All Entries Tagged With: "physician query"

Reflections on physician leadership and engagement with CDI programs

Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.

Physician leadership can come from a number of sources and in a variety of forms. Some CDI programs (a few anyway) report directly or indirectly to a physician executive (medical staff functions, chief medical officer [CMO], etc.) and other programs report to the quality department where a physician executive is frequently directly involved. In these circumstances, I hope the physician executive maintains some amount of time dedicated for CDI efforts.

Some organizations are fortunate enough to have physician leadership within the broader organization that is (or have been convinced to be) very supportive to CDI efforts. From what I’ve heard, these frequently include CMOs and chiefs of staff and/or service lines within a given facility. Finally, some physicians, such as a medical director, physician champion, advisor, or liaison, devote a portion of their time to work directly with CDI. (Read more about the expanding roles and responsibilities of CDI physician advisors in the January 2012 edition of the CDI Journal.)

Furthermore, even with supportive medical staff leadership, how that support translates into action varies. Some facilities provide physicians time to offer educational sessions to their CDI and coding teams. Others provide CDI education sessions to entire physician groups by service line.

Most CDI programs earn physician leadership and support through the tireless efforts of the CDI staff and program leaders. Only occasionally have I seen this support present from the very beginning.

Some Perspectives

I’d like to look at the “state of affairs” in regards to physician leadership.  One ACDIS weekly online poll (2008) addressed the simple question of whether respondents had a “physician champion” and if that champion was effective. That poll was rather surprising; only 46% indicated they had a physician champion, and half of the respondents with a physician champion actually rated him/her as ineffective. So, according to that poll, only 23% of programs have an effective physician advisor.

ACDIS repeated the  poll (with slightly different wording) in April 2011 and though the results showed some improvement, they were still discouraging. In 2011, 31% described having a very beneficial physician champion, 22% described their physician champion as “’minimally effective”, 24% felt the position was not affordable, and 16% indicated that their program could not find a good candidate. Even more surprisingly to me, 7% said they simply did not see the need for the roll.

Additional polls from 2008 which echo the theme of limited physician support for CDI programs include:

• “How have physicians reacted to your CDI program and query requests?” where only 40% reported a positive response from physicians
• “Are your physicians catching on to your CDI program? ” 3% yes, 74% yes and no, 23% no
• “Do you have any physicians who refuse to participate in your CDI program?” where 81% indicated anywhere from one to many physicians refuse

Other recent poll responses illustrate different aspects of physician involvement in CDI , but I thought these painted an interesting picture.

Don’t forget the most recent study, published in the January CDI Journal, in which 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts, and 54% described their advisor as either moderately effective or ineffective.

Data

I think it is  important to have data to effectively measure any focus area of interest. I believe a couple of key metric data pieces provide insight to the level of success with physician engagement. In any analysis, I would include items such as:

• Physician response rates
• Severity of illness (SOI)/risk of mortality (ROM) data
• Trends in volume of queries and more specifically the focus of queries (Do CDI staff ask the same queries repeatedly?)

I specifically would not include physician agreement rate except in a broader sense in looking for individual outlier physicians, to find those who either agree to whatever the CDI specialist asks or those who never agree with the premise of a CDI specialist’s query.

As always, I’d love to hear what elements other CDI programs use to statistically validate their physicians’ involvement with and support of their CDI programs.

Resources

Quite a bit of material is available between the ACDIS online polls (I have fun with those, obviously), various blog postings, journal articles, and conference presentations that offer useful information regarding physician engagement. Several provide inspiring examples of successes. Various items from other organizations are in the public domain.

If you are interested, shoot me an e-mail or leave a comment here and I can develop a partial list of links.

Wrap -up

I am sure most agree that fostering physician engagement in CDI efforts is one of the key challenges of every CDI program.

I certainly don’t have many great answers to this question, and I’d like to hear more thoughts, experiences, and success stories. I know some great examples would be wonderful Journal articles or blog posts.

I will toss in a final thought. Organizational cultural change typically takes five years. Certainly obtaining physician interest in documentation and coded data represents a significant cultural change.

Sometimes I wonder if just need to practice a little more persistence and a lot more patience.

Q&A: Maryland CDI network answers member’s renal failure documentation inquiry

Q: If the physician documents throughout the record that the patient has acute renal failure (ARF)—he documents this in emergency department notes, history and physical, admitting diagnosis, and in the progress notes but fails to add it to the discharge summary—would the coder be allowed to pick up the acute renal failure and code for it or would the coder leave it out and until the CDI specialist queries the physician for documentation in the discharge note?

Additionally, if the physician documents ARF in the initial consult note while the patient was still in the emergency department and it is documented in the chart by the attending physician and the renal consult but the hospitalist who last saw the patient documents renal insufficiency in discharge summary, would you leave out the ARF completely just code the renal insufficiency or would you query the hospitalist?

A: “Oftentimes, diagnoses throughout the patient’s stay are left out of the discharge summary and yet are still coded, if there is documentation in the record to support those diagnoses.” states Lillian Keane, RN, BSN, CPC, documentation specialist at MedStar Health Good Samaritan Hospital.

Keane suggests also reviewing the labs (creatinine, glomerular filtration rate [GFR]) and using the RIFLE (risk, injury, failure, loss, end-stage kidney disease [ESKD]) classification published by the Acute Dialysis Quality Initiative (ADQI) group to assist in diagnosis of ARF.

In regard to the second scenario, Keane favors querying the physician for clarification since so many physicians use the term acute renal insufficiency and ARF as one and the same. “If the diagnosis of ARF is inconsistent with the RIFLE and there is conflicting documentation, I will query at that point,” says Keane.

“We also see the terms acute renal failure and acute renal injury used interchangeably at our facility,” says Cathy DeNoble, BS, RHIA, CCS, LPN, coordinator of Case Mix Information Management and CDI specialist at Johns Hopkins Health System in Baltimore. “They are easily misinterpreted acronyms with various definitions.  At our facility the attending is the final word and when in doubt…query never assume.”

Understanding the difference between the physician’s mindset and the coding rules, presents an educational opportunity, says Keane, who presented physician education sessions on RIFLE classification, differentiating acute renal insufficiency versus ARF versus azotemia and also the stages of chronic kidney disease.

Keane cites the September 2010 article of the month AKI: The Crossroads of ICD-9-CM and Medical Literature by James S. Kennedy, MD, as one resource, other resources on the ACDIS website include:

• Consider NKF definitions when documenting renal disease
• Column: AKI and the mess we’re in
• Acute kidney injury: The crossroads of ICD-9-CM and medical literature
• Q&A: Two query alternatives for acute on chronic renal insufficiency
• Use kidney key-words to sooth your documentation troubles
• Sample queries and educational posters in the Forms & Tools Library

Editor’s Note: Special thanks to The Maryland Hospital Association Clinical Documentation Improvement Workgroup for sharing this exchange. For information about joining Maryland’s networking events contact Christine Mobley, RN, director of clinical documentation at Prince George’s Hospital Center, at christine.Mobley@dimensionshealth.org.

Book Excerpt: Build better relationships with appropriate physician queries

The Physician Queries Handbook

There are consequences for failing to understand the critical link between patient treatment and the documentation and coding for such treatment. ICD-9-CM coding based on nonspecific physician documentation has led insurers to raise patient co-payments for certain “inefficient” providers.

In the same light, coding from nonspecific physician documentation has led to negative outcomes as seen via publicly reported mortality data posted on the CMS’ Hospital Compare website or other public websites. Here, some providers have high risk-adjusted death rates for community acquired pneumonia, heart failure, myocardial infarction, or other conditions based on ICD-9-CM coded data.

Communities have witnessed their local hospitals close in part as a result of providers’ and coders’ inability to negotiate the code-based reimbursement systems that are integral to establishing medical necessity, which is required for accurately assigning diagnosis-related groups for inpatient reimbursement. As the government and the public demand for improved quality of care and transparency of data increases, the physician documentation and coder translation of the medical record becomes almost as vital as the physical care the patient receives.

Editor’s Note: The above excerpt was written by James S. Kennedy, MD, CCS, in the introduction to The Physician Queries Handbook: Guide to Compliant and Effective Communication.

Pediatric reviews: Know the rules before you play the game

by Robert S. Gold, MD

Even experienced and consistently accurate acute care hospital coders may not be familiar with pediatric

Don't throw the baby out with the proverbial bathwater when it comes to documentation and coding improvement associated with pediatrics.

diseases. Age is not a factor for some conditions (e.g., appendicitis). Others are age-specific or have age-specific diagnosis, healing, and treatment implications. Coders must consider this when assigning codes and querying physicians.

Consider a Colles’ fracture. It occurs in both children and adults, but the healing process is different because of the growth plates in the pediatric population. Aspiration pneumonia can present in both groups, but the cause may differ anatomically and microbiologically. Bronchospasm in adults likely has a completely different cause than in children. Diabetes may have similar long-term outcomes, but type 1diabetes is more difficult to manage psychosocially than type 2 in the pediatric population.

Numerous examples illustrate the differences between pediatric and adult diseases. Bacterial causes of pneumonia differ based on age group. Cerebral hemorrhage may have the same fatal outcome in children and adults, but rarely the same cause. Physicians must approach causes of respiratory distress in children quite differently. Heart failure is completely different in the two groups. Even the types of cancers that occur in children are different.

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Book Excerpt:Track physician response rates to assess program effectiveness

If a facility educates its physician stakeholders well, the number of queries left unanswered should be minimal. It is unreasonable to expect 100% query response rate, however, if the facility has not:

The CDI Handbook

• Obtained strong administrative support
• Developed comprehensive physician education
• Established medical staff documentation improvement initiatives
• Created consequences for non-participatory physicians

Generally, facilities set incremental goals. During the beginning of a program, a facility may expect to obtain 60% response rate, which should increase to between 75%-80% by the end of the program’s first year. More mature programs expect query response rates in the 90%-100% range. Although the goal is 100%, some leeway must be given if department funding in involved and if not all physicians within the department are employees of the hospital.

So with a program goal of roughly 90% for physician response to queries, all methods of finalizing queries should be considered. This may include calls to the physician by the CDI specialist and/or physician advisor, or developing an easier way for physicians to comply (e.g., fax query forms, electronic query forms).

Tracking the number of physician query responses helps facilities assess the credibility of the queries posed by the CDI staff as well as measure physician involvement, support, and understanding of the program. Program success stems from obtaining physician documentation in the medical record, not just the discovery and creation of a query. Similarly, just because a physician responds to a query does not necessarily mean he or she agrees with the premise of the clarification request.

When a CDI specialist poses a question and leaves a query that causes the physician to clarify the documentation within the medical record, most hospitals choose to record this as an “agreement” because the physician responded. While facilities should monitor this statistic, the query forms themselves should also be monitored to be sure the queries do not lead the physician or include clinically irrelevant multiple choice options. If the physician agreement rate with CDI queries is low, determine if it relates to a single CDI specialist, a single physician, or the entire program.

Editor’s Note: This post was taken from The Clinical Documentation Improvement Specialist’s Handbook by Marion Kruse, MBA, RN and Heather Taillon, RHIA.

Book excerpt: Use of clinical indicators in compliant query creation

The updated edition of the CDI Specialist's Handbook.

The easiest way to ensure CDI specialists submit appropriate queries is through the use of clinical indicators. Clinical indicators are a written set of guidelines based on the most current medical literature that help the CDI specialist determine when a clinical picture suggests a particular diagnosis.

Although medicine is both an art and a science a physician’s diagnosis is generally guided by a patient presenting symptoms, physical findings, and the results of diagnostic testing. By understanding the clinical information a physician uses to make a diagnosis, CDI staff members can ensure their queries are relevant and timely.

Consistent definition of conditions and treatments documented in the medical record is critical for accurate capture of coded healthcare data. However, what one physician may term a diagnosis another physician may label differently, which can lead to inconsistent outcomes. Therefore, when crating queries related to specific topics, refer to peer-reviewed physician journals such as:

• Journal of the American Medical Association
• The New England Journal of Medicine
• Annals of Internal Medicine
• Journal of the American College of Cardiology

When creating facility-specific query templates be sure to include clinical indicators for high-volume diseases but also be sure that the medical staff at your facility (or the specialty most closely linked to the condition) vet these queries.

Editor’s Note: This article is adapted from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition, byMarion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.

Q&A: Aspiration without pneumonia

Q: Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he

When to code for aspiration pneumonia

said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia, he said the patient doesn’t have pneumonia. He said the patient also doesn’t have a foreign body. What should I do?

A: It is difficult to answer without more information. Mendelson’s syndrome is a bronchitis or pneumonitis resulting from macroaspiration of acidic stomach contents usually associated with endotracheal intubation. When patients have this condition, coders should report ICD-9-CM code 997.39 (other respiratory complications) plus a code for the pulmonary condition. Aspiration pneumonia and aspiration bronchitis both map to the same ICD-9-CM code, 507.0 (pneumonitis due to inhalation of food or vomitus).

Because ICD is an international classification system maintained by the World Health Organization, it tends to group similar conditions under the same code. This is unlike CPT^®, with which physicians may be more familiar. The AMA maintains CPT, which includes more procedure- and encounter-specific codes. In this case, the physician must provide clarification so a coder can report the most accurate ICD-9-CM code.

Editor’s Note: William E. Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, answered this question in the June issue of Briefings on Coding Compliance Strategies

Use radiology findings to support your physician queries

Use clues from radiology and lab findings to help support your queries.

A patient’s medical record contains a wealth of information about his or her hospital encounter, including diagnoses, treatments, operative reports, and ancillary notes. Unfortunately, much of the detailed information found in a patient record is not “code-able”—that is, it is not information that may be used for diagnosis code assignment. Coders may only use documentation contained in select portions of the record—that which is provided by “hands-on” providers (i.e., those providers legally accountable for establishing a diagnosis).

Radiology reports, such as CT and MRI scans, x-rays, and ultrasounds frequently contain detailed information that can lead to more specific code assignment.

Coding Clinic advice supports the use of radiology findings to obtain additional information regarding the coding of the specific site of fractures. See the following references for more information:

• Coding Clinic, First Quarter, 1999, p. 5 (fracture site specified in radiology report)
• Coding Clinic, Second Quarter, 2002, p. 3, (ED coding using the radiological findings)

Note, however, that this guidance does not pertain to assigning diagnosis codes for conditions that the treating provider does not specifically identify or document.

Editor’s Note: This article first appeared on JustCoding.com. ACDIS members can read the entire article when it is published in October edition of CDI Journal.

Book excerpt: Query retention

Establish policies and procedures around query retention.

The AHA’s statement that queries should not replace physician documentation in the medical record raises the issue of query retention. Should CDI staff keep the query form as a permanent part of the medical record, remove it from the record and store it separately, or simply remove it from the record and eliminate it completely once the concern is resolved? The answer to this question remains open to debate.

AHIMA indicates that it is not advisable to record queries on handwritten sticky notes, scratch paper, or other notes that can be removed and discarded from the medical record. Its preferred formats for capturing physician queries include:

• A facility approved query form
• A facsimile transmission
• An electronic communication on a secure e-mail that complies with the HIPAA
• A secure electronic messaging system

To some, this instruction seems to imply that AHIMA recommends CDI programs keep physician queries as a permanent part of the medical record; however, the brief does not mandate that hospitals keep their query forms on file. Its brief “Managing an Effective Query Process” states:

“Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query would be a permanent part of the patients’ health record. If it will not be considered a permanent part of the patients’ health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subjected to health record retention guidelines.”

Editor’s Note: This article was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition, byMarion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS

Physician collaboration: Identifying the keys to success?

How do you get physicians to work with your CDI program?

Over and over again in CDI Talk, at the ACDIS conference, local chapters, anywhere two CDI professionals have an opportunity to  interact, it seems,  some very common topics arise. One of the most common it seems is how to gain cooperation and collaboration of the medical staff in CDI efforts.

An early ACDIS poll (March 2008) asked: “How have physicians reacted to your CDI program and query requests?” The results showed that only 40% reacted positively and the balance either neutral or negative.

I have yet to find the magic pill (imagine me sitting here singing Jefferson Airplane’s “White Rabbit”) which, once taken, will ensure physician collaboration in CDI efforts. If only one actually existed.

In recent ACDIS post titled “The CDI Evolution,” Juanita B. Seel RN, CCDS, described the organic development of her program. One of the things that really struck me was the apparent shift in response of the medical staff as her program focused more on completeness and accuracy of the medical record and away from financial implications of queries.

This idea— how to improve physician collaboration— has been foremost in my thoughts lately.  At my facility here in North Carolina, we are in the process of recruiting a medical director who will devote 50% of his or her time toward CDI/coding/HIMS and the balance to utilization review and case management, so I’ve been thinking A LOT about how to work effectively with this individual. And I’ve been wondering if ensuring physician collaboration is actually really simple.  Is the key truly as simple as finding the right hook, which is severity of illness / risk of mortality?  But there have been so many other things that have been discussed andtried!

How important are the various avenues employed to deliver information and promote better understanding?

• Newsletters
• Physician group presentations
• Fliers or posters
• Pocket Cards (or small handbooks)
• Individual on-the-floor ’30 second spots’
• The content of the queries, especially if attachments are used
• Web based content / presentations / Q&A
• Case Studies
• Support from:
  • Physician Advisor / Champion
  • Hospital Executives
  • Medical Staff Leadership
• Other??

What are the other things that folks have found to really motivate the medical staff?

• Public profiling data
  • Core Measures
  • Health Grades
• Quality of Medical Care
• Physician E&M billing
  • Support complexity and risks
• Short term, high intensity service line reviews
• I know that some organizations include unanswered queries with the delinquent records
• Other??

This is the single most important challenge that a program MUST overcome to be truly successful. This is one of the most important areas where we can share our success stories, our tools, our unique organizational variations, etc. So, I put it back out to the rest of the CDI community: What has been the single most effective thing that your program has done to engage physicians? AND, what has been the largest barrier for your program to obtaining physician collaboration?