All Entries Tagged With: "physician"

Dazed and confused? Or Encephalopathy?

Altered mental status, dementia, or encephalopathy: What’s really going on with your elderly patient that presents with confusion?

The typical scenario is the elderly patient with some minor dementia, who has been living fairly independently, who is described as being more confused than usual. A work up does not indicate any acute neurological conditions but the patient is admitted with altered mental status. Further work up often reveals an underlying infection or metabolic condition. After treatment of the underlying concern, the patient’s mental status returns to baseline and the patient is discharged back to their usual living arrangements.

Don't let dementia documentation confuse you.

The resources consumed in treating this type of patient often include a head CT, neurological consult, neurological checks, EEG, sometimes even a bed in the intensive care unit. But if the physician only documents altered mental status or dementia and not a type of encephalopathy, the true severity of illness of the patient may not be accurately reflected.

So what is encephalopathy?

As defined by the National Institute of Neurological Disorders and Strokes, National Institutes of Health, encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent, metabolic dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation) chronic progressive trauma, poor nutrition, or any reason for lack of oxygen or blood flow to the brain.

The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include tremors, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.

Coding Clinic provided a definition in the first quarter of 1988 (pages 3-4):

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Update physician education with tips from ACDIS members

A newcomer to the ACDIS group page on Facebook asked recently how to keep physician engagement in clinical documentation improvement high as CDI programs begin to mature.

To be sure, there’s always an initial excitement regarding new programs and the potential they hold for improvement. Sometimes, however, that energy begins to fade. Reading Tina Lewis Simpson’s comment I was reminded of a HealthLeaders Web cast, 5 Ways to Hospital-Physician Quality: Goals, Incentives, Dialogue, Infrastructure, Data, in which Rebekah Wang-Cheng, MD, FACP, medical director for clinical quality at Kettering Medical Center in Dayton, OH, offered several strategies to facilitate physician communication. Consider the following techniques to improve physician education and awareness of your CDI program:

• Educate one-on-one, face-to-face, in real time. When addressing a particular problem with physician documentation, don’t wait, says Wang-Cheng. Use a specific case that happened within the past day or two to illustrate your point.
• Educate in groups. Go where physicians gather, Wang-Cheng says. Offer education sessions during quarterly medical staff meetings, or specialty meetings
• Show data. CDI specialists constantly gather data, benchmark and report this data back to the physicians. When physicians see how appropriate documentation affects patient care and the overall mission/wellbeing of the facility they will be more likely to understand the mission behind your position.
• Walk in their shoes. Shadow a physician for a day to observe the pattern of their care. That way you’ll have a better understanding of the physician’s work flow. Armed with understanding you can adjust your query process to fit their needs as well as your own.
• Say, “Thanks.” If a physician is responsive to your inquiries, praise him or her for their helpfulness. Take your appreciation a step further, says Wang-Cheng, by sending him or her a thank you note to their home so they can show their family. “There’s nothing better than to be able to say to a spouse: ‘Look, someone said something nice about me.’”
• Start at the top. Approach physician leaders in various disciplines. This type of influence will help you “spread and sustain the education,” Wang-Cheng says.
• Listen as much as you talk. Emphasize with the physicians. Realize they have difficulties, both professional and personal, too. Don’t be afraid to admit ignorance but be sure to ask for their assistance when you do.
• Make the physician lounge a welcoming place. A CDI specialist may not have direct involvement regarding the physical location and ambiance of the physician lounge, but he or she can use the lounge as a way to get the word out about the CDI program. Visit often and leave specific, small tokens of appreciation from time to time.

Those interested in additional tips to gain physician support may want to click on Sylvia Hoffman’s blog posts, at right, including: Spring ideas to woo physician support and KISS method applies to CDI physician education, too.

Furthermore, thanks to North Cypress (TX) Medical Center Director of Clinical Documentation Improvement Mike Alcorn, LVN, there are some sample e-mail physician education packages available in our Forms & Tools Library. Read how he created his physician education strategy in CDI Strategies.

If you have any tips or innovative suggestions for how to spice up the physician education component for the more advanced CDI programs please post ‘em here. We love to hear what you’re up to. Besides what’s working for you may help solve a problem for someone else.

Don’t cut out ‘excisional’ when considering debridement queries

This is one case when you can't 'cut it out.'

Recently a client contacted me regarding a surgeon who asked the coding department to stop querying him about excisional debridements. His comment was that all his debridements are excisional. He’s a surgeon and he cuts. Bottom line.  So please stop pestering him with the queries.

As most of us know, this clearly isn’t enough to code a record and has been the reason for a significant number of concurrent and retrospective queries across country in many, many hospitals. The simplest solution, of course, is for the physician to use the words excisional debridement but as we all know, that simple solution doesn’t always translate into simple reality.

What the client wanted to know was if they could make the assumption based upon his comment, that whenever he documented debridement, that he meant excisional and code to excisional. Again, I believe most of us would say that the documentation doesn’t indicate excisional and needs further clarification. So how do we get the documentation and not irritate the physician?

In an attempt to help clear the water surrounding the word “excisional,” many coding departments and documentation teams have made attempts to develop policies and procedures for clarifying this procedure. This became especially important with Recovery Audit Contractors (RACs) and other auditing agencies focusing on this specific procedure. Add to the mix the increasing number of elderly patients that are admitted with wounds that require care and then the number of non-excisional methods of treating these wounds. Clearly there is much to consider.

So what’s the best approach? Of course education is important. Physicians must understand the importance of their documentation and how a single word (or lack thereof) impacts the severity of illness, risk of mortality, and reimbursement. Communication of coding guidelines and definitions becomes an important function of a documentation improvement team.

Whether through queries, newsletters, posters or presentations, it is important for a documentation team to recognize the need for an ongoing method to provide support and resources to healthcare providers regarding documentation. We need to help providers learn the vocabulary that best represents the diagnosis and care they provide to the patient. Making assumptions or creating policies that allow for ambiguous interpretation of documentation will only create other problems.

So, clearly this particular surgeon needs to understand that if he performed an excisional debridement then he needs to document “excisional debridement.” Providing him with the information that defines an excisional versus non-excisional debridement is also important. Hopefully, once this information is shared, he will understand the need to include the appropriate words in his documentation. If not, that leaves the query process as an important part of the documentation process.

In answer to the question of whether it’s okay to eliminate queries for excisional debridement if the physician documents just debridement, only the provider knows the depth to which he or she cut and therefore it becomes the responsibility of that healthcare provider to document accurately and appropriately. I know this answer doesn’t necessarily make a CDI specialist’s day, but look at the bright side; it’s another opportunity to have a conversation with a physician and spread the word of complete and consistent documentation!

Examine secondary health data for documentation motivation

I’ve been hearing a lot lately about the perennial question of how to get to good ‘ole physicians to “buy-in” to the CDI system. Like my fellow blogger Sylvia Hoffman asks, “How do you get an old dog to perform new tricks?”

One way (and it seems like the government’s pretty keen on this method too) gaining popularity is another aphorism—the good ‘old carrot and stick. If physicians keep proper documentation they score better on a number of rating systems. If they don’t they (and the facilities they work for) get hit with RACs, MACs, poor ratings, decreased reimbursement, you name it. With so much incentive to improve documentation techniques you’d think it’d be a “no-brainer” wouldn’t you?

Here are four sites to keep your eye on when tracking quality trends.

HealthGrades: HealthGrades provides ratings and profiles of hospitals, nursing homes, and physicians to consumers, corporations, health plans and hospitals.

Health Care Cost and Utilization Project (HCUP): A family of healthcare databases and related software tools and products made possible by a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ).

The Leapfrog Group: The Leapfrog Group is an initiative driven by organizations that buy healthcare who are working to initiate breakthrough improvements in the safety, quality, and affordability of healthcare for Americans. Organizations voluntarily report certain data requested by Leapfrog, which is then published on the Leapfrog Web site.

Premier Hospital Quality Incentive Demonstration: The demonstration involves the Centers for Medicare and Medicaid Services (CMS) partnership with Premier Inc., a nationwide organization of not-for-profit hospitals, and will reward participating top performing hospitals by increasing their payment for Medicare patients.

Documentation requirements for critical care services

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional bulling, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

• Critical care delivery by time increments for the first encounter
• Additional critical care when the patient crashes again
• A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery.

The following are a few examples of conditions that necessitate critical care:

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CDI training-docs teaching docs-available online

Those ACDIS members who’ve been with us since the beginning may remember my good friend Brian Driscoll. He helped facilitate some of those early clinical documentation study groups that led to the launch of this association. Although Mr. Driscoll has made a number of career moves since the start of ACDIS the importance of the profession remains close to his heart. So when he realized his new employer Quantia Communications developed a free training video aimed at teaching physicians about the importance of CDI he asked me to pass the tool along to you.

It features Debasish Dasgupta, MBBS, FACP, Assistant Professor of Clinical Medicine, Indiana University School of Medicine and physician advisor, Clinical Documentation Improvement Program, Indiana University Hospital who explores CDI basics telling physicians why they need to care about CDI just as much as coders and nurses and the hospital chief financial officer do. Dasgupta also presents a number of case studies that help illustrate the value of CDI.

While Mr. Driscoll says he misses us all, he confesses to be pretty happy at Quantia, an online community built primarily for physicians. Typically, Driscoll says there’s a sign-in process for this material but he’s worked with his folks to make this available specifically for us.

Let us know if you find it useful.

Chapter 3: The MS-DRG Training Handbook

We’re constantly talking about to get the word out about the importance of clinical documentation improvement. How can we teach physicians that the specific language they use in the medical record affects their patient’s treatment, their quality scoring, hospital reimbursement, and their own reimbursement too?

First to answer the triva questions wins a set!

Some of you may be familiar with The MS-DRG Training Handbook written by ACDIS Advisory Board member Gloryanne Bryant, BS, RHIA, RHIT, CCS, but for those who haven’t seen it yet there’s a collection of examples for explaining the MS-DRG system to physicians in Chapter 3, I thought I’d share with you:

“1. Call upon physicians to better document the character, underlying causes, complications, and severity using ICD-9-CM language. For example, in order to get decompensated CHF to count as an MCC, physicians must clearly state that it is acute and must document whether it is systolic or diastolic heart failure. Stating one without the other will result only in a CC.

“2. Ask physicians to clearly document the underlying mechanisms of certain manifestations. For example, if a patient has hyperkalemia as the result of the drug spironolactone, the physician needs to document the state of hypoaldosteronism. Similarly, if a patient has delirium due to narcotics, the CDI specialist needs to query the physician regarding the extent or possibility of toxic encephalopathy. “

The Handbook includes a good amount of basic, easy-to-understand information regarding the development and importance of the MS-DRG system, which I’m sure I’ll excerpt from again. Not to be pushing product but it comes in packs of 10, which. . . when we’re talking about educating physicians. . . can be a quick item for CDI specialists to hand out.

Educating physicians and others  about how the implementation of MS-DRGs increased the need for CDI is particularly important during a new CDI program’s inception. That’s when the only thing physicians want to know is: Who are you? Why are you doing this? What’s in it for me? Understanding MS-DRG basics can help them see the bigger picture behind the healthcare reimbursement system.

So here’s some trivia. First person to answer BOTH questions correctly will get a pack of the Handbooks.

1. When did the MS-DRG system take affect?
2. What three basic categories of the system?

CDIs tell the story behind the patient record

I came across this article from HealthLeaders Media the other day. It talks about the importance storytelling in healthcare. I don’t think they were talking about the “once upon a time” kind of storytelling, but more about the kind of storytelling that represents what we writer-types like to call the “narrative arc.”  Simply put, everything has a cause and effect whether it’s how some story-book character’s childhood upbringing comes to bear on their philosophical outlook or, in the case of clinical documentation improvement,  how a particular patient’s clinical indicators come to bear on his or her inpatient stay.

CDI professionals try to get all the story particulars from all the various characters as they each play their role in the development (and resolution) of a patient’s healthcare plot.

According to the article, facilities in the United States and the United Kingdom are using storytelling to enhance patient history information to get a better sense of how to treat the patient. Storytelling also helps providers develop a relationship with the patient and form a better understanding of an individual case, writes Sarah Kearns.

While I’m not suggesting that we rename clinical documentation improvement specialists “storytellers” I am suggesting CDI professionals take a second to consider the health record as if it represents the “story” of the patient’s life, the story of his or her care. Furthermore, I am suggesting that perhaps expressing your documentation improvement efforts in that way may actually resonate with the physicians and help them understand the important role you also play.

Spring ideas to woo physician support

Chocolate bunnies, marshmallow chicks, and jelly beans all bring to mind the magic of springtime. Fill a clear bag with fake grass and a few candies, tie it with a ribbon and attach your business card.

A little sweetness goes a long way.

You now have a great little thank you gift for your physicians and allied health professionals. We are all just children at heart and even the most serious surgeon will crack a smile when he sees the festive little treats. It doesn’t take a big budget to let someone know they are appreciated. Include a few documentation items, such as pocket cards, and hospital pens and now you are getting two for one—appreciation and education. This practice of passing out goodies can also be repeated for fall and winter holidays, keeping documentation fresh on the minds of your medical staff.

Keep your creative side open to suggestions when dealing with difficult doctors. Share your ideas with others and together, everyone can reap the rewards.

Consider CDI time management techniques

“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.

Time flies so try to make the most of it.

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:

• Prioritize
• 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.