All Entries Tagged With: "HIM"
AHIMA to start CDI work group
Back in March, AHIMA sent out the call for volunteers to help establish a new work group on clinical documentation improvement. The initiative comes as part of the association’s e-HIM effort and aims to determine industry needs and CDI best practices, according to a release.
“We were overwhelmed with the number of people who wanted to volunteer,” says Kathy DeVault, RHIA, CCS, manager of professional practice resources at AHIMA in Chicago.
ACDIS Advisory Board members are among the list of volunteers. DeVault planned to notify participants and begin a series of weekly, work-group calls in early April but the influx of interest pushed the start date back slightly.
Coders deserve ’superhero’ kudos
Hidden deep within the HIM office hides the coders’ universe. These hard working individuals put in long hours at small cubicles, staring at multiple computer screens. They are the unsung heroes of the hospital. This group of individuals would probably shun any fancy accolades, tell you they are simply doing their job, but this is an understatement.
Coders deserve a hero's recognition.
The coder is a type of superhero, bestowed with powers beyond that of a mere mortal. Physicians frequently use abbreviations that boggle the mind. Web sites abound with dictionaries for approved abbreviations, but low and behold the physician will always come up with something new. GLM, for example, sometimes refers to a patients’ good looking mother. ARBF means awaiting return of bowel function. The list goes on and on, but curiously the coders know what the collection of symbols stand for.
Coders also decipher the worst handwriting in the universe and make sense out of the senseless. They memorize physician signatures and read words where others only see squiggles. Coders know the DRG number of most illnesses.
Hospital reimbursement would come to a standstill were it not for the coders, making them more powerful than a locomotive. The “super coder” can read through a chart faster than a speeding bullet. They may not be able to leap tall buildings, but they sure can find the principle diagnoses in a single bound.
The Clinical Documentation Improvement department is still fairly new to the hospital scene and the profession has gone through many changes even within that period of time. Coders have been an integral component throughout this transition and it is clear that these modest groups of individuals are SUPER!
Chemotherapy documentation challenges warrant CDI attention
Given the extremely high cost of chemotherapy services, it is likely that third-party payers, including Medicare, will scrutinize these services, says Glenn Krauss RHIA, CCS, CCS-P, C-CDIS, in an article for JustCoding.com.
Here is a breakdown of areas generally targeted by payers including Medicare and their related documentation difficulty:
- Medical necessity for the supplied diagnosis: Often the clinician fails to provide the specific location of the cancer. A clinical documentation specialist can query the physician to ensure appropriate documentation.
- Coverage exclusion for specific drugs based on clinical trial effectiveness: Coders should reference local coverage determinations that generally spell out which diagnoses are considered covered benefits for common chemotherapeutic agents.
- Proper charging and billing of drug units: Just documenting patients’ nausea and vomiting is not always sufficient to support payment of anti-emetic medicines.
- Documentation to support IV administration units of service: Accurate coding for this requires clear start and stop times for IV chemotherapy administration. It is particularly problematic because clinicians do not always document the order of sequential therapy.
CDI programs might consider designating a team member specifically for the chemotherapy service line, Krauss says. A part-time specialist or member of the existing team may be enough depending on the monthly volume of patients in the chemotherapy department and the number of new patients who begin chemotherapy each month.
Focus initially on validating documentation and providing feedback to clinicians regarding documentation of IV therapy administration. The CDI specialist can help bridge the gap between customary medical record documentation and the level and detail of documentation necessary to properly and accurately capture all IV administration charges.
JustCoding.com subscribers can read the complete article online.
Q&A with the ACDIS advisory board: The problem of coders holding up charts
Q: We have a new CDI program with a huge learning curve. I am an RN in a CDI position. There are many things to ask, but the present issue is the re-querying done by the coders, which results in a large number of charts being held up. Has this been a familiar problem that others have had to deal with, and what have they done to cut down on the numbers? I appreciate any help you can offer.
Colleen Garry: I understand completely. When beginning a new program you have to be very clear and your staff needs to hold each other to consistent timelines pertaining to the query close out. Closing out a query is an art form. I suspect that the CDS nurses are not being efficient in their closeouts or are meeting significant resistance (this is normal with new programs) and the unanswered queries may be causing frustration for the coders (understandably). Query response and turnaround time is a must have to a successful program. One can educate and place queries all day long, but at the end of the day it’s all about impact.