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Summer Reading: New CDI staff exercises to perfect the review process

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

Shadowing staff

Often, the first step in becoming comfortable with the CDI record review process comes from simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your facility, reach out to ACDIS via its CDI Forum or local chapter events. Consider calling nearby facilities, asking for their CDI department manager. Many CDI specialists willingly open their doors to those just starting out. If your CDI manager is willing (or has connections of his or her own), perhaps you will be able to shadow a neighboring facility to get a better idea of how different CDI programs function as well.

Many CDI program managers ask candidates to do this during the interview process so both parties better understand the basic competencies and expectations of the job. Other program managers gradually introduce new CDI specialists to the process by shadowing experienced specialists at least once per week for a set number of hours or records per day. Other programs may require new staff members to jump into the reviews as soon as possible.

To positively influence your learning, consider first sitting alongside your CDI manager or mentor as he or she reviews a variety of common diagnoses. Where larger teams exist, consider rotating such shadowing experiences and taking note of how different individuals’ experiences and strengths affects how they conduct their reviews. Also, arrange time to shadow an experienced inpatient coder as well. You will find each person has his or her own method, and no method is necessarily better than the next.

Tandem reviews

After shadowing teammates, try tandem record reviews where your mentor, manager, or other CDI staff member reviews the record first and then turns the record over to you to let you try your hand at it. Then compare notes. Also consider flipping this activity with the new CDI specialist reviewing the record first and then turning it over to your CDI manager or mentor to see where you were successful or where opportunities for additional information might exist.

Spend some time documenting and developing your own review processes; you will need to develop a method or sequence of record review and stick with it. For example, jumping from one section to another in search of a particular tidbit or clue may cause you to lose focus. In such situations, the larger clinical context may be lost on that elusive detail, costing you valuable productivity time—you may not see the forest through the trees, so to speak.

Take time to discuss items you may have missed and where this information was found. If queries need to be written, draft them together. This process may seem laborious, but with a few afternoons concentrated on such work, you will begin to feel more comfortable finding your way through the complexity of the medical record to the valuable nuggets of information you need.

Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.


TBT: Training new staff? Consider the following tips

Take clinical documentation forward by going back to basics.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, we’re looking at an article from the January 2011 CDI Journal. “Training new staff? Consider the following tips,” covers how to help staff acclimate to the CDI role.

Patience and persistence help train new CDI staff

Training new staff is a challenge, particularly if your facility does not have a plan in place. Luckily, Deborah Dallen, RN, clinical documentation coordinator and one of three CDI staff at the 500-bed Albert Einstein Medical Center in Philadelphia, does.

Dallen has been at Albert Einstein since it first implemented its CDI program eight years ago. In that time, she’s seen her share of CDI staff come and go, so she has some experience training new team members. In the fall, one of Albert Einstein’s CDI team left the job, and a new staff member arrived. A little less than a month after starting, the new employee had her first moment of true CDI understanding.

“We really had a breakthrough,” says Dallen. “It can be very difficult explaining these concepts.” Terminology such as DRGs, relative weights, major diagnostic categories, and CCs/MCCs cause most inexperienced individuals to glaze over in confusion or boredom, she says. New employees start to “look at you like you have three heads. But then all of a sudden they understand it,” Dallen says. “This new staff member, she got it. She was able to explain [the key concepts] back to me.”

Learning methods

To help staff get to that moment of understanding, Dallen employs an arsenal of educational tactics. New staff spend most of their early days on the floor shadowing other CDI workers. Dallen also has them spend at least a day with coding staff to determine the similarities and differences between the roles and how they are performed.

New employees receive binders of educational materials, and Dallen provides “alone time,” usually two, half days per week for the first month, for the staff to read over them. During this time, new CDI specialists read the materials and jot down any questions or concerns. Later, Dallen allots time for one-on-one learning in which staff can talk about the readings, resolve any confusion, and respond to situations from job shadowing sessions.

Every other week, mentor and mentee might spend an entire day together in a more typical classroom-style or tutoring-type setting. Dallen dubs these “reinforcement days,” in which lessons learned through experience are supported via review of texts, regulations, and the greater understanding of a seasoned professional.

Book Excerpt: Repeat Reviews


The CDI Specialist’s Complete Training Guide

Your organization may have polices dictating the frequency of record review and re-review, as well as how to determine which records CDI specialists should target for such efforts. Be sure to discuss such parameters and the expectations of the CDI staff within them. The staffing of your CDI department as compared to the number of admission/discharges may also influence standard practices of repeat reviews.

Repeat reviews should examine any physician orders written since the date of the last review for any changes in the plan of care or abrupt discontinuation of a treatment (which may indicate a possible condition was ruled out). Review any diagnostic test or study results, progress notes, and assessments for consistency, incongruity, or ambiguity, as set forth by the Association for Clinical Documentation Improvement Specialists and the American Health Information Management Association physician query practice briefs as reasons for queries.

In general, not all records need to be reviewed every day, but repeat reviews should be scheduled for records in which:

  • A principal diagnosis has not yet been determined
  • A symptom is identified as the principal diagnosis
  • An open query is pending
  • A surgical intervention occurred
  • The patient required a change in care level (either to an intensive care unit or shift from ICU to a general medical unit)

The mission or focus of the CDI department also influences the practice of repeat record reviews.  Programs reviewing records primarily for reimbursement typically stop reviewing the record once no further changes in MS-DRG can be made. Those reviewing for severity of illness/risk of mortality most likely review records repeatedly until discharge, to ensure every possible secondary diagnosis gets identified.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

Physician queries and education require ongoing efforts

German Shepherd

You can teach an old dog new tricks you might just have to try multiple times.

In the beginning, when placing queries for the type of heart failure or urosepsis, you may think that physicians will eventually learn the more specific documentation required and that your queries will no longer be necessary. I innocently thought that I would run reasons to query my physicians. Silly me!

Although not as frequently, I still had to ask those very same questions—hey doc, can you please specify the type of heart failure—years later. But I also found so many other opportunities for clarification as I grew in my understanding of the role and as clinical practice and coding rules changed.

I doubt I would have ever run out of questions, nor will you.

Many of the physicians I first worked with were very supportive and responded to education, queries, conversations etc., positively. Seeing my teaching reflected in their documentation was very encouraging. As with any group of students, however, there will always be the overachievers, the slow to grasp but committed learners, and those that just don’t understand why (nor do they care) clinical documentation matters to so much of the healthcare practice.

One physician (whom I very much learned to appreciate) sat down with me one day and said, “Laurie, did you know on average it takes 12 attempts to train a German shepherd to fetch but it takes 21 years to teach a doctor?”

So don’t worry about job security, because we are not training German shepherds to fetch, we’re helping physicians document the care they provide in a changing healthcare landscape. There will always be a reason to prove how valuable your assistance can be.

TBT: Training new staff? Consider the following tips

Become a CDI mentor and help new CDI specialist understand the value of the role they play.

Help new CDI specialists understand the value of the role they play.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the January 2011 edition of the CDI Journal.

By some estimates, there are upwards of 4,000 CDI specialists working at hospitals across the nation. As pay-for-performance initiatives increase and ICD-10 implementation becomes a reality, even more facilities will recognize the important role CDI plays in today’s healthcare system. But as the value of CDI staff increases, so does the demand for their services. As a result, few managers will have the luxury of hiring staff with concurrent record review experience.
Thus, once you hire new staff, you need to determine how to train them. First, hire the right person for the job, says Melanie Halpern, RN-BC, MBA, CCDS, CCRA, CDI manager at University of Medicine and Dentistry of New Jersey. For Halpern, that means someone with a strong clinical background. “I don’t want to have to stop and go back over basic clinical information when training,” she says.
The best scenario, of course, is finding someone who already has experience in CDI. Barring that, look for someone with experience in abstracting information from the medical record, such case managers or utilization review nurses, says Deborah Dallen, RN, clinical documentation coordinator at Albert Einstein Medical Center in Philadelphia. Dallen trained a new CDI staff member who previously performed utilization review for Blue Cross. Although Dallen has been a CDI specialist at Albert Einstein since the program’s inception eight years ago, she came to CDI from a career in case management.
“I tell [new hires] that their previous experience will really help them in this role,” she says. “Of course, once they’re here, they think none of that experience applies. They think we’re crazy for hiring them. Eventually, the [understanding] clicks and they make the connection between their previous role and their new responsibilities in clinical documentation improvement.”
Begin by analyzing your new hire’s strengths, weaknesses, individual personality traits, and learning preferences. “You have to know where they are coming from,” says Halpern.
Even if the new hire is an experienced nurse who understands core measures, “you can’t just throw him or her a problem list and set them to the task,” she says. To get new staff excited, encourage them to use their experience to enhance the program, says Halpern. “Start with the individual’s strengths and illustrate how their specific strengths can help the program,” she says. In that way you “get them interested, excited about how they can help.”
Sandy Beatty, RN, BSN, CCDS, clinical documentation specialist at Columbus (IN) Regional Hospital, asked coworkers how they wanted to learn; not surprisingly, she received different responses from each new team member. One wanted to shadow Beatty as she worked through her day and then be shadowed in turn. Another wanted to take on the task by herself and have Beatty examine her efforts, like a student turning in a paper to a professor.
“If you are a manager, you need to understand basic adult learning principles,” Halpern says. “You cannot hammer people with information for eight hours a day.”
Dallen devotes at least two half-days per week to one-on-one training with new staff. She also employs a variety of other strategies, including hands-on learning, job shadowing with both CDI and coding staff, independent learning via reading materials, and reinforcement through repetition. To keep track of her efforts, Dallen developed a staff orientation checklist, which sets satisfactory comprehension of basic CDI functions at 90 days.
It may take up to a year for a new CDI specialist to become fully comfortable with their new role, but for competency, a six-month expectation is fair, says
Colleen Stukenberg, MSN, RN, CMSRN, CCDS, clinical documentation management professional at FHN Memorial Hospital in Freeport, IL. By the end of six months, you should be well beyond teaching the specialist about coding and query basics. By then, “you should be able to introduce new concepts and have them really working as a member of the CDI team,” Stukenberg says.
Editor’s Note:Don’t spend time creating training materials from scratch. ACDIS’ acclaimed CDI Boot Camp instructors have created The Clinical Documentation Improvement Specialist’s Complete Training Guide to serve as a bridge between your new CDI specialists’ first day on the job and their first effective steps reviewing records.

Excerpt: Introduction to The CDI Toolkit

The CDI Toolkit

Most healthcare providers have limited resources, including limited time to develop their own clinical documentation improvement (CDI) tools. The CDI Toolkit provides clinical information, practical information, and a variety of tools in CD-ROM format for easy adaptation or modification in numerous settings.

Complete and accurate documentation is necessary for appropriate financial reimbursement and has a long-lasting effect on physician and hospital quality scores. It is also necessary for public health reporting of disease and procedure outcome measures, including resource utilization. Clinical documentation specialists (CDS) are responsible for ensuring  that documentation in the medical record includes complete and accurate, codable, terminology that facilitates accurate calculating and reporting of  severity of illness (SOI) and risk of mortality (ROM). Inaccurate and nonspecific documentation leads to inappropriate reimbursement and profiling for providers and hospitals.

The Centers for Medicare & Medicaid Services (CMS) is assessing Medicare spending per beneficiary episode through its value-based purchasing (VBP) initiative. VBP aims to promote high- quality, safe, patient-focused care that avoids preventable adverse events, including healthcare-acquired conditions, while reducing costs.

SOI and ROM calculations based on the interaction of multiple comorbidities and sequencing of diagnoses are the underlying theme of quality reports. Conditions can affect SOI and ROM regardless of whether they are complications and comorbidities (CC) or major complications and comorbidities (MCC).

In this CDI Toolkit the clinical categories reflect the Major Diagnostic Categories, and within each section we have included specific examples of scenarios in which queries are necessary. A facility’s query process must consider etiology of the symptoms and/or disease and disease manifestations and/or consequences.

Increased clarity and specificity is important for accurate coding, but it’s also necessary for an accurate and complete reflection of patient acuity and provider performance.

Queries should seek clarification and specificity. They should not question providers’ clinical judgment. A query is not necessary if there is no clinical support of a diagnosis. Written and verbal queries that may be construed as leading providers are impermissible. Queries that appear to prompt a particular response are similarly impermissible.

Queries should present the facts in the current medical record. They should not introduce new information or information not in the current medical record. Query forms should not be designed so that only a signature is required. The same standards should apply regardless of whether a query is part of the permanent record. Additionally, diagnoses should be carried throughout a medical record and not appear only on a query.

Audits should be a part of any facility’s ongoing monitoring of its  CDI program. Sample audit suggestions included in various chapters serve as an exploratory tool for non-punitive and process improvement opportunities.

Review your facility’s Short-Term, Acute-Care Program for Evaluating Payment Patterns Electronic Report (ST PEPPER) to determine whether an audit for medical necessity and/or coding is necessary. TMF Health Quality Institute develops and distributes ST PEPPER under contract with  CMS. This report isn’t necessarily indicative of a problem; it provides benchmark data that compares a facility with other facilities.

If resources and time permit, consider a more formal random sampling. If resources and time are limited, consider a focused review of suspected problematic issues of concern nationwide, identified in your ST PEPPER report or through your denial management program.  Consider monitoring one of your audit focuses during the first quarter (e.g., October–December), changing processes and implementing changes during the second quarter (January–March), and re-monitoring during the third quarter (April–June). Another audit could be monitored January–March, changes implemented April–June, and re-monitored July–September.

Consider self-audits during which clinical documentation staff compare their queries to the organization’s query policy and practice. CDI managers should conduct staff query audits for compliance monitoring. Managers also should audit cases with only one additional International Classification of Diseases code after the principal diagnosis code. Learning from others internally and externally through networking and national association membership is important.

Collaborate internally with the following colleagues:

  • Providers (e.g., attending and consulting physicians, pathologists, radiologists, anesthesiologists, emergency department physicians, psychiatrists)
  • Physician assistants and advanced practice nurses
  • Non-providers  (e.g., nurses, patient care technicians, dietitians, speech therapists, rehabilitative therapists, quality staff, laboratory, infection control, utilization, care management, risk management, dialysis, emergency department)

Collaborate with your medical records and forms committees and provide input regarding language included in any form that may directly or indirectly affect codable documentation. Expand your CDI steering committee to include multidisciplinary representation.

Externally collaborate with CDS’  locally, statewide, and nationally. Attend conferences, meet colleagues, and continue relationships post conference. Be open to new ideas and approaches. Be willing to share with others for the betterment of the profession.

Editor’s Note: This post is an excerpt from the introduction of The CDI Toolkit written by Nancy Rae Ignatowicz, RN, BS, MBA, CCDS. The CDI Toolkit contains sample queries, powerpoint presentations, educational materials, and other items to help CDI specialists advance their programs.

Book Excerpt: CDI requires specified role with varied experience

The CDI Handbook includes everything you need to know about CDI when first starting out.

When determining who to hire as CDI specialists, the facility needs to remember a number of additional factors specific to the CDI role. For example, staff must have strong cross-disciplinary awareness. If coders are used they must have str5ong clinical knowledge. If nurses are used, they must have an understanding of the basic tenets of coding and coding guidelines. In addition, the CDI team members must be willing to embrace opportunities to grow from others on the team with different backgrounds.

Whether a facility uses coders, nurses, or some combination of both, and regardless of to whom the CDI staff reports the goal of capturing complete and accurate documentation should not be compromised in favor of other agenda. Without clearly defined responsibilities, a case manager who also performs some CDI tasks may push one set of responsibilities aside for another given the limitations of time, experience, and administrative expectations. Conversely, a coder might not pursue a query if tasked with concurrently coding a chart, meeting productivity standards, and maintaining discharged not final billed goals.

Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS

New eLearning platform makes ICD-10 education easier

Because the courses have become somewhat dated and are incompatible with our current online learning platform, ACDIS has made the difficult decision to eliminate its e-learning courses. The existing e-learning library will be available until November 15, 2012.

To help those who hold the Certified Clinical Documentation Specialist (CCDS) credential earn continuing education units (CEUs) ACDIS has begun offering credits associated with its online newsletter the CDI Journal and will begin offering 1 CEU associated with its Quarterly Conference Calls beginning Thursday, November 15, from 1-2 p.m., ET.

The new online learning courses being developed will offer more titles (including CDI specific programs), greater interactivity, and more opportunities for you to earn continuing education credits. Below is a six-minute video preview which walks through two of the online courses for ICD-10—Anatomy and Physiology and the ICD-10 Basics Boot Camp. Click this link to learn more and/or to  purchase new courses. Additional courses are available on an enterprise-wide basis. For additional information, contact our sales team at 800-780-0584.

Maybe, possibly, definitely: Stay informed regarding ICD-10 delay

Which countdown to ICD-10 calendar will you use?

On February 14, CMS acting administrator Marilyn Tavenner told American Medical Association (AMA) meeting attendees that CMS would “reexamine” the timeline for ICD-10-CM/PCS implementation. Tavenner offered no details, just the vague possibility of potential reconsideration.

The healthcare industry jumped with the news.

American Health Information Management Association (AHIMA) immediately published a release urging healthcare professionals to move forward with their ICD-10 implementation and training plans, and downplayed the announcement, pointing its vague language.

“This is a promise from CMS to examine the timeline, not to change it,” said Dan Rode, MBA, CHPS, FHFMA, vice president for advocacy and policy at AHIMA, in the release. “But government officials are sending mixed signals that many in the healthcare community will interpret as a reason for delay.”

The AMA celebrated.

“The timing of the ICD-10 transition could not be worse for physicians as they are spending significant financial and administrative resources implementing electronic health records in their practices and trying to comply with multiple quality and health information technology programs that include penalties for noncompliance,” wrote Peter W. Carmel, MD, AMA president in a February 16 release. “Burdens on physician practices need to be reduced—not created—as the nation’s health care system undertakes significant payment and delivery reforms.”

The very next day, February 15, HHS Secretary Kathleen Sebelius said “the federal government will delay for an unspecified time the implementation date for the ICD-10 diagnostic and procedural coding system,” HealthLeaders Media reported.

Specifically, the HHS release stated that the agency “will initiate a process” to delay the ICD-10 implementation date for “certain health care entities.”

And that was pretty much it.

The rest of the release reiterates that the provider community feels burdened by the ICD-10 implementation, but also reiterates the importance of the move to ICD-10 because it will “provide more robust and specific data that will help improve patient care.”

Meanwhile, CMS confirmed to ACDIS’ parent company HCPro Inc., that the agency will use the rulemaking process when revisiting the ICD-10 implementation timeline; a process known to be lengthy, a process that does not always furnishes an expected result (meaning after the rulemaking CMS may just decide to keep the implementation date firm).

So multiple experts from ACDIS Advisory Board members to AHIMA directors repeated the refrain,; “Stay the course with ICD-10 implementation.”

I’m on their side.

In a phone conversation earlier this week, an ACDIS member told me that she was glad to hear CMS delayed ICD-10 by two years. Two years, she said.

Of course, I asked where she got her information and she cited some reputable sources which, on closer examination, actually said nothing of the sort.

All this commotion—all this maybe, possibly, definitely thinking about it—may ultimately cause serious difficulties for those in the midst of ICD-10 implementation plans. The possible delay could cause facility administrators to pull back the purse strings on training funds. Programs could decide to delay important technology purchases to save money since the implementation date isn’t imminent.

Meanwhile, we hear how far behind facilities actually are in their ICD-10 planning. CDI staff (according to a recent survey) say they do not even know if a ICD-10 implementation committee is meeting at their facility or what will be expected of them as the coming change draws near. Possibly postponing the actual “go-live” date only adds to facility procrastination on these issues.

The more advanced facilities have already evaluated their staffing needs in terms of CDI specialists’ concurrent record reviews and coding needs. These facilities have already budgeted for additional employees and charted a course for staff member training beginning with anatomy and physiology. Even more advance programs have already begun reviewing their top MS-DRGs for documentation improvement opportunities related to ICD-10.

History may prove me wrong (especially as rumors also abound about HHS opting to skip ICD-10 and jump directly to ICD-11!) but I remain convinced that ICD-10 implementation is inevitable and that the sooner facilities prepare themselves the better.

Book Excerpt: Training new CDI staff members

Because CDI is still a relatively new and emerging profession…finding seasoned professionals can be difficult and it may be necessary to provide between three to six months of on-the-job training before the new hire can effectively conduct all aspects of the role.

Many new hires require some coding or clinical education. Initial and ongoing education represents an important aspect of successful CDI programs. Generally speaking, CDI specialist education should include:

  • Revenue cycle overview and case-mix index basics

    The Clinical Documentation Improvement Specialist's Handbook, Second Edition

  • Introduction to hospital and medical staff profiling
  • Basics of ICD-9-CM principals and Medicare Severity Diagnosis-Related Group (MS-DRG) methodology
  • MS-DRG definitions and sequencing guidelines
  • Major diagnostic category (MDC)-specific documentation guidelines and strategies
  • Present on admission basics
  • Core measure basics
  • Compliant and effective physician querying strategies
  • Orientation to the ICD-9-CM Official Guidelines for Coding and Reporting and Coding Clinic for ICD-9-CM
  • Basic tenets of ICD-10
  • In-depth review of CC/MCC
  • Review of AHIMA and ACDIS Code of Ethics
  • Review of AHIMA physician query guidances and tools
  • Mentoring with seasoned staff for three to four weeks to allow for accurate application of core CDI principals
  • Orientation to physician groups and hospital medical staff structure

Lastly, regardless of the educational and professional background of those chosen to staff the CDI program, it bears repeating that successful programs require the support of HIM, quality management, and case management. Moreover, the support of the hospital administration, the compliance department, and the medical staff leadership is crucial to the immediate and long-term viability of a CDI program.

Editor’s Note: This post was taken from The Clinical Documentation Improvement Specialist’s Handbook by Marion Kruse, MBA, RN and Heather Taillon, RHIA.