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Stampede to the CDI director

Clinical documentation improvement (CDI) specialists are a passionate group and they love ACDIS director Brian Murphy. They love him so much, in fact, that his appearance in the exhibit hall at the 2015 ACDIS conference in San Antonio this week caused a stampede.

Spectacular CDI specialist Sharme was not quick enough to escape the oncoming masses and was trampled in the rush to Brian.

In addition to being passionate, CDI specialists are also polite and nurturing, so Sharme’s stay at the bottom of the stampede was relatively short. She did come out of it with some minor injuries, though.

At first, she was concerned that she might have a minor concussion, but Dr. Jon quickly ruled that out. Sharme only suffered a contusion on the back of her head. That bump wasn’t the only injury to her skull, however. She also suffered a 2-cm laceration behind her ear.

Sharme did not sustain any broken bones, but she did end up with a nice puncture wound on her hand courtesy of someone’s very high heel. Sharme avoided any more serious injuries and instead has a collection of bruises more colorful than a Texas sunset.

Because she is surrounded by CDI specialists, Sharme decided to appropriate an ICD-10-CM Manual and thrill her audience of assistants with a recitation of the codes for her wounds.

For the contusion to the head, we need to know the exact location. Contenders include:

  • Scalp
  • Eyelid and periocular area
  • Nose
  • Ear
  • Lip and oral cavity
  • Other parts of the head

Sharme ended up with a bump on the back of her head, so we’ll go with S00.83XA (contusion of other part of head, initial encounter).

For the laceration, we have the same options for location. Sharme’s wound falls under scalp, but we need some additional information before we code the injury. Does the wound contain any foreign bodies? Dr. Jon did not locate any, so our code is S01.01XA (laceration without foreign body of scalp, initial encounter).

On to the puncture wound. Without even looking in the ICD-10-CM Alphabetic Index, we know we’ll need laterality. We’ll probably also need to know whether any foreign bodies remained in the puncture.

Sharme’s left hand bore the brunt of the heel, which left a small piece of itself behind, so we would report S61.442A (puncture wound with foreign body of left hand, initial encounter).

We would also report individual codes for all of Sharme’s other contusions.

Sharme shows just how super she is, though, by returning to her duties as a conference room moderator.

Data gathering

Great tip from 3M’s Donna Smith, the Association of Clinical Documentation Improvement Specialists conference general session speaker.

“We’re collecting data for the future. It is a little shortsighted to just ask, which DRG changes affect the bottom line.”

You probably won’t see much change initially with DRG payments. In fact, most experts predict only a 1-2% shift in DRGs initially. However, that is likely to change the longer we use ICD-10. CMS uses two years’ worth of claims data when calculating payment rates, so once the agency has that data, it could make significant changes to DRG assignments.

Donna also offered another great reminder: “We want to make sure we are reporting all of the diagnoses important to the patient for severity of illness.”

The better we can illustrate how sick our patients are and the resources we used to treat them, the better off we’ll be.


Everything’s bigger in Texas, including the food

CatwStomachAcheSuper CDI specialist Cheryl loves Mexican food. Really, she loves it a little too much.

She decided to celebrate the end of her teaching duties at the Association of Clinical Documentation Improvement Specialists’ (ACDIS) annual conference with the super-duper-haven’t-eaten-in-two-months special at Lotsa Enchiladas Mexican Restaurant.

She awoke this morning with severe abdominal pain intensified by movement, nausea, and vomiting. At first, she wasn’t very concerned. She thought it was just the aftermath of a massive Mexican food binge. Then she noticed blood in her vomit and decided it was time to go to the hospital.

Dr. James diagnosed Cheryl with a nontraumatic stomach rupture. Her fellow CDI specialists Laurie and Sharme came to commiserate and wish her well. Then they headed back to the conference where they promptly searched the ICD-10-CM Alphabetic Index for a code for Cheryl’s malady.


Splash goes the CDI

CDI-Journal-ACDIS-2015-ADOur friends at the Association of Clinical Documentation Improvement Specialists (ACDIS) and 1,400 or so of their closest friends have descended on San Antonio for their annual conference. Things did not start off swimmingly.

Peerless CDI Laurie was out for a stroll along the Riverwalk when a very enthusiastic Great Dane decided to say hello, much to his owner (and Laurie’s) chagrin. The very Great Dane knocked Laurie into the San Antonio River. Unfortunately, a boat full of tourists was passing by just as Laurie took her tumble. The boat captain didn’t see Laurie and clipped her shoulder on the way by.


Einstein was right

“The definition of insanity is doing the same thing over and over again and expecting different results.” – Albert Einstein

news blocksThe closer we get to ICD-10 implementation, the more we see the same attempts to delay or bypass it.

Rep. Ted Poe, R-Texas, introduced H.R.2126 April 30 in another attempt to kill ICD-10. The bill is identical to the one he introduced April 24, 2013. H.R. 2126 is likely to die in committee, just as H.R. 2126 did two years ago.

Not surprisingly, Steven Stack, MD, incoming president of the American Medical Association, supports Poe’s bill and also wishes for ICD-10’s demise. Stack is in favor of skipping ICD-10 all together and jumping right to ICD-11. So you want to wait another 10 or 15 years to replace a coding system that is out of room now? Yeah, that’s a good idea. Not.

The World Health Organization is currently planning to release the beta version of ICD-11 in 2017. Keep in mind that CMS has been modifying ICD-10 for 20 years or so. If we needed 20 years to modify ICD-10, why would we need less time to modify ICD-11?

The AMA sent Poe a letter reiterating its same claims for why we should not move to ICD-10. The AMA sent Poe a very similar letter in 2013.


Another ICD-10 bill hits Congress

news blocksCongress is getting involved in the ICD-10 transition again with a new bill introduced into the House of Representatives May 12.

The good news is H.R. 2247, Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-TEN Act), would not change the October 1, 2015 implementation date or require payers to accept both ICD-9 and ICD-10 coded claims. Rather, the bill would require CMS to conduct 18 months of end-to-end testing open to all providers to determine whether the fee-for-service claims processing system works with ICD-10.

It’s interesting to note that the bill only mentions fee-for-service payments—basically physician practices. Both inpatient and outpatient facilities are paid under a prospective payment system.

During the transition period and any ensuing extensions, CMS could not deny reimbursement only because of the “use of an unspecified or inaccurate subcode,” according to the bill.

The AMA has previously pushed for a similar guarantee, but so far, CMS isn’t going for it.

Rep. Diane Black, R-Tennessee, introduced the bill, which currently has three co-sponsors. It is competing with H.R. 2126, introduced by Rep. Ted Poe, R-Texas. Poe’s bill, however, would kill ICD-10.


Conference preparation is not for wimps

MattOur friends at the Association of Clinical Documentation Improvement Specialists are putting the final touches on their conference preparations. They have sent off the final shipment to San Antonio (and not a moment too soon!).

Matt, who has been coordinating packing and shipping for the conference, fell afoul of some falling boxes in the warehouse. One of the boxes landed on his foot, squashing it flat. At least, that’s what Matt claimed. It turns out the box only crushed two toes. Still painful and not particularly pleasant, but not as bad as initially thought.

Our crack staff of CDI specialists immediately pulled out their ICD-10-CM Manuals to check on what documentation they need to code Matt’s injury.

We know Matt suffered a crush injury, so we start in the Alphabetic Index under crush, crushed, crushing. Judging by the list of options, you can crush a lot of body parts. ICD-10-CM does include an entry for foot, but also includes a more specific entry for toe(s)—S97.1-.

The dash tells us we need more characters for our code and we can find one of them in the Alphabetic Index. ICD-10-CM divides the toes into the great toe and the lesser toe(s). Which ones did the box crush?

Super CDI specialist Cheryl (a former ED nurse) identifies the great toe and one lesser toe as the injured parties. That means we’ll report two codes:

  • S97.11-, crushing injury of great toe
  • S97.12-, crushing injury of lesser toe(s)


Lies, darn lies, and survey results

question marksWe love surveys, especially about ICD-10. Seriously, how many ICD-10 surveys have you been asked to fill out in the past year alone?

It’s very easy to look at survey results and think things look really good or really bad, depending on the survey and what you want to see.

Take the NueMD 2015 Attitudes Towards ICD-10 survey, for example. When I first saw the results, I freaked out a little. How could 25% of the 1,000 respondents not be familiar with the ICD-10 coding standards? Even worse, how could 15% not be familiar with the proposed timeline for implementation?

When you look at who took the survey, things become somewhat clearer (and slightly less alarming). NeuMD surveyed small and medium-sized physician practices, but they didn’t just ask the physicians and coders.

Of the 1,000 respondents, 43% were clinicians, 16% were office managers, and another 13% were administrators. Billers, both in-house and contracted, made up 15% of the respondents. Eight percent identified themselves as “other.” Coders are not specifically identified, so they are probably part of that category.

It makes sense that the non-clinicians would not be familiar with ICD-10 coding standards. They don’t need to know them. What percentage of clinicians are familiar with the coding standards or, more importantly, the documentation requirements? We don’t know. The survey results don’t tell us.

When you see survey results, think critically about them, just like you would any documentation that you see. What do the results really mean? Whose views are reflected in the results? Are the results relevant to you?

Survey results can be a good way to evaluate where you are or how you compare to others. Just make sure you’re making meaningful comparisons.

If at first you don’t succeed

news blocksIf nothing else, Rep. Ted Poe, R-Texas, is consistent. He again introduced legislation to kill ICD-10. (The bill is H.R.2126 if you are interested.)

Poe has tried this trick before. He introduced an almost identical bill April 24, 2013. That bill, H.R. 1701, was never even discussed in committee.

Members of the House Energy and Commerce Committee’s Subcommittee on Health seemed to agree that we need ICD-10 during the February 11 ICD-10 implementation hearing. So it seems unlikely that this bill would make it very far.

Six fellow Republicans signed on as cosponsors of the bill, but the Democrats seem to be staying away. More indication that this bill is a non-starter.

With less than five months to implementation, we don’t need this kind of distraction. What we need are assurances that another delay won’t happen. Sadly, we probably won’t get the date written in stone and most of us will probably remain skeptical. It’s okay to be a skeptic. Just don’t slow down your ICD-10 implementation work because you think Poe might get a bill heard.

A plague upon you and your pit bill

plague germsIn case getting allergic rhinitis from your dog wasn’t bad enough, a Colorado man contracted the plague from his pit bull. And then he may have passed it on to another person. Person-to-person transmission of the plague last happened in 1924.

In all, four people became infected with plague in 2014 through contact with the dog or his owner.

Eight Americans, mainly in the desert Southwest, contract plague each year on average. Fortunately, medical science has come a long way since the Middle Ages, and we can now successfully treat plague.

Because of its relative rarity here in the U.S., doctors don’t always suspect plague. In fact, physicians initially diagnosed the dog owner with pneumonia due to Pseudomonas (J15.1) before correctly diagnosing the plague.