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Q&A: Reporting right-sided heart

SharmeBrodie_May2017

Sharme Brodie RN, CCDS, answered this week’s CDI question.

Q: If you have an acute exacerbation of a chronic right heart failure (CHF) with a preserved ejection fraction (EF)— above 55%—can you code it as heart failure with preserved EF? All the clinical symptoms are exemplifying right failure. For example, ascites, pronounced neck vein distension, swelling of ankles and feet, etc.

A: ICD-10-CM has codes associated with the documentation of right-sided failure and for left-sided failure. Each ventricle supplies different portions of the circulation, so heart failure can be described as either right or left depending on the symptoms. When the right ventricle fails, we call it right-heart failure. In this case, fluid backs up into the peripheral circulation, into the legs, head, and the liver. Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. [more]

CDI Week Q&A: CDI and Quality

Ignatowicz

Nancy Ignatowicz, RN, MBA, CCDS

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Nancy Ignatowicz, RN, MBA, CCDS, a remote/traveling CHI nurse with MedPartners, based in Bourbonnais, Illinois, and a member of the 2017 CDI Week Committee, answered these questions on CDI and quality. Contact her at nrmignatowicz@comcast.net.

Q: Can you describe the relationship of CDI to quality initiatives, and how CDI can make a difference?

A: CDI and quality can have a variety of relationships. For instance, CDI can offer concurrent notification of actual or potential issues to the quality department. CDI can assist with concurrent data collection and quality interventions. CDI queries can also address present on admission status, cause-and-effect relationships, surgical puncture/laceration specificity, risk of mortality, and severity of illness. For example, CDI can help capture pressure ulcers, catheter-associated urinary tract infections, pathological fractures (which may have been diagnosed intra/postoperatively), surgical lacerations integral to the procedure, and diagnoses that were present on admission but not previously identified in the documentation.

Q: Has reviewing for quality measures hindered your department’s “traditional” CDI chart reviews or overall productivity? [more]

Q&A: Denial management teams

Have CDI questions?

Have CDI questions?

Q: What guidance do you have for building a denial management team?

A: As with any team, it is important to have the right players working together with identified roles and responsibilities established for each. The members of the denials management team should be representative of departments with a direct tie to the various types of denials. Include the following groups: [more]

Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

[more]

Q&A: Electronic query formatting

Have CDI questions?

Have CDI questions?

Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?

A: This is going to be contingent on the system your facility uses.

Some EHRs have pretty complex platforms that will allow you to build templates and write a narrative. Here you would write your question, provide all of the appropriate details, and there would be a more formatted, outlined section below where the individual leaving the query can populate the form within that template.

[more]

Q&A: Documenting excisions in dermatologic settings

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Have CDI questions?

Q: I work in dermatology and need to know what documentation is required for excisions. We are struggling with getting paid.

A: In dermatology, you often find vague documentation like “lesion” and “mass.” So the physician needs to be much more graphic as far as whether the lesion is red, itchy, scratchy, burning, and/or abnormally sized. If you can get the actual size of a lesion or a mass that they are going to excise, they also need to document the size of the excision.

[more]

Q&A: Missing documentation for acute kidney injury

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Ask ACDIS all your CDI questions!

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?

[more]

TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

[more]

Q&A: Rejections for claims for removing impacted cerumen

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Ask ACDIS

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

[more]

Note from CCDS Coordinator: Do you really need the CCDS certification?

CCDS certification

I received an interesting question recently from someone contemplating Certified Clinical Documentation Specialist (CCDS) certification. She asked:

“I am wondering whether obtaining the certification gives the CCDS holders any special privileges? Are they able to perform duties that they otherwise would not be able to if they did not hold the certification (not by knowledge, but by law)?”

In my five-plus years with ACDIS no one has ever asked this question. Obtaining the CCDS credential does not give the holder any additional rights, privileges, or responsibilities. It does not legally empower the holder to perform any duties.

What the CCDS credential does, however, is recognize individuals who have an advanced level of CDI knowledge and who have the proven ability to work as clinical documentation specialists. Candidates for the CCDS designation are required to have at least two years of experience in the profession.

The CCDS demonstrates an accomplishment that captures both experience and knowledge in the field, and many facilities suggest or require their CDI staff hold the CCDS or earn it following the two-year minimum requirement to sit for the exam, after hire. Facilities often hire individuals with nursing (clinical) or coding experience for the clinical documentation team and train them to become proficient. It is the decision of the individual facility to determine who to employ as a CDI specialist and what responsibilities are given to individuals who perform the CDI role, which may differ depending on whether or not they hold the certification.

What I didn’t tell the writer is that, for a lot of people, CCDS certification is a matter of pride. In the fall of 2016, ACDIS conducted a survey of CCDS holders and asked them what they see as the value of their credential. Their responses included:

  • The credential differentiates me as a leader
  • I am set apart as the CDI who went the extra mile to prepare for and achieve the certification for my very specialized profession
  • I am the go-to-person for others to come to with questions for assistance
  • The credential demonstrates that I put forth the effort to be knowledgeable about the work I perform
  • Professional certification is about promoting the highest standards in our industry
  • Personal satisfaction
  • It shows I take my job seriously and intend to stay on top of the knowledge I need to do the job well
  • It shows I have the experience of clinical chart review for appropriate diagnoses and the clarification/query process to physicians
  • The credential sets me apart—I have skills and knowledge
  • It’s proof that I value this job, want to continue to do it, and want to improve myself; I feel it’s a definite plus and shows that I take pride in what I do.
  • It adds much credibility with the physicians in my institution—I think I am perceived as being more professional and more knowledgeable in my role

From the same survey, several managers told us:

  • Certified individuals are viewed as more knowledgeable about coding guidelines and best practices. They are more committed to their work, better trained, and have better understanding of the role and what is required to do the job well. And because of recertification requirements, they stay current with changes in the industry.
  • Certification holders often serve as team leads, help with new staff orientation, and staff education.
  • It communicates a commitment to their craft. Requirements are such that they have to stay current with on-going changes that are occurring. It helps when interacting with their “customers,” as they really are trained and understand what they are doing.
  • Identifies that you have attained increased knowledge related to your daily practice.

What will drive you to seek CCDS certification? Whether personal pride, or a suggestion or requirement from your employer, we are here to encourage your efforts and cheer your accomplishment.

Visit the ACDIS website and download the Exam Candidate’s Handbook for more information about certification.

Editor’s note: Penny Richards is the CCDS Coordinator for ACDIS. If you have any questions regarding the CCDS credential or exam process, contact her at prichards@hcpro.com.