Q&A prompts additional thoughts on CDI staff productivity

My recent Q&A in CDI Strategies (“Productivity Measures for CDI Specialists”) generated a few reader responses so I

How many records should you review in a day? The answer isn't easy.

thought I would take a moment to talk a little more about the record review processes we used as my previous facility.

Generally, my first reviews took about 15-20 minutes since I reviewed them the day after admission and the volume of information in the record wasn’t overwhelming.  During the first review I made notes on my worksheet of anything that I felt needed another look and focused my second reviews on those conditions.  I re-reviewed those records without any queries every other day until discharge so that I didn’t have so much data to comb through.  On follow-ups I reviewed only back to the date of my last review since I had the notes from those earlier examinations to remind me what I needed to watch for.  On subsequent reviews I looked at labs, medications, new orders, procedure notes, ancillary documentation, etc. — but only if it was newly introduced to the record.

If I knew the physician had provided solid documentation for the principal diagnosis, then I focused my follow up reviews on capturing secondary diagnoses if they were not documented well and on Hospital-acquired conditions (HACs).  At that time, I did not have responsibility for core measures or any case management duties.

Of course, the more responsibilities one has in relation to the record will result in reviews that take longer for each chart.  But I typically had about five to 10 new admissions per day (some days were heavier than others), and of course Mondays were frantically busy. We did not review weekend short stay discharges if they were already gone on Monday.  For those records the coders would identify any query opportunities and either query themselves or refer it to a CDI specialist for follow up.

As an aside, the recently released 2010 Physician Query Benchmarking Report illustrates that the majority of CDI specialists (32%) review between six and 10 new patient charts per day, with a slightly smaller number of respondents indicating that their CDI specialists review 11–15 charts daily (31%), as depicted in Figure 32 on p. 18. Rereviews echoed this trend, with 27% indicating they perform between six and 10 rereviews per day and 22% reexamining 11–15 records daily, as depicted in Figure 33 on p. 19.

I’ll also mention that these results were similar to those illustrated in Figure 20 and 21 on p. 41 of the 2010 CDI Program Benchmarking Survey published last July. [more]

CDI & RAC comments sought for new survey

This year, HCPro will release a white paper that identifies a number of ways to maximize the impact of a clinical documentation improvement (CDI) team on a facility’s RAC process. We value your input and appreciate your time and effort in completing this brief, anonymous, six-question survey. As a thank you, we will be happy to send you a copy of our completed white paper. Upon completing the survey you will have the opportunity to request your free copy.

The link below will take you to the survey’s website; simply click on the link to answer the questions . If the click-through does not work, please cut and paste the URL into the address bar of your browser. To take the short survey, please click here.

AHA’s RAC Trac offers insight for CDI program ethics

AHA analysis of RAC targets offers insight into CDI professionalism.

As we all are aware, the Recovery Audit Contractors (RAC) are advancing full speed ahead with their efforts in identifying “improper payments” made to providers by the Medicare Trust Fund. At first the RAC primarily focused on MS-DRG validation given the handicap of Medicare not having approved medical necessity issue reviews. As of August, however, each of the four RAC began  such reviews with the hope of recovering provider money. As of October, it seems the primary RAC comment in regards to this analysis is that care provided to the patient on an inpatient basis  should have been performed as an outpatient service.

I call your attention to the recently released American Hospital Association’s (AHA) RAC Trac report, “Exploring the Impact of the RAC Program on Hospitals Nationwide,” which highlights results of a second quarter 2010  survey.

Before I discuss the report’s findings let me talk briefly about the AHA’s RAC Trac initiative.

RAC Trac is an internet-based free survey the AHA  started in January of 2010 in response to a perceived lack of data and information from CMS regarding the RAC impact. Hospitals willing to participate in the quarterly survey simply register with the AHA which aggregates and analyzes the data quarterly.

The AHA report highlights RAC related results impacting hospitals as a whole, and breaks them down further by each of the four designated geographic RAC regions.  Connolly Healthcare, the RAC for region C, encompasses 40% of the hospitals in the United States and accounts for $57.3 % or $11.2 million of the $19.2 million of denials reported by the 1,389 hospitals who participated in RAC Trac survey.

Some notable points from the report

• Seventy percent of hospital respondents experienced some type of RAC activity through the second quarter of 2010
• $19.2 million in denied claims have been reported since the first quarter of 2010, as mentioned above
• Eighty-five percent of denied dollars were complex denials totaling over $15.5 million dollars
• By the second quarter of 2010, Region B had nearly half of all reported denials
• The average dollar value of a complex denial was $5, 598
• Incorrect coding of MS-DRGs or other coding errors represented the top reason by dollars for complex denials for 86% of hospitals
• Hospitals reported appealing 16% of RAC denials available for appeal and hospitals reported appealing denials totaling over $5 million in value; 16% of hospitals reported appealing at least one RAC denial.
• Of the claims that have completed the appeals process, 13% were overturned in favor of the provider

Use RAC Trac targets to improve CDI focus

While we are not in the business of ICD-9 coding and MS-DRG assignment, we certainly influence the process by virtue of our efforts to improve physician documentation in the medical record. The majority of our CDI programs track success of their individual programs by number of clinical queries left by the CDIS, physician response rate, and if the query impacted financial reimbursement by virtue of principal diagnosis or secondary diagnosis clarification and documentation.

This is definitely where we all should express some concern.

In my travels lately, I have had the opportunity to observe CDI specialists at work and to review numerous RAC coding error denials. The RAC frequently asserts that diagnoses were not clearly and sufficiently documented throughout the record (e.g.,  not in the discharge summary, contrary to official coding guidelines), were not clinically significant,  were not sufficiently documented in the record, or that the principal diagnosis was improperly sequenced.

While I disagree with deleting a diagnosis from a case on the sole basis of not being in the discharge summary, I was surprised with the number of cases in which I unfortunately agreed with the RAC’s determination of coding errors. It was clear, based upon the available documentation in the record, that a query was probably left by the CDI specialist  in the name of complete and accurate clinical documentation and that the physician simply documented a condition based on that query.

The message here is to uphold and adhere to our clinical knowledge in the daily practice of concurrent chart review in the quest to improve and facilitate clinical documentation improvement. Avoid seeking clarification of clinical diagnoses not clinically relevant, just for the sake of capturing that elusive CC/MCC.

Look what transpired effective October 1^st with acute renal failure no longer being a MCC.  Our real goal in clinical documentation improvement is to clarify ambiguous and missing clinically relevant diagnoses, regardless of whether the diagnosis is a CC, MCC, secondary or principal diagnoses. Lastly, we need to fulfill our role and duty in educating coders on the clinical side of coding, increasing their core competencies and skill sets in properly and accurately applying coding conventions and policies governing ICD-9 and MS-DRG assignment.

I encourage everyone to read the report to see the specific issues identified by RAC region where your hospital is located. CDI is an evolving field and we must never lose sight of the continuous evolutionary mindset and thought process we must exhibit in maintaining the professional standards of clinical documentation improvement.

Editor’s Note: Listen to the upcoming audio conference RAC Medical Necessity Reviews: Understand Target Areas and Prepare for Audits on Wednesday, November 3, 1 p.m. EST, featuring Kimberly Anderwood Hoy, JD, CPC, director of Medicare and Compliance for HCPro Inc., and Michael Taylor, MD, vice president of clinical operations at Executive Health Resources in Newtown Square, PA.

There’s no time like the present: Start CDI prep for ICD-10 now

Half full or half empty? Is your CDI staff ready to tackle ICD-10 challenges?

I could throw a few other idioms in here: a stitch in time saves nine or the best defense is a good offense. No matter what clever turn of phrase used to talk about it, the underlying premise remains the same—don’t wait to raise CDI staff awareness regarding ICD-10 implementation because that October 1, 2013 implementation deadline isn’t going away.

“The compliance dates are firm and not subject to change,” CMS said in a recent MLN Matters article. “If you are not ready, your claims will not be paid. Preparing now can help you avoid potential reimbursement issues.”

CDI staff seem to have at least basic knowledge about the coming change to ICD-10. Well, sort of. It depends on your perspective—whether you are a glass half-full or glass half-empty kind of person to quote another idiom—since slightly more than half, 52% of respondents to a recent poll indicated that they had familiarity with ICD-10. We defined basic familiarity as awareness of CMS’ implementation timeline, the reason ICD-10 is necessary, and items of that nature.

Maybe you’d be a little overly optimistic if you were leaning towards taking a drink from your half-full glass since 44% of respondents to a later question indicated that their facility doesn’t have an ICD-10 training timeline to their knowledge and another 51% said that CDI staff don’t have a seat at the table when it comes to ICD-10 implementation planning.

A number of experts, including AHIMA’s Kathy DeVault and ACDIS’ Board Member Gloryanne Bryant, say CDI staff have a vital role to play in ensuring a smooth ICD-10 transition.  While no one’s advocating CDI specialists received a complete immersion in ICD-10 code sets at this early date they do recommend reviewing the draft of the new codes and coding guidelines.

Today is the last day to participate in the ICD-10 Preparation for CDI Staff survey. We will release the complete benchmarking report later this fall. You can read more tips from our ACDIS advisers in the coming October edition of the CDI Journal. Are you involved in ICD-10 transition planning? Let us know.

Physician advisor feedback sought

CDI profession continues its evolution

A new and growing field is opening up doors for registered nurses. This is the role of the clinical documentation specialist. The clinical documentation specialist (CDI) reviews inpatient medical records for proper documentation and provides education to health care providers.

CDI staff members provide documentation care.

Healthcare billing compliance in the United States has evolved dramatically in the past 30 years. The Health Insurance Portability and Accountability Act of 1996 (HIPPA) required providers who transfer healthcare information, use the same healthcare transactions, code sets, and identifiers. When documentation in the medical record does not support code assignment equal with the diagnosis made or the service rendered, either the circumstances must be coded as it is documented or the provider must be questioned for clarification, according to the Physician Queries Handbook by M. Brown, J. Kennedy, M. Kruse and L. Spryszak.

The clinical documentation program function was previously performed by utilization management staff or coding staff.  Due to CMS changes the decision was made by many hospitals to dedicate staff solely for the purpose of concurrent chart reviews, retrospective clarification requests, and physician education.

Clinical documentation programs were started in the mid 1990′s when hospitals realized that CDI programs could increase their case mix index through more accurate code assignments and therefore obtain higher reimbursement for their facility.  Documentation programs have since evolved in order to address compliance guidelines set forth by the Office of Inspector General.

The CDI nurse works collaboratively with physicians and allied health professionals to ensure that the information in the medical record is accurate and with the medical coding staff to support that appropriate clinical severity is captured for the level of service given to all patients.

Prior to clarifying the level of specificity in the medical record, the CDI specialist must recognize the manifestation and management of under documented conditions by carefully reviewing the medical records. Certain conditions may be present in the medical record but not worded correctly or a diagnosis may not be stated clearly.  Clinical clues must therefore be drawn out from the record.

The CDI nurse serves as a resource for the physician and medical staff on the current coding guidelines. Documentation nurses design education programs including handouts, power point presentations, posters, etc. for medical staff and participate in their ongoing education. In fact, one of the greatest challenges in education comes from helping physicians understand the ICD-9-CM language of the clinical care they provide.

The physician must be taught the specificity that is needed to capture severity of illness. The language required by third party payers may not be what most physicians are accustomed to writing. An example of this is the documenting of congestive heart failure (CHF).

Prior to 2007, the documentation of “CHF” was sufficient for the diagnoses to be coded as a comorbidity. The new MS-DRG system requires that physicians specify acute or chronic, systolic or diastolic.

A second example is anemia. In order to be considered a comorbid condition, it must be written as blood loss anemia. Physicians rarely document this way in their daily notes. The ongoing documentation requirements can be overwhelming and confusing. The clinical documentation nurse is now a valuable resource in today’s healthcare field.

CDI specialists report a wide range of annual salaries. A survey done in 2008 by Association of Clinical Documentation Specialists (ACDIS) revealed annual salaries ranging from $40,000- $80.000 per year—the average salary being reported at $60,000 per year.  (The 2009 CDI salary survey that will be available to ACDIS members on the Web site soon.)

Qualification requirements for CDI staff members may vary from hospital to hospital, but most require a two year minimal work experience in nursing or other clinical area with either an associate or bachelor degree accepted. In addition, most hospitals provide a three to six month training period and some institutions require a one year commitment contract.

Physician query benchmarking report released

More than 350 people responded to the 20-question physician query benchmarking survey launched earlier this year. The survey asked respondents  a wide range of physician query questions:

• What should you query?
• When should you query?
• How should you query?
• Why should you query?
• What information do you need to track once physicians respond?
• What’s the best way to track CDI information?
• And oh, by the way, how often do you do all this?

Most CDI professionals want to know how other facilities fare in getting physicians to respond to queries. In response to question 18 on the survey, 19% said they have an 81%-90% response rate, followed by 17% with a 71%-80% response rate. Thirteen percent of respondents say they’ve achieved a 96%-100% response rate.

ACDIS members have full access to this report at www.cdiassociation.com, click on the “Helpful Resources” section and scroll down to the links beneath the White Paper title.

2008 salary survey shows modest means for most

Most CDI specialists make between $60-$70,000 a year, according to the ACDIS 2008 salary survey. Whether you feel your current salary’s suffient for your workload or not consider this: When I first started my career as a reporter at hometown newspaper the argument of the day revolved around the superintendent-of-schools annual salary increase. That year (if I remember correctly) they raised his salary to $120,000. At the time, the mayor the city made $60,000 annually.

Now, the average 2007 salary of WellPoint, Inc. board of directors member was $350,000, according to a report from Atlantic Information Systems, Inc. Not to make a target of WellPoint. . . but. . . we all know how insane the corporate salary intakes seems in this day and age, from our local officials to our sports heros to our healthcare administrators.

What’s the solution to these spiraling salaries? Who knows.  Some say transparency’s the key. I’d guess that might induce additional feelings of jealousy and greed—i.e., if that guy gets so much money why shouldn’t I?

We have a few salary outliers in our own industry—less than 5% of those surveyed last year reported earning more than $90,000—but for the most part CDI specialists are just working folks.

Need proof? Check out last year’s salary survey and keep an eye out for your invitation to particpate in the 2009 version.

Perhaps we have to wonder at our collective ideologies when a bank president thinks its fine to spend millions on office decor.

Physician queries: White paper, ACDIS survey, book

Only a few months ago AHIMA released guidance for physician queries so it is no wonder that concerns remain for most CDI professionals. They want to know how to query, what to query, and when to query. For those just starting CDI programs, these questions are paramount to forming an effective CDI process.

ACDIS has begun working on a book regarding physician queries which we hope to release later this year. Please let me know if there’s a particular issue you think we need to address by either sending an e-mail to mvarnavas@cdiassociation.com or posting a comment to this blog.

You can access a free white paper “Master physician queries: Clarify coding with compliant questions” written by our own Shannon McCall, RHIA, CCS, CCS-P, CPC-I,

Shannon McCall

ACDIS board member and director of coding and health information management for HCPro, Inc.  Just click on the link, fill out the information, and check the physician query box.

Also, as a reminder, the physician query benchmarking survey remains open until February 13, 5 p.m. One lucky participant will be chosen at random to receive a free admission to this year’s ACDIS conference at Caesar’s Palace in Las Vegas. If the winner already has a paid seat to the conference then he or she gets a free pass to the pre-conference event, ICD-9 Coding Essentials: What every CDI specialist needs to know. (Which Ms. McCall teaches, by the way! I’m signed up for this session myself and am really looking forward to it!)

ACDIS will publish the survey results and post them on the Association Web site.

Participate in Physician Query Benchmarking Survey

CDI professionals spent the bulk of 2008 worrying and wondering what guidance AHIMA would finally offer for conducting physician queries. The back and forth negotiation of final guidance development proved fruitful for many healthcare stakeholders from compliance to finance, health information to clinical documentation improvement.

But it’s time to take the guidance off the shelf and see how those in our profession actually use the physician query process every day. Please take a moment to participate in our ACDIS Physician Query Benchmarking Survey.

We will analyze the results and issue a report later this spring. While the best part of participation really comes from the sharing of information and the general condition of creating community. . . ACDIS Director Brian Murphy sweetened this incentive by adding a little contest to the mix.  One lucky participant will be chosen at random to receive a free admission to this year’s ACDIS conference at Caesar’s Palace in Las Vegas. If the winner already has a paid seat to the conference then he or she gets a free pass to the pre-conference event, ICD-9 Coding Essentials: What every CDI specialist needs to know.

So, click here, take the survey, help your fellow CDI professionals, and enter for a chance to win! Note that we plan to conduct these benchmarking surveys on a quarterly basis, and offer them exclusively for ACDIS members.