00 41461 cdijournal mayjune by ACDIS

MAY/JUNE 2018 Vol. 12 No. 3

EXPLORATIONS

IN CDI OPPORTUNITIES WITHIN ALTERNATIVE SETTINGS

anAssociation Associationof ofClinical ClinicalDocumentation DocumentationImprovement ImprovementSpecialists Specialistspublication publication www.acdis.org www.acdis.org an

San Antonio, Texas | May 21–24, 2018

Join us in San Antonio for the nation’s first and only conference dedicated to the CDI profession.

2018 ACDIS Keynote Speaker

The 11th annual ACDIS Conference features unparalleled networking, the ACDIS Achievement Awards, and 50 sessions in the following tracks: • Clinical and coding • Management and leadership • Quality and regulatory

• Outpatient and risk-adjusted CDI • CDI expansion • Pediatric CDI

WHAT’S HOT IN 2018? We’ve added a sixth track dedicated to pediatrics and an optional closing night reception. Our popular interactive conference app returns, featuring Twitter notifications, conference materials, a session planner, and audience polls. Register now at hcmarketplace.com/acdis-conference

Joe Flower Healthcare Futurist hcmarketplace.com/ acdis-conference customerservice@ hcpro.com

800-650-6787 Visit hcmarketplace.com/acdis-conference for complete details, including agenda and hotel information.

CR-57

CONTENTS FEATURES 8 Proving investment returns for outpatient endeavors For many, outpatient CDI is a new frontier. Those with established programs, however, need to prove a return on investment for their efforts.

16 Inpatient psychiatric facilities: A whole new world Inpatient psychiatric facilities use ICD-10 codes, but all the other requirements are totally different.

24 CDI in home healthcare focuses on education The number of patients seen in their own homes is expected to rise in the coming years.

DEPARTMENTS 4 Associate Director’s Note Melissa Varnavas discusses the reasons for expanding CDI reviews past the inpatient acute care walls.

6 Note from the ACDIS Advisory Board Anny Pang Yuen shares some tips for venturing into outpatient CDI reviews.

11 Radio Recap Brett Senor and Sonia Trepina joined ACDIS Director Brian Murphy to discuss how HCCs can be best captured in the ED.

21 Coding Clinic for CDI Sharme Brodie unpacks the guidance in the newest Coding Clinic for CDI professionals.

27 Physician Advisor’s Corner Drew Siegel walks through some commonly encountered diagnoses and helps CDI specialists investigate the clues.

31 Coding Corner Lori-Lynne Webb shares the growing need for CDI in the outpatient space and tips for expansion.

34 Meet a Member Suzanne Megown is a CDI specialist at St. Luke’s Hospital in Chesterfield, Missouri, and a

3 CDI Journal | MAY/JUNE 2018

MAY/JUNE 2018 Vol. 12 No. 3

member of the St. Louis ACDIS chapter, AHIMA, the Missouri component of AHIMA, and eHIMA.

OPINIONS & INSIGHTS 12 CDI efforts affecting the special care nursery Cathy Farraher shares how she expanded CDI and improved her facility’s length of stay in the special care nursery.

14 Dysphagia: A topic not easy to swallow Amy Sanderson walks through everything CDI professionals need to know about pediatric dysphagia.

20 Remote CDI? Really? Really! Karin Killenberger discusses what makes a good remote CDI specialist and how to tell if remote work is right for you.

29 Aligning HIM coding and CDI professionals: A progressive approach to partnership Steve Robinson shares best practices for aligning CDI and coding forces.

CONTINUING EDUCATION CREDITS BONUS: Obtain one (1) CEU for reading this Journal ACDIS members are entitled to one CCDS continuing education credit for reading the CDI Journal and taking the 20-question quiz. Visit the May/June Journal page on the ACDIS website to take the quiz. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978-750-8400. 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 © 2018 HCPro, a division of BLR. 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 customerservice@hcpro.com. • 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 does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

ASSOCIATE DIRECTOR’S NOTE Branching out By Melissa Varnavas

I’m a third-generation Varnavas. Back when my great–grandparents emigrated here from Greece, good old doc Fullerton used to come around and care for the family when they were sick. Back then, no doubt, he’d soothe their aches, offer advice, and prescribe what medicine he could. Those days are generations past. Now, I see my primary care physician once a year (as my dad would say, “like a good doobie”). If, heaven forbid, something were amiss with my health, she would serve as my initial contact referring me to a world of other possible healthcare providers. My parents now have a slew of specialists they see on an ongoing basis— from eye doctors to dermatologists to oncologists—and their primary care physician serves as the point of contact oversees their coordination of care For the past decade, CDI specialists have worked diligently to care for the medical records of patients principally treated in short-term acute care facilities in urban areas (see the most recent CDI Salary Survey). Government initiatives shifting healthcare reimbursement from pay-forservice to pay-for-performance and new coding grouping systems (hello, MS-DRGs) made it imperative to capture the complex conditions physicians treated there. But clinical documentation isn’t just for inpatient services. That seems like a no-brainer, doesn’t it? The scope of care a patient requires doesn’t start in the hospital. It starts with the visit to the patient’s primary care physician, but it doesn’t end there, or at least it shouldn’t. As Journal readers know well, CDI professionals are branching out into a wide variety of settings, populations, and types of care. In this edition, ACDIS Editor Linnea Archibald connects us with people conducting record reviews in physician practices, home health agencies, and inpatient psychiatric hospitals. This edition of the Journal includes information about pediatric reviews and documentation concerns in the special care nursery.

EDITORIAL Director Brian Murphy bmurphy@acdis.org Associate Director, Membership and Product Development Rebecca Hendren rhendren@acdis.org Associate Editorial Director Melissa Varnavas mvarnavas@acdis.org Membership Services Specialist Penny Richards, CCDS Coordinator prichards@acdis.org Editor Linnea Archibald larchibald@acdis.org Associate Director for Education Laurie L. Prescott, MSN, RN, CCDS, CDIP lprescott@hcpro.com Director of Sales and Sponsorships Carrie Dry cdry@hcpro.com Copyeditor Adam Carroll acarroll@hcpro.com

DESIGN Design Services Director Vincent Skyers vskyers@blr.com Graphic Designer Tyson Davis tdavis@blr.com

These stories provide a backdrop for our CDI community, illuminating the possibilities not only for professional growth, but for where this profession might someday live—in every healthcare setting.

4 CDI Journal | MAY/JUNE 2018

That’s grandiose talk, but professionals attempting to start CDI programs in these settings share a common concern—how to get started. The biggest obstacle often relates to the payment system. The federal government, in the form of CMS, essentially has different reimbursement rules for each setting, and each setting also often has its own coding system, code grouping system, and rules and regulations regarding documentation. To be sure, it’s a large obstacle to overcome. Yet, those in the trenches tell stories about how they’re pulling apart these problems and gaining a foothold in their efforts by following the steps of their inpatient colleagues. First, they audit the existing records looking to see if everything coded (regardless of the code set used) was documented. Then they audit the records, to see if everything documented was coded. Through their auditing efforts they discover what trends appear and they investigate further. They talk to the coding team, the quality team, and physicians and try to uncover why those trends exist. Armed with this information, they’re able to make a case for which trends represent documentation improvement opportunities and how CDI efforts might benefit the program. It doesn’t end there, of course. As Sonia Trepina, MPA, director of ambulatory CDI services for Enjoin CDI in Collierville, Tennessee, explains in the article “Proving investment returns for outpatient endeavors,” that’s just the baseline.

From there, CDI staff need to determine how to structure their query process, how to measure CDI productivity, and how to engage physicians and other clinical care workers responsible for documentation. In home health, says Betty Brown, RN, COS-C, WCC, director of clinical compliance with U.S. CareNet in Augusta, Georgia, that caregiver could be a skilled nurse, social worker, or a physical, occupational, or speech therapist; and that documentation needs to get captured at the point of care, in the patient’s home. CDI professionals in the home health setting need to go still further than that, chasing down documentation from the referring physician to make sure the services provided are warranted. Is it daunting? Of course. But as Trepina says, “start with the data. From the data, figure out your [documentation opportunities]. Don’t get overwhelmed by the data ,and don’t try to make it a full-blown program right out of the gate.” If I did a little digging I might be able to get into the archives of my own local hospital to see what a medical record ooked like around my great-grandparents’ time, but my guess is that those records would be sparse. Who knows what kind of medical records doc Fullerton kept? All I know is that the care I want for my family—my parents and nieces and nephews—depends on the solid root system that is the medical record regardless of what branch of service that care is provided.

ADVISORY BOARD Sam Antonios, MD, FACP, FHM, CCDS CDI/ICD-10 Physician Advisor Via Christi Health Wichita, Kansas Samer.Antonios@via-christi.org

Angie Curry, RN, BSN, CCDS CDI Director Conifer Health Frisco, Texas angelia.curry@coniferhealth.com

Paul Evans, RHIA, CCDS, CCS, CCS-P Clinical Documentation Integrity Leader Sutter West Bay Area Emeryville, California evanspx@sutterhealth.org Katy Good, RN, BSN, CCS, CCDS CDI Training Materials Specialist Enjoin Gallup, New Mexico katy.good@enjoincdi.com

Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM-RN Director, Clinical Documentation Excellence Wake Forest Baptist Health Winston-Salem, North Carolina thicks@wakehealth.edu Robin Jones, RN, BSN, CCDS, MHA/Ed System Director, Clinical Documentation Excellence Mercy Health Cincinnati, Ohio RAJones@mercy.com

Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software Austin, Texas fran@iodinesoftware.com

Jeff Morris, RN, BSN, CCDS Supervisor, CDI University of South Alabama Health System Mobile, Alabana jwmorris@health.southalabama.edu

Laurie Prescott, RN, CCDS, CDIP, CRC CDI Education Director HCPro/ACDIS Middleton, Massachusetts lprescott@acdis.org

Erica E. Remer, MD, FACEP, CCDS President and Founder Erica Remer, MD, Inc. Cleveland, Ohio area eremer@icd10md.com Susan Schmitz, JD, RN, CCS, CCDS, CDIP Regional CDI director Southern California Kaiser Permanente Pasadena, California susanschmitz59@yahoo.com

Deanne Wilk, BSN, RN, CCDS, CCS Manager of CDI Penn State Health Hershey, Pennsylvania dwilk@hmc.psu.edu Irina Zusman, RHIA, CCS, CCDS Director of HIM Coding and CDI Initiatives NYU Langone Health Greater New York City area izusman@gmail.com

CDI Journal | MAY/JUNE 2018

NOTE FROM THE ADVISORY BOARD Tips for outpatient expansion By Anny Pang Yuen, RHIA, CCS, CCDS, CDIP

Because healthcare is changing so rapidly, many CDI programs recognize the importance of expanding their existing programs to cover areas that may be new to the majority of CDI specialists. As healthcare reimbursement shifts from fee-forservice to value-based models, CMS and other payers rely increasingly on reported data from programs like the Physician Quality Reporting System (PQRS) and Hospital Inpatient/Outpatient Quality Reporting (IQR/OQR). These programs evaluate the overall quality of patient care and the provider’s ability to manage costs effectively while providing that care. In turn, CMS uses this reported data to evaluate existing quality measures and/or develop new initiatives. Payers and technology firms promoting the use of analytics also use this data. CDI is now at the forefront in ensuring that the most specific diagnosis and/or procedure is captured across the continuum of care. Organizations have realized that the accuracy of reported data depends on accurate documentation of patient diagnoses and treatment plans regardless of the healthcare setting (inpatient, outpatient, etc.). As a result, more and more CDI programs are expanding their coverage to settings like outpatient, skilled nursing facilities, and/or service lines not traditionally reviewed by CDI specialists, like pediatrics and obstetrics. Broadening the CDI scope across the continuum of care allows all providers to report the most accurate data for quality measures, severity of illness/ risk of mortality, and readmission rates. In concept, a CDI department covering multiple settings can improve the accuracy of reported diagnoses and

6 CDI Journal | MAY/JUNE 2018

risk scores while helping to reduce the risk of inaccurate coding and reporting.

Data analysis Venturing into alternative settings should start with data analysis, whichallows an organization to identify key opportunities and prioritize focus areas. Focus areas may include office/clinic settings, emergency departments, observation status, etc. For example, if analysis identifies a significant opportunity to improve documentation in the outpatient setting related to capture of Hierarchical Condition Categories (HCC), evaluate which provider and/or clinic will benefit most from HCC education and target initial efforts there. The organization and CDI team should become familiar with their current data and develop a strategic plan. Focusing on the largest–impact areas first will make the expansion into the outpatient setting more effective in the long run.

Process improvement There’s no cookie-cutter method for outpatient CDI; rather, like everything in life, the practice of outpatient CDI will involve process improvement. This may be a significant adjustment for existing CDI programs. After performing the initial data analysis but prior to implementing an outpatient CDI program, identify how providers currently document. Determine their processes by asking questions such as: ■ Do they document completely in the elec-

tronic health record (EHR)? ■ Do they document while with the patient or

later in the day?

■ Do they like to be called, texted, or messaged

within the EHR? This helps staff creat a query process that has the least possible impact on the provider’s workflow. Unlike in the inpatient setting where the hospital is reimbursed by MS-DRGs, a provider in the office setting is paid by a reimbursement formula for physician services: Relative value units (RVUs). This formula calculates the volume of work expended by a provider when treating a patient; therefore, the more patients a provider sees, the more the provider is reimbursed. Consequently, providers would not want CDI specialists to interfere with their current workflow and thus constrict the number of patients they see in a day. What’s more, most providers are still adjusting to the decrease in time spent with their patients due to the implementation of EHRs. If CDI efforts aren’t planned appropriately, they will likely be met with some resistance.

Leverage technology Besides getting to know the organization’s data and current process flows, it’s vital to leverage technology to better improve the CDI process. Gathering data from a CDI perspective will allow the CDI team to develop more focused educational efforts and processes to ensure the greatest effect for the organization. Furthermore, the CDI and HIM teams can provide so much value during the process of implementing an EHR. Both of these teams understand the organization’s needs in terms of improving documentation gaps, meaning they will be helpful in streamlining and creating specific provider alerts within the EHR. For example, if the patient has Metformin as a daily medication during an office visit and is asking for a referral, an alert in the EHR could remind the provider to document the chronic condition associated with this medication refill request (e.g., type 2 diabetes). As healthcare continues to evolve with a stronger focus on data and technology, it’s an exciting time for CDI. There are so many opportunities to venture into uncharted territories. It’s time to be innovative and think

outside the traditional CDI frame of mind, while remaining nimble and open-minded to change. Understand that implementing an outpatient CDI program is like planting a flower and that it will take time, some trial and error, and nurturing for it to grow. The horizon is endless, and the CDI journey to alternative settings is just beginning. Editor’s note: Yuen is the principal of AP Consulting Associates, LLC and was a member of the ACDIS Advisory Board from 2015 to April 2018. The opinions expressed do not represent a consensus agreement of ACDIS or its Advisory Board. Contact Yuen at anny. yuen@apconsultingassociates.com.

BOOK EXCERPT An organization may want to consider the following questions when establishing an outpatient CDI program: ■■ Is your organization part of an accountable care

organization (ACO)? ■■ Do your providers participate in the Value-Based

Payment Modifier Program? ■■ Do your providers participate in Medicare

Advantage? ■■ Does your organization have access to risk

adjustment data (i.e., patient overall risk-adjusted score)? ■■ Do your providers receive reports from the Phy-

sician Quality Reporting System (PQRS)? ■■ What is your organization’s volume of denials for

medical necessity of patient status? ■■ What is your organization’s volume of denials for

outpatient surgical cases for medical necessity as a covered benefit?

Editor’s note: This is an excerpt from the book First Steps in Outpatient CDI: Tips and Tools for Building a Program by Anny Yuen, RHIA, CCS, CCDS, CDIP, and Paige Knauss, BSN, RN, LNC, ACM, CPC, CDEO.

CDI Journal | MAY/JUNE 2018

Proving investment returns for outpatient endeavors

or many, outpatient CDI is still a new frontier. An outpatient CDI effort might be kicked off by success on the inpatient side and some preliminary wins with outpatient record reviews for ambulatory or emergency services. Programs with full-blown CDI efforts into system-owned physician practices or other large-scale outpatient endeavors, though, need to prove a return on investment. This can be complicated for a couple reasons—namely, the prospective reimbursement model of outpatient claims and the dearth of outpatient CDI software programs to run meaningful metrics and reports. So, what can outpatient CDI professionals do to justify their

8 CDI Journal | MAY/JUNE 2018

continued efforts to the facility’s leadership? For this edition of the CDI Journal, ACDIS spoke to a couple people intimately aware of the troubles with calculating outpatient return on investment and how to crack this tough nut.

We use our vendor tools to see if there are any HCCs that haven’t been addressed this year. That’s essentially how we’ve shown our ROI.” – Jessica Vaughn, RN, BSN, CCDS

Defining a starting point The term “outpatient” means different things to different programs.

There are, however, some things any program can start with, regardless of whether it’s reviewing physician practice records, ED records, or any other outpatient area. “At the start of it all is data analytics,” says Sonia Trepina, MPA, director of ambulatory CDI services for Enjoin CDI in Collierville, Tennessee. “People are realizing the importance of that piece now. We’re in an environment of big data.” (To read a Radio Recap of an episode featuring Trepina, see p. 11.) Do some deep dives into chart audits and dissect the current metrics of the chosen outpatient population before beginning. This establishes a baseline against which to measure metrics six months or a

year into program development, Trepina says. As any CDI professional looking at an altered mental status diagnosis knows, it can be difficult to see things clearly without an established baseline. Additionally, initial data collection serves as the basis for a larger expansion into outpatient efforts. While the facility leadership may know the substantial effect CDI has on the inpatient records, proving there’s a clear and present opportunity for CDI expansion can help ensure leadership’s support for the needs of an outpatient program. That data sets the stage for you to justify why leadership should pour money and resources into this expansion plan. It also can illuminate the exact direction of your expansion and help find the right area for your CDI program to review. “We did some data analysis to see where the opportunities were located and piloted prospective queries,” says Jessica Vaughn, RN, BSN, CCDS, manager of outpatient clinical documentation excellence at Wake Forest Baptist Health in Winston-Salem, North Carolina. “We started by looking at prospective Medicare Advantage charts.”

Working with prospective payment problems Even armed with preliminary data to justify expansion and compare outcomes to the baseline, outpatient CDI can be challenging because Medicare’s outpatient reimbursement is prospective in

nature—meaning documentation improvements made in the chart this year won’t have a financial effect until at least one year later, depending on the diagnosis and quality measures attached to the chart. CMS uses a risk–adjustment methodology based on hierarchical condition categories (HCC). HCCs have to be captured on an annual basis in order to factor into the risk-adjusted payment for future years. CDI specialists have all heard it before, but even if you know a patient’s amputated leg is never going to spontaneously grow back, CMS needs that amputation documented annually. Trepina suggests focusing on cap-

Start with the data. From the data, figure out your [documentation opportunities]. Don’t get overwhelmed by the data, and don’t try to make it a full-blown program right out of the gate..” – Sonia Trepina, MPA

turing data and improving documentation related to patient and population risk scores (which are calculated partially based on HCC data, along with other demographic details such as age, sex, etc.). “If you’re looking at the risk-adjustment perspective, the risk score is really important,” she says. “You’d have to start at the patient level and then summarize that by practice and

provider. If you have multiple practices and they have similar populations, and one has a risk score of 0.9 and the other has a risk score of 0.7, investigate what’s going on there.” From there, CDI programs should track the HCCs being captured by physician and by practice to see how documentation efforts might close those gaps, she says. Even with solid dollar figures to show to leadership, CDI managers can demonstrate how the team is moving the needle, improving the documentation, and capturing the population’s conditions. The CDI team at Wake Forest Baptist Health does this very thing, according to Vaughn. “We use our vendor tools to see if there are any HCCs that haven’t been addressed this year,” she says. “That’s essentially how we’ve shown our ROI [return on investment]. We took our biggest value-based contract and started in our three largest clinics and with the payer that we could improve the risk-adjustment score on.” And, capturing those HCCs isn’t just important for the financial health of the institution, Trepina adds. “It is a model that supports quality care for the patient,” she says.

Leveraging software and automation Few outpatient CDI software solutions exist because the area is so new, but “the technology is moving in the [outpatient] direction,” says Trepina.

CDI Journal | MAY/JUNE 2018

Even though Wake Forest Baptist Health uses an electronic HCC tool, there is room for improvement, according to Vaughn. For example, the tool only includes roughly half the possible HCCs and “didn’t have cancer listed because [the company] thought it would be a liability,” she says. Despite this shortcoming, it actually helped Vaughn and the team prove their efforts mattered. “We were able to break down what the

10 CDI Journal | MAY/JUNE 2018

tool was doing for the risk-adjustment score versus what we were doing for it,” she says. “In the clinics we were in, we were able to make a 9% increase further than the clinics without CDI specialists.” Close examination of specific data sets can go a long way in helping programs illustrate their effectiveness, says Trepina. By starting with the HCC data and measuring risk scores over time, a CDI team can prove their positive effect on

finances (even if it doesn’t come to fruition for a year or more) as well as their benefit to patient care through better documentation. “Start with the data. From the data, figure out your [documentation opportunities]. Don’t get overwhelmed by the data, and don’t try to make it a full-blown program right out of the gate,” Trepina says. “Then, after you’re up and running, regularly evaluate to see what you’ve done and what you could add.”

RADIO RECAP

Focus reviews for HCC opportunities in the ED “HCCs [Hierarchical Condition Categories] aren’t just an ambulatory focus. This is inpatient and ambulatory, so it’s really important for [CDI professionals] to be tuned into this model,” said Brett Senor, MD, physician associate for Enjoin CDI on an episode of ACDIS Radio. HCCs affect both the inpatient and outpatient arenas. But, according to the episode’s poll, only 22% of CDI programs review for HCC capture. At the very least, CDI professionals should know about the model, said Sonia Trepina, MPA, director of ambulatory CDI services for Enjoin. The HCC model is a risk–adjustment methodology used for Medicare Advantage, population benchmarking for Accountable Care Organizations, and quality programs, Trepina said. Sometimes, conditions that qualify for an HCC also count as CCs/MCCs in the MS-DRG system. “Basically, HCCs are a statistical process used to identify and adjust for variations in patient outcomes that stem from differences in their patient characteristics across the health organizations,” she said. “It’s really important to get that risk score correct because it’s used prospectively for budgeting purposes.” While some aspects of a patient’s risk score are beyond a CDI specialist’s scope—such as the patient’s

demographics and Medicare eligibility status—the HCC portion of the score has to do with the patient’s comorbid conditions. And, because of the prospective budgetary aspect, HCCs have to be captured annually. Typically, HCCs are captured at patients’ primary care office during their annual visit. But, according to Senor, this isn’t always the case. “The ED is frequently overlooked and, it turns out, they [the ED physicians] serve as the primary healthcare providers for a lot of patients, particularly those that are termed ‘frequent flyers,’ ” he said. “Frequent flyer” patients (those who return repeatedly to the ED for ongoing care of chronic and emergent conditions) may account for higher costs and resource consumption, Trepina said, and capturing all their comorbid conditions will ensure that enough money is allocated for their care. “Maybe there’s another answer for them; maybe they shouldn’t be coming to the ED,” she said. With an adequate budget set aside for their care, these patients may have better care options in the following year. So, how can CDI professionals improve the capture of HCCs? Data analytics and physician education, according to Senor and Trepina. The analytics and a retrospective

documentation review will help CDI teams identify areas for improvement, Trepina said. Once the data is in hand, physician education starts. According to Senor, ED physicians need to be educated on three things: ■ Recognizing acute and

chronic comorbid conditions that are commonly encountered in the ED ■ Understanding the language

necessary to capture the appropriate specificity of these conditions ■ Demonstrating that each con-

dition was monitored, evaluated, assessed, or treated (MEAT) during an encounter Though the percentage of CDI programs reviewing for HCC capture is still small, compared to the the poll results from a previous ACDIS Radio episode, there has been an increase from 15%. “It’s great to see that there are more people in the CDI role doing this,” said Trepina. “Getting CDI professionals involved and aware of HCCs is so important.” Editor’s note: To listen to the complete show from February 14, click here. ACDIS Radio is a free biweekly show. To learn how to register and listen live, click here.

CDI Journal | MAY/JUNE 2018

NOTE FROM THE CDI PRACTICE GUIDELINES COMMITTEE

CDI efforts affecting the special care nursery By Cathy Farraher, RN, BSN, MBA, CCCM, CCDS

At a recent meeting, my facility coders discussed that our special care nursery (SCN) patients were an outlier for length of stay (LOS). This surprised CDI staff— the reputation of the unit was very good, so how could it be an outlier? At that time, CDI staff did not perform reviews on the SCN population. Knowing what I do about the importance of documentation and its effect on quality metrics, however, I asked my supervisor if she would allow me to see if I could help with the problem. Finance provided a report noting the following types of cases: ■■ Cases with a LOS of 21 days or more with an

APR-DRG weight of less than 3.0 ■■ Cases with a LOS of 14 days or more with an

APR-DRG weight less than 2.0 ■■ Cases with a LOS of 7 days or more with an APR-

DRG weight of less than 1.0 You may be wondering at this point what this is all about. Maybe you’re asking yourself, “I know about MS-DRGs, but what’s this APR thing?” So was I when I first started reviewing non-Medicare patients.

APR-DRG basics The All Patient Refined Diagnosis Related Groups (APR-DRG) system classifies patients according to their reason of admission, severity of illness (SOI), and risk of mortality (ROM). It’s similar to the MS-DRG system, but the numbers and the calculated LOS, etc., are different based on the population, which is neither elderly nor disabled. The APR-DRG system was developed by 3M™ to allow for more specific analysis of outcomes in the non-Medicare population. According to 3M’s data, APR-DRGs allow for better capture of quality and cost improvement, outcomes and performance measurement, prospective reimbursement, comparative profiling, clinical and operational redesign and improvement, documentation and coding improvement, financial and strategic planning,

12 CDI Journal | MAY/JUNE 2018

evaluation of resource needs, and payer negotiation for reimbursement that matches case–mix complexity. The APR-DRG scores are calculated from discharge billing codes and are based on primary and secondary discharge diagnoses, age, and preexisting medical conditions. In addition to other scores, the APR-DRG ranks ROM as low, medium, high, and extreme. APR-DRGs have four severity levels, and significant pediatric and adult problems have a separate APR-DRG, allowing for better risk adjustment, especially among pediatric patients. Birth weights for newborns, which will affect the risk of complications and mortality, are also separated into different APR-DRGs, something critically needed for accurate data analysis. APR-DRGs also offer a way to separate data pertaining to adults with eating disorders or substance abuse issues, for example, or pediatric patients with cystic fibrosis or scoliosis. This system is used by most commercial carriers.

Data analysis and education Having learned about the APR classification system, my next step was to take the data given to me and try to make sense of it. Having absolutely no experience with neonates or newborns professionally, I began by researching the types of problems these babies may experience, and the common diagnoses they face. As it turns out, babies aren’t all that different from adults when it comes to diagnoses like acute hypoxic respiratory failure, toxic metabolic encephalopathy, sepsis, etc., so I knew that much of my work would involve education. My first step was to meet one-on-one with the department chair. During our meeting, I provided a real-time look at a scenario being grouped, then explained the corresponding LOS associated with the final APR-DRG, as well as the same situation with some additional severity diagnoses added. Not surprisingly, she asked if I could present to the entire team as soon as possible. Complete and total engagement was the atmosphere in the room as I entered. Our lead coder came with me to support the validity of my presentation, as well as to answer any questions the attending neonatologists had about specific coding information. During my presentation (which, due to the cuteness factor of babies, was © 2018 HCPro, a division of BLR.®

one of the most fun presentations I’ve ever delivered) I provided the physicians with specific examples of cases that were documented as usual and compare them with the same examples documented with the specificity and acuity recommended by CDI professionals, and let them know how this affected their patients’ expected LOS. There were a few questions regarding our query process—a few comments along the lines of “We weren’t taught this in medical school, so why should it affect our quality ratings?”—but aside from that, the group was ready and willing to run with what I offered. Acute respiratory failure received quite a bit of discussion. Several of the physicians were adamant that they did not allow their patients to succumb to respiratory failure. When asked what they were treating when they provided CPAP or intubated a newborn, they all agreed that they were treating respiratory failure, as well as preventing it from becoming more severe. (Read an ACDIS white paper on pediatric respiratory failure here.)

Chart reviews and query opportunities I began reviewing cases immediately. Most didn’t have much opportunity, but those that did resulted in an incredible shift in expected LOS. Some of the more common diagnosis opportunities included: ■■ Apnea of prematurity or of newborn ■■ Jaundice ■■ Atelectasis ■■ Aspiration pneumonia ■■ Sepsis ■■ Respiratory failure ■■ Acidosis or alkalosis ■■ Hypernatremia or hyponatremia ■■ Retinopathy of prematurity ■■ Encephalopathy ■■ Congenital circulatory or cardiac anomalies ■■ Intraventricular hemorrhage (graded) ■■ Regurgitation and rumination ■■ Dehydration

There was also opportunity for additional education when queries were sent out. From the beginning,

I encouraged the providers to reach out with questions and did my best to provide real-time responses. With each verbal encounter, I included a reminder that a query was just a question, and not in any way intended to offer a “correct” answer—I was simply a second pair of eyes as a reviewer and was not rendering any medical judgement. The response rate, which is in my opinion the most important metric to measure, was in the high 90s. The department head and our physician advisor reached out to physicians when a query remained unanswered, and soon we were a hair away from 100%. Within a short time, our LOS statistics were in line with those of our peers, and we’ve since backed off on these reviews; however, the department chair is only a phone call away should the LOS begin to shift back into outlier territory. I recommended periodic audits to determine whether there will be a future need to resume reviews. For those interested in learning more about APRDRGs, LOS, and SOI/ROM, take a look at these articles: ■■ “Use of the APR-DRG Risk of Mortality Score as

a Severity Adjustor in the Medical ICU” by Daniel Baram, Feroza Daroowalla, Ruel Garcia, Guangxiang Zhang, John J. Chen, Erin Healy, Syed Ali Riaz, and Paul Richman, published in Clinical Medicine Insights: Circulatory, Respiratory, and Pulmonary Medicine ■■ “Predicting who dies depends on how sever-

ity is measured: Implications for Evaluating Patient Outcomes,” by Lisa Iezzoni, Arlene Ash, Michael Shwartz, Jennifer Daley, John Hughes, and Yevgenia Mackiernan, in the Annals of Internal Medicine ■■ “Q&A: Understanding SOI and ROM in the APR-

DRG system,” by Sharme Brodie, RN, CCDS, in CDI Strategies ■■ “Book excerpt: APR-DRG and the pediatric CDI

professional,” in CDI Strategies ■■ The APR-DRG fact sheet from 3M Editor’s note: Farraher is a CDI specialist at Newton Wellesley Hospital in Newton, Massachusetts. She was a member of the Massachusetts ACDIS chapter’s leadership team and is currently serving as co-chair of the CDI Practice Guidelines Committee. The opinions expressed do not represent a consensus agreement of ACDIS or its Advisory Board. Contact her at cfarraher@partners.org.

CDI Journal | MAY/JUNE 2018

CLINICALLY SPEAKING

Dysphagia: A topic not easy to swallow By Amy Sanderson, MD

The term “dysphagia” has many synonyms used by providers in medical documentation. However, not all of these symptoms are able to describe, with specificity, the real problem so it can be translated into its corresponding code assignment. What exactly is dysphagia? In short, it’s any abnormality in the process of swallowing that negatively affects the safety, efficiency, and adequacy of the intake of liquids and/or solids. Why is dysphagia important to recognize and treat in the pediatric population? Infants and children must be able to consume enough energy and nutrients to grow physically and develop cognitively. To understand dysphagia, let’s first explore the mechanism of a normal swallow (see references 1 and 2). There are four phases of swallowing: ■■ Oral phase ■■ Swallowing reflex ■■ Pharyngeal phase ■■ Esophageal phase

The important components of the oral phase are salivation, lingual-palatal coordination, and airway protection. Airway protection relies upon the epiglottis and laryngeal adduction. After the bolus of liquid or food is prepared during the oral phase, the swallowing reflex occurs. Next, propulsion of the bolus occurs during the pharyngeal phase. The esophageal phase consists of peristalsis and anti-reflux mechanisms. In neonates and young infants, all four phases of swallowing are reflexive and involuntary. Older infants are able to voluntarily control the oral phase, which allows for their learning to chew solid food. Although the swallowing reflex remains involuntary as the child ages, it can

14 CDI Journal | MAY/JUNE 2018

be voluntarily controlled if desired. Unlike the swallowing reflex, the pharyngeal and esophageal phases are always involuntary in children of all ages. Common signs and symptoms of dysphagia include: ■■ Weak or discoordinated suck ■■ Absent swallow reflex ■■ Laryngeal penetration (food and/or liquid enters

the laryngeal vestibule) ■■ Aspiration (food and/or liquid enters the airway

below the level of the vocal cords) ■■ Coughing or choking with feeds ■■ Nasopharyngeal regurgitation ■■ Arching or irritability with feeds ■■ Apnea, bradycardia, or desaturation with feeds

There are many medical conditions that may predispose an infant or child to developing dysphagia (see table 1). Table 1: Examples of conditions that may predispose a pediatric patient to dysphagia Anoxic or traumatic brain injury Congenital brain abnormalities raniofacial malformations (cleft lip/palate, C tongue tie, Pierre Robin sequence) euromuscular disorders (hypotonia, spinal musN cular atrophy, myopathies) Congenital heart defects astrointestinal disease (esophageal atresia, traG cheo-esophageal fistula, reflux) Prematurity Esophageal caustic injuries Medications that cause somnolence Laryngeal cleft Vocal cord paresis Esophageal motility disorders

CDI specialists can use the history of present illness to their advantage when looking for clues to dysphagia. The following parental or caregiver descriptions can prompt further exploration (see reference 3): ■■ My baby isn’t sucking well ■■ My child doesn’t want to feed ■■ My baby isn’t swallowing correctly ■■ Milk comes out my baby’s nose ■■ My baby is always hungry ■■ My baby always spits up and arches his back with

feeds ■■ My baby’s lips turn blue when she feeds ■■ My baby gets tired with feeds

To look for evidence of dysphagia in the medical record, it is helpful to review the results of diagnostic studies, such as videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallow (FEES) (see references 1 and 3). The VFSS is sometimes referred to as a modified barium swallow. This study allows for evaluation of swallowing in all phases. During the test, the patient swallows liquid or food impregnated with barium, and radiographic images are taken as the patient swallows. The main disadvantage of VFSS is radiation exposure. FEES does not involve exposure to radiation, but the patient must be able to tolerate passing of a nasal endoscope. Furthermore, FEES cannot evaluate all phases of swallowing; it only allows for visualization of the larynx and hypopharynx immediately before and after, but not during, the pharyngeal phase. Another excellent place to look in the medical record for evidence of dysphagia is a consult note from the feeding team or speech-language pathologist. These professionals perform bedside feeding evaluations by observing patients during specific feeding sessions. In addition, the diet listed in the order profile can provide yet another clue to dysphagia if it mentions that liquids must be thickened.

Although provider documentation may suggest a patient has dysphagia, the jargon may not allow coders to abstract the diagnosis. For example, a CDI specialist may read that a patient has “swallowing dysfunction” or “oromotor dysfunction.” Neither of these phrases allows coders to capture dysphagia. “Feeding difficulties” does have a code, but this term may not describe the specific problem of dysphagia. For example, “feeding dysfunction” could describe oral aversion or a behaviorally based feeding problem, which occurs when a child has adequate ability to consume food, but refuses to do so. “Gastrostomy tube dependent” codes to gastrostomy status but this diagnosis alone may miss the underlying indication for a gastrostomy tube. Moreover, documentation of aspiration pneumonia can be a good prompt to query for dysphagia. In summary, dysphagia is an important diagnosis to identify, document, and treat. CDI specialists can use various sections of the medical record to uncover clues that a patient may have this condition. For those looking for more resources on dysphagia, here are a few references for you: 1. Dodrill, P., Gosa, M. M. (2015). Pediatric Dysphagia: Physiology, Assessment, and Management. Ann Nutr Metab, 66 Suppl 5, 24-31. 2. Jadcherla, S. (2016). Dysphagia in the high-risk infant: potential factors and mechanisms. Am J Clin Nutr, 103(2), 622S–628S. 3. Merrow J. M. (2016). Feeding Management in Infants with Craniofacial Anomalies. Facial Plast Surg Clin North Am. 24(4), 437-444. Editor’s note: Sanderson is a pediatric intensivist at Boston Children’s Hospital. She has been the physician advisor of the CDI program since its inception in 2014. She is also an assistant professor in anaesthesia at Harvard Medical School. She was a contributor 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 Amy.Sanderson@childrens.harvard.edu.

Pediatric CDI Building Blocks for Success.

CDI Journal | MAY/JUNE 2018

Inpatient psychiatric facilities: A whole new world

“

I remember talking to some of the folks who work in CDI at conferences, and when I would ask them about psych units, none of them had CDI working on those units at all,” says Suzanne Dennis, CTRS, CCDS, director of clinical services/documentation specialist at Acadia Healthcare Company, Inc., a Franklin, Tennessee–based a company that owns private psychiatric hospitals in the United States and Puerto Rico. Finding other people who conducted concurrent documentation improvement efforts in freestanding inpatient psychiatric facilities proved difficult for Dennis. Inpatient psychiatric facilities use ICD-10 codes, just like their inpatient

16 CDI Journal | MAY/JUNE 2018

acute care counterparts, but their payment structure, documentation requirements, prevalent clinical conditions, and additional documentation requirements needing capture are totally different.

Payment and criteria differences When the inpatient prospective payment system (IPPS) became law in the 1980s, freestanding psychiatric hospitals were exempt. Like some cancer centers today, psychiatric facilities were not paid based on DRGs—that is, until the Balanced Budget Refinement Act of 1999. This new act specified that, beginning in 2005, psychiatric hospitals would be paid under the Inpatient

Psychiatric Facility Prospective Payment System (IPF PPS).

When I asked [people at conferences] about psych units, none of them had CDI working on those units at all.” – Suzanne Dennis, CTRS, CCDS

Since then, Medicare has required psychiatric facilities to provide: ■ Proof that the active treatment

can reasonably be expected to improve the patient’s condition ■ Documentation for services

necessary for diagnostic treatment

■ Proof that the patient’s inpa-

tient stay meets the need for active inpatient treatment by IPF personnel at the time of admission, 12 days after admission, and no less than every 30 days that the patient continues receiving treatment Even after meeting those criteria, Medicare still only covers patients for 190 days of care in freestanding psychiatric hospitals. Psychiatric facilities follow the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM5) for diagnostic criteria for mental disorders and use ICD-10-CM for code assignment. The disconnect between these clinical and coding definitions makes CDI specialists’ role more difficult when it comes to physician engagement. For example, the DSM-5 replaced the term “dementia” with either major or minor neurocognitive disorder. ICD-10, however, still includes a code for dementia. This means that providers working in the psychiatric setting may be documenting clearly according to the DSM-5, but their documentation may not seamlessly translate to ICD-10 codes. “Our CDI program really started with ICD-10. I invited everyone [to an educational session] and explained the effect of ICD-10,” says Linda Jackson, RHIT, director of HIM at Arkansas State Hospital, the only freestanding, state-run psychiatric facility in Arkansas, based in Little Rock. At the time, however, “DSM-5

had only recently taken effect and they were already overwhelmed.” When the DSM-5 was published in 2013, the diagnostic codes in the manual corresponded to the ICD codes. However, each year since, the four Cooperating Parties updated ICD-10, so the correspondences slipped over time. Such discrepancies equal big educational

“concentrates on operational systems critical to the safety and quality of care, treatment, or services provided to the individual.” When Joint Commission surveyors come into a facility to conduct reviews, they scrutinize every aspect of operations, including documentation. While acute care settings also often undergo Joint Commission

There’s more scrutiny for us than there is for acute care hospitals. If you want to show you’re being transparent, it has to start with the documentation.” – Linda Jackson, RHIT

opportunities for both clinical and coding staff. “The physicians [received] some education, but a lot of it has gone to the coders,” says Dennis. That way, when coders encounter something in the documentation like “major neurocognitive disorder,” they know what ICD-10 code it corresponds to. (For a guide on translating DSM-5 terminology to codes updated in the 2018 release of ICD-10-CM, visit the American Psychiatric Association website.)

Outside scrutiny Coding and reporting requirements for inpatient psychiatric care are stringent enough to warrant CDIlevel reviews, but psychiatric facilities also receive scrutiny from other outside agencies, too. Most receive accreditation from the Joint Commission, which evaluates specific documentation concerns via surveys on a triennial basis. The survey process, according to The Joint Commission,

surveys, “it’s a different set of federal tags and requirements under Medicare for free-standing psych hospitals than it is for psychiatric units within an acute inpatient hospital,” says Dennis. “There’s more scrutiny for us than there is for acute care hospitals,” says Jackson. “If you want to show you’re being transparent, it has to start with the documentation. These are people who can come into the facility and have pretty much free rein, looking at documentation and anything else.” Ensuring that the documentation (and consequently the coded data) is correct and accurate shores up a psychiatric facility’s accreditation from the Joint Commission and its reimbursement from CMS. Since CDI professionals are educated on the coding and clinical nuances, they’re uniquely positioned to ready the facility for surveys. Since the CDI staff helped with other projects in the past, facility

CDI Journal | MAY/JUNE 2018

administrators asked them “to handle the surveys when it’s that time of year,” says Jackson. “We put in the work and we got a lot of kudos.”

Implementation and processes Like other settings, the reasons for CDI program implementation vary depending on the needs of the facility. For Jackson, the impetus came from the impending ICD-10 implementation date, which followed quickly on the heels of the DSM-5 rollout. Due to the importance of capturing specificity in ICD-10, Jackson started her CDI efforts by investigating a selection of records and identifying the number of unspecified diagnoses. “I was startled by how many there were,” she says. Then, armed with an array of information, she invited key players— from clinical staff to facility leadership—to a presentation demonstrating the effect of documentation specificity when moving to ICD-10. “I basically told them, we can’t go into ICD-10 the way we’re documenting now,” she says. “I was trying to lead them to the water. After you start by scaring them, you have to give them a lifeline.” The best possible lifeline, she explained to the stakeholders, is CDI. In fact, Jackson’s presentation was so compelling that the administrators asked her to hire two CDI specialists rather than just one. Of course, finding one—let alone two—trained CDI specialists with psychiatric experience would be near–impossible. So, Jackson hired

18 CDI Journal | MAY/JUNE 2018

two nurses from within the facility and set about educating them. “I sent them to an ACDIS Boot Camp, and they took a coding class offered at the University of Arkansas for Medical Services,” she says. She also had the nurses visit other CDI programs. “They went to two acute care hospitals, a children’s hospital,

I basically told them, we can’t go into ICD-10 the way we’re documenting now. I was trying to lead them to [implementing CDI]. After you start by scaring them, you have to give them a lifeline.” – Linda Jackson, RHIT

and another local facility and shadowed the CDI teams there.” Though none of these learning experiences were directly related to psychiatric facilities, Jackson says that hiring from within gave the new CDI specialists the clinical understanding and physician relationships to translate what they learned to their own facility. Because of this education, the CDI process at Arkansas State Hospital looks very similar to that at an acute care facility, focusing on concurrent reviews and concurrent queries. Dennis’ CDI journey was less traditional, coming to Acadia Healthcare Company from a process improvement role that included some documentation work. Acadia wanted to leverage her previous documentation experience to ensure accurate reimbursement and

survey readiness. Still, Dennis is the only person in a corporate CDI role at Acadia. Because Acadia is a corporation that owns private psychiatric facilities, Dennis focuses on education and retrospective audits. She periodically visits each facility with Medicare patients to review records and conduct education, she says. “Basically, I look at records, I audit, and I train,” says Dennis. “I look at all the documentation from all the caregivers, not just the physician, and ask myself whether all the documentation from the care team supports the care plan.” In addition to her own auditing, Dennis works with an outside company that does coding and documentation audits to identify any potential errors. “The companies we use tend to do the education with our coders, but I assist them,” she says. “If a facility is having a difficulty, we may do some extra focused audits with them too.” Because Acadia’s facilities are farflung across the entire country, Dennis’ CDI work alternates between her home office and the facilities. “If I’m in a facility, I would be doing chart reviews, meeting with the quality director, medical director, CEO, and identifying opportunities for improvement and an improvement plan,” she says. “If I’m working from home, I might be doing some remote auditing, but more often I’m following up with facilities about their progress and working on projects with our Compliance and Clinical Services team.”

Physician education opportunities

says Dennis. “That all rolls into the complexity of the patient.”

Though Jackson and Dennis have very different CDI processes and facilities, all CDI professionals have to interact and work with providers.

“When we first started reviewing charts, we had a lot of comorbidities missing,” says Jackson. “It was helpful to have the nurses documenting those conditions, too,” as that gave the CDI specialists the indicators to support queries. Upon the CDI program’s rollout, Jackson also did a lot of education on unspecified diagnoses, especially when it came to missed medical comorbidities.

In one sense, “doctors are doctors, whether they’re in behavioral health or not,” says Jackson. However, CDI professionals who work with different specialties also know that “one doctor’s love language is different from another,” she says. So, just as in the acute care setting, CDI professionals working in psychiatric facilities need to get to know the individual personalities of their medical staff, keeping in mind the clinical scenarios and query opportunities will likely differ from those in the acute inpatient setting. For example, psychiatric physicians typically capture the patient’s psychiatric condition, according to Jackson, but those patients may experience other conditions that fall more on the medical side of things, which psychiatric physicians aren’t used to documenting. Think about the trauma physician who documents the largest, most severe injury, but neglects documenting the smaller ones: They’re simply not what that physician is principally focusing on, even though they’re still being treated. Similarly, on the psychiatric unit or facility, this is where CDI has the most opportunity, Jackson and Dennis agree. “You have to ensure that the patient’s medical problems that are being treated are also captured,”

“That’s one way to measure your success, actually,” she says. “You need to decrease the amount of unspecified diagnoses.” Dennis extols the benefits of educating nonphysician clinicians at psychiatric facilities. “I talk to physicians, nurses, social workers, activity therapists, and some direct care staff. Really, I educate anyone who may be doing some of the charting,” she says. This helps ensure that all the members of the care team—whether they’re concerned with the patient’s mental or physical health—understand the need for complete and accurate documentation and are helping to paint the clearest picture possible of that patient. Dennis also suggests creating some forms and templates for the providers to use in their charting. “Every form is only as good as the person filling it out, though,” she warns. “When you have facilities using multiple different forms, you keep stumbling upon facilities that are missing needed documentation.”

At Acadia, Dennis developed forms by identifying which of the facilities performed the best on CMS and Joint Commission surveys. Then, she took the forms from those facilities and, after some minor revisions and finessing, rolled them out companywide to ensure everyone documented to the level of specificity needed for survey success. CDI should also be a visible resource to the providers, says Jackson. “The CDI specialists are members of the UR [utilization review] committee, they meet with the administration,” she says. As the saying goes; “out of sight, out of mind. You’ve got to be involved.” Jackson also sends out a monthly newsletter to the providers giving them documentation tips and highlighting one physician each month. “A little healthy competition goes a long ways,” she says. Also included in the newsletter are tips for nursing documentation to bring them into the documentation process, Jackson says. “We include specific things they should be noticing.” Ultimately, though the documentation requirements and the clinical conditions may differ from a traditional inpatient acute care facility, CDI operating in a psychiatric facility still has the same goal as any other: Accurate documentation and coding that reflects the patient’s stay. To accomplish this, Jackson suggests starting with collaboration and education. “You have to tap into the resources you have at your facility,” she says. “It all starts with the culture.” CDI Journal | MAY/JUNE 2018

GUEST COLUMN

Can remote CDI really work for you? Really? Really! By Karin Killenberger, BSN, RN, CCDS

Working as a remote CDI specialist can be either totally fulfilling or a bit difficult. If you’re a people person, you will miss the camaraderie of working in the hospital setting, the ability to problem-solve by bouncing ideas off your coworkers, the gossip, and the potlucks. On the other hand, if you’re organized and self–motivated enough, enjoy peace and quiet, and prefer wearing your pajamas to work, remote might be right up your alley. Hospitals looking to save money have long found remote staffing an effective alternative to on-site employees. Of course, it only works in an organization that has a 100% electronic medical record, and an established, successful CDI program. Besides the relaxed dress code, a remote program has other perks, both for employers and employees. For the hospital, there is a brick-and-mortar savings of not having to provide a large office for numerous CDI specialists. The hospital is also able to hire from a much wider pool of applicants, as candidates don’t need to live in the same state as the facility. For the CDI professional, there’s no commute, no parking issues, and increased productivity due to fewer interruptions. And, again, let’s not discount the ability to wear your fuzzy bunny slippers to work.

you answer yes to the following questions, then remote might be more suitable: ■■ Are you disciplined? ■■ Are you a self-starter? ■■ Are you able to problem solve on your own with-

out help? Remote CDI professionals often don’t get to speak with the doctors they query, unless by some miracle the physician initiates contact. Usually physicians receive an electronic query and answer it, possibly (but rarely), calling you to discuss it. You won’t be in meetings with other CDI specialists or coders, except for web conferencing or phone calls. There is no on-site IT department, so you have to solve your own computer issues (unless the issue is with your hospital’s server or software, in which case the hospital’s IT department should be able to assist you). When you do have burning questions that need immediate answers, remote programs often leverage instant messaging, email, or phone to connect staff to a CDI manager, a physician champion, or a fellow CDI specialist.

Tips for remote CDI professionals

■■ Are you unable to function without supervision?

In my experience as a CDI professional, I found that working as a traveling contractor was difficult because the physical travel ate up so much of my time. I had to deal with long drives to airports, waiting on luggage, waiting on rental cars, getting lost trying to find the hospital I was assigned to, and then doing it all in reverse when it was time to head back home. Of course, there is travel and traffic to the hospital if you are an in-house CDI specialist as well.

If you answered yes to any of these questions, remote is probably not the right fit for you. On the other hand, if

Now, I have about a 30-second “commute” to my office and find working for a hospital across the country fairly simple. I think my past experience as a traveling

Determining whether remote work is for you First, take a self-inventory. Ask yourself the following questions: ■■ Are you easily distracted? ■■ Do you crave human contact?

20 CDI Journal | MAY/JUNE 2018

CDI professional helps me a lot in my job, as I’ve learned there are many ways to accomplish the same thing. Know what your organization expects of you as a remote CDI specialist and understand the metrics you must meet. Even though you can work in your comfy clothes and let your cat sleep on the desk, you still need to keep up with Coding Clinic, read the CDI Journal, get on the quarterly conference calls, and stay current. Keep an open mind, as you will be dealing with physicians you have not had the pleasure to meet face-toface. Not knowing personalities can make you “hear” things in an email that really aren’t there. Remember to be professional when you answer the phone, as it may be a physician calling you about a query.

Even though you don’t reside in the same physical space, keeping the lines of communication open between you and your manager, the physicians, and anyone else you need to deal with is key. No one will know you are having a problem if you don’t tell anyone. I’ve found it helpful to network with other remote CDI staff in order not to feel isolated. Also, don’t neglect taking short breaks to stretch, start the dishwasher, and pet that cat. That all helps with productivity! Editor’s note: Killenberger is a remote CDI specialist at Harmony Healthcare based in Howell, Michigan. Contact her at karinkillenberger@gmail.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

CODING CLINIC FOR CDI

CDI concerns appear in newest Coding Clinic release By Sharme Brodie, RN, CCDS

So, the first AHA Coding Clinic for 2018 is out, and I must admit, I was surprised at its length. At only 26 pages, it is one of the shorter editions of late. Some of the questions covered within its few pages, however, were ones I often discuss while teaching my classes, which was a pleasant surprise.

Salter-Harris fractures Let’s start with the coding information about Salter-Harris fractures on p. 3. This type of fracture occurs through the growth plate and can affect the development of the fractured limb. The question about coding of this type of fracture was asked because the Alphabetic Index and Tabular List instructions really are confusing; it was not clear if one code or two are necessary for accurate code assignment. Coding Clinic answered that coding of a Salter-Harris fracture takes priority over a simple fracture, because of future care implications due to the involvement of the growth plate, making it very important to identify a

fracture as a physeal fracture. Only one code is needed to identify a single physeal fracture.

Liver cirrhosis and chronic viral hepatitis On p. 4 of this Coding Clinic, a question was asked regarding the coding of ascites when a patient presents with ascites due to liver cirrhosis and chronic viral hepatitis. There was some concern because the Index to Diseases leads to code K71.51, Toxic liver disease with chronic active hepatitis with ascites. The question asked whether this code would be inappropriate since the physician didn’t document “toxic liver disease.” Coding Clinic answered that the coder should assign codes B18.2, Chronic viral hepatitis C, K74.60, Unspecified cirrhosis of liver, and R18.8, Other ascites, to capture these conditions. The rationale given was “while the ascites is due to the cirrhosis, and the cirrhosis is due to the chronic viral hepatitis C, ascites is not always present with these

CDI Journal | MAY/JUNE 2018

conditions, so it is appropriate to convey the full clinical picture and assign an additional code for the ascites.” It went on to say that code K71.51, toxic liver disease with chronic active hepatitis with ascites, was not appropriate in this case since the patient did not have toxic liver disease. What I really appreciated about this question and answer was that it mirrors what we teach in our boot camps: “trust your gut.” When the advice given seems wrong or is confusing, Coding Clinic stated that “a basic rule of coding is that further research/review may be required, if the code indexed does not identify the condition correctly” and, as always, the provider should be queried if any additional clarification is needed.

Colonoscopies We talk in class a lot about colonoscopies, perhaps because I’m a former GI nurse. Specifically, we talk about how biopsies affect code assignment. On pp. 6—7, Coding Clinic discussed a patient coming in for a screening colonoscopy due to increased risk of cancer. The question didn’t mention the patient’s age, but stated the patient had a family history of colon cancer. During the procedure, a rectal polyp was removed, and the pathology report came back “hyperplastic polyp with focal adenomatous changes.” The question asked whether to assing code K62.1, Rectal polyp, or code D12.8, Benign neoplasm of rectum, be assigned for a hyperplastic rectal polyp with focal adenomatous changes. The answer was to assign code Z12.11, Encounter for screening for malignant neoplasm of colon, as the first-listed diagnosis, then assign code D12.8, Benign neoplasm of rectum, as an additional diagnosis for the hyperplastic polyp with focal adenomatous changes, as well as code Z80.0, family history of malignant neoplasm of digestive organs. This is a definitive finding of an adenomatous polyp. A mixed polyp would be treated clinically as an adenoma, which requires stricter surveillance and follow-up. This is a great example of why it’s so important to demonstrate what’s going on with the patient clinically for code assignment. If this patient was not of a certain age, a screening colonoscopy may not be covered by

22 CDI Journal | MAY/JUNE 2018

certain payers, but with the family history code of malignant neoplasm, medical necessity for screening and follow-up testing may be supported. Often, coded data is also used for many different reasons, which is why we want it to be as accurate as possible.

Time on a ventilator Ventilator time is usually a lengthy conversation during class, but I don’t think we’ve ever discussed the scenario found on pp. 13—14 of this Coding Clinic. The question asked about a patient with progressive muscular dystrophy, who is “vent dependent” at night and as needed during the day. The patient was admitted to the hospital with acute-on-chronic respiratory failure. While in the hospital, the patient was connected to his own ventilator equipment via his tracheostomy tube. The respiratory therapist evaluated and monitored the patient throughout the hospitalization. Would it be appropriate to assign an ICD-10-PCS code for the use of the patient’s ventilator? I am very happy Coding Clinic responded by stating “since the patient is still being evaluated and monitored, as well as receiving ventilator assistance and utilizing hospital resources that the ownership of the equipment has no bearing on code assignment. We would count the hours of ventilation according to established guidelines, with the start time being when the ventilator starts.”

Identifying body parts When building an ICD-10-PCS code, it’s not usually a problem for a CDI specialist or coder to determine the appropriate body system or body part value. Sometimes, however, it’s not as clear as we would like. In the example on p. 14, the patient had necrosis and cellulitis of the right breast with a small area of skin necrosis. The patient underwent an open debridement of the “right breast tissue,” including skin and subcutaneous tissue. The question asked what the appropriate body part value would be in this instance. Would it be the skin or right breast tissue? Coding Clinic answered that we should use code 0HBT0ZZ, with the specific body part value being “right

breast.” It’s important to have the correct body part value because debridement of the skin remains a medical DRG, but debridement of the breast tissue leads to a surgical DRG, which has a higher weight.

Alcohol abuse Another frequent topic of conversation in class, which was discussed on p. 16, was alcohol abuse and withdrawal. In the scenario, a 21-year-old was admitted due to alcohol abuse and the provider documented alcohol withdrawal. The physician was queried and clarified that the patient had alcohol withdrawal but was not alcohol– dependent. However, coders cannot assign a diagnosis of alcohol withdrawal without dependence, so they asked Coding Clinic how to accurately code this case. The answer tells us that in ICD-10-CM, “alcohol withdrawal” is categorized as alcohol dependence and ICD-10-CM does not classify “alcohol withdrawal” with alcohol abuse, rather than dependence. Only the code for “alcohol abuse” would be assigned. Maybe at some point ICD-10-CM will have a code for “abuse with dependence,” but until then, this is how it will be coded. Sometimes, what’s going on clinically with the patient and the code assignment don’t match. This is why it’s important for CDI specialists to be aware of the information supplied in the Official Guidelines for Coding and Reporting and in Coding Clinic so we know when a query is needed.

Change in mental status I found the next question and answer on p. 16 to be very helpful, and I think many of you will also. The question asked, “A patient with mental status changes is admitted and after diagnostic studies, the provider diagnosed sepsis due to Escherichia coli (E. coli) urinary tract infection (UTI). What are the appropriate code assignments for this diagnostic statement? There is confusion among coding professionals regarding the application of the instructional note stating: ‘Use additional code (B95B97), to identify infectious agent’ at code N39.0, Urinary tract infection, site not specified, versus assigning a code that identifies both sepsis and the infectious agent.” The answer makes sense to me, but I understand the confusion. Coding Clinic stated to assign code A41.51,

Sepsis due to Escherichia coli [E. coli], and code N39.0, Urinary tract infection, site not specified, for the UTI. It continued with the advice that the organism (E. Coli) is represented in the A41.51 code and that assigning code B96.20 as an additional code would be redundant. In the past, most of us would have queried the provider for the organism responsible for the sepsis, but based on this information, we will not have to do so going forward.

Coding non-provider documentation for social information As CDI specialists, it’s very important for us to know when we absolutely need to query a provider or when another clinician’s documentation is acceptable for code assignment. What about when the information being coded is social information about the patient versus medical diagnoses? Would it be appropriate to assign these codes based on documentation by other clinicians and not just provider documentation? On p. 18, the answer was just what I expected: “Categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, represent social information, rather than medical diagnoses. As such, it is acceptable to report these codes based on information documented by other clinicians involved in the care of the patient.”

’Concern for’ Lastly, the information given on p. 18 defines “concern for” as a term that should be interpreted as an uncertain diagnosis and coded following the guideline for “uncertain diagnosis” in the inpatient setting. The Guidelines state that codes are assigned for uncertain diagnoses in the hospital inpatient setting if the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms indicating uncertainty.

Editor’s Note: Brodie is a CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps. com/courses/10040/overview.

CDI Journal | MAY/JUNE 2018

CDI in home healthcare focuses on education

here are 12,400 home health agencies which provided care to 4.9 million patients in 2014, according to the Centers for Disease Control and Prevention. In light of efforts to keep patients from being readmitted to hospitals, and to keep the hospital stays they do undergo as short as possible, the number of patients seen in their own homes is expected to rise more in the coming years.

coded data] could review the documentation and know it’s complete and accurate, it will ensure appropriate reimbursement,” says Joan Usher, BS, RHIA, ACE, president and CEO of JLU Health Record Systems in Pembroke, Massachusetts.

Unlike traditional CDI programs, which begin by focusing on CC/ MCC capture rates and MS-DRG optimization for reimbursement, home health CDI efforts seem to be born from quality concerns despite the fact that home health agencies do use ICD-10-CM codes and Home Health Resource Groups (HHRG) for billing and reporting purposes.

For example, Medicare compensates home health agencies based on a 60-day episodic payment derived from the HHRG, says Betty Brown, RN, COS-C, WCC, director of clinical compliance with U.S. CareNet in Augusta, Georgia. Each time a home health provider visits the patient’s home, that provider must document the care he or she provides. Each note the home health providers document must meet specific Conditions of Participation requirements (medical necessity, skilled need, and homebound status) for Medicare to reimburse the home health agency.

“In home health, we have specific process and outcome measures we need to meet [which are] publicly reported on Home Health Compare. We could advance those measures with improvements in documentation. If [the agencies abstracting

24 CDI Journal | MAY/JUNE 2018

In addition, Medicare and CMS (by way of the Medicare Administrative Contractors [MAC]) require a number of documentation criteria in order to qualify for payment.

If the documentation criteria are not met for each note, then Medicare can request the agency to submit the entire record for an additional developmental review to determine if each note met the criteria for payment, Brown says. “If the criteria were not met, then a potential episodic payment can soon become a per visit payment,” she says. Patients receiving home healthcare also need to have seen a physician within either 90 days before or 30 days after the start of care, says Usher. “We still find that the face-to-face documentation coming over from the physicians isn’t complete and puts the agency’s reimbursement at risk,” she says. “CDI can review this documentation and provide some education to the physicians, audit as needed, and query the providers and clinicians.” This means that the CDI specialist may also be reaching out to and working with a physician not employed by the home health agency. When the referring physician’s documentation is unclear, it

can not only set up the agency to lose its episode payment from CMS, but also spell worse care for the patient, Brown says. “Documentation isn’t just important payment-wise, it’s also important for the patient,” she says. “Each nurse needs to know what’s happening with that particular patient.”

CDI program implementation Like other CDI expansion efforts, home health faces several potential stumbling blocks such as gaining leadership support. Usher suggests focusing discussions on the ways in which coded data is used. “Information governance is becoming more and more important,” she says. Information governance means that the documentation in each patient’s medical record is correct and accurately reflects the care given so that the coded data can be used for a myriad of purposes— forecasting population health, quality reporting, accurate reimbursement, monitoring case-mix index, and improving patient care and safety. “The documentation has to show that you’re taking good care of your patient,” says Brown. “Otherwise, you’re doing your patients and your agency a disservice.” Each home health provider needs to know what’s actually happening with individual patients in order to care for them in the most effective way. All that information comes from the documentation, says Brown, who also suggests focusing on outside scrutiny from both publicly

reported quality data and CMS auditors for program justification. Since CMS looks at the documentation to decide whether to pay for an episode of care, CDI programs need to make clear to administration the differences between complete documentation qualifying for an entire episode of care versus paying per the note, Brown says. “You need to ensure you’re getting appropriate reimbursement supported by the level of documentation in the EHR,” agrees Usher. As far as staffing for the fledgling CDI program goes, it largely depends on the size of the home health agency and the number of referring physicians who may need education. According to Usher, there are essentially three models for CDI: 1. Case management model: CDI works with case management or utilization review as well as discharge planning to improve documentation 2. Clinically based model: CDI works concurrently on clinicians’ visit documentation, as close to real time as possible 3. Health information management (HIM) based model: CDI is part of the organizationwide information governance team According to Usher, CDI specialists in home health should at minimum have three to five years of a clinical or HIM background, regulatory experience, and an understanding of ICD-10.

Home health CDI efforts should also include collaboration with quality assurance nurses who can look at the charts retrospectively, after coding, to identify potential education opportunities, says Brown. Then, the program manager can educate the referring physicians or home health clinicians visiting patients to ensure future documentation avoids the identified mistakes.

Timing and location troubles Gaining support and staffing a CDI program is only part of the battle, however. For one thing, the patient and the associated documentation aren’t within the walls of the facility— and that means the provider isn’t either, making the query process more difficult. Another trouble is that the care and documentation take place in the patient’s home, making it impossible for CDI specialists to query concurrently like they would in a traditional inpatient acute care setting. “We encourage that [home healthcare clinicians’] documentation takes place in the home because you’re getting your best assessment captured in the home,” says Brown. “Unfortunately, we know that’s not always the case. It’s patient care, and you’re trying to do your job. Plus, we are in the patient’s home, and so we are a guest and we need to honor their wishes.” The best practice, though, is to document at the point of care: either in the home or in the car immediately after the visit, Usher says. Additionally, some home health agencies still have medical records

CDI Journal | MAY/JUNE 2018

that are at least partially paperbased, Brown says. Thus, for CDI specialists to review those records, they have to wait for the information to be scanned into an EHR or they need to be in the home health office, waiting for the records to arrive.

When Medicare reviews the claims and decides whether to pay for the 60-day episode of home healthcare, it will be looking at the other clinicians’ documentation, so the CDI team in home health needs to do so as well, says Brown.

do work for the same organization as the CDI professional. Add in the fact that they have virtually no obligation or incentive to comply with a home healthcare CDI specialist they may have never met in person, and things get even dicier.

“Most home health agencies use an electronic medical record, but there are some mom-and-pop agencies that don’t have the whole thing electronic,” she says.

“You have to look at all those beautiful pieces of the picture,” she says. “If your MAC wants to do an additional documentation request, all those disciplines have to meet all three of the criteria too, not just the physician’s documentation.”

“We try to work with liaison nurses. When the [home health aides] have a liaison nurse in the hospital, they definitely have relationships with the physicians on each floor,” says Usher. “Identify your top five referring physicians and focus on educating them. The CDI specialist could work with the liaison nurse and educate them, or the liaison could provide an introduction to the physician.”

Clinician education Since CDI specialists aren’t querying the clinician in real time and the documentation may not be immediately available for review, much of CDI work in home health focuses on education. CDI’s role is to prepare the clinicians to document fully when they’re in the home or soon after they’ve left, according to Brown. “Once you find some issues in the documentation, it’s all about education,” she says. “After education, you make a plan of action. Then you go back through and inspect what you’re expecting,” meaning that, after the education is provided, the CDI professionals should look at documentation to ensure the education stuck in the clinician’s mind. And CDI education cannot be limited to physicians, Usher adds. Since most home healthcare is provided by nurses and other clinicians, those providers are doing the majority of the documentation. “You have to improve the documentation with the nurses and therapists,” says Usher.

26 CDI Journal | MAY/JUNE 2018

Take advantage of any existing time when the clinicians are all together under one roof to provide education, Brown suggests. “Usually, our clinicians are in the office working once per week to go over all the different patients and their needs. That’s usually where I provide some education. In-person education is always the best option because you can see if people understand what you’re saying. It’s our role to give them the tools they need to succeed,” Brown says.

Referring physician education Another complicating piece of the home health puzzle is that, unlike the acute care facilities, the referring physicians aren’t employed by the home health agency itself. This can complicate things for CDI specialists. “For home health, they’re making a referral for services. It can be much more difficult to query an MD and actually get a reply,” she says. As a CDI professional in any setting knows, physicians can be difficult to win over even when they

Home health CDI professionals should also have supportive materials on hand to give to referring physicians regarding documentation requirements and high-volume improvement opportunities, Usher suggests. Providing resources that help with physicians’ individual practice work makes the CDI specialists welcome helpers rather than impositions. “If you are going to meet with a physician office and you can give them a handout on a particular kind of code they would use (i.e., how to properly code sepsis), then it’s helpful to their own staff too,” she says. Regardless of the challenges, Usher says it’s time for CDI to get involved. “The CDI world is an asset for all healthcare organizations,” she says. “Without it, it sets the clinician and the organization up for failure.”

PHYSICIAN ADVISOR CORNER

Detective skills ensure CDI results By Drew Siegel, MD, CCDS

One of the more interesting aspects of CDI is taking on the role of a detective to identify and evaluate clues in the medical record that suggest the presence of an undocumented diagnosis, then using these clues to write a compliant and clinically-supported query. In many cases, these clues are obvious, but the more challenging cases contain clues that require additional interpretation. Let’s look at a few of the more interesting and often undocumented diagnoses and find the diagnostic clues to form a compliant query.

Respiratory failure Chronic respiratory failure is a complication occurring in many patients with long-standing progressive lung diseases such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, or pulmonary fibrosis caused by radiation pneumonitis or drug toxicity. Continuous home oxygen use is an indicator that the diagnosis has been established. Many patients are undiagnosed, and in this setting clues that suggest the presence of chronic respiratory failure are found in the arterial blood gas results. Acute hypercapnic respiratory failure develops when there is an abrupt increase in the arterial carbon dioxide (CO2) level resulting from conditions causing alveolar hypoventilation, as in over-sedated patients. The sudden rise of CO2 does not allow enough time for the body to adapt. If adequate ventilation is not promptly restored, the CO2 level remains elevated and the arterial pH stays in the acidotic range. If the CO2 rise occurs more gradually, the kidneys respond to the respiratory acidosis by retaining bicarbonate to return the acidotic pH back to normal levels. The kidneys need several days to initiate the metabolic processes required for bicarbonate retention. The arterial blood gas results differentiate between uncompensated respiratory acidosis and compensated respiratory acidosis and this distinction is important to determine if acute or chronic respiratory failure is present.

Acute hypercapnic respiratory failure is identified when uncompensated respiratory acidosis, characterized by acidosis (low pH), hypercapnia (elevated pCO2), and a normal bicarbonate (HCO3) level is present. Once bicarbonate levels begin to rise as a result of renal metabolic changes and the pH normalizes, compensated respiratory acidosis develops. The pCO2 level remains high, but the pH normalizes because of an increased HCO3 level. This constellation of findings is known as respiratory acidosis with metabolic compensation, as shown in the following ABG example (normal values in parentheses): pH 7.38 (7.35–7.45), pCO2 51 (35–45), pO2 80 (75–100), HCO3 41 (22–36). Note the normal pH, the elevated pCO2 (respiratory acidosis), and the elevated HCO3 (metabolic alkalosis restoring the pH to a normal level). When these findings are identified, CDI specialists should query for chronic hypercapnic respiratory failure. Let’s look at a sample query for respiratory failure: Clinical Indicators: This patient was admitted with a diagnosis of acute pyelonephritis. He has a history of COPD and reports being told that he may require home oxygen use in the future. He has noticed a decreased exercise tolerance over the last six months. He has not been under medical care during the past year. Lab: ABG (on room air): pH 7.40, pCO2 51, pO2 67, HCO3 42. CXR—No infiltrates. Hyper-expanded lungs consistent with his diagnosis of COPD. Evaluation/treatment: O2 1 L nasal cannula, ABG, pulmonary consult In your clinical opinion, does this patient meet the criteria for a respiratory diagnosis or condition related to the above findings? ■■ Chronic Respiratory Failure _______ (specify: with

hypoxia, with hypercapnia, with both hypoxia and hypercapnia, other___, or unable to specify type) ■■ Respiratory Failure—Other (specify acuity: Acute,

Acute on chronic, unable to specify acuity AND

CDI Journal | MAY/JUNE 2018

type: with hypoxia, with hypercapnia, with both hypoxia and hypercapnia, other___, or unable to specify type) ■■ Respiratory acidosis with metabolic compensation

without evidence of respiratory failure ■■ Other:________ (specify) ■■ Unable to determine if a respiratory condition is

present

Acute kidney injury Acute tubular necrosis (ATN) is the most common cause of acute kidney injury (AKI) in hospitalized patients. Renal hypoperfusion or exposure to nephrotoxins causes renal ischemia and necrosis of renal tubular cells, resulting in renal failure. Patients with preexisting renal or liver disease are at an increased risk for developing ATN. Shock, heart failure exacerbation, and other conditions causing renal hypoperfusion may have resolved completely several days before ATN becomes clinically apparent. Exposure to aminoglycoside antibiotics, radiocontrast media, and other nephrotoxins may have occurred up to a week before ATN becomes apparent. Dehydration and excessive fluid losses from diuretics and severe diarrhea, for example, can cause AKI without ATN. In this setting, the AKI resolves quickly once volume is restored. On the other hand, ATN follows a prolonged course usually lasting up to two weeks. In most cases, gradual improvement of renal function occurs with a return to preexisting GFR and creatinine levels, though permanent renal damage may occur. The presence of granular or muddy-brown casts in a urine specimen are strongly associated with ATN, but their absence does not rule out this diagnosis. A query for ATN is recommended when renal failure persists longer than three to four days, especially if the serum creatinine continues to increase and granular or muddy-brown casts are found in the urine. Let’s look at a sample query for ATN: Clinical Indicators: Patient was admitted with an UGI hemorrhage complicated by hypovolemic shock. Acute kidney injury diagnosed three days following admission

28 CDI Journal | MAY/JUNE 2018

and the most recent progress note documents that creatinine remains elevated during the past week. Lab: Creatinine (admission and subsequent): 0.56>0.67->1.23->2.45->3.21. Urinalysis: Many muddy-brown casts present on microscopic examination. Evaluation/treatment: UA and micro, serial creatinine levels, treatment of hypovolemic shock. Please clarify the patient’s renal status based on the documentation and laboratory findings as noted above: ■■ Acute Kidney Injury (AKI) ■■ AKI with Acute Tubular Necrosis (ATN) ■■ Creatinine elevation and the presence of mud-

dy-brown casts are not clinically significant ■■ Other: ________(specify) ■■ Unable to clarify or specify

Heart failure The presence of an Implantable Cardioverter-Defibrillator (ICD) is a clue that the patient likely has chronic systolic heart failure. The majority of ICDs are implanted for primary prevention of life-threatening cardiac arrhythmias in patients with low left ventricular ejection fractions (LVEF). Causes of reduced LVEF include conditions such as extensive myocardial scarring following myocardial infarctions and cardiomyopathies caused by chronic ischemia, viral infections, or medication toxicity. An LVEF of 50% or lower is characteristic of systolic heart failure. Current guidelines recommend that patients with a reduced LVEF of 40% or lower should receive an ICD for the prevention of ventricular tachycardia and fibrillation. In patients with an ICD, CDI specialists should look for other evidence of systolic heart failure including echocardiogram results and heart failure medication use, to further support a systolic heart failure query. Now get out there, put on your Sherlock Holmes’ cap, and use your clinical expertise to search for documentation clues hidden in the medical record. Editor’s note: Siegel is a retired physician and has a second career as a CDI specialist for Barnes-Jewish Hospital in St. Louis, Missouri, and for MedPartners based in Tampa, Florida. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. Contact Siegel at dsiegelgi@gmail.com.

GUEST COLUMN

Aligning HIM/coding and CDI professionals: A progressive approach to partnership By Steve Robinson, MS-HSM, PA-O, RN, SSBB, CDIP

When building a successful proactive clinical documentation approach in any patient care venue—inpatient, outpatient, or professional—the effort of setting up communication dynamics is essential and should certainly be a priority. Traditionally, CDI specialists are responsible for identifying and communicating documentation inefficiencies, while HIM coding professionals are tasked with ensuring correct coding that properly captures episodes of patient care. There can be a blend of those responsibilities, especially outside the inpatient setting. Where there are two distinct roles, these questions almost always arise: ■ Where do the two practices intersect and where

do they diverge? ■ How does CDI influence coding applications? ■ How does coding impact the CDI process?

Let’s take a moment to explore the opportunities for CDI specialists and HIM coding professionals to communicate, collaborate, and achieve common goals—transparency, compliance, and information integrity. HIM and CDI are united by a common thread: accurate documentation driving all profiling comparatives, patient severity/mortality depiction, and fiduciary outcomes— critical to healthcare facility survival. The roles of coders and CDI specialists are vital to the organization’s patient care and national profiles, compliance with regulatory mandates, and financial stability. Though the two professions are complementary, they often operate from different perspectives. CDI specialists are charged with verifying documentation and identifying gaps based mainly on rules established by CMS and the American Hospital Association.

Ultimately, their job is to communicate with care providers, verbally or via written queries, to clarify documentation in the medical record. Inpatient coders, on the other hand, review medical records after discharge and assign ICD-10 codes that correspond to abstracted documentation. So, what could go wrong with this scenario? Do we need two independent groups of documentation professionals posing questions to providers?

Identifying differences leads to solutions During a recent AAPC conference session attended by both inpatient and outpatient HIM and CDI professionals, participants were asked to identify coding and CDI differences and recommend solutions. Based on their responses, here are some examples of disconnects that can hinder mutual understanding, productivity, and overall effectiveness. CDI specialists are more likely to: ■ Focus on MS-DRG and APR-DRG assignment ■ Lack understanding of all the nuances of coding

rules, and therefore may not query accurately or apply the most appropriate ICD-10-CM/PCS code ■ Need a way to directly contact a coder or easily

access an effective coding-oriented tool to support the query process ■ Query for regulatory concerns such as APR-DRGs

(severity of illness and risk of mortality scores), Patient Safety Indicators (PSI), hospital-acquired conditions, readmissions, and MS-DRGs ■ Experience difficulty with physicians who are not

open to, or not educated in, the documentation querying process

CDI Journal | MAY/JUNE 2018

HIM coders may: ■ Require better understanding of the full clinical

picture of condition(s) to interpret and apply accurate coding specificity ■ Need access to the CDI specialist post-discharge

to clarify final DRG assignment or apply clinical understanding ■ Focus on finalizing the record and proceed with

billing if additional diagnoses or procedures do not impact the MS-DRG

the coding picture, “they become more vested in what they do” and understand the role they play in patient care and outcomes. “Collaborate with them and make them feel like they are part of the entire hospital system team,” Younger says.

Creating a culture of collaboration The ability of CDI professionals to engage coders in the application of governmental guidelines can positively influence quality of care, patient outcomes, and accurate reimbursement. Here are seven strategies recommended by progressive organizations successfully aligning CDI and HIM practices:

In most of these scenarios, we discussed best practices for optimal outcomes and reached a consensus: CDI, HIM, physicians, and other documentation stakeholders should discuss differing priorities to foster understanding and achieve the most productive results. As a starting point, we need to find a way to acknowledge how those differences—such as CDI promoting APRDRG assignment—could prompt a more collaborative approach. At a minimum, CDI specialists and coders need a means of concurrent communication to avert lack of code specification or mismatches.

■ Establish work teams including HIM and CDI pro-

When CDI specialists and coders lack the time for meaningful discussions, engaging a dual-credentialed auditor (clinical and coding credential) to address issues can help bridge the gap. Maintaining statistics on audit effectiveness and educational trends (CDI, coding, physicians) will help validate the need for an auditor as a full-time employee. These are good first-step examples, but teamwork is still essential. Success happens when everyone on the team is equally invested in the objectives and the overarching goal.

based on team efforts and audited outcomes.

A recent Becker’s article on medical coding offers practical advice for hospitals, which also applies to CDI professionals seeking alignment with coders. “Collaborate with your coders. Coding is such a unique profession,” says Adrienne Younger, RN, CCDS, manager of CDI education at Nashville, Tennessee–based Ardent Health Services, in the article. She further states that in providing coders with additional resources to better understand the clinical side of

30 CDI Journal | MAY/JUNE 2018

fessionals to ensure understanding and proper application of clinical applications. Work together to resolve issues on audited cases, particularly mismatches between CDI and coding. ■ Assign a CDI and coding-credentialed auditor to

review missed opportunities such as all PSI designations without exclusions, lack of present-on-admission designations, and mismatches without resolution. ■ Conduct ongoing provider and staff training ■ Engage senior leaders to support a culture that

encourages HIM and CDI collaboration. ■ Acknowledge departmental lines in both perspec-

tives and practices while still promoting collaboration between CDI and coding. Examples include policy regarding the timeline between patient discharge and billing, criteria related to provider queries, and guidelines for pre-billing records for coding versus timelines for auditing records after discharge. ■ Develop and document policies and procedures

approved by HIM and CDI team members. ■ Support team building and camaraderie by: §§

Initiating jointly led educational sessions and rotating topics among departments

§§

Budgeting CDI and coding attendance at the same educational offerings

§§

Forming specialty teams to help educate physicians and other clinicians on new versus old documentation concepts

Above all, keep in mind the importance of building a culture of collaboration through clear communication and understanding of mutual responsibilities and goals. The shift to value-based care, along with automated speech recognition, computer-assisted coding, and natural language processing, is changing the culture of coding and clinical documentation. Together, CDI and HIM professionals will play a crucial role in meeting quality standards that improve clinical and financial performance.

Remember the words of Andrew Carnegie: “Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” Editor’s note: Robinson is the director of hospital and physician services at LW Consulting, Inc. in Harrisburg, Pennsylvania. Robinson holds advanced degrees and a unique understanding of the complete clinical documentation processes and its impact on healthcare facility revenue cycle and documentation compliance. His experience includes clinical documentation and quality leadership for over 250 healthcare facilities nationwide managing process improvement, throughput, and clinical documentation consulting engagements. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

CODING CORNER

The future is now: CDI in office/outpatient settings By Lori-Lynne A. Webb, CPC, CCS-P, CHDA, CDIP, COBGC

Back in 2016, I wrote the following synopsis for HCPro about outpatient/ office diagnosis reporting, clarifying some of the misunderstood procedural guidelines between inpatient and outpatient services. “For those who code for outpatient or office based services; instead of reporting a ‘principal’ diagnosis, you would code the firstlisted diagnosis, as well as signs and symptoms that are documented by the provider of care. In some cases, it may take more than one visit or encounter to arrive at and/or confirm a specific ’diagnosis.’ ICD-10-CM guidelines allow us to continue to report signs and symptoms over the course of the outpatient workup. The majority of the signs and symptom codes are found in Chapter 18 of the ICD-10-CM diagnosis codes, however, other signs and symptom codes can be found in many of the other sections and chapters of ICD-10-CM.” Things are more complicated now, though, than when I wrote that article. Today, we are challenged to ensure

our outpatient clinical documentation is up to the same high standards that we employ for inpatients. ACDIS is working to meet this challenge; it published the position paper “Queries in outpatient CDI: Developing a compliant, effective process” in January, and will begin working with AHIMA on updating the Guidelines for Achieving a Compliant Query Process practice brief this summer. No doubt CDI will continue to evolve, with the office/outpatient services sector growing at a fast and furious pace.

Differences and similarities between inpatient and outpatient CDI An inpatient CDI program focuses primarily on the inpatient chart during the patient’s stay, with particular attention paid to case-mix index, CC/MCC conditions, and MS-DRG assignment. In an outpatient CDI program, chart reviews happen much more quickly and almost simultaneously with the provider’s original documentation, especially when the care is documented into an electronic medical chart/record. Office/outpatient care also has different billing forms and coding rules and regulations to follow, as nearly all of the care provided in the outpatient/office setting

CDI Journal | MAY/JUNE 2018

is submitted on a Healthcare Financing Administration (HCFA) form, rather than a uniform bill form. Physicians also either assign ICD-10-CM codes themselves or rely heavily on their office/outpatient coders to help them capture critical diagnosis codes in the EHR because outpatient reimbursement is tied to specific relative value unit (RVU) allocation, rather than DRG status of severity. For the physician and clinical office team, their reimbursement may be tied to the RVU number or the amount of office collection status reimbursements from insurers; alternatively, the team members may all be paid employees of an outpatient practice wholly owned by a hospital network. Medicare is also helping to “speed along” the CDI process for outpatient/office documentation. In the next few years, Medicare will be changing how physicians and physician practices receive payment from Medicare programs through regulations such as the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS), and the Alternative Payment Models (APM). Under these new payment models, physician documentation is set to correlate with and be reimbursed pursuant to those program specifications in FY2019, despite rumblings from various stakeholders calling for the removal or delay of the MIPS.

Benefits of outpatient CDI As CDI develops a detailed outpatient/office CDI strategy and formalized protocol, program leaders need to ensure the focus is not on the practice’s revenue, but on the capture of the care provided during the encounter to support high-quality care, medical necessity, clear diagnosis, and reasonable diagnostic testing. Below are some of the benefits an office/outpatient CDI program can bring to the practice: ■ Fewer claim denials and rejections from insurance

carriers and third-party payers ■ Increased reimbursement, especially in Hierar-

chical Condition Category (HCC)/risk adjustment coding and quality improvement programs within Medicare and private insurance carriers ■ Fewer physician queries to and from coders due

■ Increased coder and billing staff productivity, in

addition to higher employee satisfaction due to information being readily accessible and complete ■ Improved documentation and transparency within

the patient chart/electronic record for patient portal viewing and record access requests ■ Enhanced continuity of care and communication

for patients with multiple providers that oversee their care, as they may be providers from different specialties and/or networks ■ Improved communication between all providers

and facilities that may need access to specific diagnosis oversight (e.g., diabetic education with the dialysis provider and the nursing home)

Outpatient CDI departmental collaboration Outpatient CDI programs still share similar protocols with inpatient counterparts, such as collaborating closely with their coding and accounts receivable colleagues, and looking at insurance denials and inappropriate payment reimbursements. CDI staff will also help provide physician education and training for critical clinical documentation in addition to ICD-10-CM diagnoses. The coding staff will also be integrated closely with the CDI personnel in regard to Current Procedural Terminology® (CPT) and Healthcare Common Procedural Coding System (HCPCS) coding, in addition to charge capture auditing on a pre-submission and post-payment review of charges. This, of course, is very similar to an inpatient CDI practice. Coders, CDI, and reimbursement teams that collaborate together form a nearly perfect way to ensure that patient care is at the top of the priority list; however, enlisting the help of the IT or data analytics staff can also assist with protocol and analysis functions to support a long-term look at not only the outpatient CDI program, but the overall health of an outpatient physician practice.

Outpatient CDI practices As you challenge the office CDI staff, below are some of the ways in which they can have a huge effect on the practice’s overall policy, procedure, and protocols:

to better up-front documentation

32 CDI Journal | MAY/JUNE 2018

■■ Case finding/identification: Identification of office/

outpatient cases that need to be reviewed based on provider-specific (specified) surgical office/outpatient-based procedures, diagnoses, supplies, equipment, and ancillary services, in addition to other parameters that are problematic in that setting. These reports may need to be expanded to report out a single payer, or multiple payers; to encompass peer-to-peer provider reports that review services where revenue capture is missing or lacking; or even to cover potential risk factors that may need review. ■■ Encounter/provider prioritization: CDI specialists

need a way to identify which encounters require review. If the office can determine which providers and/or cases need to be reviewed, it can maximize the efficiency and productivity of the clinical documentation staff. Have the providers help identify specific cases so the staff can be educated on high-risk documentation issues. ■■ Workflow: Physicians/providers, CDI specialists,

coders audit for encounter completion of a patient visit. These templates can also give the physicians the opportunity to document more thoroughly and completely, which may in turn result in quicker coding and turnaround/reimbursement of insurance claims. The biggest challenge of implementing CDI in an office/outpatient practice is making all the staff aware of CDI efforts and having the staff embrace the changes in workflow, as well as in the way they interact with each other, providers, and patients to ensure quality care. Editor’s note: Webb is an evaluation and management and procedure based coding, compliance, data charge entry, and HIPAA Privacy specialist, with more than 20 years of experience. Her coding specialty is OB/GYN office and hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. Contact her at webbservices.lori@gmail.com or you can also find current coding information on her blog at http://lori-lynnescodingcoachblog.blogspot.com/. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

and clinical personnel all need to look at the planned patient schedule and determine which cases will need to be reviewed that day. These identified cases need to be communicated and routed to staff appropriately. If more than one person is working on a specific record, there should be a tracking mechanism in place to ensure all parties have completed their assigned work. ■■ Queries, messaging, and alerts: Just as in an

inpatient system, queries need to be routed directly to the providers via the electronic chart or some other communication system. In the outpatient/office areas, speed is of the essence: Queries need to be accessed and responded to quickly and easily, as many patients are seen by the provider within a narrow window of time. ■■ Templates: Templates within the EHR can be

helpful to substantiate the medical necessity for the patient’s diagnosis, the patient’s condition, and even the documentation of time spent in counseling and coordination of care during the encounter. Templates can help when CDI and

CDI Journal | MAY/JUNE 2018

MEET A MEMBER

Continued learning keeps CDI specialists engaged Megown: The hospital decided to expand the CDI program, and I volunteered to join the team as I recognized this was a burgeoning field. CDI Journal: What has been your biggest challenge? Megown: During the early stages of the CDI team’s development, it was challenging to get physician and administration buy-in and to maintain continuing education with all the providers. CDI Journal: What has been your biggest reward?

Suzanne Megown, RN, BSN, CCDS, CDIP, CCS, is a CDI specialist at St. Luke’s Hospital in Chesterfield, Missouri, and a member of the St. Louis ACDIS chapter, AHIMA, the Missouri component of AHIMA, and eHIMA. A CDI specialist for the past nine years, she worked in pain management, pediatrics, and case management (among other focus areas) before joining her facility’s documentation improvement efforts. Megown has lived in St. Louis for more than 20 years and enjoys traveling, especially to the National Parks; playing golf with her husband and family; and being involved in her church. CDI Journal: What did you do before entering CDI? Megown: I’ve done a little bit of everything in nursing. I’ve worked in case management and utilization review, as the team lead RN for a pain management center, in the GI lab/women’s center, in the post-anesthesia care unit (PACU) and as the pediatric PACU charge nurse/ preceptor, as the charge RN for cardiothoracic transplant/cardiovascular intensive care unit, as a staff RN for medical-surgical/trauma/neuro ICU, and as a staff RN for medical-surgical.

Megown: Having the opportunity to be the team lead for clinical documentation education with the hospital’s resident program and cardiology division physicians/ NPs in particular has been rewarding. Also, just watching the impact of improved documentation in multiple areas of the hospital. CDI Journal: How has the field changed since you began working in CDI? Megown: The face of CDI has continued to evolve with the transition to ICD-10 in 2015 and the expansion of CDI into so many related fields, such as quality, compliance, outpatient, and data analytics. CDI Journal: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on The Forum or through ACDIS? Megown: ACDIS has been a wonderful source of information, including the website, white papers, quarterly conference calls, and webinars pertaining to ICD-10 and the numerous updates since the transition. I would like to mention Karen Newhouser, a member of the ACDIS Advisory Board, in particular, as a wonderful role model, source of information, and friend to me, encouraging my professional growth and prompting me to obtain my CCDS certification. CDI Journal: If you have attended, how many ACDIS conferences have you been to? What are your favorite memories?

CDI Journal: Why did you get into this line of work?

34 CDI Journal | MAY/JUNE 2018

Megown: I attended attended my first ACDIS Conference in May 2017 in Las Vegas! I loved meeting other CDI specialists from all parts of the U.S., attending the sessions at the conference, and sightseeing. CDI Journal: What piece of advice would you offer to a new CDI specialist?

Megown: I was a life guard, water safety instructor, and taught swim lessons at the local park system pools and at the YMCA. CDI Journal: Tell us about a few of your favorite things: ■ Vacation spots: Grand Canyon, Sandestin Flor-

ida, Lake Tahoe, Caribbean ■ Hobby: I love to golf, swim, hike, and play tennis.

Megown: Continuing education is the key to staying abreast of the ever-changing world of CDI and being a resource to others.

■ Non-alcoholic beverage: Green tea

CDI Journal: If you could have any other job, what would it be?

■ Activity: Participating in various church groups

Megown: To own a family business. CDI Journal: What was your first job (what you did while in high school)?

Plus, I’m a movie buff. ■ Foods: Mexican, Indian, Italian

and volunteering for Autism Speaks. Editor’s note: Are you interested or do you have a colleague who would like to be featured in our “Meet a Member” segment? Contact Editor Linnea Archibald at larchibald@acdis.org.

CDI Journal | MAY/JUNE 2018

AHIMA’s 2018 Clinical Coding Meeting! September 22–23 | Miami, FL

Outpatient/ Physician Coding

Inpatient Coding Revenue Cycle

CDI Compliance/Auditing

Save $100 if you register before July 23! Plan to join your peers for the perfect mix of business and pleasure. You can't afford to miss the countless educational and networking opportunities offered. Meet with peers, gain valuable takeaways, and bring back unique knowledge and solutions about topics and trends health information professionals are facing. CNEs* Available!

ahima.org/clinicalcoding 36 CDI Journal | MAY/JUNE 2018

*The American Health Information Management Association (AHIMA) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

638.18

2018 JANUARY S

ACDIS Webinars

FEBRUARY

MARCH

APRIL

S 7

MAY S

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER S 1

JAN. 25

JUNE 14

FEB. 22

JULY 19

MAR. 22

AUG. 23

CC/MCCs for CDI: Clinical Indicators and Query Opportunities

CDI Conversations: Patient Safety Indicators and Effective Collaboration APR. 10

Respiratory Failure: The Ins and Outs of Diagnosis Documentation, Coding, and Clinical Validation

NOVEMBER

CDI Workshop: Unpack Clinical Validation Efforts and Query Practices

19 26

DECEMBER S

S 1

CDI Conversations: Simplifying Complex Trauma Reviews Sepsis: Resolving Documentation and Coding Conflicts Through CDI ACDIS Live! Malnutrition OIG Investigations and Auditor Denials: How a Multidisciplinary Team-Based Approach Is Your Best Defense OCT. 11

Pediatric CDI in the NICU: Tiny Children, Big Documentation Requirements

Learn more at hcmarketplace.com

CDI Journal | MAY/JUNE 2018