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.
by Melinda Tully, MSN, CCDS
For providers, the days of earning full Medicare payment by simply submitting complete and accurate information are drawing to a close. In 2013, Medicare will begin paying healthcare providers and facilities based on the quality of care provided, not just the quantity of services.
Then, starting in 2014, base payments will depend on the outcomes of the care documented.
So how do we shape up before we face even bigger federal cuts? Simple. Clinical Documentation Improvement. CDI. It’s an acronym that everyone in the healthcare industry should become familiar with.
I sometimes like to think of CDI as investigative reporting for healthcare. CDI helps make sure the patient record is telling the true clinical patient story, including what care the physician provided and why, to ensure the record is coded and billed appropriately. For healthcare facilities and physician practices to thrive through these changes they need to understand the value of CDI and its direct impact on both patients and physicians.
Patients a Priority
Regardless of the rule or regulation, physicians will not change what they do until they see what’s in it for patients. While it’s easy to see how better clinical documentation can help patients, it’s hard to make that a reality in a typical healthcare setting where clinicians are juggling tight schedules and hectic patient workloads.
The most successful CDI programs work with clinicians to enhance the core training they learned in medical school, teaching them how to document a patient’s true clinical story during their workflow to best represent the complexity of a patient’s case and decisions made along the way. This helps keep patients safe, improves communication between clinicians and protects providers from lost revenue.
Quality scores are becoming more transparent to the public every day and high mortality rates and medical errors make headlines. While many CDI programs are led by finance departments, clinical documentation is not an issue reserved for HIM departments. Clinical leaders from many areas including chief medical officers and quality officers need to be involved in CDI to keep the patient’s best interests in mind.
For the last several years I have worked with physician leaders at a large academic medical center to identify and implement CDI efforts focused on improving quality. These efforts have transformed the organization’s performance metrics, improving mortality indexes so they more accurately reflect the severity of illness of their patient population. These quality indicators are important because decisions are made based on these types of quality metrics – whether it’s by patients seeking treatments or payers evaluating providers. The best part about this customer’s success is they have improved their documentation and now their clinical information is so good that when physicians look ahead to pay-for- performance, Accountable Care Organization implementation and bundled payments, they know they are in good shape for the future. [more]
Engage the physician in query development
Experienced CDI programs often suggest that the best form of physician education is physician involvement. The earlier physicians get involved in the development of the CDI program, the greater their investment becomes. With the program parameters established, CDI staff can turn their attention to the development of physician query templates.
The medical staff most closely linked to a particular condition should vet the clinical guidelines incorporated in the query forms. For example, many facilities have clinical guidelines to help determine types of congestive heart failure based on recent medical literature and as supported by the cardiology department.
The American Hospital Association’s Coding Clinic for ICD-9-CM supports the development of guidelines for querying physicians. It states:
Facilities can work together with their medical staff to develop facility-specific coding guidelines, which promote complete documentation needed for consistent coding assignment. … These facility guidelines must not conflict with the Official ICD-9-CM Guidelines for Coding and Reporting developed by the Cooperating Parties and additionally they should not be developed to replace the physician documentation needed to support code assignment.
Further, the ICD-9-CM Official Guidelines for Coding and Reporting state:
A joint effort between the healthcare provider and the coding professional is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized.
Physicians are not the enemy. Despite how busy they are, they want to comply. They want positive feedback. They want to do the best job they can for their facility and, perhaps more importantly, for their patients.
Editor’s Note: This post is an excerpt from The Physician Documentation Improvement Pocket Guide instruction manual. The Physician Documentation Improvement Pocket Guide, by Pamela P. Bensen, MD, MS, FACEP, is a tri-fold laminated card which comes in packs of 25, to assist CDI specialists in their physician education efforts.
By Heidi Hillstrom MS, MBA, RN, CCDS
As a 10-year veteran of a successful CDI program, I am accustomed to being asked, “How did you build your program?” My response invariably is how vital it is to bring your physicians on board.
Before you respond, “But you don’t know how difficult this is with our physician group!” Or, “Get real Heidi! That isn’t going to happen here!” Let me assure you that obtaining physician support for CDI efforts is definitely achievable.
It all hinges on relationship building. This didn’t happen overnight, for us of course. Once they understood there was no implied criticism of their documentation ability or attempt to tell them how to practice medicine, a lot of the initial hostility disappeared.
First, be visible to your doctors. Whenever possible, perform your reviews on the units. Greet them by name. Don’t be afraid to enter into general conversations that are occurring. It doesn’t have to involve documentation. The performance of a favorite sports team can be a great conversation starter. During these conversation moments, you will have opportunities to discuss clinical documentation, but keep it brief and to the point.
Second, be respectful of your physicians’ limited time. I requested to be included on the agenda of their staff meetings. Personally, I never tell a physician I’m there to provide them with “documentation education.” They are well educated, and this can be perceived as being condescending. Instead, I tell them that I am here to provide them with the most recent documentation “information” that impacts their practice.
I found formal power point presentations tend to lose their attention fairly quickly. Rather I present an informative agenda tailored to their particular specialty and encourage open discussion. I ask them to share their expertise in understanding the clinical indicators for a diagnosis. This is really where the collaboration begins.
Be prepared to listen to their frustration with the documentation process without becoming defensive. A little empathy can go a long way. It is crucial to follow up with any questions they may have. Finally, ask them for their input on how the CDI clinicians can improve their communication process.
Once I became more than a faceless documentation query, building a relationship became much easier. Now, I am often approached on the units and contacted, by physicians, with additional documentation questions and or concerns. Friendly conversation became natural. My template or note became a message from me. My queries are more likely to get a response. In fact, once the physician and clinician relationship grew and clinical documentation is now a collaborative effort, I am often greeted with, “Hey Heidi, is that question for me?” once they saw a query form in my hand.
In closing, I am pleased that I have gone from a physician fiend that they avoided to a friend who physicians seek out.
Editor’s Note: Heidi Hillstrom, MS, MBA, RN, CCDS, is Clinical Documentation Manager at St. Luke’s Hospital in Duluth, MN. Contact her at email@example.com.