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Summer Reading: Physician Education Discussion Scenarios

LauriePrescott_May 2017

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

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

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example: The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids. For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Could you identify a probable etiology for her pneumonia? The physician responds, “It is probably due to aspiration.” The CDI specialist thanks the physicians and asks, “Could you please clarify that possible cause-and-effect relationship in the record?” She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”  Jane should then document this verbal query and the results as part of the CDI notes for this account. [more]

Summer Reading: Stepping out on your own

LauriePrescott_May 2017

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

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

‘Flying solo’

After a few trial runs, new CDI specialists should be given the opportunity to review records on their own. Before composing any queries during this initial stage, the manager or mentor should review a draft of the query proposed and provide feedback to identify any additional opportunities and compliance concerns, as well as to save the fledgling staff member from any potential physician ire due to a misplaced query.

Such feedback should reinforce concrete rules of the CDI road and should be supported by official rational from governing bodies such as AHA Coding Clinic for ICD-10-CM/PCS, Official Guidelines for Coding and Reporting, ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, or in-house policies and procedures.  Of course, mentors and managers should offer their expert opinions and tips on how to practice effectively, as well. This feedback should also offer the new staff member an opportunity to voice questions and concerns, and accelerate the learning process. This step in the process can continue until the new staff member and the preceptor agree that the new CDI specialist is functioning well independently and is comfortable “flying solo.”


Summer Reading: A letter to new CDI staff

LauriePrescott_May 2017

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

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

Dear Clinical Documentation Improvement Specialist,

I remember my first day as a new CDI staff member very well. I had been through an extensive interview process—three interviews, a written test, and a meeting with the consulting firm that trained me. At the time, all I understood was that I was going review records and help medical staff meeting documentation needs. After more than 20 years of nursing experience, and time spent as a nursing school clinical instructor and in management, staff development, and healthcare compliance roles, I figured this would be an easy jump for me. It was a jump that felt like I had leapt right off a cliff.

I spent my first day training with two inpatient coders and the consultants. These two ladies were an interesting pair. One had been coding for more than 25 years, and I concluded she could diagnose most disease processes better than a number of physicians I knew. The second was new to the inpatient process, having coded in outpatient and clinic settings for a few years. We were implementing a new CDI program. Everyone looked to me to make this program a success. I soon understood this was much more of a challenge than I ever imagined.


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. [more]

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