Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.
AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.
Urosepsis could be UTI or Sepsis secondary to UTI.
Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).
Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.
Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.
FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.
CHF requires specificity of acute or chronic and systolic or diastolic heart failure.
Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.
Problems with speech post CVA may indicate a diagnosis of Aphasia.
Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.
Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)
Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)
Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene
Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.
Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.
DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.
I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)
↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.
Susan Hassmiller, PhD, RN, FAAN, senior advisor for nursing at the Robert Wood Johnson Foundation, is spending her summer vacation doing something extraordinary. She is not spending her days soaking up the sun, or taking a cruise to Alaska. Instead she is traveling in Europe, learning about the life and work of Florence Nightingale.
Throughout Hassmiller’s journey across Europe, she is blogging about her experience to commemorate the 100th anniversary of Nightingale’s death.
Here is an excerpt from one of Hassmiller’s posts:
“Seeing the famous St. Thomas’ Hospital today, I thought Florence Nightingale would roll over in her grave with disgust! What were
they thinking, I asked the tour guide? Well, she said, it was the ‘60s. No excuse, I barked back! Prince Charles doesn’t like it either, if that makes you feel any better, she responded.
Applying best practices. The most visually prominent buildings in the hospital now consist of a couple of plain, brown, nondescript, blocklike structures—not anything like Nightingale, once the most famous hospital designer in the world, would have had it. Or, rather, did have it. Her friend, Queen Victoria, laid the first stone and Florence Nightingale contributed to the design and relocation of the St. Thomas’ Hospital of the mid-1800s, with the intention of applying best practices she had brought back from the Crimean War as well as her own research and statistics.”
Editor’s Note: This article first appeared on our sister blog Stressed Out Nurses.com. I am personally curious to know if Florence holds a special place in the hearts of any CDI specialists and if her life and lessons might hold some application to the role of the clinical documentation improvement specialist as many attempt to adapt from the primary role of patient care to the role of documentation care and analysis.
Folks of a, ahem, certain age, know the iconic theme music from the 1976 comedy Laverne & Shirley. Well, Lynne Spryszak, RN, CCDS, CPC-A, CDI Education Director for HCPro, Inc., in Marblehead, MA, and her compatriot, independent consultant Margi Brown RHIA, CCS, CCS-P, CPC, got a bit giddy planning out the details of their ACDIS Conference presentation Bridging the CDI gap: Bringing the clinical/coding reconciliation process together and decided to rewrite the lyrics and add in some important CDI phrases.
Those familiar with the show will remember how the characters were portrayed as best friends with completely opposite personality types (similar to another famous TV series The Odd Couple). So it’s perhaps not so surprising that Spryszak and Brown (themselves opposites as Spryszak comes to CDI from a clinical background and Brown approaches the process from an HIM/coding point-of-view) thought the 1976 show might add a little entertainment and additional insight to their presentation as facilities continue to struggle with ways to help coding and CDI professionals understand the value they each bring to the healthcare table.
Spryszak and Brown discussed strategies for setting up new CDI programs to reduce inter-department tensions, the process of MS-DRG assignment through the working DRG to the final reconciliation process, and some steps for improvement along the way. Their session included information about:
- Starting off on the right foot
- How to structure a program and get the support necessary for a successful and sustainable program
- Structuring the program with a blended model: RN and HIM as partners
- Understanding how we see the medical record differently
- Comprehensive approach
- Starting the program and incorporating the “interdepartmental” involvement: CM, quality, core measures, departments
- Learning about the “driver”
- The driver = the running principal diagnosis
- How clinical people can easily keep the “driver” in mind without becoming coders
- Tightening the reconciliation process
- How the admitting DRG evolves to the working DRG to the final DRG
- Developing and maintaining the full circle program
The Minnesota group May meeting will be postponed until June 23rd due to potential nursing strikes among six hospital systems as well as the upcoming ACDIS meeting.
Dubbed as possibly the biggest strike in U.S. nursing history, by the Minneapolis Star Tribune, the debate between the Minnesota Nursing Association and the hospital systems stems from wage increases, formal nurse-patient ratios, and scheduling flexibility, Star Tribune reports.
Minnesota Nursing Association was set to make an announcement on today, Friday May 28, regarding contract negotiations between some 12,000 nurses employed at North Memorial Health Care, HealthEast Care System, Allina Hospitals & Clinics, Park Nicollet Health Services’ Methodist Hospital, Children’s Hospitals and Clinics of Minnesota, and Fairview Health Services, according to The Minneapolis/St. Paul Business Journal.
Minnesota ACDIS Chapter members say some CDI specialists may be asked to fill in temporarily as bedside nurses if a strike takes place as expected on Tuesday, June 1.
I really wanted to come up with some good joke here that involves the cities of Philadelphia, Kansas City, KS, Portland, and Boston but, heck, I just can’t come up with anything.
I’d have to make fun of my beantown-base but I love it here too much to pick on our Bowstown axscents or wonder where the CDI specialists who sign up for the Boot Camp will end up paahking (prolly somewheres down by the Norf End, I magine).
So, jokes aside, I thought I’d let you know that ACDIS recently released its schedule for the summer series of CDI Boot Camps.
The Boot Camps continue to quickly sell out so I encourage you to register early if you are interested, especially since class sizes are limited to guarantee individual instruction and a low student-teacher ratio. Without further jesting on diction the schedule is:
- Philadelphia, PA, May 3-6
- Kansas City, KS, June 21-24
- Portland, OR, July 26-29
- Boston, MA, August 2-5
The four-day educational session covers:
- 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
- Problematic diagnoses, including congestive heart failure, sepsis, and renal disease
In addition to our open registration classes, the CDI Boot Camp is also offered as an on-site program for organizations that have a number of employees who need training. To explore the possibility of hosting a CDI Boot Camp or to discuss other training programs, call 877/233-8828 or e-mail firstname.lastname@example.org.
By Kimberly Richert RN, CCDS
I recently read two articles, the first about the shortage of nurses, and the second about a shortage of nursing jobs. These articles made me think about my present job in clinical documentation improvement, and how I ended up here. This is the best job I have ever had, and I do have to thank God everyday for it.
Looking back to when I started my nursing career, I never knew then that there were so many opportunities in the nursing field. I never knew this is where I would be after 20 years of nursing. I do remember thinking that I would never need to go to school again. Wow, was I wrong.
Through nursing school, you are taught how to do hands-on patient care, from the basics on how to give a bed bath, and caring for the patient, to the critical thinking necessary to help solve healthcare problems as they emerge. All this learning affords new nurses a set of skill to build on.
You start out in an area that will hire a brand new nurse. As you know, not all areas of the hospital will hire you, unless you have the experience. So at the beginning of your career, you take what you can get. After you have some experience under your belt, you are able to get into those areas that really interest you. You get into a specialty that really keeps your job fun and interesting. You fit into a group of people you just love to work with. You form friendships that last a lifetime. This is the best part of life. Your nursing career has given you a way to make it through this crazy world.
Now, you must remember your education will never end. Even when you are finished with nursing school, you are constantly learning. You can go into fields where you do not perform direct patient care, like clinical documentation improvement, but remember that your nursing background is the basis of your new specialty.
It is very important that you become certified at some “specialized” aspect of this profession. Now is the time to demonstrate and validate your specialized skills and experience. Having the credentials in your specialty adds credibility to your leadership, and sets you apart from other roles in healthcare.
For me, clinical documentation was a saving grace professionally speaking. I just knew I could not do patient care anymore. When you get older, you can’t do things like you did when you were younger. From a physical standpoint, clinical nursing made it difficult to continue. Such rigors were enough to make me look into some other career opportunities. This is how I ended up in clinical documentation, a new department at our facility, that sought to fill these new positions with registered nurses. So far, it has been a great adventure.
The clinical documentation specialist is not just a “chart hound.” You really have to put your critical thinking to use. This is where pen and paper draws the most accurate clinical picture of the patient. The documentation team is focused on performing concurrent chart reviews to provide clarity within the clinical record. Such efforts help improve institutional metrics such as severity of illness and risk of mortality which in turn leads to better patient care.
To have the opportunity to change healthcare for the better is an awesome task to have. Yes, this my job and I absolutely love it. I am a nurse and always will be.
Editor’s Note: Kimberly Richert RN, CCDS, is lead CDI coordinator at Morton Plant Mease Healthcare in Clearwater, FL. Contact her at email@example.com or post your response here.
The outlook wasn’t brilliant for the CDI that day:
The chart stood unattended, with one hour left to stay,
And then when Dr. Cooney didn’t chart, and Dr. Barrow did no more,
A pall- like silence fell upon the patrons of the floor.
A straggling few got up to go in deep despair. The rest
Clung to the hope which springs eternal in the breast:
They thought, “If only Dr. Casey could get a whack at that,
We’d put up even money now, with Dr. Casey at the bat.”
There was ease in Dr. Casey’s manner as he stepped into his place:
There was pride in Dr. Casey’s bearing and a smile lit Dr. Casey’s face.
And when, responding to the query, he lightly doffed his hat,
No stranger on the ward could doubt ‘twas Dr. Casey at the bat.
The usual sneer had fled from Dr. Casey’s lips; his teeth clenched in rage:
He pounded with cruel violence his pen upon the page.
And now the nurse she holds the query, and now she lets it go,
And now the air is shattered by the force of Dr. Casey’s NO!
Oh, somewhere in this favored land the sun is shining bright,
The band is playing somewhere, and hearts are light,
And somewhere men are laughing and little children shout;
But there is no joy at the hospital – mighty Dr. Casey had struck out.
“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”
~Hamlet, Act III, Scene I
I truly think that Shakespeare was a frustrated CDI nurse.
I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:
“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”
If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.
Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?
I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.
“E-mail eats the day away.” Sounds like a play on the ‘ole “apple a day” routine, doesn’t it? It’s actually an PR piece touting a new software that sorts and prioritizes your e-mail. Imagine if automatic e-mail management saved you hours every day. I’ve seen some pretty disorganized e-mail in my day. One co-worker had more than 600 messages in her inbox at one time. She wondered why her e-mail wouldn’t work.
That press release got me thinking about how clinical documentation improvement (CDI) specialists manage to juggle their responsibilities and how they can effectively make the case for CDI to physicians whose time management techniques are already being tested.
Physicians often say their biggest concern about providing high quality documentation in the patient record is the amount of additional time they think it will take, according to Ruthann Russo, PHd, JD, MPH, RHIT, partner in the law firm Russo and Russo, LLP, in Bethleham, PA.
In her handbook Time Management for Clinical Documentation, Russo pools a variety of sources to show how various stakeholders’ demands affect a physician’s time management capabilities. For example, insurance companys frequently assume that a primary care visit takes a physician a mere 16 minutes. When micro-management of that caliber can affect your fiscal well being, imagine the time management stress that must result.
“Supporting your physicians in the time management process can result in better clinical documentation practices,” Russo writes.
Here are some time management tips you can either share with your physicians or keep to use yourself:
- Plan your day
- Plan for breaks and take them
- Handle each piece of paper (or e-mail) only once
- Make decisions, don’t procrastinate
- Block out specific time to respond to phone calls
- If there’s a task you dread, do it right away and get it out of the way
Physician support for CDI programs suffers when they worry about how additional documentation requirements could encroach on their already limited available time, Russo says. So, be open and honest with physicians. Talk about their time concerns and be realistic about how much time your additional interactions may take. Initial physician training sessions are a perfect time to raise these concerns and share some of your own time management techniques.
Good communication is a key attribute of a successful clinical documentation improvement specialist (CDIS). The CDIS must be able to function in a variety of different settings. These include the CDIS office, the patient care unit, and presenting at rounds. All require flexibility, quick thinking, and a sound knowledge of clinical documentation policies.
Many hospitals have been reluctant to use nurses in the role of CDIS, adhering to the belief that nurses cannot be retrained to think like coders. Why would anyone want them to? Nurses bring their own qualities and strengths to the job.