1 Coming Out of the DARC: Improving CDI and Coding Alignment Kathy Dorich, RN, CCDS, CPHQ, System Manager CDI Kelly Tarpey, RN, MS, CPHQ, System Director CDI Advocate Health Care Downers Grove, Illinois 2 Susan Bittner, RHIT, CCS (Key reference) Clinical Data Manager Advocate Health Care [email protected]Kelly Tarpey, RN, MSN, CPHQ System Director, Clinical Documentation Improvement Advocate Health Care [email protected]Kathy Dorich, RN, CCDS, CPHQ System Manager CDI Advocate Health Care [email protected], 3 Learning Objectives • At the completion of this educational activity, the learner will be able to: – Understand the impact of the CDI/coder relationship and interdependence – Develop a multidisciplinary CDI/coding team to build alignment in practice and share ongoing learning opportunities – Explore tools that help create alignment between coding and clinical criteria for complex diagnoses (e.g., Advocate’s Document Alignment Reference Card—“DARC”) 2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission. 1
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Coming Out of the DARC: Improving CDI and Coding Alignment
Kathy Dorich, RN, CCDS, CPHQ, System Manager CDIKelly Tarpey, RN, MS, CPHQ, System Director CDI
• At the completion of this educational activity, the learner will be able to:
– Understand the impact of the CDI/coder relationship and interdependence
– Develop a multidisciplinary CDI/coding team to build alignment in practice and share ongoing learning opportunities
– Explore tools that help create alignment between coding and clinical criteria for complex diagnoses (e.g., Advocate’s Document Alignment Reference Card—“DARC”)
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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CDI/Coding Relationship
Tammy Combs, RN, MSN, CDIP, CCS, CCDS, Director and lead nurse planner of HIM Practice Excellence for AHIMA; April 27, 2017 blog “Journal of AHIMA”
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Background: Advocate Health Care
• Faith based, not‐for‐profit health system based in Downers Grove, Illinois
• More than 250 sites of care
• 12 acute care hospitals
– 3 academic medical centers
– Children’s hospital with two campuses and the state’s largest integrated children’s network
Named one of the “Top 5 large health systems” based on quality by Truven Analytics
Six Advocate hospitals have earned Magnet® Recognition from the American Nurses Credentialing Center (ANCC)
One hospital National Baldrige winner 2 additional
hospitals winners of Illinois Performance Excellence awards (state—Baldrige)
Named one of the “Top 5 large health systems” based on quality by Truven Analytics
Six Advocate hospitals have earned Magnet® Recognition from the American Nurses Credentialing Center (ANCC)
One hospital National Baldrige winner 2 additional
hospitals winners of Illinois Performance Excellence awards (state—Baldrige)
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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On a scale of 1 to 5, how would you rate your site’s current CDI/coding relationship?
1: Always aligned
2: Usually aligned
3: Sometimes aligned
4: Rarely aligned
5: Never aligned
Polling Question
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ICD‐10 Impact
• So much new learning for everyone!
• New ICD‐10 concepts
– Glasgow Coma Scale
– Post‐procedural respiratory
– Pressure ulcers
– Procedure coding
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Kelly & Kathy’s 7 Principles
• The past is in the past!
• We will actively choose to manage our relationship with care and respect
• CDI and coding professionals think differently—aren’t we lucky!
• We can learn so much from each other
• Because we think differently, we sometimes communicate & make decisions differently
• We commit to leading with facts & transparency—not opinions and assumptions
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Kelly & Kathy’s 7 Principles
• We have different viewpoints and metrics, yet we have aligned goals – We want the care & resources used in patient care to be accurately
reflected in the documentation & final code assignment
– We have a shared responsibility to help our physicians bridge documentation gaps
• Coding guidelines are the law of the land (even if they just don’t make clinical sense)
• Most conflict between our professional groups exists in the “gray” areas between clinical care and coding guidelines—we can actively manage this better with aligned decisions & approaches shared across our teams
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Building Our Structure
Opportunity: Needed a system‐level forum for
CDI & coding problem solving
• Members personally selected and invited
• Characteristics of members– Professionally knowledgeable
– Good problem solving & communication skills
– Transparent influencers
• Kickoff meeting
Share our principles & expectations for the work group
Role model alignment
Start some action: Develop mission statement/next steps
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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System CDI/Coding Alignment Team
What is it?• Team of 3 coding and 3 CDI leaders + system
CDI and coding leaders
• Meet twice monthly
• Structured agendas/minutes with action items/owners
Key expectations• Champions of this shared new vision
• Represent all CDI and coding colleagues at all sites
• Fact‐based decision‐making whenever possible
• Creative, productive, professional discussion is welcome!
• As we leave, we have one voice in all decisions made
Mission statement
• We are one team of CDI and coding professionals actively working together to develop a culture of learning and collaboration that is transparent, fact‐based, and constantly evolving. Our shared goal is to ensure that the care and resources used in patient care are accurately reflected in the documentation and final code assignment.
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CDI/Coding Alignment Log
Opportunity: Method for site CDSs & coders to identify objective sources of conflict at their sites
What is it?
• Excel log
• Located on organization’s intranet site (All CDSs & coders have access)
• Encouraged to place unresolved questions or topics on their site– Frequent mismatch conversation topics; knowledge gaps; areas of confusion
How it’s used
• Identification of key issues for CDI/coding alignment team– Prioritize & sort topics
– Assign needed action to the topics: DARC/coding pathway/training
• Communication tool to point to key references and answers– As topics are addressed, the resolution is added to log
Outcome
• Issues are transparent!
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CDI/Coding Alignment Log
• Key columns:• Patient #• Site• Name of logging associate• Coding question to verify• CDI/coding alignment recommendations (after review)
To be addressed
Completed/more information
Work in progress
Coding FAQ review
We can't do right now
Legend
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Site CDI/Coding Team Meetings
Connecting the dots: Site CDI/coding meetings already occurring at each hospital
• Recently formalized with CDI standardization
• Meeting at least monthly, using agendas and minutes
• Address site‐specific trends, challenging cases, and mismatch topics
Opportunity: Finding resolution to unresolved conflicts
• CDI coding alignment log is now the place to escalate challenging topics
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Documentation Alignment Reference Cards (DARC)
Opportunity: Reference tools needed to help align “gray” areas of practice
What is it?
• Templated tool created by CDI/coding alignment team to clarify key coding references, key clinical indicators, and CDI tips for complex diagnosis/topics
How it’s used
• Coding references all in one spot
• Concurrence on relevant clinical indicators
• Identification of query opportunities
• Reference to use in physician training
• Resource for teaching new associates
• Assists in writing appeals for denials (clinical foundation)
Outcome
• Decreased mismatches
• Increased alignment between CDI & coders at individual sites and across the system
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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DARC Template
• Code Assignment: Published coding guidelines and relevant issues of Coding Clinic
• Key Clinical Findings: Evidence‐based practice, Advocate clinical protocols and practice guidelines
• Incorporates learning from the first 3 months of use
• Site CDI team leader in charge of collecting site feedback from CDI, coding, & physician advisor site feedback
• Alignment team reviews every piece of feedback from sites
• Revisions made as appropriate
• Formal feedback provided to sites
• Revised DARC published
DARC Reference Card Feedback (3 month review)
CDI/Coding Alignment Notes
DARC CARD Name: ______________________
DARC CARD Number: ____________________
DARC CARD Owners: _____________________
DATE OF REVIEW: 05/04/2016
Site Recommendation DARC Change Made? (yes/no)
Rationale Site/s
Key columns:Site RecommendationDARC Change Made? (yes/no)RationaleSite That Made Recommendation
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Completed DARC References
• Cerebral edema
• Excisional debridement
• Glasgow Coma Scale
• Pressure ulcers
• Respiratory failure
• Malnutrition (with and without dietitian consult)
• Type II NSTEMI
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Document Control
• Goal is to ensure the most recent info is published and used in decision‐making
• All cards receive:– Title
– Document #
– Initial publication date
– Most recent review date
– Last revision date
• All key CDI/coding alignment information is housed on intranet
• All old documents are archived
• Standard review process– Cards evaluated with code
changes
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Our Alignment Journey Never Ends!
• Always looking for better ways to quantify mismatches found in reconciliation process
• EMR changes are providing an opportunity to re‐evaluate our integrated CDI and coding workflow
• Continue to mature our site CDI/coding meetings
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.
2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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