1 Presented by Jenan Custer & Rae Freeman, HCCS and Dr. James Dunnick, The Dunnick Group Hospital Transformation Consortium Clinical Documentation Improvement Series Four Key Roles for CDI: Roles 3 & 4 – Nurses & Scribes October 17, 2017 A PORTION OF THESE MATERIALS WERE PRODUCED PURSUANT TO THE Iowa Small Hospital Improvement Program (SHIP) Grant FY 17 IA Contract #5888SH01 and the Georgia Small Hospital Improvement Program FY17. WEBINAR ETIQUETTE Hospital Transformation Consortium • All attendees are in “Listen Only” mode • Questions or comments? - Open “Questions” pane in dashboard. - Type in comments or questions. - Comments & questions will be monitored and addressed! • This webinar will be recorded and will be posted to the dashboard for you to view on demand and share. • Handouts are available for download in the Handouts pane and will be posted on your dashboard. WEBINAR RESOURCES Hospital Transformation Consortium
Transcript
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Presented by Jenan Custer & Rae Freeman, HCCSand Dr. James Dunnick, The Dunnick Group
Hospital Transformation ConsortiumClinical Documentation Improvement Series
Four Key Roles for CDI:Roles 3 & 4 – Nurses & Scribes
October 17, 2017A PORTION OF THESE MATERIALS WERE PRODUCED PURSUANT TO THE Iowa Small Hospital Improvement
Program (SHIP) Grant FY 17 IA Contract #5888SH01 and the Georgia Small Hospital Improvement Program FY17.
WEBINAR ETIQUETTE
Hospital Transformation Consortium
•All attendees are in “Listen Only” mode
•Questions or comments?
- Open “Questions” pane in
dashboard.
- Type in comments or questions.
- Comments & questions will be
monitored and addressed!
•This webinar will be recorded and will
be posted to the dashboard for you to
view on demand and share.
•Handouts are available for download
in the Handouts pane and will be
posted on your dashboard.
WEBINAR RESOURCES
Hospital Transformation Consortium
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As an IACET Authorized Provider, HomeTown Health, LLC offers CEUs for its programs that qualify under the ANSI/IACET Standard. HomeTown Health, LLC is authorized by IACET to offer 0.1 CEUs/1 credit hour for this program.
In order to obtain these units, you must: • Attend webinar/view recording in its entirety within 30 days• Pass online quiz with 80% or better.• Complete webinar evaluation.
Following this webinar, all attendees who have viewed the recording in its entirety will receive an email with a link to the quiz and evaluation.
Anyone that misses the webinar can view the recording online, posted on the program Dashboard, for CEUs.
CONTINUING EDUCATION
Hospital Transformation Consortium
CONTINUING EDUCATION
Hospital Transformation Consortium
HTHU provides over 300 courses online, over 100 Webinars a year, and various live training conference and workshops. Accredited Education from the International Association for Continuing Education & Training (IACET). (Who accepts the IACET CEU? Full list at www.iacet.org)
• American Association of Respiratory Therapy• American Board of Medical Microbiology• American Society for Clinical Laboratory Science• American Society for Quality• American Speech-Language-Hearing Association• Board of Certified Safety Professionals• The Child Care Development Associate National
Credentialing Program• Clinician’s View (Occupational, Speech, and Physical
Therapy)• Federal Emergency Management Agency• Georgia, Massachusetts and Ohio Board of Nursing• Georgia Professional Standards Commission• Human Resources Certification Institute (for their
Professional in Human Resource Designation)• National Association of Rehabilitation Professionals in the
Private Sector• National Association of Social Workers
• National Board for Certification in Occupational Therapy, Inc. (NBCOT)
• National Council for Therapeutic Recreation Certification
• National Registry of Emergency Medical Technology (EMT)
• National Registry of Microbiologists• National Society of Professional Engineers• Society for Human Resources Management• State of Georgia, FL and Iowa Board of
Professional Engineers• The American Association of Integrative Medicine• The American College of Forensic Examiners
Institute• The American Council on Pharmaceutical
Education• The American Psychotherapy Association• The International College of The Behavioral
Sciences• The National Board for the Accreditation of
Occupational Therapy (NBCOT)
ACTION ITEM: GROUP PARTICIPATION
Hospital Transformation Consortium
Are you on this webinar with a group?
If so, please enter:first/last names and email addresses of those in attendance with you in the
Questions Pane.
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Program Goals
Clinical Documentation Improvement Series
A CDI program’s purpose is to improve healthcare records to ensure improved patient outcomes, data quality and accurate reimbursement. This series of continued ICD-10 support with a specific focus on C DI will bring together Physicians, coders, and others that have the ability to increase revenue by coding to t he highest level of specificity.
The goal of this program is to improve hospital financial processes by helping to develop a CDI program within small/rural hospitals through specif ic training to the four main roles within a CDI Progra m: CDI Specialists, Physicians, Nurses and Scribes.
Welcome & Introductions Desi Barrett,
HomeTown Health, LLC
Four Key Roles for CDI:
Role #3 and #4 – Nurses & Scribes
Jenan Custer & Rae
Freeman, HCCS
From a Physician’s Perspective Dr. James Dunnick,
The Dunnick Group
Upcoming Events & Resources Jennie Price
AGENDAClinical Documentation Improvement Series
Trainer BiographyClinical Documentation Improvement Series
Jenan Custer, RHIT, CCS, CDIP, CPPDirector of Coding Operations at HCCS Healthcare Coding & Consulting Services
• Jenan is a CCS, CPC, CDIP, AHIMA ICD-10-CM/PCS Approved Trainer, AHIMA Ambassador, and AS in Health Information Management
• She has been involved in the coding and HIM areas for over 14 years and has been a partner with Home Town Health for four years
• Jenan oversees a coding team exceeding 200 remote coders, consulting services, and coding for over 100 facilities all across the United States
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Trainer BiographyClinical Documentation Improvement Series
Rae Freeman, RHIA, CDIP, CCS-PSenior Manager, Consulting at HCCS Healthcare Coding & Consulting Services
Rae Freeman is HCCS’s Senior Manager of Consulting. In this role Rae, an acknowledged HIM expert, performs speaking and education functions in addition to administering HCCS’s consulting services program.
Rae received a Bachelor of Science degree in Health Information Management from Southwestern Oklahoma State University and is an RHIA, a Certified Documentation Improvement Practitioner (CDIP) and a Certified Coding Specialist-Physician based (CCS-P).
Rae has worked in healthcare for 21 years in positions ranging from coder to Physician Office Manager and HIM Director. She is president-elect for the Florida Health Information Management Association and is a past president of the Texas HIM Association as well as the local Southwest Florida HIM Association.
Disclosure of Proprietary InterestClinical Documentation Improvement Series
HCCS does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event.
The education offered by HCCS in this program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant, Iowa FY17-18, Contract #5888SH01 and the Georgia SHIP Grant Program FY17.
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Physician’s Perspective
Trainer BiographyClinical Documentation Improvement Series
Dr. James Dunnick, MD, FACC, CHCQM, CPC, CMDP The Dunnick Group, LLC
• Dr. James Dunnick is board certified in internal medicine and cardiology. He has 25 years of clinical practice experience specializing in congestive heart failure, cholesterol, hypertension, and the effects of heart disease in women.
• He has authored and published articles, medical textbook chapters and presented original research at national meetings.
• Dr. Dunnick attended IU Bloomington and IU School of Medicine in Indianapolis, where he placed in the Honors Division.
• He is a Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) and is also certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
Disclaimer:1. Do NOT assume we are correct, we make mistakes.
2. Read and self educate.
3. CPT books, government manuals, online resources.
4. Obtain professional teaching, from more than one source.
5. Consultant opinions very.
6. Auditor’s opinions vary.
7. States vary.
8. Payers vary.
9. Rules change.
This is meant as general and initial information only.
Learning Objectives
Attendees will understand:
• Payer scrutiny is increasing
• Physician difficulty in being compliant
• The why of physician pushback
• How to increase physician partnership
CMS processes approximately 5 million claims…
Per day
210,000 per hour
THE PAYER - CMS
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2015 Federal Budget
1. MC/MC 24%
1. SS 24%
3. Defense 16%
CMS Payments
Medicare is in $$ Trouble
The Government is not kidding about cost
containment.
Medical Need
• 323,000,000 people USA
• 100,000,000 obese people
• 86,000,000 pre diabetics
• 30,000,000 diabetics
• 1,700,000 cancer diagnoses
• 700,000 MIs
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Payers are in $$ Trouble
Payers are not kidding about cost containment.
Learning Objectives
Attendees will understand:
• Payer scrutiny is increasing
• Physician difficulty in being compliant
• The why of physician pushback
• How to increase physician partnership
What is E/M?
E/M
• It is how payers turn cognitive effort into $$
• Every office note, hospital note
• In patient or out patient
• The largest cost to payers
• The largest focus of upcoming audits
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What is E/M?
• E/M has parts
• Each part has parts
• Parts have components
• Components have elements
• The elements leads to levels
• Each level has requirements
• Some parts have points
• Points are defined and added together
• Risk is defined and labeled
• All are needed and in the correct combination
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Three key E/M components
A. History
1. History present illness
2. Past medical family social history
3. Review of systems
B. Physical Exam
1. 1995-Body Parts or organ systems
2. 1997- General or specialty specific
C. Medical Decision Making
1. Problem points
2. Data points
3. Risk
What is E/M?
Learning Objectives
Attendees will understand:
• Payer scrutiny is increasing
• Physician difficulty in being compliant
• The why of physician pushback
• How to increase physician partnership
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E/M HPI
• John presents today with chest pain. He had a CABG
three years ago and unfortunately has restarted
smoking. He is now at 1 pack per day. He remains
overweight.
• His older brother and his father died of heart disease
and this pain reoccurrence is causing him more
concern.
• He is compliant with his beta blocker and aspirin.
• He does not have palpitations, shortness of breath, or
syncopal spells.
Auditor Sees
John presents today with chest pain. CCHe had a CABG three years ago. PMHUnfortunately has restarted smoking. Now at 1 pack per day. SHHe remains overweight. PE, SHHis older brother and father died of heart disease. FHThis pain reoccurrence is causing him more concern. ROS PEHe is compliant with his beta blocker and aspirin. PMHHe does not have palpitations, shortness of breath, or syncopal spells. ROS
Auditor Grades
• No elements
• This is not a provider billable note.
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Learning Objectives
Attendees will understand:
• Payer scrutiny is increasing
• Physician difficulty in being compliant
• The why of physician pushback
• How to increase physician partnership
CDI
The Provider’s view
• Reduce my clerical work
• Reduce my MA work
• Reduce my time lost
• Let me help my patient
Compliance
The Role of Scribes
• The Rules
• The Physician’s View
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The Joint Commission
A Scribe is:
• Unlicensed
• Enters Information
• Directed by a provider
CDI
Variations:
• States
• Payers
• Who may have a scribe
• Scribe Signature
Provider is responsible for the note
Any action falling outside the definition of
“human transcriptionist” is not scribing.
“The scribe is functioning as a ‘living
recorder,’ documenting in real time … This
individual should not act independently, and
there is no payment for this activity.”
Source: CGS Medicare
What Scribes cannot do
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HPI W/O Scribe
HPI: CP for 3 days now worse.
With Scribe
CC: Chest pain
HPI: 62 yo wm with severe crushing chest pain off/on for three
days. The longest episode was 30 seconds.
It occurs when he walks up the hill to his barn and then seems to
resolve at the top when he rests. Yesterday he had to stop half
way up the hill due to the pain.
MDM W/O Scribe
MDM: 1. CP worse. Plan LHC.
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MDM With Scribe
MDM: 1. Unstable Angina. The history is very c/w unstable angina
or pre infarct angina. I do not want to risk an ischemic event
during non invasive testing nor due to a delay in testing. We will
admit him to the hospital today, start antiplatelet agents and beta
Quarterly Coding & ICD-10 Update Series presented by HCCS In order to help hospitals stay on top of the latest changes and ongoing challenges in coding requirements, experts in the field come together to share their knowledge in the world of coding
and ICD-10. Recommended audience will include: Coders, HIM Managers/Directors, Business Office Staff interested in the topic.
June 27, 2017: Hitting the Mark on Compliant OB coding in ICD-10 Webinar
presented by HCCS , The Dunnick Group, LLC, & HTHJoin the Coding Team of Trainers for this series on Clinical Documentation Improvement for small hospitals,
including a discussion on the four key roles needed for a successful CDI Program. Training will be provided
for CDI Specialists, Coders, Physicians, Nurses, and Scribes in implementing a program in your hospital.
Webinars held at 10 am CST/ 11 am EST on dates below.
July 18, 2017: Four Key Roles for CDI: Role #1 - CDI Specialist Webinar Training 0.1 CEUs
August 15, 2017: Four Key Roles for CDI: Role #2 - Physicians Webinar Training 0.1 CEUs
October 17, 2017: Four Key Roles for CDI: Role #3 - Nurses & Scribes Webinar Training 0.1 CEUs
March 2018: Rural Coding/CDI Specialist Certification Support Course 1 Support Course 0.1 CEUs
Rural Coding/CDI Specialist Certification Support Course 2 Support Course 0.1 CEUs
Rural Coding/CDI Specialist Certification Support Course 3 Support Course 0.1 CEUs
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UPCOMING LIVE EVENTS
Georgia & Florida:CDI Break-out Session
HomeTown Health’s Annual Spring Conference
April 25-27, 2018Savannah, GA
Save the Date!
Iowa:HomeTown Health’s
Annual Spring ConferenceMarch 14-15, 2018
CALENDAR OF EVENTS
View your Program Dashboard
GA/FL: www.hthu.net/htc17
IA: www.hthu.net/iahtcBoth are password protected: contact Jennie Price at
