them a (figurative) pat on the head for the things they are doing correctly. And ask them if they would accept their documentation if it came from a resident.
“Good documentation for ICD-10 is what we should be teaching residents because it’s good clinical care,” Weygandt says.
ICD-10 is coming, whether the AMA wants it to or not. Work with your physicians now so you are all ready for the change.
Editor’s Note: This article was originally published on The ICD-10 Trainer Blog.
The Connecticut ACDIS Chapter meets Thursday, Sept. 12, noon to 2 p.m., at The Hospital of Central Connecticut in New Britain. Lunch will be provided. For additional information, email Maryann Shanley at email@example.com.
Meets Friday, Sept. 12, 12:30-4 p.m., at the Anne and Robert Lurie Children’s Hospital of Chicago. The agenda includes:
- 12:30-1:30 p.m., registration/lunch
- 1:30 p.m., Official welcome
- 1:45 p.m., Shellaine Kang, manager of HIM and CDI will provide an overview of pediatric APR-DRG methodology and pediatric CDI
- 2:15 p.m., Anthony Chin, MD, pediatric surgeon and physician advisor and Cynthia Castiglioni, MD, hospitalist and physician advisor will discuss clinical documentation challenges
- 3-4 p.m., tour of hospital
The next meeting will be held Friday, September 13, 8:30 a.m. to 1:30 p.m., at Center Pointe, Covenant Health, Knoxville. The agenda includes:
- 8:30 a.m., Welcome and announcements
- 8:45 a.m., Sherri Ernst, RN, MBA, corporate manager of revenue integrity and Mary Boruff, RHIA, revenue integrity supervisor, “RAC audits and appeals”
- 10 a.m., John Adams, MD, “Sepsis/SIRS/septicemia”
- 11 a.m., James Kennedy, MD, “Updates in Coding Clinic”
- 12 p.m., Lunch and presentation provided by CDI Search Group
- 1 p.m., Tenn. ACDIS Chapter business meeting
The next Georgia (formerly the Southeast) ACDIS Chapter meets Friday, Sept. 13, 9:15 a.m. to 2:30 p.m., at Athens Regional Medical Center. The agenda includes:
- 9:15 a.m., Registration and continental breakfast
- 10 a.m., Anne Mosomillo, director of care management, welcome and introductions
- 10:15 a.m., Christy Williams, RN, BSN, ICD-10 Certified Trainer, senior manager with 3M HIS Consulting “Severity of Illness and Risk of Mortality-The Basics”
- 11:25 a.m., Linda Franklin-Yildirim, RN, MN, MBA, CCDS, “From Paper to Electronic: Transformation to E-queries”
- 12:25 p.m., 3M HIS discussion and lunch
- 1:30 p.m., GA-ACDIS business meeting
- 2:15 p.m., Announcements
The New York City Five Boroughs ACDIS Chapter meets Thursday, Sept. 19, 6-8 p.m., at Wyckoff Heights Medical Center, Brooklyn. For information, email Wanda Mejias-Gonzalez WMejias@wyckoffhospital.org.
The Michigan ACDIS Chapter holds its next meeting Saturday, Oct. 12, from 7:30 a.m. to 4:30 p.m., at North Central Michigan College (NCMC) in Petoskey. The agenda includes:
- 7:30 a.m., Continental breakfast
- 7:45 a.m., Welcome and introductions
- 8 a.m., Nancy Ballinger, Ballinger Coaching and Consulting, Keynote address
- 9 a.m., Kitty Kremer, BA, RHIT, director of coding education at Anthelio Healthcare Solutions, “ICD-10-CM/PCS Basics”
- 10:15 a.m., Amy Rector, RN, CCDS, CDIP, director of CDI at Anthelio Healthcare Solutions, “Documentation and the Query Process”
- 11:15 a.m., Dan Gerard, RPh, pharmacist for critical care services at McLaren Northern Michigan, “Sepsis: Clinical Indicators and Treatment Modalities”
- 12:15 p.m., Lunch
- 1 p.m., Debbie Rough, president of Namson Change Consulting, “Accountability”
- 2 p.m., Fran Jurcak, RN, MSN, CCDS, senior director at Huron Healthcare, “Ensuring Quality through Accurate Documentation: Going beyond the low hanging fruit”
- 3:15 p.m., Kathleen Luther-Huff, RHIT, director of Accretive Health, Beaumont, “The Building Blocks of Effective Queries”
The SC ACDIS Chapter holds its meeting Friday, Sept. 27, 9:30 a.m. to 3:30 p.m., at Providence Hospital in Columbia. Agenda includes:
- Karen Carr, discussing cardiac conditions
- Ali Williams, discussing orthopedic CDI concerns
- Peggy Likovich, discussing renal conditions and CDI
- Brandy Mangum, discussing neurological concerns
- Tara Bell, discussing respiratory conditions
The Virginia ACDIS Chapter meets Saturday, October 5, 10 a.m. to 2 p.m., at CJW Medical Center in Richmond. For information, contact Lisa Romanello at Angelisa.Romanello@hcahealthcare.com.
The ACDIS NW Chapter holds its annual conference Friday, October 11, 8:30 a.m. to 5 p.m., at the St. Charles Health System, in Bend. The agenda includes:
- 8:30 a.m., Registration and continental breakfast
- 9 a.m., Introduction by meeting host Charonne Sutherland
- 9:15 a.m., NW Chapter business meeting
- 9:30 a.m., CDI Search Group sponsor recognition
- 10 a.m., Aaron Askew, MD, Orthopedic Surgeon
- 11 a.m., Bev Jackson, ICD 10 Ambassador
- 12:30 p.m., Lunch provided with live music by Bill Keale
- 1:30 p.m., John Blizzard, MD, Cardiothoracic Surgeon
- 2:30 p.m., Break
- 2:45 p.m., Mathew Hegewald, MD, Pulmonologist/Intensivist
- 3:45 p.m., Kenneth Goode, RN, Orthopedic Specialty Coordinator
- 4:30 p.m., Door prize (must be present to win)
We recently received an inquiry from an ACDIS member who, unfortunately, was not able to attend this year’s ACDIS National Conference and came up short on her needed Certified Clinical Documentation Specialist (CCDS) continuing education (CE) credits.
There are a number of ways to obtain CE. (For complete information about re-certification please visit the webpages dedicated to the topic on the ACDIS website.) Many ACDIS local chapter events offer CCDS credits and most are extremely reasonably priced between $25-$45 depending on whether you belong to the chapter or not.
Additionally, some of the CE courses you’ve already taken through your facility or related association (AHIMA, ANCC, ACMA) may qualify for CCDS CE too. (There is a list on the re-certification tab of what is acceptable. If you have any questions, contact ACDIS Membership Services Director Penny Richards at firstname.lastname@example.org.)
In addition, your ACDIS membership provides up to eight CE credits per year should you choose to take advantage of them. The Quarterly Conference Calls each offer one CE and the quarterly CDI Journal also offers one CE for each issue.
Members are notified of the date and time for the live conference calls but you need not listen live to obtain the CE; simply visit the ACDIS site, look for the conference call tab on the left navigation bar, listen to the streaming audio, and take the related survey. A certificate will be mailed to you once you complete the survey.
Similarly, ACDIS members can read the CDI Journal and take the short, 15-question content-related quiz, and receive CE credits for their efforts. The quiz is typically posted two weeks after the Journal content. Please remember, however, the CDI Journal is a web-based PDF document and members must login to their ACDIS account to access it.
Illinois: The meeting tentatively planned for July 12 has been cancelled. Chapter leaders are looking for someone to host the fall meeting in September or October. For information, contact Colleen Stukenberg MSN, RN, CMSRN, CCDS, by phone at 815/599-6820, or email CStukenberg@fhn.org.
Arizona: Meets Wednesday, July 17, at 6 p.m., at Mimi’s Café, Desert Midge Mall in Phoenix. For information, contact, Gloria Richardson at 480-882-5246, or email GRichardson@SHC.org.
New York: The NYC 5 Boroughs ACDIS Chapter meets Thursday, July 18, 6-7:30 p.m., at NYU Langone Medical Center (SMILOW MPR), 550 First Avenue, New York. For information, contact Wanda Mejias-Gonzalez by calling 718-302-8542 or email email@example.com.
Pediatric: CDI professionals working in children’s hospitals are invited to join an informal teleconference on Wednesday, July 24, 12:30-1:30 p.m., to talk about recent developments and concerns. For information, contact ACDIS Associate Director Melissa Varnavas at firstname.lastname@example.org. This group is currently seeking additional volunteer leadership.
Critical Access Hospitals: CDI professionals working in critical access hospitals are invited to join an informal teleconference on Wednesday, July 24, 2-3 p.m., to talk about recent developments and concerns. For information, contact ACDIS Associate Director Melissa Varnavas at email@example.com. This group is currently seeking additional volunteer leadership.
North Carolina: Meets Friday, August 2. For information, contact Leah Taylor at 704-878-7436, or email Leah.Taylor@iredellmemorial.org.
Indiana/Kentucky: Meets August, 16, 8:30 a.m. to 4 p.m., at Baptist Health Louisville, Ky. The committee reserved a block of rooms at the Breckinridge Inn for chapter members and guests at a special rate of $59/night. The hotel is approximately 1.2 miles from Baptist Health and has complimentary airport shuttle. The agenda includes:
- Registration and continental breakfast
- Welcome and recognitions
- Value-Based Purchasing and CDI: Doreen Ireland, J.A. Thomas
- Engaging and Motivating the Clinician: Dee Schad Banet and William Templeton, MD
- Impact of ICD-10-CM/PCS on CDI: Mary Stanfill, UASI
- Medicare Fraud and Abuse-The risk of inappropriate queries: Tracey Goessel, MD, FairCode Assoc.