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.
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.
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
- 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.
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,
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?
- 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
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
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?
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.
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
- Metabolic/respiratory acidosis
- Metabolic/respiratory alkalosis
- Sepsis/severe sepsis/septic shock
- Systolic/diastolic heart failure
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.
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.