an Association of Clinical Documentation Improvement Specialists publication www.acdis.organ Association of Clinical Documentation Integrity Specialists publication www.acdis.orgAssociation of Clinical Documentation
Integrity Specialists
JANUARY/FEBRUARY 2020 Vol. 14 No. 1
Exploring new challenges: CDI foray into alternate settings
Exploring new challenges: CDI foray into alternate settings
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© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 3
JANUARY/FEBRUARY 2020 Vol. 14 No. 1CONTENTS
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CDI Journal (ISSN: 1098-0571) is published bimonthly by HCPro, 35 Village Road, Suite 200, Middleton, MA 01949. Subscription rate: $165/year for membership to the Association of Clinical Documentation Improvement Specialists. • Copyright © 2020 HCPro, a SimplifyCompliance Healthcare brand. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.acdis.org. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of CDI Journal. Mention of products and services doesnot constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.
FEATURES9 Taking your first step in outpatient CDI
Outpatient CDI isn’t just inpatient CDI in an emergency department or clinic. It’s a different skillset, and it’s a different mindset.
15 Don’t let behavior health reviews psych you out Why delve into psychiatric record review? For some programs, the expansion into psychiatric units or facilities may be driven by the needs of the patient population.
20 Go big, or go home health Those developing CDI efforts in home healthcare have a different animal to contend with—one with its own documentation needs, policies, obstacles, and opportunities.
27 CDI in skilled nursing facilitiesA new payment model and the growth of health systems nationwide has propelled some CDI professionals into this unconventional setting.
DEPARTMENTS4 Associate Director’s Note
Melissa Varnavas delves into the value of listening and sharing your experiences and stories.
6 ACDIS Advisory Board InsightMembers of the ACDIS Advisory Board discuss tactics for physician engagement in today’s CDI landscape.
13 Podcast RecapAnalyn Dolopo-Simon shares how CDI can help reduce physician burnout.
18 Editor’s Note Linnea Archibald shares the work of the Forms & Tools Library Committee and recommends resources for expansion.
25 Physician Advisor’s Corner Amy Sanderson unpacks the clinical nuances of cerebral edema and brain compression.
30 Coding CornerKay Piper explains how to influence ICD-10-CM Alphabetic Index and Tabular List changes.
37 Coding Clinic for CDISharme Brodie explains the contents of the fourth quarter Coding Clinic release for CDI professionals.
41 Meet-a-MemberNancy Franciotti is the CDI manager at Inspira Health in Woodbury, New Jersey, and a member of the Philadelphia/Southern New Jersey/Delaware ACDIS local chapter.
43 A year in reviewA comprehensive listing of all the CDI Journal articles published in 2019, organized by topic, to help you reach your 2020 goals.
CONTINUING EDUCATION CREDITSBONUS: Obtain one (1) CEU for reading this Journal
ACDIS members are entitled to one continuing education credit for reading the CDI Journal and taking the 20-question quiz. Click here to take the quiz.
ASSOCIATE DIRECTOR’S NOTE
EDITORIAL
Director Brian [email protected]
Associate Director, Events Melissa [email protected]
EditorLinnea Archibald [email protected]
Associate Editor Carolyn [email protected]
Associate Director for Education Laurie L. Prescott, MSN, RN, CCDS, CDIP [email protected]
Director of Sales and SponsorshipsCarrie Dry [email protected]
CopyeditorAdam [email protected]
DESIGN
Sr. Creative DesignerVicki [email protected]
Association of Clinical DocumentationIntegrity Specialists
Practicing the art of listeningI was reading this article online about responding to the question “tell
me about yourself” in a job interview. The best answer to this question, wrote Gary Burnison, came from a woman who’d managed to hike the seven highest summits in the world. You can read the article and its recommendations for yourself on CNBC.com.
Having just hired a lovely 20-something-year-old woman to join us at ACDIS, and having gone through a few interviews prior to her hire, made me wonder: If we’d asked her just that question, in just that way, how would her response have resonated with each of us in the room?
Before joining the ACDIS team, Carolyn Riel worked as a content creator and recipe developer at Aroma Housewares, a small kitchen appliance company in San Diego. She moved out to California follow-ing friends after college but eventually found the high cost of living, difficult commute, and work-life balance taxing and came back east to her Massachusetts home.
Carolyn told us that when she was little, she wanted to be either a veterinarian or a baker. Eventually, she ruled those out and picked up writing as a talent.
In turn, we told her about the position. The ACDIS associate editor helps the administrative team craft interesting content, drawing on the expertise of the association’s membership in order to share stories of success and struggle that resonate with the community and help indi-viduals grow professionally from that shared experience.
In thinking about Gary Burnison’s piece, I wondered what I would say now, after more than 14 years at ACDIS’ parent company and 12 with the association itself, in answer to that question.
“Tell me about yourself,” the interviewer would ask.
Burnison says to set aside the work-life response and share some-thing personal, something interesting. Perhaps I’d talk about my poetry then; describe how I’m interested in the intersection of religion with modern daily life and the appreciation of varied human cultures that, despite their vast differences, all pay deference to two things—home (i.e., earth, family, location) and mortality.
Perhaps this interviewer and I would speak philosophically about how subtle discrimination engrained in societal systemics undermines
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not only individuals but all of society. Perhaps they’d be interested in chatting about the meaning behind a perfect line break in a stanza of verse.
More likely, I’d stick to the work-life script. I’d talk about starting with ACDIS and not knowing what CDI was. I would talk about increasing the size of its online journal from eight to 12 pages, then to 24, and now to 40-plus.
I would talk about helping fledgling groups network on the local level. I’d talk about how our initial state-fo-
cused efforts expanded across the country and the globe, and how attendance at the meetings now num-bers in the hundreds. I’d talk about attending my first ACDIS Conference and its exhibit hall of four vendors and how the event now welcomes such a range of exhibitors that the conference features therapy dogs and food trucks.
But I’d like to think that I’d flip Burnison’s script entirely and talk about you, about what it has meant to be entrusted with your stories and experiences, about how privileged I am to have stood beside you as we’ve
grown together professionally. I would talk about what these past 14 years have meant to me and how appre-ciative I am to have a position that allows me to invest my talents in a way that has hopefully, in some small measure, helped you.
Ideally I’d talk about the amazing ways you have extended your hand to me and tell my imagined inter-viewer about all the ways you have worked hard for us, for yourselves, for your colleagues, for this profession. I’d talk about the funny way you handled that noncom-pliant physician, the gift you surprised me with at the ACDIS Conference even though we’d never met, the farewell hugs you’ve given at the close of the confer-ence every year for the past 10+ years.
When ACDIS Editor Linnea Archibald introduced our newest team member to our internal colleagues, she’d listened well to Carolyn’s story not only during the job interviews but throughout the onboarding process. She recounted Carolyn’s childhood career aspirations—which included not only veterinarian and baker but also unicorn, art teacher, and bus driver. Carolyn’s talents include loon calls and making just about anything in a rice cooker. If you get the chance, email her and ask for details.
With this edition of the CDI Journal, I turn over its content and management to Linnea, Carolyn, and your well-abled hands. I’m not going anywhere—just stand-ing back a bit, refocusing on our ACDIS chapters and events, and letting these lovely ladies enjoy being a bigger part of your story for a while.
I’d like to think I’d flip Burnison’s script entirely and talk about you, about what it has meant to be entrusted with your stories and experiences, about how privileged I am to have stood beside you as we’ve grown together professionally. I would talk about what these past 14 years have meant to me.Melissa Varnavas
ADVISORY BOARD INSIGHT
Tackling CDI’s biggest challenge: Innovative physician engagement tactics
As mentioned in CDI Strategies, the ACDIS Advisory Board is working on a year-long project focused on tackling the CDI profession’s number one problem: physician engagement and educa-tion. To kick off the conversation—which will ulti-mately include a series of surveys, white papers, and more—members of the Advisory Board shared their innovative tactics on the final 2019 Quarterly Membership Conference Call.
With the advent of remote work opportunities and the continued rise in productivity expec-tations, it can be difficult to identify helpful tac-tics for modern CDI work, said Advisory Board member Tracy Boldt, RN, BSN, CCDS, CDIP, CCDS-O, manager of CDI at Essentia Health in Duluth, Minnesota.
While technology has certainly helped in some regards, it can tether CDI professionals to their computers and take them out of providers’ view, so organizations need to find solutions to foster physician buy-in and adapt along the way.
“With the electronic health record and the com-puter-assisted coding products that various orga-nizations use, we tend to be more screen driven. That’s kind of where [technology is] pushing us. That’s where I felt the need [for new physician engagement efforts] was coming from. How can we be a partner at the table with the providers?” said Boldt.
Say yes to requests
First, don’t be afraid to say yes when physicians ask for help, even if it’s not a task that tradition-ally falls under the CDI program’s purview. Obvi-ously, CDI departments need to be wary of scope
creep and fatigue from over-stretching their staff, but they should try to be as much of a resource to providers as possible. Those added efforts can change providers’ perspective about the CDI program’s goals, said Advisory Board Member Vaughn Matacale, MD, CCDS, director of the CDI advisor program at Vidant Health in Greenville, North Carolina.
“We have a never-say-no approach,” he said. “Our program has always tried to keep in the know of what’s important to the medical staff. Over the last 10 or so years, what’s important to the medical staff has changed. Sometimes it’s length of stay, sometimes it’s mortality, sometimes it’s SOFA [Sequential Organ Failure Assessment], sometimes it’s case mix. We try to keep aware of that. Wherever the interest is, wherever the need is, we try to come in and support that need.”
Listening to physicians and taking their con-cerns, questions, and interests to heart not only helps build engagement but positions the CDI team as trusted subject matter experts. Physi-cians are much more likely to reach out with other documentation-related questions if they’ve found the CDI team to be helpful in the past, Matacale said.
“When we do that, we build trust,” he said.
Matacale also recommended taking the time to understand the tools connected to concerns phy-sicians face. For example, get to know the staff involved with informatics. Learn the physicians’ workflow in the EHR system. Ask what improve-ments and innovations could help eliminate stum-bling blocks.
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“It’s really important to be aware of the tools that are required to meet [your] goals,” said Matacale. “We do partner with some of our informatics team. It’s really important to have those partnerships to make sure you can deliver the message along with the method.”
Leverage orientation
All organizations periodically welcome new physi-cians to the staff. Get in front of these newbies as soon as possible, Boldt suggested. Start by reaching out to the department or individual responsible for onboard-ing new staff, she said.
“We partnered with our onboarding team. We know when the providers’ orientation schedules are,” said Boldt. Some of Boldt’s facilities gave CDI staff “a fair
amount of time” with new providers—about 30 min-utes—where the team shares an educational presenta-tion on the importance of CDI efforts.
Thirty minutes may not seem long enough. But Boldt said “many of the providers that are new to our organi-zation have some sort of prior knowledge of CDI”—and for that, she added, “kudos to the CDI industry.”
Remember, onboarding education doesn’t end with orientation. At Essentia, the CDI team provides the new physicians with additional resources at the end of the orientation session so they can refer back to the materi-als and reach out with questions as they arise.
“We give them a trifold and we point them to our resources on SharePoint to teach them more about our clinical definitions and where we stand. Then, if they have questions, they reach back out to us,” she said.
Matacale also advised CDI professionals to remem-ber that physicians may undergo additional onboarding sessions with departments that are at least tangentially connected to CDI. While the CDI team at Vidant was granted a 45-minute time slot in the new provider ori-entation program (the longest of any department), they also work with other groups to ensure all the information the physicians receive is consistent and supports other departments’ needs.
“We partner with our liaisons—our onboarding team—in order to get in front of those providers early. They also have time with coding and compliance, which ties in,” Matacale said.
Engage physician advisors
Engaging the help of a physician advisor (or multi-ple advisors, depending on the organization’s size and structure) can be a huge boon to CDI efforts as well. Not only do physicians respond more readily to peer-to-peer education, but physician advisors can also serve as the face of CDI for the medical staff when the CDI team is partly or completely remote.
“We divide geographically so when we do our clinical rotations, some are at community hospitals and some are at flagships and we have different service lines,” Matacale said. “We try to have some face-to-face rep-resentation to maintain our credibility with the medical staff.”
Just like playing to the physicians’ interests and spe-cific needs, physician advisors may be best employed when they are focused on projects they’re interested in, Matacale added. Giving physician advisors domains and projects that interest them will not only promote greater job satisfaction but improve effectiveness due to their enthusiasm and specific focuses—avoiding the “jack of all trades, master of none” problem.
“We also divide by area of interest. I like PSIs. I like quality. So, I do a lot of projects within those areas,” he said. “We have one [advisor] that likes risk adjustment, one that likes UR, so we try to partner with our CDI spe-cialists as well as our administrators to bridge the gaps and meet the needs that are out there.”
We have a never-say-no approach. Our program has always tried to keep in the know of what’s important to the medical staff. Over the last 10 or so years, what’s important to the medical staff has changed. [...] We try to keep aware of that. Wherever the interest is, wherever the need is, we try to come in and support that need.Vaughn Matacale, MD, CCDS
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Though smaller organizations (or less established CDI programs) may not be able to employ full-time phy-sician advisors, Boldt offered some “budget friendly” options that she’s used to increase the reach and effec-tiveness of her two, part-time advisors at Essentia.
First, give them some designated CDI backup. The career ladder within Essentia’s CDI department
includes a CDI educator position. This individual is focused mainly on physician education and works closely with the two part-time advisors to extend their reach. This position makes it possible for the rest of the CDI staff (who primarily review records) to work from home three or so days per week, without sacrificing physician engagement.
“Our clinical documentation educator is really that face with the providers, at their elbows, at their section meetings, with our physician advisors,” Boldt said.
Also, don’t discount the value of physician support from non-official advisors. While physician advisors are typically compensated for their time (according to ACDIS’ May 2019 survey, 91.16% receive compensa-tion), an informal physician champion can have a big effect.
“We also have what I would consider a champion: somebody we can go to if we have questions or I need a message disseminated,” said Boldt. “We have some-body by service line, by organization. It’s an underlying hierarchy of providers we can reach out to. This is how we do it on a budget-friendly basis.”
While organizations, CDI departments, and physi-cians differ, and each individual may respond well to different tactics, remember to keep physician engage-ment in sight this year, said ACDIS Director Brian Mur-phy on the call.
“If you don’t have engaged providers,” he said, “you’re probably going nowhere.”
Editor’s note: ACDIS members can now register for the 2020 Quarterly Conference Calls on the ACDIS website. Click here for more details.
ADVISORY BOARD
Sheri Blanchard, RN, MSN, FNP-BC, CCDS, CCSCorporate Director of CDIOrlando HealthOrlando, [email protected]
Tracy Boldt, RN, BSN, CCDS, CDIPManager, Clinical Documentation IntegrityEssentia HealthDuluth, Minnesota [email protected]
Angie Curry, RN, BSN, CCDSSenior Consultant, Client Services ManagerHealthcare divisionNuance Healthcare Nixa, Missouri [email protected]
Katy Good, RN, BSN, CCS, CCDS CDI training materials specialistEnjoinGallup, New [email protected]
Fran Jurcak, MSN, RN, CCDSVice President of Clinical InnovationIodine SoftwareAustin, [email protected]
Vaughn Matacale, MD, CCDS Director, Clinical Documentation Advisor ProgramVidant HealthGreenville, North [email protected]
Chinedum Mogbo, MBBS, MsHIM, RHIA, CDIP, CCDS, CCSManager, CDITenet HealthcareDallas, [email protected]
Jeff Morris, RN, BSN, CCDSSupervisor, CDIUniversity of South Alabama Health SystemMobile, [email protected]
Laurie Prescott, RN, CCDS, CDIP, CRC CDI Education Director HCPro/ACDIS Middleton, Massachusetts [email protected]
Erica E. Remer, MD, FACEP, CCDSPresident and founderErica Remer, MD, Inc.Cleveland, Ohio [email protected]
Susan Schmitz, JD, RN, CCS, CCDS, CDIP Regional CDI director Southern California Kaiser Permanente Pasadena, California [email protected]
Deanne Wilk, BSN, RN, CCDS, CCS Manager of CDI Penn State Health Hershey, Pennsylvania [email protected]
Irina Zusman, RHIA, CCS, CCDS Director of HIM coding and CDI initiatives NYU Langone Health [email protected]
We have what I would consider a champion: somebody we can go to if we have questions or I need a message disseminated. We have somebody by service line, by organization. It’s an underlying hierarchy of providers we can reach out to. This is how we do it on a budget-friendly basis.Tracy Boldt, RN, BSN, CCDS, CDIP, CCDS-O
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“Outpatient CDI isn’t just inpatient CDI in an emergency depar tment or
clinic,” wrote ACDIS Director Brian Murphy in an article regarding the 2019 ACDIS Symposium: Outpatient CDI in Austin, Texas. “It’s a different skillset, and it’s a different mindset.”
In it, Murphy explains how out-patient CDI professionals need to review patient charts pre-visit, post-visit, or in some cases “not at all, but spend their time educating networks of physicians dispersed throughout their organizations.” These special-ists must understand Hierarchical Condition Categories, evaluation and management coding, and spe-cific details of the Official Guidelines for Coding and Reporting, as well as have a complex understanding of chronic disease processes and how to manage problem lists.
Defying the daunting
“Implementing an outpatient CDI program can be daunting,” says Judy Moreau, RN, MBA, vice president of mid-revenue cycle at Trinity Health, and Andrea East-wood, RHIA, BAS, director of clin-ical encounter and documentation excellence at Trinity Health, who pre-sented together at the Symposium.
A few hospitals in the Trinity Health network began implementing outpa-tient CDI in July 2018. For the first phase of implementation, “we had our hospitals identify one or two
Taking your first step in outpatient CDI
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departments where there might be an opportunity for outpatient CDI,” says Moreau, such as observation or the emergency department.
“We chose a nonprescriptive approach because we felt it was more helpful for them to pick their own departments where they
thought they might have extra resources to give the support that starting an outpatient CDI program would require.”
The hospitals also needed to pro-vide a thorough outline for how they were going to roll out implementa-tion within the fiscal year. Unsurpris-ingly, some sites had trouble getting started, so Moreau and her team created a playbook for them.
“With inpatient, everyone knows what you’re supposed to be look-ing for. But outpatient, everyone has [slightly] different needs, and met-rics could look different from hos-pital to hospital,” Moreau notes. A major hurdle with launching an out-patient CDI program is that because the avenue is still so new, it is diffi-cult to set benchmarks.
The introduction to the Trinity play-book lists items to investigate in
hopes of determining the areas that would benefit most from improved documentation, as well as an out-line of the program’s roles and responsibilities.
After the introduction section, the playbook is structured in chapters for each of the outpatient review areas. Each chapter outlines the CDI scope for that department, a list of potential clinical and coding areas of focus to prioritize initiatives, guidance on collecting baseline data, and tips on how to estimate potential financial benefits.
“We also recommend outlining the key roles of everyone involved and listing specific skill sets needed,” says Eastwood.
Moreau and Eastwood agree on the importance of documenting practices and procedures through-out the rollout phases, too. In the playbook, each chapter contains a reminder to document both the workflow and the collaboration that occurs among the team.
“We will do huddles with the phy-sician champion and document how long they are, what will be/was discussed, and all other important information,” says Eastwood.
The playbook chapters also con-tain sample documentation training tools, such as infusion start and stop times for an emergency room nurse. “They need to first know the impor-tance of documentation in order to better collect it,” Eastwood says.
For their second phase, Trin-ity Health expanded to outpatient surgery centers and non-hospi-tal-based services, such as urgent
care and cardiology. “Look at areas [within the healthcare system] with high rejection rates or high bill-hold rates for potential opportunities as a starting point,” suggests Moreau.
Above all else, Moreau stresses to “always be looking at denials, because that always presents an opportunity.”
Documentation trouble spots
Lack of documentation can make the difference between receiving a denial or not. If a patient has multiple reasons for a visit, every condition should be thoroughly documented so it can be put on a claim.
Start and stop times for injec-tions and infusions, while extremely important, are often forgotten. “Infu-sion and injection start and stop times must be documented, as there is always an area of opportu-nity here,” Moreau emphasizes. She adds that only 1% of the emergency department visits had an infusion chart before Trinity implemented their outpatient CDI program.
Start and stop times are also important for noting the hours a patient is in observation or recovery status. There is a high potential for missed opportunities with patients staying in observation for 36–48 hours, as these patients could meet inpatient criteria. Payers will not con-sider inpatient admission until the patient has passed the two-mid-night mark, but changing a patient who passes that threshold from observation to inpatient can mean a drastic shift in reimbursement. Also note that, in order for the hospital to be reimbursed for observation,
With inpatient, everyone knows what you’re supposed to be looking for. But outpatient, everyone has [slightly] different needs, and metrics could look different from hospital to hospital.Judy Moreau, RN, MBA
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a patient needs to stay there for at least eight hours.
“Sometimes orders get missed to change the status of a patient, so the wrong status ends up get-ting billed,” Moreau says. Failing to convert observation status to inpa-tient status can negatively affect a facility’s reimbursement and lead to potential denials.
Moreau also suggests keeping up to date with the Medicare list of inpatient-only procedures, as sometimes there are outpatient sur-geries performed that are on that inpatient list.
Additionally, educate physicians, regardless of setting, to document medical necessity. For example, consider joint replacements. “Medi-care wants to see that a patient has failed other treatments before the joint replacement was performed,” Moreau says.
Outpatient CDI staffing
“It takes a multidisciplinary team to run a successful outpatient CDI program,” Moreau says. A suc-cessful outpatient CDI team is likely to consist of clinicians, charge-of-entry staff, auditors, outpatient cod-ers, a chargemaster, denials coor-dinator, and CDI specialists.
Before launching the program, outline every team member’s roles and responsibilities. The team will need a leader to hold the group accountable and set goals for next year as well as to reevaluate what was done the previous year and find room for improvement. Much of implementing an outpatient
CDI program is trial and error, so looking back on what worked well and making those changes in the upcoming year is imperative for growth and success, Moreau says.
The purpose for a multidisci-plinary team is to have each mem-ber serve as a subject matter expert for their area of responsibil-ity and expertise. Most of the indi-viduals in the key roles have been performing their tasks or functions for a long time, and it’s important for team members to look at pro-cesses and challenges with a new set of eyes to invigorate collabo-ration, explains Moreau. Pioneer-ing a new outpatient CDI program requires trying new things and will call for some professionals to step outside of their comfort zones.
Implementation tools
“The first tool you need to get started is a basic data collection tool,” says Eastwood. A struggle many new outpatient CDI programs run into is collecting core data to prove the benefits of the program. Eastwood recommends starting with a homegrown tool such as a spreadsheet segmented into dif-ferent financial classes, such as observation patients converted to inpatient or medical necessity denial volume. For each category, record the numbers for both Medi-care and all payers within the fiscal year.
“Something we really looked at was inpatient statuses with one-day length of stay; maybe they should have been observation cases,”
says Eastwood. This data will pro-vide a starting point to compare before and after outpatient CDI implementation.
Eastwood also recommends providing the outpatient CDI team with a sample implementation plan. “This is an easy way for them to get their ideas down on paper,” she says. “It helps them communicate and articulate to us, but also they can start their plan of attack and outline initiatives within that specific area.”
A sample implementation plan can be as simple as a spread-sheet, much like the basic data collection tool Eastwood suggests. The spreadsheet can include infor-mation such as review area, initia-tive, people to involve, start date, and status. “What is important is giving your team a starting point,” she says. “Give them a guide to get going in the right direction.”
Finally, Eastwood and Moreau suggest using a fiscal year outpa-tient CDI implementation checklist; essentially, it provides a high-level outline of key activities that will get the outpatient CDI program up and running. This checklist will also allow capturing of specific financial data from the start, helping to prove return on investment (ROI) and financial benefits down the road.
Proving ROI
Because of the prospective pay-ment system used for reimbursing outpatient settings, nearly all out-patient CDI programs struggle to prove an ROI for their efforts. The ROI process happens slowly, and
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often it’s difficult to track where the financial gains are coming from.
“A major area that we found potential to prove financial ben-efits was with patients converted from observation status to inpatient status based on CDI work efforts,” says Eastwood. She suggests cal-culating the difference between the average observation reimburse-ment and the inpatient diagno-sis-related group (DRG). Take the inpatient DRG reimbursement for the specific case where a patient was converted from observation to inpatient due to CDI’s efforts, sub-tract the average observation reim-bursement, and the final answer is the case-specific CDI benefit. “Do not just give the dollar amount, but give the math behind it,” Eastwood suggests.
Eastwood also recommends tracking denial rates before and after implementation of the outpa-tient CDI program. “Determine the
number of denials for a period of time and the associated lost reve-nue,” she says. “Track the number of denials reduced for a period of time after the outpatient CDI ini-tiatives have been implemented.” You can then calculate the financial benefit related to denials by sub-tracting the dollar amount of the current denial period from that of the baseline denial period.
Eastwood and Moreau are work-ing with the finance department at Trinity Health to develop enter-prise outpatient CDI financial ben-efit tracking. So far, they have been able to set up tracking for query impact in observation and the emergency department using their CDI software.
Starting point
As with any new CDI initiative, there are many possible starting points for outpatient CDI. Moreau and Eastwood, for their part,
suggest looking for patients in observation who might be able to change to inpatient status. Addi-tionally, start collecting baseline data and then adding the antici-pated targeted financial benefits. “This allows the team to have a goal,” says Eastwood.
Track metrics such as query outcomes for observation, total CDI review rates, query rates, and query response rates. Providing tools to the team such as a play-book or sample documentation recording will also help by provid-ing them with a launching point and goals to strive for.
Eastwood notes that some hospi-tal sites are not fully embracing the tools they were given, as the learn-ing curve is steep. “Outpatient CDI changes quickly,” she says. “But any work in outpatient CDI is bet-ter than no work. We know our tools might not be perfect, but at least it’s a starting point.”
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PODCAST RECAP
Preventing physician burnoutBetween 35% and 54% of doctors and nurses expe-
rience burnout, according to a report issued by the National Academy of Sciences Engineering and Med-icine (NASEM). The report found an estimated 60% of interns and residents experience burnout as well. The ACDIS Podcast: Talking CDI examined this topic in an episode titled “CDI’s role in preventing physician burnout.”
According to Analyn Dolopo-Simon, ACM, CCDS, CDI program director for University of California-San Diego (UCSD) Health, the issue is very apparent to her CDI team as they’re present on the floor with the phy-sicians and interacting with them daily. In fact, many of the CDI staff have known the physicians since they were interns, so they have an ongo-ing, collegial relationship.
“We’ve heard how long these hours are that they are work-ing to respond to queries and to document, among other things,” she said on the podcast. In addition to CDI queries, the physicians are also working on patient care documentation and fielding queries from coding and other departments, Dolo-po-Simon said.
“I’ve always known that the [doc-umentation] they’re doing is … usually late [at night] after their shift, so we keep this in mind when interacting with them,” she said.
CDI specialists are, of course, aware of the number of queries they send themselves, but they may not know how many other demands the physicians have on their limited time. CDI, according to Dolopo-Simon, can be an instrument of change, however.
UCSD Health has set up a CDI excellence program under the chief of coordination and chief medical
officer. “It is basically a group of professionals who have the tools and requirements to educate and teach,” Dol-opo-Simon said, including the following departments:
n Population health
n Case management
n Coding
n Compliance
n CDI
The goal of the program is to simplify the messaging and communication between physicians and depart-ments while onboarding attendings, interns, and resi-dents. “All of us have the same message about doc-
umentation,” she said: “Make sure it is as accurate as possible.”
UCSD Health is trying to stream-line the onboarding and mes-
saging process and make it even more effective, said Dolopo-Simon. One method is to simplify queries by creating templates. “This way no matter where you get the query from, it is the same template, so everyone
knows what to expect,” she said.
The UCSD program was a grant recipient of the Sanford Insti-
tute for Empathy and Compassion, which has also helped them in their effort to
reduce physician burnout. “Sanford was concerned about burnout and caregivers leaving the profession because of the crushing workload and documentation requirements,” noted Dolopo-Simon.
Beyond CDI efforts, the grant will allow the organi-zation to look at the neurobiology of compassion in an attempt to identify root causes of burnout and help find methods to prevent it. “We have a huge research in
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neuroscience,” she said. “We have the key researchers in place to look into this and hopefully positively impact future residents and interns.”
There needs to be a balance between friendliness and the reality of productivity requirements.
“Our CDI program is on the floor doing concurrent documentation,” said Dolopo-Simon. “We are trying to impact the documentation so retrospective queries can be lessened and we can discuss cases while the patient is currently being treated.”
While some physicians may view CDI as a bother, some appreciate integrating with CDI efforts and goals. Because of these differing perceptions, CDI programs have to balance their queries against extending com-passion to those who may be feeling under the gun. One of the best approaches to this problem, Dolopo-Si-mon said, is an awareness of physician scheduling.
“When we first come in, we do a download and say what assignments are on our schedule and follow up on queries,” she said. However, she added, the CDI team knows that in the morning between 7 a.m. and 10 a.m., the physicians are actively rounding and discussing
patients—so that may not be the best time to expect a query to be answered. “We have to be cognizant of that.”
“We try to go through our schedules and reviews while on the floor,” she said, “because sometimes peo-ple will see us and come up and say that they have a few minutes if we need anything. So those 10 seconds of human interaction really help a lot versus another electronic ping.”
Ultimately, Dolopo-Simon stressed that human inter-action and compassion toward physicians goes a long way to reduce burnout. “We end our queries thanking physicians for their response,” she said; “that makes it more customer-friendly.” She added that being pres-ent and available for feedback allows people to vent, and sometimes just being heard has a huge effect on someone’s mood.
“Also, chocolate,” she added. “You have to under-stand that people are humans.”
Editor’s note: To listen to the November 20, 2019, show, click here. The ACDIS Podcast: Talking CDI is a free show. Click here to learn how to register. You can also search for teh show in Apple Podcasts, Google Play, and Spotify, to listen on the go.
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 15© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 15
Why delve into psychiatricrecord review?
For some programs, the expansion into psychiatric units or facilities
may be driven by the needs of the patient population, says Rhonda Mark, RN, BS, CCDS, a CDI specialist at Cleveland Clinic
Indian River Hospital (CCIRH) in Vero Beach, Florida.
When CCIRH acquired a new behavioral health center, the psychiatric patients who needed med-
ical clearance or needed treatment for medical conditions began being routed through her facility prior to being placed in the behavioral
CASE STUDY
Don’t let behavioral health reviews psych you out
Don’t let behavioral health reviews psych you out
CASE STUDY
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health center, says Mark. This brought many more medical patients with psychiatric diagnoses into the inpatient CDI program’s purview.
“We’ve become the center where they send everyone before they’re placed in the psych facili-ties,” she says. “We’re seeing the geriatric conditions, and we see a lot of dementia with behavioral disturbances.”
That’s why, adds Teresa Hegard, MAN, RN-BC, ACM, CCDS, CCS, CDIP, CRC, CDI specialist at Mayo Clinic Rochester, capturing both medical and behavioral health con-ditions not only ensures a complete and accurate record but also may help CDI staff members who are reviewing the record in other areas of the hospital to capture diagno-ses or help other providers have a more complete view of the patient.
“Our patients often transfer between units,” Hegard says. “Specificity of the major depres-sions can be CCs or even HCCs [hierarchical condition categories], so if the depression is accurately documented in the psych realm, it provides a potential opportunity to capture the diagnosis during future inpatient or outpatient stays.”
Consider unspecified major depression, for example. If the phy-sician simply documents “major depression, unspecified,” the case will fall into DRG 881, Depressive Neuroses. If, however, the physi-cian specifies that major depres-sion more thoroughly (e.g., single episode versus recurrent, with
psychotic symptoms or without), the case will fall into an entirely dif-ferent DRG with a higher relative weight.
While the financial effect can cer-tainly help CDI professionals prove a return on investment for their efforts, getting started can still be difficult.
“We’re not looking at them solely as psychiatric patients, so we are getting all their medical diagnoses documented,” says Maria Levy, a
CDI specialist at Mayo Clinic-Roch-ester. “Some of the patients aren’t in a condition where they can accu-rately explain their condition to us, and we need to make sure their records are still complete.”
Psychiatric patients are often suf-fering from chronic conditions—conditions that will bring them back to the hospital time and time again, says Hegard. These conditions need to be accurately documented to affect the overall quality of patient care.
“Take for example when a patient comes to the hospital for a surgical procedure,” says Hegard,” It can be a short-term problem. For behavior health patients, however, ongoing chronic care and treatment, may be needed.”
But those new to reviews for this setting and patient population may feel they’ve been thrown in the deep end, drowning in unfamiliar diagnoses and terminology.
So, those expanding to this area need to read up on the coding and documentation requirements for common psychiatric conditions within the ICD-10-CM code set, too.
“Providing additional resources and references to CDI staff is an educational opportunity to gain
insight and knowledge into the world of behavioral health,” Hegard says.
Don’t forget though, that “psych facilities are much more aligned with DSM-5 [Diagnostic and Sta-tistical Manual of Mental Disorders, Fifth Edition] verbiage than they are with ICD-10,” Mark says.
So, “look up the diagnoses in the DSM-5,” says Levy. “If you come from a nursing background, regular inpatient diagnoses will already be familiar to you, but unless you have psych experience, you’re in a totally different world.”
Physician education
As with any new CDI endeavor, physician engagement can make or break the success of a fledgling
We’re not looking at them solely as psychiatric patients, so we are getting all their medical diagnoses documented. Some of the patients aren’t in a condition where they can accurately explain their condition to us, and we need to make sure their records are still complete.Marie Levy
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 17
project. The good news is that psy-chiatric physicians may actually welcome CDI professionals’ pres-ence in their department and the organizational attention and sup-port CDI brings.
“Excellent buy-in from psychiat-ric providers will enhance the over-all documentation and clinical pic-ture of the patient,” Hegard says.
Despite the welcoming arms, CDI specialists reviewing these records need to choose where to focus their limited time and resources. In Vero Beach, Mark says most of Cleveland Clinic’s psychiatrists are consultants, making it difficult to have a lasting impression on their documentation habits. Instead, she suggests, focus on the attendings who need to sign off and follow up
on the psychiatric consult’s diagno-ses and documentation.
“We’ve had to do more research on what the appropriate documen-tation is for these patients and the appropriate codes for them. The psych consult will document differ-ently than the hospitalist does, and we don’t have as much contact with the psychologists because they do a lot of telehealth,” she says. “We can usually clear up anything with the attending through the query process.”
One helpful tactic to gain physi-cian buy-in is to stress the impor-tance of documentation for improv-ing patient care. With most psy-chiatric patients, the behavioral health conditions are here to stay and will need to be managed and
monitored for years, if not their entire lives.
“One of the very simple things for physicians is to not just list a psych condition as a ‘history of’ because these conditions are often impact-ing their care. It’s a chronic condi-tion and they’re continuing medica-tions,” Mark says.
Behavioral health patients are seen in many different settings and CDI professionals need to have knowledge of specific condi-tions which can affect patient care, according to Hegard.
“Adding CDI to behavioral health case reviews seems like a natural progression of any program,” she says. “It is critical to get the patient’s medical and psychiatric diagnoses captured and coded accurately.”
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NOTE FROM THE ACDIS EDITOR
Help for your expanding CDI program by Linnea Archibald
One of the most fun things I get to do as the ACDIS editor is work with some of our committees—namely, the CDI Week planning committee and the Forms & Tools Library Committee.
While the two committees have different scopes and focus, at their core, their mission is the same: to sup-port CDI professionals, recognize their efforts, and help them advance their careers and their departments.
While I’ll share more about CDI Week (which takes place September 14–18) later in the year, I wanted to spend some time highlighting the work of the Forms & Tools Library Committee because their efforts can be especially helpful as we bid adieu to 2019.
The beginning of a new year often spells change and expansion for CDI programs. Whether 2020 holds other service lines, a new setting, additional staffing, or job stratification, there are resources available on the ACDIS website and in the Resource Library to help—many due to the generosity of the ACDIS membership and the work of the Forms & Tools Library Committee.
The samples in the Library are donated by members of the ACDIS community and then reviewed for com-pliance and helpfulness by the Forms & Tools Library Committee. Each month, the committee meets to review any materials submitted in the previous month by answering the following questions:
1. Is the sample compliant? If not, in what way?
2. Is the sample helpful? Why or why nott?
3. Would you recommend the sample for publica-tion? Why or why not?
4. What revisions are necessary?
During the meeting, the committee formulates spe-cific recommendations and advice to accompany each posted resource. This means that those pulling resources from the Library not only get a sample form to use in developing their own tools, but they also know
that the sample has been vetted and can read any accompanying recommendations from the committee, which comprises CDI professionals from a variety of backgrounds and experiences.
So, how can ACDIS members leverage these resources? Let’s look at expansion opportunities to see how the materials within the Library can help.
Outpatient CDI
If 2020 holds an outpatient expansion for your CDI program, there are a number of resources available to help you get off the ground smoothly. First, you’ll need to establish a vision for staffing and responsibilities. Take a look at the sample outpatient CDI job descriptions donated to the Library by Tamara Hicks, RN, BSN, MHA, CCS, CCDS, ACM, the director of clinical documentation excellence at Wake Forest Baptist Health in Winston-Sa-lem, North Carolina.
Even if your program specifics vary from hers, you can still leverage Hicks’ manager and staff job descriptions to shape your own, adapting them for your focus and needs. To get a fuller picture of the scope of outpatient programs at different organizations, also take a look at the ambulatory CDI specialist job description provided by Yvonne Whitley, RN, BSN, CRCC, CPC, CRC, the supervisor of ambulatory CDI at Novant Health Medical Group in Charlotte, North Carolina.
Training your brand-new staff for a brand-new pro-gram can present some challenges. While new staff on the inpatient side can shadow mature staff until they get up to speed, outpatient CDI newbies are starting from scratch. Coming again from Wake Forest, the Library also houses a sample outpatient staff orientation plan, breaking down weeks 1 through 12 for a new CDI pro-fessional. To go along with the orientation plan, there’s also an onboarding timeline available in the Library so you can track your new team members’ progress.
As you bring new staff on board and begin to launch the new outpatient program, you’ll also need to develop
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 19
a workflow. Luckily, there’s a sample process for outpa-tient reviews in the Library, also provided by Hicks. To ensure staff members adhere to the workflow and any productivity metrics set forth by program leadership, Valerie Parent, RN, BSN, CCDS, CCRN-K, the CDI manager at Eastern Maine Medical Center in Bangor, contributed a record review tracking tool and a monthly tracking tool for outpatient use.
Pediatric CDI
Outpatient CDI isn’t the only expansion area covered by the Resource Library. Whether you’re starting a CDI program at a stand-alone children’s hospital or expand-ing reviews to the pediatric unit in your facility, there are resources available. While pediatric CDI leaders may be able to adapt a standard inpatient acute care CDI specialist job description to suit the needs of the pediatric space and the programmatic structure may be largely the same, pediatric patients are completely different from a clinical standpoint, so you’ll need to develop unique query forms for this setting.
Recently, the Forms & Tools Library Committee received and reviewed several neonatal queries sub-mitted by Erica Braun, MS, BSN, RN, CCDS, manager of inpatient coding and CDI at Nebraska Methodist Health System in Omaha, that may be helpful in your pediatric expansion efforts:
n Neonatal birth weight
n Neonatal hypoglycemia
n Neonatal weight loss
The Committee is also currently reviewing several other pediatric and neonatal submissions; stay tuned for additional samples soon.
Job title stratification
Maybe your program expansion isn’t based on the settings you review, but rather on the job titles repre-sented in your department. If that’s the case, we have resources for you, too. One popular addition for mature programs is the role of CDI data specialist or analyst. As CDI departments get involved with more initiatives, the data pool grows ever larger and more complex. Opting to employ a CDI staff member specifically with the purpose of data analysis and management can
help a program measure their outcomes and identify new areas for potential expansion down the line.
Those looking to add an analyst to their staff have three sample job descriptions to review: One from Robin Jones, RN, BSN, MHA/Ed, CCDS, regional director of CDI, West Florida Division, at AdventHealth in Tampa, one from Deanne Wilk, BSN, RN, CCDS, manager of CDI at Penn State Health in Hershey, and one from Tonya Motsinger, MBA, BSN, RN, system director of CDI at OhioHealth in Columbus.
Programs looking to enhance physician engagement may also be looking to add a physician advisor to their team in 2020. According to our survey published in the May/June 2019 edition of the Journal, 36% of respon-dents with a physician advisor said that their physicians were very or extremely engaged (compared to 28% of those without an advisor who said the same). If you’d like to take advantage of that engagement boost, take a look at our sample physician advisor job description from the CDI Companion for Physician Advisors: Notes from the Field by Trey La Charité, MD, FACP, SFHM, CCDS, available in the Library.
The Library also holds a sample CDI educator job description contributed by Lee Ann Landon, BSN, CCMC, CCDS, CDI manager at Honor-Health in Scott-sdale, Arizona, and a second level reviewer job descrip-tion from Diane Kohler, RN, CCDS, manager of the CDI department at Centura Health in Centennial, Colorado. Both positions can help your department deepen its work and standardize processes for smooth sailing in 2020.
While I’ve covered many of the new additions to the Resource Library, this article is far from exhaustive. Over the past year, the Forms & Tools Library Committee has reviewed dozens of samples, adding them to the Library with best practice recommendations. Next time you’re looking to advance your program, update a policy, or develop a new tool, make sure to check in at the Library. You never know what you may find.
Editor’s note: Archibald is the editor for ACDIS. If you’d like to write for an ACDIS publication, be featured in an article, need help locating resources on a particular topic, or want to submit a sam-ple to the Library, contact her at [email protected]. If you’d like to volunteer for an ACDIS board or committee, please review the January call for volunteers and submit an application here.
20 CDI Journal | JANUARY/FEBRUARY 2020 © 2020 HCPro, a Simplify Compliance brand
“In my current role, I really don’t have an average day,” says Caryl Liptak, MSHAI, RHIA, system
director of CDI and coding at Bap-tist Health System in Louisville, Ken-tucky, of her day-to-day work in a home health CDI program.
While most traditional inpatient CDI efforts have been around for more than a decade, efforts in out-patient CDI are gaining ground experientially, too. Those develop-ing CDI efforts in home healthcare, however, have a different animal to contend with—one with its own documentation needs, policies, obstacles, and opportunities.
Clinical targets
According to Medicare, home healthcare is “a wide range of healthcare services that can be given in your home for an illness or
injury. Home healthcare is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility.” Home healthcare has the overarching goal of treating ailments with the hopes of helping a patient “regain independence, maintain current condition or level of function, and/or slow decline.”
While Medicare lists services of home healthcare to include wound care, intravenous or nutrition ther-apy, and monitoring serious illness and unstable health status, Paula Anderson of Landmark Health in Huntington Beach, California, notes that many of the cases she comes across are for patients in older gen-erations. “Right now, most home health is for the geriatric popula-tion,” she says. “Familiarize yourself with Hierarchical Condition Cate-gory (HCC) models and the most
common conditions in the geriatric population.”
While sepsis, respiratory failure, and malnutrition may send shivers down inpatient CDI professionals’ spines, home health CDI comes with its own set of complicated diagnoses.
“We see a lot of wound care needs being treated without documenta-tion of the etiology,” says Regené Collier, RN-BC, BSN, COS-C, HCS-D, Baptist’s home health coding/CDI specialist manager. “Then we need to go back to the healthcare team and clarify the etiology in order to capture the specificity needed for coding,” again running into the need for performing an outside-source query.
As with inpatient and outpatient CDI, home health CDI often comes to a halt when a physician neglects
Go big, or go home health
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 21
Go big, or go home health
to make a definitive diagnosis on a patient’s chart.
“Problems that we encounter in home health CDI involve not having a diagnosis for symptoms such as weakness, falls, and gait abnormal-ities,” Collier says. “The lack of con-firmation for the etiology of wounds is another frequent reason we must place coding on hold and query the physician.”
“We also find that we need spec-ificity for common diagnoses that are still queried on the inpatient side,” Liptak adds. “Such as spec-ificity of diabetes and heart failure as well as linking a condition to the underlying cause with terms such as due to.”
“We cannot code suspected diagnoses or diagnoses that are resolved upon discharge from the inpatient facility,” Collier says as well.
“My company specializes in treat-ing high-risk Medicare advantage plan patients,” says Anderson. “We treat the sickest patients and have to adhere for strict documentation standards for the CMS risk adjust-ment model.” With sicker patients comes stricter documentation stan-dards, and thus even more of a necessity for the utmost specificity in diagnosis and coding.
Targeted home health efforts
Liptak aand Collier are working with their team on “developing a process in which the coding and CDI team codes the chart at the time of referral before the first visit is made,” Collier says. The team then
performs a quality check of the Outcome and Assessment Infor-mation Set (OASIS) form once the visit and clinical documentation is completed.
“This will allow us to determine if a query to the provider is needed for further specificity of diagnosis,” adds Liptak. “Then we can get a more accurate diagnosis earlier in the process of developing a care plan and completion of the OASIS, do a secondary concurrent review for quality, as well as any newly added diagnoses as the care plan evolves.”
CMS requires use of the OASIS form to track patient-specific assessment of care, determine the agency’s reimbursement, and measure the quality of care that the agency provides, says Collier. The form must be completed at spe-cific points during a patient’s home health service and provides infor-mation on changes in a patient’s health status. It must be filled out at the start of care, recertification (or 60 days, if there is a significant change in condition), and upon end of care.
“If a patient goes to an inpatient facility while under home care, a transfer OASIS form must also be submitted,” Collier adds. “When the patient goes home, a resumption of care must be completed.”
“CDI can make a difference with these forms by making sure they are completely accurate before submission,” says Liptak. “Review-ing OASIS forms fits into the CDI flow because it’s a central part of
what we do. It confirms a patient’s homebound status and need for continuing care.”
Collier adds that because the OASIS form measures both out-comes and risk factors, it is also a key component for an agency’s performance improvement.
Identifying challenges
While in some cases the home health agency may be an arm of the overarching healthcare sys-tem, there are also many third-party home health agencies, which may make tracking those medical records challenging.
“With home health CDI, we depend on medical records from outside sources,” says Anderson. “Some of these records are not always easy to obtain.”
Specifically, finding the sources of certain documentation—never mind finding complete documenta-tion—can be tricky. The data may come from “the patient’s primary care physician, recent hospital vis-its, et cetera,” Anderson says.
In her book, The CDI Guide for Home Health and Hospice, JJoan L. Usher, BS, RHIA, ACE, writes that CDI specialists can help home health agencies shore up lacking provider documentation.
“Home health agencies continue to struggle with obtaining timely and complete documentation of face-to-face meetings,” she writes. “This is where CDI may be able to step in and contact the physi-cian, work with the hospitalist or
22 CDI Journal | JANUARY/FEBRUARY 2020 © 2020 HCPro, a Simplify Compliance brand
community physician to identify needed documentation.”
As CDI professionals every-where know, getting timely answers from clinicians isn’t as simple as it sounds. Home health CDI profes-sionals face an even steeper climb.
“Being a postacute setting, I believe that home health presents the added challenge of not having a process that allows home health coding and CDI teams to query physicians directly,” says Collier.
“In home health, querying provid-ers is very new,” adds Liptak. “In my discussions with others within the home health setting, I believe there are only a few agencies who are writing queries. […] Gaining buy-in from others within the home health agency as well as the pro-viders takes time and understand-ing of the need.”
Though most home health CDI specialists do review charts con-currently, as is the case with inpa-tient CDI, this issue of delayed que-rying and long response times can make reviewing and coding charts concurrently a challenge. Because this is the case, Collier suggests holding charts until all documenta-tion is received and all queries have a response from the physician.
Proving return on investment
As with outpatient CDI, proving return on investment (ROI) can be a difficult task. It is hard to show that specific home health CDI efforts are the reason behind certain finan-cial gains, especially considering the field is so new and so niche.
(For more information about outpa-tient CDI programs, read the article on p. 9.)
Sometimes, the proof of ROI is not even known to the CDI specialists. “In terms of ROI, that is determined by a team of healthcare economists that are much higher up than me,” says Anderson.
But there are a few tactics that can help. “I believe our biggest return on investment is shown with improvement of quality ratings,” says Liptak. “Being able to com-plete coding timelier and accurately on first pass through the depart-ment makes a difference. … When coding was outsourced, there was not a dedicated team reviewing the OASIS for quality.”
“Timely completion of coding, facilitating completion of the chart, and timely billing really helps,” echoes Collier. “Having coders and a CDI team who are vested in the agency and an integral part of the team is imperative.”
While there might not yet be hard data to support the home health CDI efforts, Liptak and Col-lier agree that they have set them-selves up for success by hiring the right people for the job. “Of our seven coding and CDI specialists, five are RNs, one PT [physical ther-apist], and one OT [occupational therapist],” says Collier. “Everyone on the team has extensive home healthcare experience and is knowledgeable of CMS rules and regulations for home health and hospice services.”
“They have inherent knowledge of all this information,” Liptak says, “so that gave us a running start.” She also noted that they chose team members with coding knowl-edge, which helped with training both sides of the equation.
Tips for getting started
According to Collier, it’s import-ant that the home health CDI specialists have experience and knowledge of certified home care regulations. “I recommend that the home health CDI specialists have a minimum of three to five years’ experience with a proven record of being a high performer in regard to assessment skills, documentation, and timeliness,” she says.
Liptak adds that education to pro-viders on the need for queries is of the utmost importance—in partic-ular, queries requesting specificity. “This is even more critical with the onset of the Patient-Driven Group-ing Model (PDGM) starting January 1, 2020,” she says.
Also, just as in other settings, lean on your colleagues in other departments and seek leadership support, Collier says.
“We have been blessed to have the guidance and leadership from our inpatient CDI team,” she says. “This has provided the home health team with so many learning oppor-tunities and resources.”
“At the end of the day,” Anderson adds, “CDI is all about the data and the documentation.”
S M T W T F S
3 4
5 6
7 8
9
10
11
12 13
14 15
ACDIS Podcast:
Talking CDI, 11:30 a.m.
LA chapter meets,
4-5 p.m.
16
OK chapter meets,
12:30-3:30 p.m.
Hudson Valley, NY,
chapter meets 2-4 p.m.
17
St. Louis, MO, chapter
meets, 1 p.m.
18
19
20 21
22
MN chapter meets,
1-2 p.m.
23
CC/MCCs for CDI:
Clinical Indicators &
Query Opportunities
(ACDIS webinar),
1-2 p.m.
24
OH chapter meets,
12 p.m.
25
26 27
J A N U A R Y 2 0 2 0
W A N T T O S T A Y U P - T O - D A T E
O N A L L T H I N G S A C D I S ?
S U B S C R I B E T O C D I S T R A T E G I E S !
29
ACDIS Podcast:
Talking CDI, 11:30 a.m.
MI chapter meets,
12-1 p.m.
28
30
31
1
ACDIS office
closed for holiday
2
ACDIS Podcast:
Talking CDI, 11:30 a.m.
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 23
S M T W T F S
3 4
5 6
7 8
9
10
11
12 13
14 15
ACDIS Podcast:
Talking CDI, 11:30 a.m.
LA chapter meets,
4-5 p.m.
16
OK chapter meets,
12:30-3:30 p.m.
Hudson Valley, NY,
chapter meets 2-4 p.m.
17
St. Louis, MO, chapter
meets, 1 p.m.
18
19
20 21
22
MN chapter meets,
1-2 p.m.
23
CC/MCCs for CDI:
Clinical Indicators &
Query Opportunities
(ACDIS webinar),
1-2 p.m.
24
OH chapter meets,
12 p.m.
25
26 27
J A N U A R Y 2 0 2 0
W A N T T O S T A Y U P - T O - D A T E
O N A L L T H I N G S A C D I S ?
S U B S C R I B E T O C D I S T R A T E G I E S !
29
ACDIS Podcast:
Talking CDI, 11:30 a.m.
MI chapter meets,
12-1 p.m.
28
30
31
1
ACDIS office
closed for holiday
2
ACDIS Podcast:
Talking CDI, 11:30 a.m.
24 CDI Journal | JANUARY/FEBRUARY 2020 © 2020 HCPro, a Simplify Compliance brand
F E B R U A R Y 2 0 2 0
V I S I T T H E A C D I S B L O G W E E K L Y
T O F I N D O U T W H A T E V E N T S
A R E C O M I N G U P I N Y O U R A R E A !
S M T W T F S
1
2
3
4 5
6
7
AZ chapter meets, 12-
1:15 p.m.
8
9 10 11
12
ACDIS Podcast:
Talking CDI, 11:30 a.m.
13
Pneumonia: Clinical
Criteria & Documentation
Requirements for CDI
Professionals (ACDIS
webinar), 1-2:30 p.m.
14 15
16
17 18
19
20
ACDIS Membership
Quarterly Conference
Call, 1 p.m.
21
22
23 24 25
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PHYSICIAN ADVISOR CORNER
Cerebral edema and brain compressionBy Amy Sanderson, MD
Cerebral edema and brain compres-sion are the result of significant brain abnormalities that can be life-threat-ening. It is important for clinicians to recognize and treat these conditions
promptly. Properly documenting these diagnoses in the medical record is important to accurately reflect just how sick these patients are. Physician may use “mass effect” or “midline shift” to describe brain compression or cerebral edema, or a neurosurgeon may only state that she performed a “decompression” or “tumor resec-tion.” None of these phrases, however, allows coders to capture the specific diagnoses of cerebral edema and brain compression.
To understand these diagnoses, let’s first review the structure of the cranial vault. Brain parenchyma, blood flow, and cerebrospinal fluid all contribute to intracranial volume. The blood-brain barrier is comprised of cells that separate brain tissue from the contents of blood vessels. Finally, the skull surrounds the brain, protect-ing it from trauma.
When intracranial pressure increases, the brain has compensatory measures to mitigate damage. However, when these measures are exhausted, worsening brain injury ensues. Damage can be exacerbated by the rigidity of the skull, limiting the amount that the brain can swell and worsening intracranial hypertension. This leads to decreased cerebral blood flow, further depriv-ing the brain of oxygen.
Cerebral edema results from abnormal buildup of water within the brain tissue. Understanding the differ-ent types is important because treatment options differ depending on the physiologic derangement (see the references at the end of the article). Different types of cerebral edema include:
n Vasogenic
n Cytotoxic
n Hydrostatic
Vasogenic edema is caused by increased permeabil-ity of the blood-brain barrier with water and other sub-stances moving from blood vessels into brain tissue. Common causes include brain tumors and cerebral abscesses. On the other hand, injury on the cellular level leads to cytotoxic edema. In this case, there is dis-ruption of individual brain cell membranes, which leads to water shifting from the outside to the inside of cells. Most commonly, this is due to lack of blood flow and oxygen to the brain, as can happen during a stroke or cardiac arrest. Hydrostatic cerebral edema can occur with obstructive hydrocephalus and happens when cerebral spinal fluid moves from the ventricles into the brain parenchyma.
Brain compression results from something such as a tumor, abscess, or hematoma pressing on brain structures. Herniation ensues when part of the brain is displaced into an adjacent space and can be due to cerebral edema and/or a space-occupying lesion that causes brain compression. It is important for cli-nicians to recognize when cerebral edema and brain compression are present as both are serious and can be life-threatening. Although cerebral edema and brain compression may have different underlying mech-anisms, patients with either or both can present with similar findings.
Common signs and symptoms of both conditions include:
n Confusion and disorientation
n Headache
n Depressed mental status
n Coma
F E B R U A R Y 2 0 2 0
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n Vomiting
n Abnormal pupil exam (fixed, dilated)
n Hemiparesis or quadriparesis
To look for evidence of cerebral edema and/or brain compression, CDI specialists can review the diag-nostic section of the medical record. CT and MRI are excellent modalities to identify brain abnormalities, but it’s important to note that imaging is not an absolute requirement for the diagnosis of brain compression or cerebral edema; physicians can make these diagno-ses based on a patient’s history and physical exam. Other documented diagnoses can be a clue to cerebral edema and/or brain compression (see table below).
Examples of medical conditions that may be associated with brain compression and/or cerebral edema
Brain tumor
Hydrocephalus
Ventriculo-peritoneal shunt malfunction
Intracranial hemorrhage
Stroke (ischemic, hemorrhagic)
Diabetic ketoacidosis
Hypo/hypernatremia
Meningitis/Encephalitis
Cardiac arrest
Cerebral abscess
Acute liver failure & hyperammonemia
CDI specialists can also look at documented ther-apies and treatment plans. Osmotic agents such as hypertonic saline and mannitol are commonly used to decrease intracranial pressure. Hyperventilation can be used as a temporizing measure to decrease intracranial hypertension since this causes a decrease in cerebral
blood flow. Corticosteroids such as dexamethasone are a mainstay of treatment for vasogenic edema due to brain tumors. In addition, hypothermia and seda-tive medications are sometimes used when a patient has suffered a significant brain injury because they can decrease cerebral metabolism, which may provide some benefit to the injured brain. Reviewing procedure notes or operative reports may supply insight. CDI spe-cialists can look for placement of an external ventricular drain, placement or revision of a ventriculo-peritoneal shunt, decompressive craniectomy, brain tumor exci-sion, drainage of a cerebral abscess, or evacuation of an intracranial hemorrhage/hematoma.
In summary, cerebral edema and brain compression are important diagnoses to identify, treat, and docu-ment. However, physicians don’t always document them in a way that can be coded. CDI specialists can find clues to these important diagnoses in several parts of the medical record and can aid in their capture.
For those looking for more resources on brain compression and cerebral edema, here are a few references:
n Smith, M. Refractory Intracranial Hyperten-sion: The Role of Decompressive Craniectomy. Anesth Analg. 2017; 125(6): 1999-2008
n Stokum, J. Molecular Pathophysiology of Cere-bral Edema. Journal of Cerebral Blood Flow & Metabolism. 2016; 36(3): 513–538
n Koenig, M. Cerebral Edema and Elevated Intra-cranial Pressure. Continuum (Minneap Minn). 2018; 24(6): 1588-1602
Editor’s note: Sanderson is a pediatric intensivist at Boston Chil-dren’s Hospital. She has been the physician advisor of the CDI program since its inception in 2014. She is also an assistant pro-fessor in anaesthesia at Harvard Medical School. She was a con-tributor to the book Pediatric CDI: Building Blocks for Success. Opinions expressed do not necessarily represent those of ACDIS or its Advisory Board. Contact Sanderson at [email protected].
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 27
Like many other non-acute care settings, skilled nurs-ing facilities (SNF) have not been a common setting
for CDI department development. While there’s been a small faction of CDI professionals working in SNFs since the beginnings of CDI, the last few months have brought many more programs into this setting.
There are a couple reasons a CDI department may find themselves tasked with reviewing SNF records. First, more and more healthcare facilities are part of systems, so if CDI reviews charts in some of the settings and facilities, the organi-zational leadership may see fit to expand the department to cover the continuum of care at the health sys-tem. Secondly, CMS recently insti-tuted the Patient-Driven Payment
Model (PDPM), changing the way SNFs are reimbursed and neces-sitating documentation and cod-ing training to comply with the new system. This second driving factor is behind most CDI expansion to SNFs in the last year or so.
Reimbursement evolution
Before October 1, 2019 (fiscal year 2020), physician documenta-tion had very little to do with reim-bursement for SNFs. Until that point, SNFs were paid using a methodol-ogy called the Resource Utilization Group (RUG) score instead.
“The focus was on the amount of time physical, speech, and occupational therapists spent on the patient. It also included trans-fusion times, etc.,” says Madhu Subherwal, MHA, MBBS, CCDS,
CDIP, CDI manager at Torrance (California) Memorial Medical Cen-ter. “The physician documentation didn’t drive the reimbursement, as it does in the inpatient setting, so CDI wasn’t necessarily in this area. The therapists and nurses were trained to accurately document the amount of time spent with the patient and the RUG score was derived.”
The RUG system was established in the 1997 Balanced Budget Act, and it hasn’t been substantially changed since that point. Because it was the status quo for so long, therapists became adept at docu-menting in a way that ensured the reimbursement was accurate for each case. PDPM, however, threw a wrench into things.
“With the introduction of PDPM, reimbursement is no longer
Developing new skills: CDI in skilled nursing facilities
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rehab-time dependent. It is based heavily on physician documenta-tion. We quickly found out that we were lacking in that area,” says Subherwal.
Not only is the payment now based on physician documentation, just like on the inpatient acute care side of things, but the new model also requires changes to SNF cod-ing practices. Since ICD-10 codes weren’t used for reimbursement purposes under the RUG meth-odology, those submitting the bills
didn’t necessarily need to know the ins and outs of ICD-10 coding at all. At Subherwal’s organization, one of the SNF nurses was also submitting for reimbursement until the advent of PDPM; she had only minimal coding training.
“PDPM SNFs are going to be paid on diagnosis codes rather than therapy minutes now. It’s been two decades since it was updated last,” echoes Kalena Britt, BSN, RN, CCM, CCDS, director of CDI, HIM, at Rochester (New York) Regional Health. “It’s going to require ICD-10 codes, which SNFs aren’t used to. You have to have the documenta-tion to support those codes, which is where CDI comes in.”
Because so much has recently changed for SNFs under PDPM,
CDI leaders looking to expand need to start by reading up on SNF payment methodologies, old and new, before rolling out a CDI review process, Subherwal says.
“We did an audit of the SNF accounts to understand where the opportunities were before starting our concurrent reviews too,” she says. “We did a lot of education—both me and the CDI specialist leading the project. A lot of online research about PDPM so that we were in a position to be effective
when the change happened on October 1, 2019.”
Review processes
While CDI professionals can review SNF records concurrently like they do in the inpatient acute care setting, knowing the details of the coding and reimbursement requirements will help ensure they’re reviewing for the correct items.
First, the principal diagnosis has to be focused on the reason the patient was transferred to the SNF. Because of this, Britt says her SNF review process starts when the patient is still an inpatient at the acute care facility.
“There will be a SNF CDI spe-cialist for pre-service,” she says. “Our principal diagnosis is really based on hospital documentation
and a surgery if applicable. They’ll be triggered [by social work] when someone’s being discharged to a SNF, then they’ll review and see if the inpatient CDI specialist has reviewed the case. If they have, wonderful. If not, the SNF CDI spe-cialist will review it and query the in-hospital provider to get more specificity on a diagnosis code so we can get the most appropriate primary diagnosis for the SNF.”
Issues can arise, according to Subherwal, if the wrong principal diagnosis from the acute care set-ting gets carried over and used as the principal diagnosis at the SNF. Take for example, a patient who was admitted to the acute care setting with sepsis and pneumonia. When the sepsis is resolved, the patient is transferred to the SNF to finish the IV antibiotics for the pneumonia. While the sepsis may have been the root cause of the acute care admis-sion, the pneumonia is the cause of the patient’s transfer and would therefore be the principal diagnosis at the SNF.
“A sepsis patient should not be transferred [to a SNF],” Subherwal says. “It would be for the contin-ued care of the pneumonia. Yet, the physicians are still document-ing that the patient has sepsis due to pneumonia. The CDI specialists now has to go in and get clarifica-tion from the physician whether the sepsis is still present or not.”
Once the patient has arrived at the SNF, the timing of the CDI review is paramount. Accord-ing to Britt, it’s helpful to give the
PDPM SNFs are going to be paid on diagnosis codes rather than therapy minutes now. It’s been two decades since it was updated last. It’s going to require ICD-10 codes, which SNFs aren’t used to. You have to have the documentation to support those codes, which is where CDI comes in.Kalena Britt, BSN, RN, CCM, CCDS
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 29
physicians a little time to document and review the patient’s condition before jumping into CDI reviews. After that, even considering the dif-ferences between SNFs and acute care facilities, the CDI process is largely business as usual.
“Once the patient is transferred to a SNF, that record will be reviewed within 48 hours to give the provider time to start their documentation,”
she says. “The CDI specialist will go in, review the documentation, and make sure it’s consistent through-out. It’s a lot of work and it’s a totally different environment, but the CDI thought process is the same.”
Subherwal also warns not to wait too long because of the billing cycle. While acute care facilities drop bills post-discharge, SNF minimum data set (MDS) coordinators submit the initial five-day prospective payment system assessment, so the correct principal diagnosis needs to be listed and the documentation needs to be consistent at that point.
“The CDI specialist is reviewing the account at the time of admission to the SNF, then every day for the first five days, and works up the prin-cipal diagnosis and the secondary diagnoses, and queries if anything needs to be clarified. The SNF RN
has access to the CDI application where all this information is found,” she says. “The CDI specialist revisits the account as needed throughout the course of the patient’s stay, or if the SNF MDS coordinator communi-cates with him or her that there has been a change in the patient’s con-dition. An interim payment assess-ment can be dropped at that time.”
Provider education
Since the RUG model was based on therapy time, physician docu-mentation didn’t hold sway over reimbursement until PDPM took effect. This means that SNFs are likely in need of some in-depth CDI physician education—which may be the perfect starting point for CDI program rollout in this setting.
After an initial chart audit, the CDI team will have the ammuni-tion to begin educating physicians. For those involved in an inpatient CDI program rollout, this process will look similar. Different organiza-tions and physician groups will lend themselves more readily to different types of education. While formal group education may work well for some organizations, others may find that one-on-one meetings with phy-sician leaders works better. (For tips on physician education, check out this article from the May/June 2019 edition of the CDI Journal.)
Regardless of tact, however, make sure to extend the educa-tional invite to the other departments involved in patient care at the SNF, as these ancillary departments also affect reimbursement with their documentation.
“There’s a lot of collaboration on the SNF side to make sure every-one’s documentation supports the codes on the claim,” says Britt. “You’re going to have to look at a lot of documentation from different pro-viders—such as occupational ther-apy, physical therapy, etc.”
At the beginning, Subherwal sug-gests, focus on the basics of the documentation requirements; you can always build on them later, just as happened with the inpatient acute care setting. While the beginnings of inpatient acute care CDI focused pri-marily on principal diagnosis selec-tion and CC/MCC capture for reim-bursement reasons, CDI programs have evolved to focus on quality programs, risk adjustment, denials management, and more. Start with the basics, Subherwal says, then move on from there. Remember, not only is PDPM a whole new ball game for SNFs, but CDI is likely a foreign concept as well.
“A patient is no longer in an acute setting, so the documentation has to reflect why the patient was trans-ferred for ongoing care of a condi-tion that was being treated in the acute setting. If it isn’t documented and coded properly, it is kicked back from Medicare as an inappro-priate admission. CDI professionals have to educate the physician about how the documentation needs to reflect the aftercare of the acute con-dition,” she says. “For SNFs, the idea that the physician’s documentation is going to drive the grouping and payment of the SNF stay is new.”
CDI professionals have to educate the physician about how the documentation needs to reflect the aftercare of the acute condition.Madhu Subherwal, MHA, MBBS, CCDS, CDIP
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CODING CORNER
Cleaning up the code set: How to influence ICD-10-CM Index and Tabular List changes
by Kay Piper, RHIA, CDIP, CCS
Exciting changes to ICD-10-CM are published in an often-overlooked document called the Addenda. It lists additions, revisions, and deletions to the Alphabetical Index and Tab-
ular List. This might seem mundane until you realize the changes’ potential effect on coding and CDI. The National Center for Health Statistics (NCHS) is the fed-eral agency responsible for maintaining the ICD-10-CM code set, and they want our suggestions for what to add, remove, or change. You can submit a suggestion simply by emailing them. Note that this article focuses on Addenda for ICD-10-CM codes; the Centers for Medicare and Medicaid Services (CMS) is the federal agency responsible for maintaining ICD-10-PCS, and code requests for ICD-10-PCS should go to CMS, not NCHS. To help you get started, take a look at Figure 1 on p. 33 for a list of links and email addresses.
NCHS’ process for addenda
NHCS provides a public process for changes to Alphabetic Index and Tabular List entries. These changes may be easy fixes such as correcting typos, or they may have code assignment implications, such as changing an Excludes1 note to an Excludes2 note.
Addenda and code proposals are posted online where they are accessible to the public at any time. This keeps the process transparent and helps cod-ers and CDI professionals understand why changes occurred—even years later. ICD-9-CM code proposals are available back through 1998, and ICD-10-CM pro-posals are available back through 2010.
New codes and Addenda are proposed biannually at the ICD-10 Coordination and Maintenance Com-mittee (C&M) meeting. The Addenda are usually pre-sented at the end of the meeting day. The committee
posts proposed Addenda in the C&M agenda prior to the meeting (see Figure 2 on p. 33; p. 63 of the C&M agenda has proposed Tabular changes, and p. 77 has proposed Index changes). Files are downloadable, allowing the public to review and prepare comments. Comments must be submitted in writing during the stated comment period, which typically lasts several weeks following the meeting. NCHS and CMS consider all the comments before making a final decision. Input from any one commenter may lead to a modification in the committee’s proposals.
Addenda’s effects
It’s important to review the Addenda because they may affect coding for health data studies, payment, and/or reporting codes that are CC/MCCs. The Addenda may also affect the All Patient Refined Diag-nosis Related Group (APR-DRG) severity of illness (SOI)/risk of mortality (ROM) scores. For instance, the fiscal year (FY) 2021 Addenda (presented at the September 2019 C&M meeting) proposes that the Excludes1 note prohibiting R57.0, Cardiogenic shock, be changed to an Excludes2. This would allow it to be reported with I46.-, Cardiac arrest. Both are MCCs, but the addition of cardiogenic shock would increase the SOI from 2-moderate to 3-major for the APR-DRG. See Figures 3 on p. 33 and 4a.–4b on p. 34.
Addenda may have query implications as well. For instance, currently ICD-10-CM has no unique code for critical limb ischemia, an advanced stage of peripheral vascular disease (PVD) causing severe pain, non-heal-ing wounds, and gangrene. Rather than assigning the nondescript code for ischemia (I99.8, Other disorders of circulatory system; the code it defaults to), which groups to MS-DRG 303, Atherosclerosis without MCC, CDI staff may consider querying for I73.9, PVD, which groups to MS-DRG 301, Peripheral Vascular Disorders without MCC. The proposed Addenda for codes effective on
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October 1, 2020, have both Index and Tabular entries directing to I70.-, Arteriosclerosis (also MS-DRG 301), thus eliminating the need to query.
Types of corrections
Suggestions range from updating clinical terminology to considering the effect of new coding guidelines to ensuring correct spelling. Many who submit sugges-tions are clinical/technical editors working on updating code books for publishers. Often, ideas for suggestions come from coding dilemma discussions posted on pro-fessional community message boards. See the sam-ple email in Figure 5 on p. 35 that suggests addition of Excludes1 notes as well as an inclusion term. Note that the reference for the change is provided in the email (it’s based on C&M meeting minutes). Also, note that the suggested entries appear exactly as they would in the Tabular List in terms of headers and spacing. All the actions to “add” appear in the left margin, which is the correct way to show how the entry would look in the actual code book.
What not to submit
CDI professionals strive to ensure their work helps their organizations receive appropriate payment and accurately report quality of care data. While these are important goals, ICD-10-CM’s primary purpose is tracking morbidity. When requesting a new code or a code change, do not include information regarding a code’s effect on reimbursement or quality measures. These code determinations fall outside the purview of the NCHS/C&M committee and will weaken the pro-posal. Also, do not ask NCHS to answer coding ques-tions; submit those to the American Hospital Associa-tion’s (AHA) Coding Clinic. However, you may forward Coding Clinic answers to NCHS if they would help the committee consider frequently used codes for which Alphabetic Index or Tabular List changes would pro-vide widespread benefit.
Process for submitting
Stay organized using the following suggestions:
n Keep a running list of suggestions as well as whether and when they were implemented.
n Create a folder to store your documentation on issues to send in, and another one for sugges-tions that have been implemented.
n Save emails from coworkers or other sources who offer ideas for suggestions.
n Submit suggestions by batch rather than individ-ually, if applicable. Each submission can contain multiple suggestions.
n Send screen captures to visually illustrate the issue. Use the official NCHS files rather than an online codebook or an encoder, which could vary in look from the official version.
n Type suggestions as they would be displayed in the Alphabetic Index or Tabular List. This helps everyone visualize the changes.
n Copy/paste proposed Addenda into a Word® document, then format them according to how you’d like to see the final entries. There is no template or format required for your comments, although the suggested entries must be written to look exactly like the code book entry. Use prior Addenda as a guide and refer to Figure 6 on p. 35.
Support your submission by doing the following:
n Give the facts. State, for example, “The Index says this, but that sends you to a different diagnosis.”
n Resist saying something is an error. It might not be.
n Include background information so everyone understands the changes being suggested.
n Cite Coding Clinic advice if applicable.
n Explain how the entry was categorized in ICD-9-CM and how it’s different in ICD-10-CM. Should it be the same? Did it inadvertently get changed?
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n Review entries in the World Health Organization’s (WHO) version of ICD-10, which NCHS modifies for usage in the United States. NCHS tries not to change the coded data too much to ensure that it matches WHO’s data (see Figure 1 for references).
n Have a coworker review your suggestion when possible. Sometimes another person can catch something that should be changed.
n Research the Alphabetic Index and Tabular List to see if there are other entries in which to place your suggestion or if your suggestion impacts other codes. Address anything it impacts.
Involve your organization:
n Inform your leadership that you wish to sub-mit suggestions for changes. You may want to gather input from other stakeholders and submit comments on proposed Addenda as an orga-nization. Legal and/or compliance departments may want to looped in on suggestions and their outcomes. Ask your organizational leaders how to proceed. For instance, leadership may want one person to serve as the gatekeeper and submit all suggestions in batches, or conversely may permit staff to submit suggestions individu-ally. Clarify if you are representing the organiza-tion versus operating as an individual.
Feedback
Those submitting suggestions may receive an acknowledgment of receipt from NCHS, along with a statement that they will research the suggestion and bring it to a future C&M meeting if appropriate. Indi-viduals may be asked to submit additional informa-tion. If your suggestions aren’t included in the inpatient
prospective payment system (IPPS) final rule, you may want to resubmit them for further consideration. Stay positive even if you don’t hear back immediately.
Get involved
Please get involved either by personally emailing NHCS or by submitting suggestions through ACDIS’ Regula-tory Committee. The Regulatory Committee has two purposes:
n To educate CDI professionals on new rules and regulations and keep members informed about any changes that could affect CDI practices
n To advocate for the CDI professional by provid-ing commentary and information to various reg-ulating agencies to support and defend the CDI practice and keep ACDIS members updated on those advocacy efforts
The Regulatory Committee regularly posts updates on the ACDIS website and in CDI Journal articles on questions that arise or on rules or regulations affecting the industry. Be sure to review these updates and arti-cles to stay abreast on the latest changes.
Finally, don’t be shy about making suggestions or commenting on proposals. CDI staff are experts on clinical documentation practices and their influence on coded data. In addition, don’t be concerned about duplicating someone else’s submission. When multi-ple people send in the same concern, it can create a sense of urgency and lend more weight to the sug-gestion. Remember, our codes create data that’s used to ensure appropriate payment and the best possible patient care outcomes. A clean code set is easier to use, making our CDI and coding jobs easier and help-ing us to produce accurate data. By taking time to get involved, we create better information for healthcare in the future.
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Figure 3: Example Of Proposed Tabular Changes Allowing R57.0 To Be Reported with I46
ICD-10-CM TABULAR OF DISEASES – PROPOSED ADDENDA
All proposed effective October 1, 2020
I46 Cardiac arrest
Delete Excludes1: cardiogenic shock (R57.0)
Add Excludes2: cardiogenic shock (R57.0)
Figure 2: ICD-10 C&M meeting agenda
Figure 1: Website Resources & Email Links
§ Suggestions for ICD-10-CM Index and Tabular List
§ Coding questions for AHA Coding Clinic
§ NCHS ICD-10-CM files
§ Proposed FY 2021 Addenda
§ ACDIS Regulatory Committee
§ ICD-10-PCS code requests
§ World Health Organization ICD-10
ABOUT THE AUTHOR AND FEATURED PROFESSIONALS
Piper is the inpatient coding educator for SSM Health System, based in St. Louis, Missouri. She has a passion for helping others improve their coding knowledge and skills. In her current role, she provides education for coders at 17 hospi-tals in four states. Piper is the coding roundtable coordinator for the Missouri Health Information Management Association (MoHIMA), has pre-pared educational materials for AHIMA, and has served on the American Hospital Association’s Coding Clinic Advisory Board. Contact her at [email protected].
While writing this article, Piper had help from the following contributors:
§ Marion Gentul, RHIA, CCS, from Elsevier
§ Anita Schmidt, BS, RHIA, a clinical techni-cal editor, coding solutions, at Optum360
§ Brigid T. Caffrey, BA, BA, MS, CCS, CDIP, an HIM and CAC-CDI product capability consultant, NLP innovation, at Optum360
§ Darlene Hyman, RHIA, CCS, COC, a cod-ing education specialist at University of Maryland Health Services
§ Amber Davidson, RHIT, CCS, CCS-P, a health information data specialist at the Children’s Hospital Association
34 CDI Journal | JANUARY/FEBRUARY 2020 © 2020 HCPro, a Simplify Compliance brand
Figure 4B: Code R57.0 Omitted Due To An Excludes1 Under Code Category I46 (Decreased SOI)
MS-DRG 248 Percutaneous cardiovascular procedures w non-drug-eluting stent w MCC or 4+ arteries or stents
§ APR-DRG 174, Percutaneous cardiac intervention with an AMI
§ 2-Moderate SOI
§ 2-Moderate ROM
Effect on SOI/ROM Is an MCC Description
Principal N/A I21.09, STEMI involving other coronary artery of anterior wall
Exempt Yes I46.2, Cardiac arrest due to other underlying cardiac condition
Figure 4A: SOI/ROM Impacted By Reporting R57.0
MS-DRG 248 Percutaneous cardiovascular procedures w non-drug-eluting stent w MCC or 4+ arteries or stents
§ APR-DRG 174, Percutaneous cardiac intervention with an acute myocardial infarction (AMI)
§ 3-Major SOI
§ 2-Moderate ROM
Effect on SOI/ROM Is an MCC Description
Principal N/A I21.09, STEMI involving other coronary artery of anterior wall
Exempt Yes I46.2, Cardiac arrest due to other underlying cardiac condition
SOI-4, ROM 4 Yes R57.0, Cardiogenic shock
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 35
Figure 5: Email Suggesting Adding Excludes1 Notes And An Inclusion Term
Hello:Tabular Index change request: is ICP integral to obstructive hydrocephalus? G91.1 Obstructive hydrocephalus
ADD Excludes 1: increased intracranial pressure (benign) (G93.2)
G93.2 Benign intracranial hypertension
ADD Pseudotumor cerebri Excludes1: hypertensive encephalopathy (I67.4) ADD obstructive hydrocephalus (G91.1)
Thank you,Anonymous
ICD-10 Coordination and Maintenance Committee Meeting September 10-11, 2019 P. 64 G93 Other disorders of brain G93.2 Benign intracranial hypertension ADD Pseudotumor ADD Excludes1: obstructive hydrocephalus (G91.1)
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Figure 6: Examples and Questions to Consider When Suggesting Changes
General questions:
§ Is there new clinical terminology that is synonymous with archaic terms?
- Example – Acute Kidney Injury
• The term “injury” coded to traumatic injury
• Terminology changed to mean acute renal failure
• This necessitated updating the Index quickly to ensure accurate coded data
§ How does a Guideline change or new Coding Clinic advice affect the Index or Tabular?
§ Do existing or proposed codes need new or revised Includes or Excludes notes?
§ Do existing Excludes notes need to be deleted or revised?
§ Is the spelling correct for all entries?
§ Is something missing from the entry?
§ Did the final code changes carry through to the Index and to all the code descriptions in the Tabular?
§ Do the Index and Tabular entries make sense?
Index questions and examples:
§ Are index entries confusing or unclear?
§ Does the index mis-direct to an incorrect code?
§ Are there entries for proposed codes?
§ Is there something that seems unusual?
- Example: Bicornate uterus indexed to an acquired deformity code rather than congenital code. ICD-9-CM listed it as anomaly. ICD-10-CM listed it as an acquired condition.
- Example: Osteomyelitis with Pathological Fracture had no Index entry for Femur yet there was a code for it.
Tabular examples:
§ Index terms for Deep Tissue Injury differed from terms listed in the C&M minutes.
§ Body Mass Index ranges were enclosed in parentheses but should have been enclosed in brackets in order to conform with the ICD-10-CM structure. Bracket identify synonymous terms while parentheses identify non-essential modifiers.
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CODING CLINIC FOR CDI
Fourth quarter 2019 release highlights 2020 code changes
By Sharme Brodie, RN, CCDS, CCDS-O
As is typical with fourth quarter Cod-ing Clinic releases, this most recent offering mainly contains information about fiscal year (FY) 2020 coding and Official Guidelines for Coding
and Reporting changes. By now, most CDI profession-als should have reviewed the major changes, which include 273 added codes, 21 deleted codes, and 30 revised codes.
Let’s go ahead and take a look at what the Fourth Quarter 2019 issue of Coding Clinic has to offer in terms of CDI-related information.
Segmental pulmonary embolisms
Over the years, there has been a lot of conversation about the treatment of segmental pulmonary embo-lisms, whether these patients should be put on antico-agulants, and how long they should remain on them if so. The FY 2020 IPPS final rule added codes I26.93, Single subsegmental pulmonary embolism with acute cor pulmonale, and I26.94, Multiple submental pulmo-nary emboli without acute cor pulmonale.
According to this issue of Coding Clinic, these changes will “enable important clinical differentiation and will be beneficial for hospital quality measures, as well as for research and evaluation of treatment efficacy.”
Atrial fibrillation
On p. 6, Coding Clinic discusses atrial fibrilla-tion (A-Fib) coding, which in code category I48 was expanded by four codes to include:
n I48.11, Longstanding persistent a fib
n I48.19, Other, persistent a fib
n I48.20, Chronic a fib, unspecified
n I48.21, Permanent a fib
Coding Clinic goes on to describe the different types of A-Fib on p. 7, reminding us that chronic persistent A-Fib has no widely accepted clinical definition or meaning and that it is coded to I48.19, Other persistent atrial fibrillation.
Phlebitis and thrombophlebitis
The next topic of conversation is phlebitis and throm-bophlebitis. Coding Clinic lists eight additional codes added to code category I80 to capture whether phle-bitis or thrombophlebitis involves the peroneal vein or muscular branch veins, and to differentiate proximal from distal.
New codes were also added to identify acute and chronic venous embolism and thrombosis of deep ves-sels of the distal lower extremities, including the pero-neal vein and calf muscular vein.
The calf veins are made up of three paired veins—posterior tibial, peroneal, and anterior tibial—along with two sets of muscular veins, soleal and gastrocnemial. A calf vein thrombosis is a clot affecting deep veins of the calf.
Sixteen codes were added to code category I82, Other venous embolism and thrombosis, which are listed on pp. 9–10 of this edition of Coding Clinic. The new codes will differentiate acute and chronic thrombosis involving deep veins of the proximal lower extremity from acute and chronic thrombosis involv-ing deep veins of the distal lower extremity. Previously, ICD-10-CM did not provide specific codes to capture deep vein thrombosis of the peroneal vein or muscular branch veins; coding professionals were instructed to use to nonspecific codes.
Pressure-induced deep tissue damage
On pp. 10-11, Coding Clinic tells us about the 11 added codes to category L89 to capture
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pressure-induced deep tissue damage of various sites and align with updates to National Pressure Ulcer Advi-sory Panel (NPUAP) pressure ulcer staging. Prior to this change, deep tissue pressure injuries were coded to unstageable. Changes to the NPUAP pressure ulcer staging were made based on recent clinical literature and expert consensus; however, they resulted in minor inconsistencies with ICD-10-CM. The new codes will help resolve the discrepancy.
CDI professionals should clarify whether the term “deep tissue injury” is described in the setting of trauma to accurately capture the provider’s intent or meaning. If due to trauma, the codes added to the L89 code cat-egory would be inappropriate.
Breast lump in overlapping quadrants
On p. 12, we learn that category N63, Unspecified lump in breast, includes two new codes to identify unspecified lumps in the right or left breast that are of overlapping quadrants:
n N63.15, Unspecified lump in the right breast, overlapping quadrants
n N63.25, Unspecified lump in the left breast, overlapping quadrants
There are also codes for EDS unspecified (Q79.60) and for other EDS (Q79.69).
Ehlers-Danlos Syndrome (EDS)
Ehlers-Danlos Syndrome (EDS) is a group of inher-ited disorders that mostly affect the skin, joints, and blood vessels. EDS is a life-long progressive condition that has a major effect on the lives and daily function of those living with this condition. The most prevalent and common types of EDS include:
n Classical (Q79.61): These patients have wounds that split open with little bleeding that leave scars that widen over time to create “cigarette paper” scars. Typically, these patients have loose skin that sags and wrinkles.
n Hypermobile (Q79.62): A certain set of criteria must be met for a patient to be diagnosed with EDS. Some common symptoms include joint
hypermobility, somewhat elastic (stretchy) skin, easy bruising, and chronic musculoskeletal pain.
n Vascular EDS (Q79.63; vEDS): Can cause unpredictable tearing (rupture) of blood vessels, leading to internal bleeding and other potential life-threatening complications. It is also asso-ciated with an increased risk of organ rupture, including tearing of the intestine and rupture of the uterus during pregnancy. The long-term out-look for vEDS is generally poor. The median life expectancy for people affected by vEDS is 48 years.
There are also codes for EDS unspecified (Q79.60) and for other EDS (Q79.69)
Prader-Willi Syndrome (PWS)
A unique code Q87.11 was created in this year’s IPPS to capture Prader-Willi Syndrome (PWS), a rare com-plex genetic neurodevelopmental disorder that results in a number of physical, mental, and behavioral prob-lems. Signs and symptoms vary among individuals and may slowly change over time from childhood to adult-hood. The new code will hopefully facilitate communi-cation and research related to PWS.
Providers caring for this population, including neu-rologists, who assign codes as part of their documen-tation should be educated that there is a new code available.
Cyclical vomiting syndrome
On p. 15, we find that code R11.15, Cyclical vomiting syndrome unrelated to migraine, has been created to identify cases in which a patient has cyclical vomiting that is totally unrelated to a migraine. Cyclical vomiting not otherwise specified (NOS) and persistent vomiting are inclusion terms at code R11.15.
In addition, the titles for codes in subcategory G43.A, Cyclic vomiting, have been revised, and “in migraine” was added to codes G43.A0 and G43.A1. Cyclical vomiting syndrome is described as episodes of severe vomiting that have no noticeable cause. Episodes can last for days or hours and alternate with symptom-free periods. Each episode tends to start at the same time
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 39
of day, lasts the same length of time, and occurs with the same symptoms and level of intensity. Treatment usually involves medications, including anti-nausea and migraine therapies that may lessen symptoms.
Pyuria
Pyuria (p. 16) is a lab finding of white blood cells (WBC) in the urine and is commonly associated with a urinary tract infection (UTI), but a UTI is not the only rea-son that WBCs might be present in a person’s urine—kidney stones, tumors, and inflammation could also cause this finding.
According to Coding Clinic, when a patient has pyuria without a UTI present, code R82.1, Pyuria, would be assigned. Subcategory R82.8, Abnormal findings on cytological and histological examination of urine, was expanded, and two codes were created to uniquely capture pyuria and other abnormal findings on cyto-logical and histological examination of urine as follows:
n R82.81 Pyuria
n R82.89 Other abnormal findings on cytological and histological examination of urine
CDI record reviews should evaluate the need for query to capture a UTI if supported by clinical crite-ria, including the presence of localized genitourinary symptoms, urinary tract inflammation as demonstrated by pyuria, and a urine culture with an identified urinary pathogen.
Fracture of orbit
On pp. 16–17, Coding Clinic discusses changes made to subcategory S02.1, Fracture of base of skull, and sub-category S02.8, Fractures of other specified skull and facial bones. These new codes were created to provide additional detail on fractures of the orbital roof.
The codes also specify the right, left, or unspecified side. These changes to subcategory S02.1 and S02.8 resulted in 60 new codes, including the seventh charac-ter extensions. CDI specialists, particularly those work-ing with trauma patients, will need to query to capture the additional level of specificity if it’s not clear in the medical record.
Multiple drug ingestion
A new subcategory (T50.91.-) has been created for poisoning by, adverse effect of, and underdosing of multiple unspecified drugs, medications, and biological substances. A total of 18 codes have been added to better identify and track these episodes of care. Unfor-tunately, in the past it has been difficult to identify every-thing a patient may have ingested. CDI professionals should educate providers to identify any and all sub-stances involved to allow for proper code assignment.
Exertional Heat Stroke
If you live in one of the warmer states like I do, you might appreciate the new codes created to identify heatstroke and sunstroke (T67.01-), exertional heat-stroke (T67.02-), and other heatstroke and sunstroke (T67.09-). The hope is that the new codes will improve tracking of these conditions.
One of the questions in this Coding Clinic asks how to code when a patient is admitted with seizures related to heatstroke while playing basketball. The answer is to assign code T67.02XA, Exertional heatstroke, ini-tial encounter, and code R56.9, Unspecified convul-sions for the seizures. The instructional note at T67.0 directs the coder to “use additional code(s) to identify any associated complications of the heatstroke.” Lastly, code Y93.67 is assigned for Activity, basketball.
History (of)
On p. 20, Coding Clinic discusses seven new per-sonal history codes. Six of them are for personal history of in-situ neoplasms (Z86.002–Z86.007), and one is for personal history of latent tuberculosis infection (Z86.15). These codes will allow for the reporting of personal history of carcinoma in situ of other additional specific sites that do not have specific codes in ICD-10-CM:
n Z86.002, Other and unspecified genital organs
n Z86.003, Oral cavity, esophagus and stomach
n Z86.004, Other and unspecified digestive organs
n Z86.005, Middle ear and respiratory system
n Z86.006, Melanoma
n Z86.007, Skin
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Sepsis and organ dysfunction
“Ask the Editor,” starting on p. 64, once again speaks to the issue of whether there is an assumed relation-ship between sepsis and any acute organ dysfunction because of the subentry “with” and the advice given in Coding Clinic, Fourth Quarter 2017. This new edition of Coding Clinic answers that “the exception to the ‘with’ guideline which said ‘unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for ‘acute organ dysfunction that is not clearly asso-ciated with the sepsis’)” was added for FY 2018. The answer reiterates this Official Guidelines update and confirms the need to acute link organ dysfunction to the sepsis to allow accurate capture of the presence of severe sepsis.
Social determinants
Coding Clinic instructs, “If the patient self-reported information is signed-off and incorporated into the health record by either a clinician or provider, it would be appropriate to assign codes from categories Z55-Z65, describing social determinants of health.”
A question asks for a definition of the word “clini-cian,” and Coding Clinic answers that “The ICD-10-CM Official Guidelines for Coding and Reporting do not have a unique definition of the term ‘clinicians.’ In the context of code assignment for social determinants of health Z codes, documentation deemed meeting the requirements for inclusion in the patient’s official medical record based on regulatory or accreditation requirements or internal hospital policies, could be
utilized since the information pertains to social rather than medical information.”
CDI professionals should determine whether social determinants of health represent a record review prior-ity, understand their program’s acceptable definition of “clinician” for the purposes of reporting Z codes, and perform an audit to identify the most common Z scores for the team to review and query on.
Mesenteric vein thrombosis
The last bit of information under “Ask the Editor” answers a question about how a diagnosis of acute ischemia of the ascending colon due to mesenteric vein thrombosis, which is attributed to antithrombin III deficiency, would be coded. The problem seems to be that the Alphabetic Index to Diseases references code I81, Portal vein under Thrombosis, mesenteric, vein. Mesenteric thrombosis is, however, included in the inclusion terms under subcategory K55.0, Acute vascular disorders of intestine.
So, the question asks, how would this mesenteric vein thrombosis be coded? Coding Clinic answers that code K55.039, Acute (reversible) ischemia of large intestine, extent unspecified, should be assigned for the mesenteric vein thrombosis, as the provider did not document focal or diffuse. As of October 1, 2019, the Alphabetic Index has been revised and coding professionals are directed to subcategory K55.0 for a diagnosis of mesenteric thrombosis. The specific code assignment would be based on the provider’s docu-mentation.
Editor’s note: Brodie is a CDI education specialist with HCPro/ACDIS in Middleton, Massachusetts. To learn more about our Boot Camps, click here. Contact her at [email protected].
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 41
MEET A MEMBER
A ‘never boring’ career that constantly challenges, changes, and grows
Nancy Franciotti, BS, RN, CCDS, is the CDI manager at Inspira Health, which is comprised of three hospitals, a comprehensive cancer center, several multi-specialty health centers, and a total of more than 150 access points. Inspira Health serves southern New Jersey and is opening a brand-new 210-bed, state-of-the-art hos-pital in Mullica Hill. Franciotti started the Inspira CDI program in 2018. It has been successful at improving the quality of documentation and was recently honored by Inspira for its success. She is a member of the Phil-adelphia/Southern New Jersey/Delaware ACDIS local chapter, began her CDI career in 2009, and sat for her CCDS certification in 2014.
ACDIS: What did you do before entering CDI?Franciotti: Lots of things! I graduated with a degree
in social work and worked in various forms of coun-seling for the first five years of my professional career. At the five-year mark I was either going to get a mas-ter’s or change careers completely. I decided to enter a nursing program. I wanted to still be able to help peo-ple, which is really my passion, but in a more holistic manner. My first love was psych nursing, and I was the nurse manager of a neurobehavioral stabilization unit that provided multidisciplinary treatment to chil-dren and adults with complex diagnoses who also had severe violent and self-injurious behavior. After my first child was born, I transitioned into case management, which led to CDI.
ACDIS: Why did you get into this line of work? Franciotti: At the time I entered CDI, case managers
really didn’t know much about the profession. 3M did a presentation at my hospital, and I knew I wanted the training. Many were skeptical about whether this was going to be a lasting initiative, but I was game to try it. It’s been the best decision of my professional career.
ACDIS: What has been your biggest challenge?
Franciotti: I think communicating the goals and ini-tiatives of a CDI program to my leaders, to physicians, coding—just gaining the buy-in of key stakeholders. I am so lucky to be in a supportive environment at Inspira, and my CDI program is well supported by my management as well as my participation with ACDIS.
ACDIS: What has been your biggest reward? Franciotti: I have a career that is constantly chal-
lenging, changing, growing—it’s never boring.
ACDIS: How has the field changed since you began working in CDI?
Franciotti: When I first began in the CDI field, we were on paper charts on paper records and calcu-lating key performance indicators manually. Since then, the software options have exploded, CDI efforts have expanded into outpatient, and ACDIS has grown exponentially.
ACDIS: Can you mention a few of the “gold nug-gets” of information you’ve received from col-leagues on The Forum or through ACDIS?
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Franciotti: There are so many! When I was lucky enough to be offered the position as CDI man-ager at Inspira Health, I imme-diately reached out to my men-tors in the ACDIS organization. I called Melissa Varnavas and Sharme Brodie for advice and they provided me with guidance and led me back to my local chapter. ACDIS has been my touchstone through my entire CDI career and has given me a community of great CDI leaders and educators that are so generous with their knowledge.
ACDIS: If you have attended, how many ACDIS conferences have you been to? What are your favorite memories?
Franciotti: I have attended two large conferences, ICD-10 training with Sharme, and most recently the Leadership Exchange and the Outpatient CDI Sym-posium in Austin, Texas. Sharme also recommended that I attend the Management Essentials preconference event, which I did in 2019. All these educational events were great experiences for me.
ACDIS: What piece of advice would you offer to a new CDI specialist?
Franciotti: ACDIS membership and active partici-pation is essential. Most of us do not report to a CDI leader, so we need to get our direction from our national organization to stay current with regulations and best practices. Always keep the goal in mind of documenta-tion integrity and clinical truth. Adaptability to a chang-ing healthcare landscape is also key. Adapt or face extinction—learn the lesson of the dinosaur!
ACDIS: If you could have any other job, what would it be?
Franciotti: Screen writer for film/TV.
ACDIS: What was your first job? Franciotti: I worked at a shop that sold designer
jeans. Jordache jeans and Sasson jeans—I wish I had saved a pair.
ACDIS: Can you tell us about a few of your favor-ite things?
n Vacation spots: Travel is a passion. My last big trip was to Aruba.
n Hobbies: I love films. In fact, I belong to two movie clubs, one where we meet once a month at a member’s house, drink wine, and watch art-house or indie films. The other is a horror movie club. I love Broadway and concerts too.
n Non-alcoholic beverage: Flavored seltzer. I drink tons of it.
n Foods: I’m a foodie and love to try new things. There are so many great restaurants in the Phila-delphia/Southern New Jersey area.
n Activities: I am a big exercise enthusiast. It’s essential for physical and mental health.
ACDIS: Tell us about your family and how you like to spend your time away from CDI.
Franciotti: I have been married to my husband Bob for 19 years. We have two sons, James (18) and John (14). They are my whole world, and we love traveling together, dinners out, and just hanging out on the weekends.
© 2020 HCPro, a Simplify Compliance brand CDI Journal | JANUARY/FEBRUARY 2020 43
2019 in review: CDI Journal article index
The beginning of a new year is the perfect time to reflect on the previous year, reminiscing over good times and bad. As the ACDIS team looks back over 2019 and ahead to 2020, we
wanted to take a few moments to remind you of the topics and articles covered last year in the CDI Journal. Below is a complete article listing, organized by topic, for your reading pleasure. We hope it proves helpful for your new year.
Programmatic and staffing
n “Set a strategic vision for success,” by Melissa Varnavas, vol. 13, issue 1, January/February 2019
n “Local chapter tips: Financial planning basics required for first steps,” vol. 13, issue 1, January/February 2019
n “Building a dream team for core CDI practices,” vol. 13, issue 1, January/February 2019
n “How to conduct CDI audits and why it’s import-ant,” by Jill Dressler, RN, BSN, CCDS, and Sandy Frey, RHIT, CCS, vol. 13, issue 2, March/April 2019
n “How to survive travel consulting,” by Angela Maxfield, RN, CCDS, vol. 13, issue 2, March/April 2019
n “Hiring and training CDI staff,” vol. 13, issue 3, May/June 2019
Professional development, leadership
n “Being an effective manager,” by Melissa Var-navas, vol. 13, issue 4, July/August 2019
n “Implementing a career ladder in a multi-hospi-tal health system,” by Tamara Hicks, RN, MHA, CCS, ACM-RN, CCDS-O, vol. 13, issue 4, July/August 2019
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n “Welcome new ACDIS Advisory Board mem-bers; farewell to those stepping down,” vol. 13, issue 4, July/August 2019
n “Leading the flock: CDI leaders share their sto-ries, tips,” vol. 13, issue 4, July/August 2019
n “Enjoy the twists and turns of your CDI journey,” by Sarah Matacale, RN, BSN, CCS, vol. 13, issue 4, July/August 2019
n “Career ladders: Helping staff along their CDI journeys,” vol. 13, issue 4, July/August 2019
n “10-year retrospective: Original CCDS holders share stories, advice for new test takers,” vol. 13, issue 4, July/August 2019
Review and query process
n “CDI nuts and bolts—The record review pro-cess,” vol. 13, issue 1, January/February 2019
n “20/20 hindsight: CDI’s role in retrospective reviews,” vol. 13, issue 1, January/February 2019
n “The evolution of query practice takes center stage,” by Melissa Varnavas, vol. 13, issue 2, March/April 2019
n “2019 update: Guidelines for achieving a compli-ant query process,” vol. 13, issue 2, March/April 2019
n “Eliminating (or at least reducing) query fatigue,” by Cathy Farraher, RN, BSN, MBA, CCM, CCDS, vol. 13, issue 3, May/June 2019
n “Query practice FAQs,” vol. 13, issue 6, Novem-ber/December 2019
Quality
n “PSIs, POA indicators offer CDI-quality starting point,” vol. 13, issue 6, November/December 2019
n “Community care: CDI programs’ role in popula-tion health initiatives,” vol. 13, issue 6, November/December 2019
Physician engagement, education
n “Physicians more engaged in CDI efforts, survey says,” by Melissa Varnavas, vol. 13, issue 3, May/June 2019
n “Physician engagement: Tips from a physician,” by Erica E. Remer, MD, FACEP, CCDS, vol. 13, issue 3, May/June 2019
n “More than 80% of respondents say physi-cians are at least moderately engaged with CDI efforts,” vol. 13, issue 3, May/June 2019
n “Focus on engagement: Physician educator roles,” vol. 13, issue 3, May/June 2019
n “Physician engagement: Six steps for solving CDI’s biggest problem,” vol. 13, issue 2, May/June 2019
n “Are we expecting too much?” by Trey La Charité, MD, FACP, SFHM, CCS, CCDS, vol. 13, issue 4, July/August 2019
n “Ending conflicting documentation,” by Trey La Charité. MD, FACP, SFHM, CCS, CCDS, vol. 13, issue 6, November/December 2019
Clinical concerns
n “Tight margins in trans aortic valve replacement,” by Stephen Houlahan, RN, MSN, MBA, CCDS, vol. 13, issue 2, March/April 2019
n “Oxygen levels related to respiratory distress,” by Howard Rodenberg, MD, MPH, CCDS, vol. 13, issue 3, May/June 2019
n “Sepsis FAQs,” vol. 13, issue 4, July/August 2019
n “Parkinson’s disease,” by Richard Pinson, MD, FACP, CCS, vol. 13, issue 5, September/October 2019
n “Review updates to the 2020 ICD-10-CM Guide-lines,” by Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC, vol. 13, issue 6, November/December 2019
n “Coding Clinic for CDI: A season for football, pumpkin lattes, and Coding Clinic releases,” by Laurie Prescott, RN, MSN, CCDS, CCDS-O,
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CDIP, CRC, vol. 13, issue 6, November/Decem-ber 2019
Coding concerns
n “Questions on ethical coding practices,” vol. 13, issue 1, January/February 2019
n “Coding Clinic for CDI: Fourth quarter publica-tion unpacks new codes, BMI documentation and coding,” by Sharme Brodie, RN, CCDS, CCDS-O, vol. 13, issue 1, January/February 2019
n “Sepsis sequencing FAQs,” vol. 13, issue 2, March/April 2019
n “How an ICD-10 code is born,” by Kay Piper, RHIA, CDIP, CCS, vol. 13, issue 2, March/April 2019
n “10 things every coder wishes providers knew about sepsis documentation and coding,” by Sarah Nehring, CCS, CCDS, vol. 13, issue 3, May/June 2019
n “Coding Clinic for CDI: Newest publication cov-ers procedures, HIV/AIDS, sick sinus syndrome, and more—all in 37 pages,” by Sharme Brodie, RN, CCDS, CCDS-O, vol. 13, issue 3, May/June 2019
n “Coding sepsis, UTI, and pneumonia,” vol. 13, issue 5, September/October 2019
n “Coding Clinic for CDI: At 40-odd pages, Cod-ing Clinic release lighter lift,” by Sharme Brodie, RN, CCDS, CCDS-O, vol. 13, issue 5, Septem-ber/October 2019
n “Review updates to the 2020 ICD-10-CM Guide-lines,” by Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC, vol. 13, issue 6, November/December 2019
n “Coding Clinic for CDI: A season for football, pumpkin lattes, and Coding Clinic releases,” by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, vol. 13, issue 6, November/Decem-ber 2019
Regulations
n “Rules, regulations, education, and advocacy,” by Candace Blankenship, BSN, RN, CCDS, vol. 13, issue 5, September/October 2019
n “Tools to help CDI professionals follow the rules,” by Melissa Varnavas, vol. 13, issue 6, November/December 2019
n “Stay informed about 2020 regulatory updates,” by Susan Schmitz, JD, RN, CCS, CCDS, CDIP, vol. 13, issue 6, November/December 2019
n “IPPS final rule: Where it started, and what it means for 2020,” vol. 13, issue 6, November/December 2019
n “Summarizing the Coordination and Mainte-nance Committee meeting,” by Teresa Krepps, RHIT, CCS, CCDS, vol. 13, issue 6, November/December 2019
Collaboration
n “All on the same team: Avenues for collaboration between CDI and the case management depart-ment,” vol. 13, issue 1, January/February 2019
n “All welcome: HIM representation in CDI grow-ing,” vol. 13, issue 5, September/October 2019
Pediatric CDI
n “The effect of pediatric mortality reviews,” by Julian Everett, BSN, RN, CDIP, vol. 13, issue 1, January/February 2019
n “Implementing heart failure criteria at Dayton Children’s Hospital,” by Rachelle Musselman, BSN, RN, Jorde Spitler, BSN, RN, Daniel Lan-tis, BSN, RN, Joseph Ross, MD, and Thomas Taghon, DO, MHA, vol. 13, issue 5, September/October 2019
n “Implementing sepsis documentation in pediat-ric, neonatal newborn cases,” by Julian Everett, RN, BSN, CDIP, vol. 13, issue 5, September/October 2019
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Outpatient CDI, expansion
n “Office visit E/M documentation requirements eased,” by Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, vol. 13, issue 1, January/February 2019
n “Implementing systemwide outpatient CDI pro-grams,” vol. 13, issue 1, January/February 2019
n “An outpatient CDI case study,” by Tammy Trom-bley, RHIT, CDIP, CCDS, vol. 13, issue 1, Janu-ary/February 2019
n “Measuring success: DIY outpatient tracking tools,” vol. 13, issue 2, March/April 2019
n “Buying in to ambulatory CDI,” by Jennifer Boles, CPC, CRC, vol. 13, issue 3, May/June 2019
n “Steps for successful ambulatory CDI implemen-tation,” by Ellen Jantzer, RN, MSN, CCDS, CCS, CRC, vol. 13, issue 3, May/June 2019
n “Case study: Outpatient quality collaboration,” vol. 13, issue 6, November/December 2019
n “Home health CDI: Different setting, same CDI,” vol. 13, issue 6, November/December 2019
Denials and appeals
n “Complex pneumonias as an external reviewer target,” by William Haik, MD, FCCP, CDIP, vol. 13, issue 1, January/February 2019
n “Denials—Planning prevention and defense,” by Irina Zusman, RHIA, CCS, CCDS, vol. 13, issue 5, September/October 2019
n “Following the trends: CDI in a changing denials landscape,” vol. 13, issue 5, September/October 2019
n “Case study: Demystifying the payer side of CDI,” vol. 13, issue 5, September/October 2019
n “In the trenches: Frontline appeal writing advice,” vol. 13, issue 5, September/October 2019
n “Setting guideposts: Organization-wide clinical definitions,” vol. 13, issue 5, September/October 2019
n “Getting defensive: Shore up the discharge sum-mary,” vol. 13, issue 5, September/October 2019
Technology and data
n “Five questions to ask when considering priori-tization software solutions,” by Angie Curry, RN, BSN, CCDS, vol. 13, issue 2, March/April 2019
n “EHR’s troubled path: Three persistent prob-lems,” vol. 13, issue 2, March/April 2019
n “Artificial intelligence: Working with computer-as-sisted coding, natural language processing,” vol. 13, issue 2, March/April 2019
n “Technology for a hybrid remote CDI network,” by T. Nichole “Niki” Baca, BSN, RN, CCDS, and Sydni Johnson, RN, BSN, vol. 13, issue 2, March/April 2019
n “Consensus recommendations for optimizing electronic health records for nutrition care,” vol. 13, issue 6, November/December 2019
ACDIS and member advice
n “CDI specialist noticed a need for improved documentation and never looked back,” vol. 13, issue 1, January/February 2019
n “After 11 years in pediatric, CDI gave her a new home,” vol. 13, issue 2, March/April 2019
n “When stepping into leadership, seek reliable mentors,” vol. 13, issue 3, May/June 2019
n “12th ACDIS Conference in Orlando: Simply Magical,” vol. 13, issue 4, July/August 2019
n “When you get stuck, phone a friend,” vol. 13, issue 4, July/August 2019
n “One giant step for CDI,” by Melissa Varnavas, vol. 13, issue 5, September/October 2019
n “CDI Week 2019 Preview: Celebrating CDI superheroes,” vol. 13, issue 5, September/Octo-ber 2019
n “Never burn a bridge you may have to cross!” vol. 13, issue 5, September/October 2019
n “Building a bridge between coding and nursing in CDI,” vol. 13, issue 6, November/December 2019
