All Entries Tagged With: "training"
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.
Book excerpt: Educating staff about ICD-10 documentation requirements
Understand the new documentation rules for ICD-10
Rebecca “Ali” Williams, RN, BSN, CDI manager at Spartanburg (SC) Regional Hospital attended an AHIMA ICD-10 training session in 2010. She brought back the information from the session and presented it to her CDI staff. This included an overview of ICD-10 and how it would impact their jobs. “Not so much knowing the codes,” Williams says, “but understanding what diagnoses and procedures would require further clarification.”
In addition, Spartanburg Regional’s ICD-10 subcommittee ran a list of its top 15 diagnoses and surgical procedures and is in the process of reviewing what documentation is required for accurate capture in ICD-10. Cardiac, woman’s surgery, and stroke treatments are all major service lines for Spartanburg Regional. As part of this effort, the team is looking at how these top 15 charts are coded now and how they would be coded with ICD-10 if the documentation remained the same. This has allowed them to identify gaps and areas of focus.
Williams designated two ICD-10 trainers, one to focus on the coders and the other to focus on training nurses, CDI specialists, and physicians. Much of the training is the same across the different professions, especially CDI and HIM because Spartanburg emphasizes the partnership between the two. “We don’t just assume the nurses remember all the intricate details of anatomy and physiology. We are going back to the basics and doing a refresher for the coders and the CDI specialists,” she says.
Editor’s Note: This post was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10,
Physician collaboration: Identifying the keys to success?
How do you get physicians to work with your CDI program?
Over and over again in CDI Talk, at the ACDIS conference, local chapters, anywhere two CDI professionals have an opportunity to interact, it seems, some very common topics arise. One of the most common it seems is how to gain cooperation and collaboration of the medical staff in CDI efforts.
An early ACDIS poll (March 2008) asked: “How have physicians reacted to your CDI program and query requests?” The results showed that only 40% reacted positively and the balance either neutral or negative.
I have yet to find the magic pill (imagine me sitting here singing Jefferson Airplane’s “White Rabbit”) which, once taken, will ensure physician collaboration in CDI efforts. If only one actually existed.
In recent ACDIS post titled “The CDI Evolution,” Juanita B. Seel RN, CCDS, described the organic development of her program. One of the things that really struck me was the apparent shift in response of the medical staff as her program focused more on completeness and accuracy of the medical record and away from financial implications of queries.
This idea— how to improve physician collaboration— has been foremost in my thoughts lately. At my facility here in North Carolina, we are in the process of recruiting a medical director who will devote 50% of his or her time toward CDI/coding/HIMS and the balance to utilization review and case management, so I’ve been thinking A LOT about how to work effectively with this individual. And I’ve been wondering if ensuring physician collaboration is actually really simple. Is the key truly as simple as finding the right hook, which is severity of illness / risk of mortality? But there have been so many other things that have been discussed andtried!
How important are the various avenues employed to deliver information and promote better understanding?
- Newsletters
- Physician group presentations
- Fliers or posters
- Pocket Cards (or small handbooks)
- Individual on-the-floor ’30 second spots’
- The content of the queries, especially if attachments are used
- Web based content / presentations / Q&A
- Case Studies
- Support from:
- Physician Advisor / Champion
- Hospital Executives
- Medical Staff Leadership
- Other??
What are the other things that folks have found to really motivate the medical staff?
- Public profiling data
- Core Measures
- Health Grades
- Quality of Medical Care
- Physician E&M billing
- Support complexity and risks
- Short term, high intensity service line reviews
- I know that some organizations include unanswered queries with the delinquent records
- Other??
This is the single most important challenge that a program MUST overcome to be truly successful. This is one of the most important areas where we can share our success stories, our tools, our unique organizational variations, etc. So, I put it back out to the rest of the CDI community: What has been the single most effective thing that your program has done to engage physicians? AND, what has been the largest barrier for your program to obtaining physician collaboration?
Journal excerpt: Tips for training new staff
Reading up on CDI can prove helpful to new staff but only if that learning is reinforced with managerial support.
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 [CDI] 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.”
That’s why she created an Excel® spreadsheet (available in the Forms & Tools Library on the ACDIS website) to help her keep track of the training needs and accomplishments of new staff. The spreadsheet includes items such as training on how to identify CC/MCCs as well as review of DRG Expert and the ICD-9-CM coding manual. It mixes in items that might be facility-specific, such as a review of how to access the hospital computer system and the CDI department’s policies and procedures.
Dallen’s tracking sheet also provides space to document who provided the training, when the training was completed, and the new staff member’s signature. Perhaps most importantly, the sheet includes a space for the CDI manager to review the new staff member’s progress after 90 days on the job.
Editor’s Note: This article excerpt was published in the January CDI Journal. ACDIS members have complete access to the Journal archives online.
Book Excerpt: Documentation pocket cards as physician training tool
Many programs have developed their own home-grown documentation pocket cards, or tip sheets, based on the clinical topics most apropos to their specific facility. Some handouts are a simple piece of paper developed by the CDI team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program.
In general, a pocket guide explains that physicians must document underlying conditions, not simply the signs and symptoms of the concerns, and link the disease to the underlying cause whenever possible. It also directs physicians to document “suspected,” “likely,” or “probable” in the absence of a definitive diagnosis.
Many facilities include prompts for more specific diagnoses such as systemic inflammatory response syndrome (SIRS) and multiple organ failure and an alphabetical list of important conditions frequently forgotten by physicians, such as:
- Acute exacerbation of chronic obstructive pulmonary disease (COPD)/asthma
- Malnutrition
- Metabolic/respiratory acidosis
- Metabolic/respiratory alkalosis
- Sepsis/severe sepsis/septic shock
- Systolic/diastolic heart failure
- Pneumonia
If generating a tip sheet for your facility, list common nonspecific terms physicians frequently use to describe patient care and compare them to similar ICD-9-CM terms that, when coded, reflect a greater severity of illness (SOI) for the patient. For example, “cystitis” may also be “urosepsis”/ “urinary tract infection (UTI),” or it may be “sepsis due to UTI.” Each term progressively increases the patient’s SOI.(6)
Some tip sheets also include Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) quality measures, history and physical (H&P) documentation, discharge summary consistency, POA, and hospital-acquired conditions (HAC). Employing such cards during both initial and subsequent training programs:
- Ensures everyone speaks the same language
- Promotes facility-wide team building
- Provides additional avenue of education regarding CMS/RAC updates
Editor’s note: This article was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN, and Heather Taillon, RHIA.
Pamela P. Bensen, MD, MS, FACEP, CEO of Medical Education Programs, Inc. in Buffalo Junction, VA, created a laminated pocket guide for physicians available in packs of 25.
Offer physicians CDI insight not just ‘education’
You never know what wisdom lurks in the cookie.
I recently received a fortune cookie from a colleague. After reading the fortune several times, I realized the hidden message certainly has direct relevance to CDI efforts toward affecting overall change in patterns of physician documentation. It read:
“Anyone can memorize things, but the important thing is to understand it.”
Most people remember reading college textbooks, listening to professorial lectures, taking notes, and regurgitating the information we supposedly “learned” on tests and final exams, as part of our endeavors of higher learning. We always seemed to ask ourselves why we were “learning” the majority of that rote information anyway. It was difficult to appreciate and understand its practicality and usefulness.
Now, let’s look at CDI training and education. The majority of training, education, and execution of CDI programs center around:
- understanding the MS-DRG system
- learning what a MCC/CC is
- gaining a practical sense and understanding of coding rules and policies governing principal and secondary condition selection/assignment
- learning how to review the record
- learning how to identify opportunities to improve clinical documentation and financial reimbursement
Finally we learn how to enter the data into the tracking software for reporting purposes. If we’re lucky we learn to track
- how many queries were left
- how many were responded to
- how many contained a positive response
- how often records were reviewed
- how much of a financial impact CDI has on hospital’s bottom line
The entire process is similar to the college experience in the sense we “memorize” the steps of CDI, apply its principles consistently, and ensure we review the standard number of records each day in the name of that learning. While I am not fundamentally against established “quotas” for record review, I do advocate for quality of chart reviews which work in tandem with CDI efforts to educate of physicians, particularly to the extent that we are not repeatedly leaving the same queries day in and day out for the likes of acute blood loss anemia or the type of congestive heart failure.
Clinical Documentation Improvement: What is your definition?
CDI as pointed out by AHIMA in their Clinical Documentation Improvement Toolkit is as follows:
- “The purpose of a CDI program is to initiate concurrent and, as appropriate, retrospective reviews of inpatient health records for conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or can be conducted remotely (via the EHR).
- The goal of these reviews is to identify clinical indicators to ensure that the diagnoses and procedures are supported by ICD-9-CM codes. The method of clarification used by the CDI professional is often written queries in the health record. Verbal and electronic communications are also methods used to make contact with physicians and other providers. These efforts result in an improvement in documentation, coding, reimbursement, and severity of illness (SOI) and risk of mortality (ROM) classifications.”
I recently wrote an article for this forum on clinical documentation improvement discussing my concern with programs which mainly focus on capturing the Almighty “CCs” and “MCCs” and those programs who teach their CDI staff to make sure they receive “credit” for the resulting capture of said CC or MCC for the initiated query.
In fact, I noticed a post on CDI Talk last month that generated quite a stir regarding so-called “credit for queries” that stirred my attention. Specifically, a coding department was receiving “credit” for physicians who positively responded to queries when the CDI staff conducted the front-end work generating the query. What a disheartening feeling to see firsthand evidence of territorial working relationships between the coding department and the clinical documentation improvement specialists.
Instead of devoting precious energy on fighting over who gets “credit” for securing a CC or MCC, let’s set our minds to the real role of CDI—clinician education on the merits of specific, accurate, and detailed documentation to affect positive change in general patterns of physician documentation. In essence, I believe we should focus on successfully engaging the physician to effectively change their documentation behavior patterns.
The Perpetual Treadmill
If you find yourself constantly leaving the same type of clinical clarification query such as the type of congestive heart failure, the stage of
Don't get stuck on a treadmill asking the physicians the same tired queries over and over. Use every opportunity to provide physician education regarding the importance of CDI.
chronic kidney disease, the type of pneumonia or if you consistently have to query the physician to “rule in” or “rule out” a diagnosis, consider a different approach. This may signify an opportunity to extol the direct impact of appropriate documentation on the physician’s business and on his or her practice of medicine. It provides CDI programs with an opportunity to explain to the physician that CDI programs aren’t simply about more documentation but more effective, clinically accurate, documentation which ultimately leads to better patient care.
Take the following interaction between a CDI specialist and physician, a verbal query that resulted in a principal diagnosis clarification:
A patient was admitted for acute abdominal pain which waxed and waned but in the last two days had become so intense the patient came to the ER. A provisional diagnosis of acute pancreatitis was documented in the initial history and physical (H&P) on the basis of abnormally elevated liver enzymes. Patient received IV hydration and pain meds over the course of the next three days, abdominal pain subsided to the point patient was stable and discharged on day four.
The CDI specialists appropriately left a query for the physcian to clarify the physician’s clinical thought process of acute pancreatitis but unfortunately there was no response from the physician. Not surprising in our line of work! This record went to coding after discharge without clarification. So the coding/CDI staff had to “chase down” the physcian for clarification of principal diagnosis after the fact. In so doing, the CDI specialist carries the record around all day long along with a laptop computer hoping to “catch” the physician on rounds and resolve the matter with a verbal query.
At this point, the physician asks: “How many times do I have to document a diagnosis in the record to avoid these queries.” CDI specialist tells the physician that he/she needs to document the diagnosis at least twice to avoid coders questioning the diagnosis, necessitating a query.
Let’s look at this case again to see if we can identify the missed physician education opportunity.
2010 ACDIS Conference: Poster session new addition to program lineup
The first ACDIS poster session will be held in Chicago.
With so many great speaker proposals to chose from, ACDIS and the Conference Committee did its best to come up with sessions to fit the diverse needs of its members. But there were a few proposals that we just couldn’t pass up despite the tight schedule. So we asked 11 presenters to participate in the first ACDIS conference poster session.
Many associations offer the poster session as a means to spotlight exceptional programs, provide additional educational opportunities, and focus on new professional best practices. Ours is no different.
For those who have not attended a poster session previously, think back to your high school science fair. Remember doing all that research on whether classical music or heavy metal helps plants grow taller? Remember assembling all your findings into easily disseminated nuggets, charts, and graphs on a tri-fold poster board? Remember fidgeting restlessly as parents and teachers streamed by to ask you all sorts of questions about your analysis?
Well, this is almost the same thing. The difference from that old high school project, of course, is in the content and the community. Topics address concerns ranging from CDI management to metrics, from team building across departmental barriers to networking with CDI from other facilities.
The posters will be on display in New Orleans room throughout the conference and presenters will be on hand to discuss their findings Friday, June 4, from noon to 1:30 p.m.
Here’s a list of the scheduled presentions:
- Terri Adell, University Hospital at Stony Brook, The pudding is in the proof: Confirming the impact of CDI specialists on the bottom line
- Bonnie Epps, Emory Healthcare, Physician Engagement in CDI in an Academic Medical Center
- Natalie Howell, Carolinas HealthCare System, Diversified in approach, united in purpose: CDI practice in Metro Charlotte, NC
- Fran Jurcak, Wellspring Partners, Dream Team: A physician-nurse documentation improvement team
- Adelaide La Rosa, St. Francis Hospital, The Heart Center, A team approach to bridging the CDI-physician gap
- Mercy Mathew, Oklahoma Heart Hospital, A successful merger of case management and CDI
- June Miller, Northwest Community Hospital, Physician education tools: Acute respiratory failure, metabolic encephalopathy, and more
- Ellen Mitchell, Lutheran Medical Center, Integration of CDI into quality management, core measures, and case management
- Kimberly Richert, Morton Plant Mease Healthcare, Improvement of Heart Failure Query Process
- MaryAnn Shanley, Connecticut ACDIS local chapter: Sharing forms, tools, and ideas
- Teri Sholder, Kettering Health Network, Combined CDI/core measures role: A case study
CDI focus for quality group’s North Carolina Webinar Thursday
NC quality Webinar to focus on CDI impact.
The North Carolina Association for Healthcare Quality (NCAHQ) will feature ACDIS North Carolina Chapter Vice President Jennifer Love this Thursday, May 27, from 3-4 p.m. for a Webinar (an online seminar) about clinical documentation improvement.
Love says the program targets physicians, analysts, nurses, administrators, and other health care professionals/ providers to help them understand how the CDI impacts overall healthcare administration. The program is open to public and costs $20. For information, visit www.ncahq.org/education.htm
