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Conference Conversations: Fox helps make CDI programs “physician-friendly”

Fox, Nicole

Nicole Fox, MD, MPH, FACS, CPE

Editor’s Note: The ACDIS Conference is only a little over two months away. Over the coming weeks, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked to Nicole Fox, MD, MPH, FACS, CPE, the medical director of pediatric trauma and CDI at Cooper University Health Care in Camden, New Jersey, who will be presenting “Playing to Win: How to Engage Physicians in Clinical Documentation Improvement.” Currently, Fox leads a team of 13 CDI specialists and achieved a 100% physician response rate to queries.

Q: What has been the biggest challenge you faced with physician engagement at your facility?

A: Actually one of the strengths of our program is physician engagement. We have a 100% response rate to our CDI queries. I think one of the general challenges with physician engagement is not recognizing that the best way for physicians to receive information is peer-to-peer. There is no substitute for a practicing physician embedded in your CDI program who will proactively educate peers and handle any concerns that arise. Physicians are never taught how to document, so they struggle with this much-needed skill set and are often hesitant to ask for help. But, they respond most effectively to one of their peers.

Q:  What are three things attendees can expect from your session?

A: Attendees can expect an interactive, dynamic presentation. They will have tangible “take-aways” to help make their CDI program physician friendly. They also will have tools to handle difficult physicians.

Q:  What one tool can CDI professionals not live without?

A: An engaged medical director for their program.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: This session challenges non-physicians to see CDI from a physician’s perspective and really evaluate their own program to determine whether or not they are set up for success in terms of physician engagement.

Q: What are you most looking forward to about this year’s conference?

A: I cannot wait to hear about other program’s successes, particularly with ambulatory CDI which is our next area of growth and expansion.

Q: Fun question: what’s your favorite breakfast food?

A: An egg white burrito with quinoa and black beans. It’s awesome with tomatillo sauce. They make a great one at the Wynn Hotel café in Vegas, so try one while you are out at the ACDIS conference.

 

Conference Conversations: Brant offers insight into recovery auditor programs

barbara brant

Barbara Brant, MPA, RN, CCDS, CDIP, CCS

Editor’s Note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we spoke with Barbara Brant, MPA, RN, CCDS, CDIP, CCS, a senior consultant with Cotiviti Health Care, presenting “CDI Specialists: Impact Potential in the Audit Process.” Since 2005, she has been involved in the development, implementation, and auditing of CDI programs. Brant has assisted health systems with ICD-10 Gap Analyses and created ICD-10-CM educational materials for specialty physician groups. Currently, she provides training and clinical support for DRG auditors. She lives in Camp Hill, Pennsylvania with her husband Marty.

 

Q: What do you think CDI specialists’ biggest misconceptions about the Recovery Auditor program are?

A: There are really three main misconceptions:

  1. Denials are determined without complete review of the documentation
  2. Recovery Auditor’s only look for “gotcha” errors
  3. CMS Recovery Audit programs are performed to only take back

Q: Recovery Auditors are not at the top of anyone’s best friend list in healthcare, but what important purpose do they serve?

A: The goal of any audit is to identify problematic issues. The purpose of CMS’ Recovery Auditors is to identify and prevent improper payments. Therefore, Recovery Auditors serve a purpose by encouraging healthcare providers to work for solutions to correct identified problems, stabilize provider revenue cycles, and ensure accurate payments for payers.

 

Q: What are three things attendees can expect from your session?

A: The three things that attendees can expect are

  1. To understand that Recovery Auditors perform very comprehensive reviews of all documentation provided.
  2. To obtain knowledge that the guidance for recommended reimbursement changes (higher or lower) is based on extensive peer-reviewed research of best-practices, clinical consensus data and Official Coding Guidelines.
  3. To use information from this session for improved denial data due to CDI performance improvements.

 

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: To encourage use of retrospective audit data to concurrently improve problematic documentation

 

Q: What are you most looking forward to about this year’s conference?

A: Interaction with colleagues and to stay updated on CDI’s expanding roles within the revenue cycle

 

Q: Fun question: what’s your favorite movie?

A: A Christmas Story – a perfectly imperfect loving family!

 

Q&A: Coding guidelines for COPD and pneumonia

Q: I’m having problems determining the correct coding guidelines for chronic obstructive pulmonary disease (COPD) and pneumonia. Have the guidelines changed regarding COPD and pneumonia? Do you now have to code the pneumonia as a COPD with a lower respiratory infection?

A: Yes, the AHA’s Coding Clinic for ICD 10-CM/PCS, Third Quarter 2016, discusses an instruction note found at code J44.0, chronic obstructive pulmonary disease with acute lower respiratory infection requires that the COPD be coded first, followed by a code for the lower respiratory infection. This means that the lower respiratory infection cannot be used as the principal diagnosis. We would assign code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) as the principal diagnosis, followed by an additional code to identify the lower respiratory infection.

If the patient has an acute exacerbation of COPD and pneumonia, we would assign both codes J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) and code J44.1 (chronic obstructive pulmonary disease with acute exacerbation). Per the instructions, either code may be sequenced first and it should be based on the circumstances of the admission, followed by a code to identify the infection, such as code J18.9 (pneumonia, unspecified organism).

CDI specialists and/or the coding staff need to clarify the type of infection to ensure the proper code assignment. There does seem to be some concerns regarding classifications of lower respiratory infection. Per the Coding Clinic, acute bronchitis and pneumonia are both included in code J44.0 (lower respiratory infections). Influenza, on the other hand, is not included in code J44.0 because it is considered both an upper and lower respiratory infection.

Additionally, the type of pneumonia needs to be clarified. For example, aspiration pneumonia (code J69) is not classified as a lower respiratory infection, but as a lung disease due to the external agents. To assign the appropriate code in the case of aspiration pneumonia, we would need to know the external agent, i.e. milk versus vomit.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.

 

Conference Q&A: Manchenton digs into surgical CDI

Manchenton

Cheryl M. Manchenton, RN, BSN, CCDS

Editor’s Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Cheryl M. Manchenton, RN, BSN, CCDS, senior inpatient consultant/project manager with 3M Health Information Systems, overseeing CDI programs, who will present “Anatomy of an Operative Note: A CSI Analysis of Operative Notes Gone Bad.” Manchenton specializes in workflow design, program management, quality metrics, and performance. She is responsible for the 3M quality services and quality services training materials and hosts the 3M CDI Management Roundtable. Manchenton is a guest for ACDIS Radio on the March 22 at 11:30 a.m. EST. She will be providing a brief preview of her conference presentation that you won’t want to miss! To register for ACDIS Radio, click here.

Q: What’s the biggest challenge you encountered in your experience with surgical CDI programs?

A: The biggest challenge is lack of timely operative notes or detailed daily progress notes. In other words, minimal documentation by surgeons including a comprehensive list of chronic conditions.

Q: What are three things attendees can expect from your session?

A: Our session will be at minimum entertaining. Attendees can expect us to share very common pitfalls with operative note templates, strategies for collaborating to improve and results of effective collaboration.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: Instead of complaining about who’s fault something is with poor documentation, coding or quality metrics, I hope our session will show attendees some creative ways to actually improve.

Q: What are you most looking forward to about this year’s conference?

A: Collaboration!

Q: Fun question: What is your favorite animal and why?

A: I love otters. They work hard but play hard too. They know how to make work fun.

 

Conference Q&A: Faustino shares her remote CDI experiences

Lara Faustino

Lara Faustino, RN, BSN, CCDS

Editor’s note: So we’re getting close to conference time!  we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we caught up with Lara Faustino, RN, BSN, CCDS, a CDI s specialist at Boston Medical Center (BMC), who will present “A Visibly Invisible CDI Team.” She has 10 years of clinical experience in three large, academic medical centers in New England and extensive knowledge in both CDI and quality enterprises. During her career, Faustino developed best practice provider education for documentation, helped with her facility’s EMR transition, and developed training strategies and tools for the ICD-10 transition. Additionally, she was nominated by peers to the Massachusetts Regional Leadership Co-Chair status (2016) and served as the national 2015 BMC representative at the ACDIS national conference.

 

Q: How does your remote CDI position give you a unique perspective on the field as a whole?

A: I believe as technology advances, specifically the integration of the electronic health record (EHR) and tele health, I view a new angle on healthcare delivery (not just the field of CDI) as a whole. As the future state of virtual physical assessment evolves using iPads/iPhones from a remote setting, a successful CDI program will adapt to the same methods of communication to enhance the physician relationship.

 

Q: What are three things attendees can expect from your session?

A: Attendees can expect to learn about decisions that prompted the program to go remote; how to identify key strategies that support the success of a remote CDI Program; and the work/life balance.

 

Q: What one tool can CDI professionals not live without?

A: Specifically, from a remote CDI perspective, an excellent internet connection to an electronic health record!

 

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: My session will challenge CDI professionals to think outside the “walls” of a hospital setting – self-discipline, autonomy, and confidence and how to maintain harmony will all be discussed.

 

Q: What are you most looking forward to about this year’s conference?

A: Networking! I always enjoy learning from a variety of CDI professionals from across the nation and it always amazes me how very similar we are, or how vastly different we approach the same types of challenges.

 

Q: Fun question: Do you have pets and if so, what are their names?

A: I do! I have a dynamic duo of dogs that keep my days exciting (my office mates!). Their names are Max (Beagle) and Oliver (Golden Retriever), but we call them “Ham & Cheese!”

 

Conference Q&A: Haik offers a clinical perspective on sepsis and respiratory failure

haikEditor Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we’ve reached out to William E. Haik, M.D., F.C.C.P., C.D.I.P., who has practiced medicine in Fort Walton Beach, Florida since 1980, and will be presenting “Sepsis: 1, 2, 3 – RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines.” He has received board certification in internal, pulmonary, and critical care medicine. Dr. Haik’s past professional accomplishments include: Chief of Internal Medicine, Director of Respiratory Care Services, Board of Trustees at his local hospital, President of the Okaloosa County Medical Society, and representative of the Government Liaison Committee for the American College of Chest Physicians. Dr. Haik’s coding background has included AHA’s Editorial Advisory Board and Expert Advisory Panel of Coding Clinic for ICD-9-CM as well as participation in the preparation of the original AHIMA CCS and CDIP examinations. He served on the original Board for ACDIS and aided in the preparation of the first certification examination. He currently serves as a final arbitrator for Medicare Part C MS-DRG modifications and as an expert consultant to the United States Department of Justice. He served on a multi-disciplinary committee which developed the 2010 and 2013 AHIMA Physician Query Practice Brief. Dr. Haik has conducted educational seminars and national teleconferences regarding physician involvement in DRG management, coding, and other related topics in association with HCFA (CMS), AHA, AHIMA, HCPro, and various state Quality Improvement Organizations. Since 1988, Dr. Haik has served as the Director of DRG Review, Inc., a physician directed hospital coding consultative service. The goal of DRG Review, Inc. is to educate medical and coding staffs in medical record documentation and coding compliance.

Q: As an MD, what do you bring to the CDI table that others don’t?

A: I think I bring a practical knowledge, a working clinical practice perspective. I have some coding knowledge as well, so I can merge the two.

Q: What are three things attendees can expect from your session?

A: Complete boredom! Just kidding! In all seriousness, attendees can expect to:

  1. Understand the clinical definition and coding nuances of acute and chronic respiratory failure;
  2. Understand the evolution of the definition of sepsis; and
  3. Understand how to apply the three different sepsis consensus statements and how, by understanding those, one can defend an adverse clinical documentation position from a RAC

Q: What is one tool CDI professionals cannot live without?

A: In my opinion, a CDI professional should have a few things in their toolkit. First, they should have a clinical background, a working knowledge of the coding clinics for ICD-10, a reference tool that answers certain clinical guide and their coding correlation.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: We do arm wrestling during my talk! Just kidding. In reality, I’m trying to get them to think inside the box! I want to get everyone to think clinically as a physician would.

Q: What are you most looking forward to about this year’s conference?

A: It is in Las Vegas, need I say more? Seriously, though, I’m looking forward to hearing some presentations on quality – HCCs, VBP – such as that. I’m really looking forward to expanding my knowledge.

Q: Fun question: do you have any pets?

A: Her name is Mary-Kate – she’s my wife. Just kidding. Actually, I don’t have any pets right now. I have had three dogs, though. They were named Bitey, Gus, and Tucker.

Conference Q&A: DeVault illuminates the shift to outpatient CDI

devault

Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA

Editor’s Note: Over the coming weeks, we’ll introduce a few of this year’s speakers who are heading to the podium for the ACDIS 10th Annual Conference which takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager, HIM Consulting Services for United Audit Systems, Inc., who presents “Clinical Documentation Improvement – From Inpatient to Outpatient: Defining the different documentation, coding, and reimbursement requirements.” She has more than 25 years of experience in HIM serving as the senior director of HIM practice excellence, coding and reimbursement for AHIMA from 2008 to 2014.

Q: What made your company want to expand into the outpatient setting?

A: We noticed that it was the next natural progression in the CDI world. With hierarchical condition categories (HCCs), Medicare Access and CHIP Reauthorization Act (MACRA), risk adjustment, etc., it’s really a prime time for CDI. Where to start is the hard part. With inpatient documentation reviews, CDI professionals have a captive audience, so to speak. With outpatient, CDI programs need to look at all the different departments where physician documentation plays a role. On top of that, there’s the physician clinics. It’s very complex on how you move the well-oiled machine of inpatient CDI into the outpatient world – everything gets really muddied.

Q: What are three things attendees can expect from your session?

A: At the end of my session, attendees will be able to:

  1. Start to delineate what outpatient CDI looks like in the post-acute care setting. It’s not as simple as duplicating your inpatient CDI program
  2. How inpatient and outpatient CDI roles differ; and
  3. Some tools to build the framework for outpatient CDI. Your CDI framework could look very different and you need to do active discovery. CDI looks different in every setting based on where their needs are.

Q: Who should attend your presentation and why?

A: CDI specialists and anyone who’s involved with coding and CDI – CDI managers, finance side, directors, HIM directors, coding managers, coders, and even physicians! Essentially, it would be good for everybody. Anybody trying to figure out what outpatient CDI looks like should definitely attend. It’s like the transition to ICD-10 in that we need to think about how we eat the elephant one bite at a time. Outpatient CDI is a whole new elephant.

Q: What’s one tool no CDI professional should be without?

A: A CDI specialist should always have their communication skills. A CDI specialist is in a unique position because they live in the middle. They need to have a relationship with providers and then they also need that communication with coders.

Q: What are you most looking forward to about this year’s conference?

A: Networking! Last year, was the first year I was there as a vendor. It’s so fun to meet our clients. It’s great to put a face to a name!

Q: Fun question: what’s your favorite movie?

A: I’m kind of a sap, so I love PS. I Love you. I also really love Brian’s Song.

 

 

 

Conference Q&A: Ericson sheds light on alternative payment models

Ericson_Cheryl_BE

Cheryl Ericson, MS, RN, CCDS, CDIP

Editor’s note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. For today’s Q&A, we caught up with Cheryl Ericson, MS, RN, CCDS, CDIP, the manager of clinical documentation services with DHG Healthcare, who will present “Leveraging CDI to Improve Performance under Alternative Payment Model Methodology.” Ericson is recognized as a CDI subject matter expert for her body of work which includes many speaking engagements and publications for a variety of industry associations. She currently serves on the advisory board for ACDIS and its credentialing committee (CCDS).

Q: Could you tell me a bit about what makes Alternative Payment Models (APM) different for CDI?

A: Participation in voluntary APMs is very complex and requires a high level of commitment from the healthcare organization. More than 800 hospitals, however, are required to participate in the Comprehensive Care for Joint Replacement Model (CJR) and an additional 1,100 or more hospitals will be required to participate in the episode payment for AMI and coronary artery bypass grafts (CABG). Because participation is based on randomly selected Metropolitan Statistical Areas (MSAs) many hospitals may be unprepared for the impact. These models are retrospective so the hospital is paid as usual under the applicable MS-DRG, but following the completion of the performance year the hospital may be required to return some of their payment to Medicare or they may receive an additional payment. This type of model, like many of the outcome measures included in the mandatory value-based methodologies, require CDI specialists to look beyond the current episode of care. The mandatory quality programs, however, only use a 30-day timeframe. In comparison, an episode of care in the APMs extends 90 days beyond hospital discharge or the date of surgery.

Q: What are three things attendees can expect from your session?

A: Attendees can expect to learn:

  1. The difference between the mandatory value-based programs such as HVBP, HRRP, HACRP, and mandatory APMs
  2. A better understanding of the mandatory bundled/episode based payment methodologies
  3. Strategies to incorporate into the CDI process to accurately reflect organizational performance under the mandatory bundled/episode payment methodology

Q: What is one tool CDI professionals cannot live without?

A: A grouper that supports risk-adjustment efforts.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: As the fee-for-service population decreases, which was reliant on CC and MCC capture, CDI specialists need to understand and modify their efforts to reflect modern CMS reimbursement strategies to support organizational financial health.

Q: What are you most looking forward to about this year’s conference?

A: Like most, I enjoy reconnecting with friends. I have the added bonus of reconnecting with former ACDIS Boot Camp participants. It’s great to learn how people have advanced in their career as the CDI profession continues to grow!

Q: Fun question: What is your favorite candy?

A: Dove Promises dark chocolate with almonds. Yum!

 

Conference Q&A: Hirsch offers insight into CDI utilization review contributions

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Ronald Hirsch, MD

Editor’s Note: Over the comings weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada.  Today, we’ve reached out to Ronald Hirsch, MD, FACP, CHCQM-PHYADV, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who will present “Medicare Regulation Update: Practical Application for CDI Professionals.” Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians and serves on the Advisory Board of the American College of Physician Advisors. He is the co-author of The Hospital Guide to Contemporary Utilization Review, published in 2015.

Q: What’s the biggest challenge you’ve encountered related to implementing Medicare regulations?
A:
Regulations and guidance from CMS are often vague and occasionally contradictory. These regulations affect everyone, including the doctor, the patient, the bedside nurse, the case managers, CDI staff, the billing and coding staff, and the C-suite (those working in upper administrative roles). Understanding the regulations and implementing them compliantly across the many affected groups is a challenge for hospitals.

Q: What are three things attendees can expect from your session?
A:
Let me just list some of these out:

  1. To hear a simple explanation of the two-midnight rule
  2. To understand the practical application of medical necessity guidelines for CDI professionals
  3. To be familiarized with the required patient notifications

Q: What is one tool CDI professionals cannot live without?
A: If they learn the two-midnight rule as I teach it, they will become the hero of their institution.

Q: In what ways does your session challenge CDI professionals to think outside the box?
A: CDI professionals work hand in hand with case managers but often do not understand their work. Gaining an understanding of that work makes them a more indispensable part of the team.

Q: What are you most looking forward to about this year’s conference?
A: As a physician advisor expert, my CDI knowledge is quite cursory. With the breadth of courses available at the conference. I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference Boot Camp for physician advisors. It will be an honor to hear from Erica Remer, MD, and James Kennedy, MD, two of the most renowned physicians in CDI.

Q: Fun question: Do you have any pets?
A:
My wife and I just got a new kitten three weeks ago. Leopold is a little wild thing during the day between naps but he loves to cuddle with us at night in bed.

Q&A: Mentioning SOI/ROM and support level of care in queries

Have a question you'd like ACDIS experts to answer? E-mail mvarnavas@cdiassociation.com

Have a question you’d like ACDIS experts to answer? Comment below!

Q: Is the statement “please document in a progress note to capture the severity of illness (SOI), risk of mortality (ROM) and care needed for this patient” appropriate to use in a query? In general, is it appropriate to mention SOI/ROM and support level of care and profiling when querying physicians?
A: Many mature CDI departments know that providers respond better to discussions regarding the SOI/ROM than they do regarding reimbursement (i.e., discussions of dollars). Most providers feel they treat the “sickest of the sickest” and pointing out how their documentation affects quality measures and reporting illustrates the direct benefit of CDI efforts for them and their patients.

However, it is important to have discussions with providers explaining the relationship between documentation, reimbursement, healthcare quality, profiling, etc. CDI staff should share information regarding the importance of SOI/ ROM during formal training sessions with the medical staff and as the opportunity arises during impromptu interactions with individual providers on the hospital floors.

I subscribe to the concept of keeping the query as concise and simple as possible. Therefore, I would not include this type of language you provided as part of the query process itself.

As an additional note of caution, since the MS-DRG and APR-DRG reimbursement systems are based on the “severity” of the patient’s condition—the more “severe” the patient’s condition, presumably, the higher the reimbursement—providers may associate the discussion with a secret code of sorts. “When I say SOI/ROM, you know I’m really addressing reimbursement.”

The 2013 query practice brief, Guidelines for Achieving a Compliant Query Practice Brief states:

“A query should include the clinical indicators…and should not indicate the impact on reimbursement.”

Consider circling back to a provider if he or she fails to respond to a query and explain why the query was placed and how a change in documentation could have positively affected reimbursement, healthcare quality, profiling, etc., reinforcing the initial education provided. Physicians often respond to concrete examples. When such is associated with their own documentation, even better. Timing such discussions and including additional illustrations of both effective and deficient documentation to prove your point helps take the emphasis off a specific situation which may be deemed leading and places it within the realm of overall program goals and general documentation improvement.

Also, I always encourage CDI specialists to trust your gut. If it feels a little murky to you, then don’t do it. Nothing is worth compromising your integrity and ethics.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass responded to this question.