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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media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms.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.