By: John Zelem, MD, FACS
With the paradigm-shifting day of October 1, 2015, the start of ICD-10 has come and gone, apparently without much incident. This is due to tremendous preparedness across the gamut. All sorts of education for coders, CDI, and especially physicians has been of paramount importance during the preceding months. This seamlessly appearing transition is both good and bad. The good is obvious, yet only the ensuing time will determine how well and how successful it has been. The bad is that physicians may do what they frequently do: The crisis is over, so back to the usual.
It is an ongoing battle to engage physicians in the area of more specific and accurate documentation because many really don’t understand WIIFM (what’s in it for me).
Consider the following acronym to help E.N.G.A.G.E your physicians:
- Executive Support. MD Report Cards, metrics, and accountability.
- Negate physician concepts. “You only want me to do this so the hospital can make more money.”
- Gain Cooperation. Help them understand their quality scores and what effect they will have on the future, including reimbursement and employment, and more.
- Physician Advisors in a CDI program can be a boost, especially in physician education and peer to peers.
- Get better documentation. There is more to documentation than the “problem list,” cloning is a risk.
- Educate. Educate physicians on the way it works—“not the way you’ve always done it.”
It’s a challenge that we must continue to improve!
Editor’s Note: This post was written by John Zelem, MD, FACS. Zelem recently spoke at Medicare Compliance Forum in Charleston, SC and will be speaking at the NYC5B ACDIS local chapter meeting on November 5. Contact him at email@example.com.
Physician education has been a challenge for CDI specialists long before ICD-10 implementation. Now that we’re nearly three weeks in, some physicians may start to feel that they don’t need continuing ICD-10 education. The reality is ICD-10 will be an ongoing learning process for everyone. But, how do you keep physicians interested in what you to say?
Erica Remer, MD, FACEP, CCDS, clinical documentation integrity officer of University Hospitals in Cleveland, Ohio, said CDI specialists need to view this time as an opportunity to not only continue ICD-10-related education, but to embed standard CDI information to keep them engaged. “This is a great opportunity to go through the things that [the physicians] weren’t doing right in ICD-9 and reinforce it with ICD-10 education,” she said during the October 14 ACDIS Radio call. “This is a fresh start and one we should be capitalizing on.”
When placing a query, teach them why you had to query in the first place, Remer suggests. Educate them so you don’t have to query them and so they document properly—fewer queries is certainly an incentive to document correctly!
Physicians want to know what’s in it for them—what they get out of documenting more specifically, Remer says. When approaching physicians with an ICD-10 subject, reiterate things like quality scores, or physician ratings on sites like HealthGrades.com and HospitalSafetyScore.org. Make sure they know how documentation affects not just the hospital but their individual jobs and reputations. This helps get physician buy-in, says Remer.
CDI specialists should also take ICD-10 implementation as a “fresh start,” an opportunity to evaluate their own practices. At University Hospitals, CDI specialists make a point to query in a more timely fashion and stay on top of operative notes to make sure they are completed quickly, Remer says. “You can’t do procedures (PCS) without an op[erative] note,” says Remer. “It’s crucial now [for documentation]. What we would really like to prevent is having to query [the physician] twice.”
Editor’s Note: This post was written using a number of ACDIS resources, including:
Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. We’ve picked up the theme, going back into our archives to highlight some salient tid-bit. This week, we looked at an article from our April 2011 CDI Journal, “A CDI program’s purpose: Documentation for care quality” by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI.
Focusing on overall quality of documentation rather than diagnostic statements and case-mix index increases requires a sea change in thinking, but the first step is losing the CC/ MCC capture mind-set. Look at the entire record from the beginning and ask, “What’s missing?”
What’s typically missing from most documentation is the physician’s description of how sick the patient looks. Medicare has stated that InterQual criteria is a screening tool but is not the end-all be-all for determining an admission. What is most important is the overall clinical picture of the patient.
The key is getting the physician to document a thorough history of present illness (HPI). [more]
Q: In my facility, we are supposed to send an e-mail to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?
A: We do suggest every CDI program have well-developed query policies. These should be consistent with those policies followed by the coding department. Look at how unanswered queries are addressed on the retrospective side.
Your query policies should include clear guidance on what instances queries are to be asked, where they are placed within the record, and who is responsible for follow-through. You should also have guidance on how queries are to be prioritized.
Query policies should also include an escalation policy that describes how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, your department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for your organization.
In my experience, if a query was unanswered, the CDI specialist and inpatient coder would discuss the need for follow up. If it was determined that the answer would provide little impact, we would close it, leaving the query unanswered. But if we concluded an answer was required, the CDI specialist would address with the provider. There was a process of escalation in those instances when no response was received.
Ultimately, your policies should indicate what instances a query can go unanswered, and when it should be followed through. There may be instances when a query does not impact the reimbursement or quality measures and can be left unanswered. These are conversations that must be discussed within your organization.
Few organizations can boast a query response rate of 100%, but there are some things you can do to boost response rates. Take a look at your query templates or perform a query audit. There should always be choices that allow the physician to offer his or her own interpretation, or to state that there is no significance or the answer is unknown. Often, physicians do not answer queries because they either do not like the choices offered or they are unsure exactly what is being asked.
It might be helpful to monitor physician query response rate based on the CDI specialist responsible for the account. You may find a specific CDI specialist is having difficulty writing effective queries or lacks assertiveness in follow-up on unanswered queries. Most programs have a set time limit or goal for queries to be answered that is tied to individual CDI productivity or effectiveness in the role. For example, an expectation that 80% of all queries asked will be answered within 48 hours.
Administrative support is invaluable in encouraging physician involvement in your program. Many organizations track physician response rates to queries in their physician profiling, or “quality report card” efforts. Instead of forwarding administration every unanswered query, set an acceptable response rate. When a physician falls below the suggested benchmark, the matter should be addressed by a department director, PA, or senior administration.
I also like to give positive reinforcement where it is due. Recognize those physicians who are working with you and are demonstrating a high response rate. It creates a sense of competition and, often, we catch more flies with honey.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview. The next Boot Camp will be held April 27–30, 2015, in Washington, D.C.
The following is one example of a possible open-ended query:
“Dear Dr. Phil,
The patient’s sodium (Na) was 129, the progress notes indicate low serum sodium level, ‘¯Na.’ An order was written to place the patient on .9NS. Please clarify the associated diagnosis being treated.”
In this scenario, the physician is highly likely to respond and document “hyponatremia.”
The 2013 ACDIS/AHIMA query practice brief describes an obtruded patient with a history of vomiting treated for pneumonia. The open-ended query asks the type/etiology of the pneumonia, which, in that example, most likely result in a response of “aspiration pneumonia.”
Sometimes an open-ended pneumonia query can be problematic, however. For example,
“Dear Dr. Oz,
The patient’s progress note indicates he is being treated for pneumonia with vancomycin. Please clarify the type of pneumonia being treated.”
Although the wording of this query does a great job of not leading, it may not result in the most clinically appropriate answer (methicillin-resistant Staphylococcus aureus pneumonia). In many cases, the physician will respond “bacterial pneumonia,” which will still lack the specificity needed for coding purposes. Other physicians may respond “complex” or severe pneumonia.
In such situations, the CDI specialist would have to use a second query in an attempt to further clarify the issue. The use of open-ended queries works best when the potential answers are limited, involve commonly used terminology, and when physicians essentially understand the type of documentation required.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
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.
Q: I have heard that we should use materials from the physician’s world support our queries, such as publications from the American Medical Association. I tried searching for documentation tips related to medical necessity but was not able to find anything relevant. Do you have any suggestions about where I should start?
A: Physicians tend to “listen” or respect such definitions if they come from medical literature/research than if we describe definitions based on AHA Coding Clinic for ICD-9-CM or the Official Guidelines for Coding and Reporting.
Let’s say your CDI program wants to develop guidelines, standard definitions, for what constitutes acute and chronic respiratory failure. The CDI staff members will look to these definitions to determine whether a query is warranted, include them on physician educational tools such as newsletters or posters, and cite them as references on related query forms. Examples of good resources are the National Kidney Foundation, American Heart Association, and American College of Cardiologists. When I search for specific diagnostic guidelines, I like to pull examples from physician professional journals such as The Journal of the American Medical Association (JAMA).
When you cite these journals it lends you and your team a bit more credibility. So when the physician asks why you have initiated a query for a particular diagnosis you can show him/her where you obtained your information and demonstrate that it came from a clinical source. Including a copy of the article with any additional follow up conversations or education is another way to reinforce that you (and your CDI team) have done your research and the guidelines (both diagnostic and expected treatment) are based on evidence in medicine.
While such literature represents a good starting place, increasingly best practice is for CDI professionals to work with coders, physicians, and other non-physician clinical providers to develop a consensus definition for commonly queried diagnoses. So, for example, you might research clinical indicators for acute and chronic respiratory failure and cite the sources you find. Then you could review these with the coding team to assess the related coding definitions. Then bring all this information to bear, working with your pulmonologists on staff using their professional associations or publications to define the terms in question. [more]
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.”
Historically, healthcare organizations have been operating under the belief that when it comes to communicating with physicians, more is better. The tendency is to “cover the bases” and make sure they are sent details on everything, just in case. This is not effective. More is simply more. At high-performance institutions, teams carefully scrutinize the message and the target audience. This discipline demonstrates respect for the physician’s time, knowledge of their professional specialization, and an understanding of their needs.
Often the number of department within an organization sending messages to practices confounds the “relevance” challenge… A useful first step is to audit the current volume of outbound messages, the relevance for the practice, the timing and overlap… Next, find out what doctors need to know. Too often, physicians are not asked what they want or need to know; instead messages are “pushed out” with little regard for the physician’s needs.
Editor’s Note: This excerpt was adapted from The Complete Guide to Physician Relationships: Strategies for the Accountable Care Era, by Kriss Barlow, RN, MBA.