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.
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.
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.
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.
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
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.