CDI Journal-May/June 2017 by ACDIS

May/June 2017 Vol. 11 No. 3

REGARDLESS OF SETTING AN EXPLORATION INTO NON-ACUTE CARE SETTING CDI

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

CONTENTS FEATURES 6 Ochsner shares physician practice CDI experience Ochsner Health System’s outpatient expansion offers a helpful case-study for CDI programs looking to follow in the health system’s footsteps.

9 Get thee to the ED For those venturing into unknown territories, the ED provides a good starting point. Documentation from ED encounters directly affects the documentation if (or when) patients move to the inpatient setting.

12 Focus on compliance in the rehab setting Due to payment methodology differences for inpatient rehab facilities, the learning curve is steep, but the work proves rewarding.

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and prove medical necessity through accurate documentation.

17 Physician Advisor’s Corner Daniel E. Catalano, MD, FACOG, explores the difficulties posed by coding pediatric cardiac conditions.

26 Coding Corner Sharme Brodie, RN, CCDS, reviews the answers in AHA Coding Clinic for ICD-10-CM/PCS, First Quarter 2017.

28 Meet a Member Robert S. Hodges, MSN, BSN, RN, VHA-CM, CCDS, will soon be moving to a new position as the clinical lead for the VISN 10 documentation improvement program for the 11 VA medical centers in Indiana, Michigan, and Ohio.

19 Profiles in pediatric CDI Many unique individuals make up the pediatric CDI field. ACDIS spent some time chatting with “the proud and the few.”

23 Remote CDI takes planning More than 40% of CDI professionals have some sort of remote CDI option. Hear from some of them about why they love their remote work.

DEPARTMENTS

CONTINUING EDUCATION CREDITS BONUS: Obtain one (1) CEU for reading this Journal ACDIS members are entitled to one continuing education credit for reading the CDI Journal and taking this 20-question quiz. Please visit the May/June Journal page on the ACDIS website to download the quiz for CCDS credits.

3 Associate Director’s Note Expanding into new settings does not change the mission of CDI: appropriate documentation for appropriate care, for everyone.

5 Note from the Advisory Board Wendy Clesi, RN, CCDS, CDIP, offers ways to help CDI programs think outside the box as they expand past the walls of the inpatient acute hospital setting.

16 Radio Recap CDI specialists in critical access hospitals work collaboratively with utilization review, possess an intimate knowledge of inpatient coding,

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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 © 2017 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 CDI programs benefit beyond inpatient needs In 2004, TV talk-show host Oprah Winfrey gave brand-new Pontiacs to every person in her nearly 300-member studio audience. It was a marketing ploy— she’d filled the audience with folks who needed cars. Desperately. The remembered refrain from that episode: “You get a car! You get a car! You get a car!” was followed by shrieks of excitement. Now imagine that the role of Oprah is played by ACDIS, and our studio audience is filled with healthcare facilities. All of them need CDI programs. Desperately. In this episode of the CDI Journal, Oprah’s refrain rings out: Children’s hospitals get a CDI program! Physician practices get a CDI program! Critical access hospitals get a CDI program! Rehabilitation facilities get a CDI program! In the 10 years since ACDIS’ i n c e pti o n, C D I p ro g r a m s

Although CDI certainly existed prior to 2007, its relative importance grew immensely under the documentation detail required to capture MS-DRG specificity. CMS knew it. The agency anticipated that facilities would work to shore up documentation, which would result in higher payments. In response, Congress required CMS to make retrospective cuts to recoup overpayments, doing so every year since. Nevertheless, CDI programs answered the call—not only meeting the challenges associated with MS-DRG implementation and the documentation and coding adjustment (DCA) reimbursement cuts, but proving their return on investment beyond these needs. In the 10 years since ACDIS’ inception, CDI professionals have consistently risen to the occasion, no matter the challenge.

Although CDI certainly existed prior to 2007, its relative importance grew immensely under the documentation detail required to capture MS-DRG specificity. expanded beyond documentation improvement related to CMS’ Medicare Severity Diagnosis Related Group (MS-DRG) reimbursement stratification method.

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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, CPC 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 Senior Designer Vicki McMahan vmcmahan@blr.com Graphic Designer Tyson Davis tdavis@blr.com

They met the demands associated with the implementation of the ICD-10-CM/PCS code set in 2015, educating physicians and working with their HIM and coding

counterparts to understand the nuances of the new code descriptions and documentation needs. They satisfied the needs of a changing reimbursement system under the Affordable Care Act, which increased emphasis on pay-for-performance over fee-for-service compensation in healthcare. (For information on quality-focused CDI reviews, see the March/April edition of the CDI Journal.) Now, CDI programs ready themselves for the next incarnation of their efforts—expanding past the walls of the traditional short-term acute care setting. We’re beyond borders now, and it makes sense—just step back to see the larger picture of the healthcare industry today.

Just as CMS metered out pay-for-performance measures on the inpatient side, it’s working its way through reimbursement renovations in other healthcare settings as well. While each facility type operates under differing compensation plans—children’s hospitals often receive reimbursement under the All-Payer Refined Diagnosis Related Groups and get paid by private insurers or Medicaid rather than Medicare; critical access hospitals get paid by cost rather than MS-DRG; physician practices often get paid on a risk stratification system such as Hierarchical Condition Categories—each of these complex systems depends on the same bedrock: the documentation associated with the care provided.

Care provided in the hospital setting costs more and often exposes patients to higher healthcare risks, as shown in the Institute of Medicine’s To Err Is Human

Altruistic CDI specialists join the profession, drawn by a mission to ensure documentation represents the complete and accurate picture of the patient’s condition and care.

We can grab the keys of our proverbial Pontiacs and ring out a refrain of our own—appropriate documentation for appropriate care, for everyone in every setting.

This mission holds true both inside and outside of the traditional hospital setting. Those invested in keeping the focus on record reviews for this purpose need not confine their vision to a hospital’s halls.

series of reports. Technology, however, plays its role by making stays more streamlined, efficient, and minimally invasive—allowing for more services to be provided in outpatient centers rather than intensive care.

We can grab the keys of our proverbial Pontiacs and ring out a refrain of our own—appropriate documentation for appropriate care, for everyone in every setting.

Today’s healthcare mantra: the right care in the right setting for the right patient.

ADVISORY BOARD Sam Antonios, MD, FACP, FHM, CCDS CDI/ICD-10 Physician Advisor Via Christi Health Wichita, Kansas Samer.Antonios@ via-christi.org Wendy Clesi, RN, CCDS Director of CDI Services Enjoin wendy.clesi@ enjoincdi.com

Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, IQCI, MBA Director, Case Management University of California Irvine wdevreug@uci.edu Cheryl Ericson, MS, RN, CCDS, CDIP CDI Education Director ezDI cericson@ezdi.us

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Paul Evans, RHIA, CCDS, CCS, CCS-P Clinical Documentation Integrity Leader Sutter West Bay Area evanspx@sutterhealth.org

Robin Jones, RN, BSN, CCDS, MHA/Ed System Director, Clinical Documentation Excellence Mercy Health, Cincinnati Ohio RAJones@mercy.com

James P. Fee, MD, CCS, CCDS Vice President Enjoin james.fee@enjoincdi.com

Mark LeBlanc, RN, MBA, CCDS Director, CDI Services The Wilshire Group m.leblanc@ thewilshiregroup.net

Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM Director Wake Forest Baptist Health thicks@wakehealth.edu

Michelle McCormack, RN, BSN, CCDS, CRCR Director, CDI Stanford Hospital and Clinics Palo Alto, California mmccormack@ stanfordmed.org Karen Newhouser, RN, BSN, CCDS, CCS, CCM Director of CDI Education MedPartners karenmpu@ medpartnershim.com

Judy Schade, RN, MSN, CCM, CCDS Clinical Documentation Specialist Mayo Clinic Hospital Schade.judy@mayo.edu Anny Pang Yuen, RHIA, CCS, CCDS,CDIP Director, Ambulatory CDI Enjoin Anny.Yuen@enjoincdi.com

NOTE FROM THE ADVISORY BOARD The CDI umbrella: Improving documentation and coding across the healthcare continuum by Wendy Clesi, RN, CCDS, CDIP

CDI professionals recognize the effect comprehensive CDI programs have on both payment and profiling outcomes in all healthcare settings. As a result, many organizations are forging ahead to apply CDI beyond the walls of the traditional acute care setting. Since the inception of MS-DRGs and adoption of various CMS value-based initiatives, CDI programs have continued to evolve, broadening in scope beyond DRG assignment and MCC/CC capture to meet the demands of various payment models and risk adjustment methodologies. In today’s economy, and given the constant state of change in healthcare, documentation improvement initiatives need to support both financial and quality interests. Effective CDI programs focus on high-quality documentation to achieve accurate and appropriate reimbursement while improving outcomes and mitigating risk associated with denials and quality-related penalties. As the landscape of CDI continues to change, CDI professionals should consider the big picture of documentation and coding, regardless of setting. Organizations throughout the industry should investigate strategies to leverage CDI across the continuum, eliminating silos to improve care delivery and quality measure outcomes essential for effective population health management. It’s time to think differently!

Reinventing CDI Once you have identified the need to expand CDI efforts, complete a comprehensive assessment of

your program’s current practices, resources, and opportunities. Answer the following questions: ■■ What CDI operational model do you have in

place today? ■■ What new coding and documentation

opportunities need to be addressed? ■■ Is your current model sufficient to manage

additional responsibilities? CDI is not a one-size-fits-all approach—what you are doing today may not work in the future. With this in mind, program leaders should develop strategies that align with organizational initiatives and modify their current infrastructure and processes to build an operational model of success. With the constant pressure to do more with less, we must remain good stewards of our resources and consider alternative approaches to what we have done traditionally in CDI. For example, have you considered creating a flagship CDI department that allows for systemization using the umbrella effect and focusing on high-quality documentation holistically, regardless of setting and impact? What does oversight of CDI across the continuum look like? Will this model allow for pooling of resources, strengthening interdepartmental collaboration, creation of a synergistic approach to documentation improvement, and elimination of silos? These suggestions may sound futuristic, but we all need to keep in mind that a CDI program does not come ready-made in a box. The possibilities are endless, and the approach will be unique to each organization.

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Creating a new vision and redesigning CDI is not a simple task. Is your program ready to move beyond the status quo? If so, start building your case for change. Look into models that position your organization to be proactive instead of reactive. Consider constructing efforts to develop resources that enable documentation improvement at the point of care, ensuring efficiency for providers and minimizing the need for cumbersome queries. Innovation is key to

success. New ideas and new strategies are imperative to keeping up with the demands associated with value-based payment models and ensuring accurate payment and quality scores for care delivery.

Editor’s note: Clesi is director of CDI services with Huff DRG Review and was an ACDIS Advisory Board member from January 2013 to April 2017.

OUTPATIENT ENDEAVORS

Ochsner shares physician practice CDI experience

ounded in 1942, the Ochsner Clinic Foundation now encompasses 28 hospitals, 60 health centers, more than 17,000 employees, and over 2,500 affiliated physicians. Its far reach makes today’s Ochsner Health System the largest in Louisiana. Ochsner began its ambulatory clinical documentation excellence (CDE) journey in 2004, when Medicare implemented its Hierarchical Condition Categories (HCC). Since HCCs

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affect patients’ Risk Adjustment Factor (RAF) scores, and ultimately reimbursement for the care required to treat sicker patients, Ochsner needed to determine the best way to ensure annual HCC capture for all patients across its vast system.

insurance company” and threw it away, according to Diana Ortiz, JD, RN, CDIP, director of ambulatory CDE at Ochsner Health System in New Orleans, who spoke about Ochsner’s efforts during a 2016 ACDIS Live! program.

In the beginning, providers received only rudimentary training on the HCC model. Most of those providers attributed this paperwork to “just something from the

In the beginning, the system struggled to identify a cohesive strategy behind its approach to HCC capture. It hired a physician leader to provide educational sessions in 2012, but

content overload prevented forward momentum. In 2013, the organization identified reimbursement shortfalls due to the lack of accurate HCC capture and provided additional physician documentation education. In 2014, the physician liaison took on the task of visiting every facility in the system. “That involved him in his car, driving across the system, and meeting one-on-one with the providers,” Ortiz says. While the one-on-one education was useful, Ochsner’s health risk assessment program helped the CDE earn administrative support, additional staffing, and full implementation in 2016.

Determining the scope and structure of the program Due to Ochsner’s size, the 2016 effort better defined the project’s scope and paved the way for CDI professionals to tackle it one step at a time. Since Ochsner considers primary care physicians to be the leaders of a patient’s care, it made sense to focus on their documentation practices and HCC capture rates. By correcting some of the problems in the primary care documentation, the entire spectrum of providers would be able to receive a more complete picture of patients’ health and care history. The CDE team divided primary care and internal medicine clinics by region. This allowed the CDE specialists to have more personal relationships with the physicians in their regions and develop more meaningful conversations for education. It also allowed the specialists

to conduct “deep dives” into a specific physician’s charts rather than being responsible for physicians all over the system. At the beginning, each CDE specialist was expected to handle approximately 10 retrospective patient chart reviews per provider per day. For educational purposes, the peer-to-peer model was crucial for Ochsner’s success, says Ortiz. Ochsner found providers responded better to education when it was provided by physicians as opposed to nurses—even nurses they already had relationships with. So physician leads were hired to cover the various regions, work alongside CDE specialists, and provide that one-onone education. The CDE specialists do not report to the physician leads, but to the ambulatory CDE director, Ortiz notes. Every CDE specialist is a registered nurse, with roughly the same experience and credentials as a new inpatient CDI specialist at Ochsner might be expected to have. This background provides two main advantages—one, the nurses already have clinical knowledge, and two, they often have standing relationships with providers already. The staffing model also includes CDE regional leads, who are CDE specialists functioning in a quality assurance role. The regional leads examine CDE specialists’ chart reviews to assess the performance of the specialists and their ability to catch documentation errors. They are also heavily involved in gathering physician documentation and

response data to assess the team’s effectiveness, target opportunities for improvement, and provide actionable, real-time feedback to the physicians they serve. In addition to regional leads, local leads serve as champions for the CDE program and provide on-site answers to physicians’ immediate questions. These individuals typically deliver messages to providers at the clinics, which frees up the physician leads and CDE specialists for chart reviews and education.

Educating outpatient CDE staff Since most facilities start with inpatient CDI programs, Ortiz knew hiring staff with outpatient CDI experience would be difficult if not impossible; she would have to build the program from the ground up. The right candidates needed to have clinical experience, strong interpersonal skills, effective communication abilities, an entrepreneurial spirit, and a willingness “to go with the flow” as the program rolled out, she says. First in the training process was an inpatient CDI boot camp. If the ambulatory CDE program ended up not being a good fit for a staff person, that staffer would already have training and could be useful elsewhere. The second step was job shadowing, starting with the inpatient CDI team, which provided insight into the team’s rapport with physicians. Additionally, the CDE specialists shadowed the second-level review and ambulatory coding teams for a better understanding of the

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workflow on the ambulatory side. This showed the new specialists what sort of things the coders were looking for, what they had to query for, and what was needed in a chart. Along with the job shadowing, the CDE specialists also underwent electronic health record (EHR) training. This training is ongoing; as the systems are updated, Ochsner provides additional education. The ongoing education lets CDE specialists share their personal tricks and suggestions with the rest of the team. The CDE specialists also review the encoder training on an ongoing basis. CDE specialists also studied ACDIS/AHIMA query best practices and official query practice guidance. At the beginning of the ambulatory CDE program, staff did not query, but it was important to give specialists an ethical compass from the outset, Ortiz says. The last and most integral piece of the education process was HCC training. While the rest of the education focused on tools and workflow, the HCC training focused on the CDE specialists’ main goal—improving risk adjustment scores for the system.

Retrospective starting point At the beginning, each CDE specialist reviewed about 10 charts per day retrospectively only. Since the documentation had already been completed, the team used these reviews for informational and educational purposes. Staff conducted audits, collected their findings, and created packets for physicians to

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explain important documentation concepts. Retrospective reviews provided a jumping-off point for the program, allowing Ochsner to illustrate largescale documentation deficiencies and solutions. It was instrumental in getting the administration on board with the ambulatory CDE program early in the development process, Ortiz says. Going forward, Ortiz says retrospective reviews will serve to mark a provider’s progress. In addition to retrospective reviews, each CDE specialist now completes between 12 and 15 previsit reviews per day—before the provider sees the patient—with the goal of helping the provider capture the correct diagnoses and HCCs during the face-to-face appointment with the patient. The CDE specialist notes documentation opportunities and queries the provider following ACDIS/AHIMA guidelines from within the EHR. When a provider opens the patient’s record, a query automatically pops up if a pre-visit CDE review and query have been completed. Though the provider cannot respond to the query directly in the EMR, he or she can respond with additional documentation specificity in the record itself. After the patient’s appointment has taken place, the CDE specialist goes back into the chart and conducts a retrospective review to see whether the provider acted on the pre-visit information. Whereas inpatient CDI reviews can only take the patient’s current visit into consideration, ambulatory

CDE can look back at three years of patient history. During the pre-review process, this is an important step since it can bring chronic conditions to the provider’s attention and remind the provider to document them. Even though a chronic condition only needs to be documented in the record once per year for a given patient, Ochsner wants every record to stand on its own. That way, whenever a specialist sees a patient, the patient’s primary care record is as complete and thorough as possible. As the ambulatory CDE program continued to mature, Ochsner expanded into other areas of patient care as well. It is now adding several specialty-focused programs within the hospitals to ensure the capture of HCCs and quality patient care across the system. Over the next two years, Ochsner plans on adding six new specialties to the program. Ochsner has been careful to introduce new duties slowly; this lets the CDE specialists incrementally build on their previous experience with each new task and ensures they aren’t overwhelmed by their workload. Although the learning curve has been steep, the team is well on its way to proving that ambulatory clinical documentation programs can be an effective and instrumental area of growth and opportunity. Editor’s note: Ortiz and members from her team spoke about their outpatient CDI efforts during the November 2016 webinar “ACDIS Live! Outpatient CDI at Ochsner: A Case Study Approach.” Listen to it on-demand.

Ambulatory CDI efforts: Get thee to the ED

any programs remain focused on inpatient populations, but branching into the ED provides a good starting point for those venturing into the outpatient arena. Not only does it offer outpatient opportunities, but the documentation from ED encounters directly affects the documentation if (or when) patients move to the inpatient setting.

The impetus for ED expansion What drives a CDI department into the crazy world of the ED? Well, like other areas, the reasons are often as varied as facilities themselves— and the transition may be easier for some departments than others.

“The ED program was something that the institution wanted when the [CDI] program was being rebuilt,” says Bernadette Slovensky, RN, MSN, CCDS, medical coordinator for CDI at Stony Brook Medicine in Stony Brook, New York. In fact, one of Stony Brook’s ED physicians was a major force behind the process.

Jessica Stevenson, RN, CDI specialist at Yampa Valley Medical Center in Steamboat Springs, Colorado, a 32-bed nonprofit facility. Like many professionals at small facilities, Stevenson wears many hats. One hat, labeled “bill reviewer/auditor,” brought ED documentation improvement deficiencies to her attention.

Just like starting a CDI program from scratch, the process goes more smoothly when administration is on board—after all, convincing physicians of the need for CDI is difficult enough on its own.

“We were already in those ED charts and realized there might be an opportunity to educate the physicians specifically,” she says.

For some programs, though, the CDI specialists themselves may need to be the lifeblood of expansion efforts. Such was the role of

So, Stevenson ventured into the ED with her one other CDI cohort. Beginning with education, they chipped away at the documentation opportunities found during bill reviews.

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CDI staffing for the ED Though CDI staffing requirements vary significantly between facilities, a couple models work particularly well in the ED: ■■ Reviewing ED documentation

as part of the whole inpatient record ■■ Reviewing ED records con-

currently on the floor The first option is familiar territory for seasoned CDI specialists. ED documentation can lend valuable clinical indicators to a query during a patient’s hospital stay. To ensure the accurate capture of a patient’s severity of illness (SOI) and risk of mortality (ROM), CDI specialists should review this documentation whenever possible. If the CDI staff reviews the ED documentation as part of the whole record, there’s likely no need to have a CDI specialist physically present in the ED. This lack of floor presence could, however, lead to missed opportunities–what Donald Blanton, MD, MS, FACEP, at CDIMD-Physician Champions in Brentwood, Tennessee, calls “disappearing diagnoses.” The second model of staffing seeks to relocate these diagnoses. At least at the beginning of a CDI program’s excursion into the ED, having someone present in the room can be valuable. “Many ED physicians mentally acknowledge secondary diagnoses, but don’t write them down,” Blanton says. If a CDI specialist physically sits in the ED, he or she can be on

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hand to ask questions and ensure physicians capture the complexity of a given patient’s condition prior to discharge, admission, or placement in observation status, he says. After the initial education, however, it may be best to cut the proverbial apron strings, according to Slovensky. “We didn’t really need to be there holding their hands,” she says. There’s a twofold reason for this approach, Slovensky explains. First, it allows the CDI specialists more freedom with their limited time. CDI staff typically work regular business hours, whereas the ED is staffed 24/7. When the CDI staff is in the hospital, as is the case in Stony Brook, they have to divide their time between inpatient and ED records. Having someone in the room with the ED physicians would be time-consuming and impractical, says Slovensky. Second, stepping back after the education allows the physicians to focus on patient care instead of having a CDI specialist breathing down their necks. After the initial educational process, “the ultimate goal is zero queries. You shouldn’t need to ask the question if the physician is educated,” Blanton says. Still, the code set includes so many specific language requirements, definitions, and thresholds between severity levels that physicians often need prompts baked into their workflow to ensure proper and accurate documentation, he says.

Common ED query opportunities If you grabbed five CDI specialists throughout their days and asked

them for their top queried diagnoses, you’d likely get some significant overlap. Acute respiratory failure, sepsis, malnutrition, and other bemoaned conditions are often a thorn in the side of CDI specialists everywhere. Acute respiratory failure can be easily overlooked when documenting a patient’s acute systolic heart failure, Blanton says. It’s certainly treated, and often with rapid improvement—so rapid that “by the time the hospitalist comes [onto the case], the patient looks so much better than when they came in that their original acuity will be lost to the hospitalist,” Blanton says. If the documentation of acute respiratory failure disappears in the fog of the ED, patients could go through their hospital stay and get discharged without anyone knowing how sick they really were upon arrival. “The insurers only know what we tell them,” Blanton says. “To them, every patient looks the same: like a piece of paper with ink on it.” The ED holds opportunities for many of the same diagnoses commonly requiring clarification on the inpatient side, but it presents unique potential for diligent reviewers as well. “We do a heavy audit of evaluation and management service (E/M) levels in the ED,” Stevenson says. Often, however, that query for E/M levels results in a reimbursement downgrade. “We’re trying to make sure everything’s accurate,” she says. Stevenson has also found many query opportunities with hydration

levels. If a patient comes into the ED severely dehydrated, is treated for the dehydration, and then is admitted for a more severe condition, the ED physicians may never get the credit deserved for their hydration work. The CDI team looks for opportunities for dehydration documentation in the ED, especially when a patient gets transferred to observation status. This allows the facility to receive accurate reimbursement. Although the CDI staff at Stony Brook review ED notes with every inpatient record, mortality cases pose a particular opportunity, Slovensky says. “Sometimes, the ED physicians are the only ones who see and treat a patient before they expire. This happens when a patient is admitted, deteriorates, and dies before the admitting physician has a chance to see them,” she says. A patient dying does not look good for the physicians or the facility if that patient’s SOI/ROM scores were low, Slovensky says, so capturing the complete clinical picture for mortality cases represents an obvious priority.

Gaining physician support Even with the maturation of CDI programs over the last decade, physician engagement still rates as the top problem facing CDI specialists—and ED physicians pose a unique challenge, according to Blanton. ED physicians work 24/7, so CDI specialists may find it more challenging to gather them all together as a group for education, and they’re often too busy to drop

what they’re doing and discuss CDI for an hour. “We have no control over patient volume. It’s often controlled chaos in the ED,” Blanton says. Slovensky—as the CDI contact for her ED physicians—attends monthly ED meetings and comes armed with case studies. “The trauma cases are especially helpful,” she says. Walking through those case studies with the ED physicians reassures them that CDI specialists don’t “ask for anything that won’t make a difference.” The CDI team at Yampa Valley Medical Center also attends monthly ED staff meetings where they present the inpatient problems they see to the ED physicians, offering the physicians insight on how documentation problems early on continue throughout the patient’s care. After the first educational push with a CDI specialist in the ED, Blanton advises using an electronic medical record (EHR) to encourage documentation habits through prompts in the system. Incorporate a user-friendly, multiple-choice system that prompts the physician for complete documentation on the spot, he suggests. Since CDI has already provided the initial education, the EHR provides a helpful nudge toward appropriate diagnoses. Ideally, this also takes less time in the ED physician’s day than answering 10 queries would.

Proving it’s worth the work From a financial perspective, identifying ED CDI benefits is more

complex than tracking MS-DRG changes. Much of the benefit comes from improved quality scores and public perception, according to Blanton. Slovensky simply showed administration how the ED work helped raise the case-mix index (CMI). Many CDI inpatient programs see a drop in CMI over time, and the ED offers an opportunity to help those numbers remain strong. Any additional documentation taking place in the ED helps immensely if an ED patient gets admitted, Stevenson adds. “It cues us into things we might need to follow when the patient gets onto the floor,” she says. Quality-based payment programs judge facilities’ performances based on comparisons with other facilities—specifically, comparisons between patients who seem to have the same SOI/ROM, Blanton says. The SOI/ROM scores come directly from the documentation in the patient’s medical record. Problems can arise if the documentation suggests a patient is healthier than he or she actually is due to undocumented secondary diagnoses. Should complications arise or the patient expire, it will look like a relatively healthy patient died unnecessarily. “CDI is about getting it right. We’re not presenting a representation of a patient that is sicker and more complex than they are, but as sick and as complex as they truly are,” says Blanton. “If you don’t put people in the right basket, they’ll be compared with healthier people.”

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Focus on compliance in the rehab setting

ndrea Johnson, RN, BSN, CCDS, the CDI specialist at Carolinas Rehabilitation in Concord, North Carolina, worked in the acute inpatient setting for six years before making a significant change. Carolinas Rehabilitation is a part of Carolinas Healthcare System, which incorporates four freestanding acute rehab hospital locations in the Charlotte area. When the health system saw how well CDI on the acute inpatient side was going, it began expanding CDI into other settings within the system. After the system sought to hire a new CDI nurse without coding or

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CDI experience—who only lasted a few months in the position—Johnson was the first to volunteer for the rehab CDI program. “I always tell myself and my children that if it can be taught, I can learn it,” Johnson says. When she arrived at her new role, however, she ran into some trouble: Since rehab doesn’t fit the traditional scope of CDI work, she had scarce resources at her disposal and was tasked with building her role on her own. Luckily, she was able to rely on some previously established groundwork from Ruth Wilson, the director of all four rehab facilities’

utilization departments; Suzanne Kauserud, the vice president of the Carolinas Rehab Hospital in Charlotte; and her predecessor. Over time, however, Johnson worked to develop her own processes, she says. This meant attending various in-services and webinars provided by vendors at Carolinas Healthcare’s rehab facilities to glean information from other experts. The process helped her identify the voids a CDI specialist could fill. “Essentially, I looked at the medical coder role and fashioned my own CDI program around it,” she says.

Having the CDI background on the acute inpatient side of the system, with chart review and querying experience, certainly helped the transition. Without that experience, Johnson’s initial struggle would likely have been steeper, she says.

to ensure accuracy, specificity, compliance, and complete capture of weighted comorbidities. When there’s room for improvement, she makes the required recommendations and offers IRF-PAI coding education.

in, however, many of the significant etiology codes were thrown out or didn’t have an ICD-10 equivalent that met compliance requirements.

However, the rehab setting poses its own unique challenges— namely, its payment system differs substantially from that of acute inpatient care.

The final form submitted to CMS includes sections from physical therapy, occupational therapy, speech-language pathology, and the PPS and IRF-PAI coordinators. For a typical patient, the IRFPAI form ends up being about 20 pages long, according to Johnson.

Since the new code set boasts much more specific codes, the rehab documentation also needs to be more specific.

Reimbursement differences Rehab facilities submit two forms of data to Medicare—one for statistical purposes and the other for billing. The coders complete the first form as if the inpatient rehab were an outpatient facility. CMS uses this form for rehab statistical purposes, not directly for reimbursement. The second form, called the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI), is a required tool used by inpatient rehab facilities for screening the clinical and functional status of a patient for classification and assignment into a per diem payment system. This form, unlike the first one, is completed like an inpatient acute record. Also unlike the first form, the IRF-PAI is completed collaboratively. The medical coding appears on page 1 of the IRF-PAI. The utilization review (UR) nurse completes the impairment code section, and a coder completes another section with ICD-10 codes. Johnson performs peer reviews of all the Medicare records and the medical coding page of the IRF-PAI

In addition to the coding differences, rehab facilities also have to submit a code for a patient’s impairment group category, similar

There may not be dollars and cents [associated with my effort], but I contribute to making sure our facility is compliant. to the Major Diagnosis Categories (MDC) in an acute inpatient facility. This code explains the condition for which the patient was admitted to rehab care. Each impairment code has to meet one of 13 criteria set out by CMS. Then, the admitting impairment also has to be linked to an etiology code. This, according to Johnson, poses some serious problems. Before the implementation of ICD-10-CM/PCS, the etiology codes used for rehab facilities were pretty general. When ICD-10 rolled

“With those codes deleted, it put the facilities in jeopardy of being noncompliant,” Johnson says.

“A lot of times, I have to go back to the ED record and x-rays to get that specificity documented properly,” says Johnson. “All that documentation of the etiology specifics needs to be provided to the rehab physicians to best meet the compliance requirements.” Due to a lack of interoperability, this process gets even more complicated if the patient was transferred from a facility outside of the Carolinas Healthcare System. For patients to be admitted to an inpatient rehab facility, they must have the ability for improvement in both their medical and functional health. Under CMS, rehab facilities need to be compliant in at least 60% of their admissions annually, meaning that 60% of the patient population needs to fall into one or more of the 13 criteria categories to qualify for reimbursement under the inpatient rehab facility prospective payment system. Without meeting that 60% mark, the facility could be at risk for losing Medicare partnership, which would substantially affect its ability to stay

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afloat and drastically reduce the number of patients it could serve. “We need to get the patients into the right impairment group and link them to specific etiology codes,” Johnson says. “There may not be dollars and cents [associated with that effort], but I contribute to making sure our facility is compliant.”

Review focus Johnson focuses much of her querying and time on compliance issues, usually found by poring over ICU and ED records. For example, traumatic brain injury patients make up a large portion of the inpatient rehab patient population, but the codes used for this injury were largely disposed of during the ICD10 rollout, Johnson says. Since Carolinas Healthcare System is a Level I trauma center, it treats many subdural hematoma patients. These patients often end up in inpatient rehab, but they will not meet CMS’ compliance threshold without documentation of measured loss of consciousness, which typically needs to be documented in the ED or documented as reported by the family members who found the patient unresponsive. By thoroughly reviewing the ED and ICU records, Johnson finds the necessary documentation to support a query to the rehab physicians and make sure patients meet the compliance standard. Each patient admitted to the rehab setting also has to have a medical condition with the potential to improve over time and a new or

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existing impairment with the potential to improve or return to baseline, Johnson says. The linkage between the compliance criteria and the etiological codes is the concrete manifestation of this idea. So, because both conditions need to be documented in the record, Johnson spends a good amount of time reviewing for the presence of both. Because each patient has a unique pairing of medical condition and impairment, every patient’s length of stay (LOS) is different. Unlike the inpatient acute setting, rehab patients have more flexible LOSs. The case-mix group, assigned based on the impairment group and etiology codes with the functional independence measure score, determines the LOS in the rehab setting. The age of the patient also factors into the LOS. “It’s a case-by-case basis,” Johnson says. “If the patient meets the required improvement goals and discharge is safe, we send the patient home. If the goals are not met, then the care team reevaluates their goals and discharge plan. The patient may need to complete their therapy at a long-term rehab hospital or, if safe, at an outpatient rehab facility and at home.”

Querying and engagement Like the acute inpatient setting, rehab physicians document in the patient’s record concurrently. Rehab patients often have a longer LOS than those in the acute

inpatient setting, so the documentation can be extensive. Because of this fact, Johnson reviews and queries concurrently for the most part. Unlike the relatively quick turnaround times in an acute inpatient or outpatient setting, however, there’s also a three-month window after the patient’s discharge for corrections to the final bill. The facility submits an initial bill and then can correct and resubmit the bill during the three months. This waiting period allows Johnson to query retrospectively as well. Primarily, her retrospective reviews focus on hitting that 60% compliance mark mandated by CMS. She tries to limit these types of queries, however, as CMS discourages changing the final bill during the three-month window. “I also collaborate with the coders before and after discharge by email (as they’re remote) to make sure I can query if there’s something more specific that hits on the compliance,” Johnson says. Unlike the acute inpatient setting, more than just the primary provider’s documentation matters. When a patient gets admitted to an inpatient rehab facility, he or she is assigned a team of physicians and clinicians who are then responsible for the patient’s holistic care. In addition to working with the coders post-discharge, Johnson works with several other groups in the process of review and querying. “I collaborate with the utilization review (UR) nurses closely because

many of them assign the impairment codes. I also review the etiologic code assignments by the rehab coders to ensure that they are compatible with the UR assignment and meet the compliance criteria,” she says. Since the UR nurse assigns the impairment code as soon as the patient gets admitted, that collaboration starts early. “I also perform the traditional CDI specialist role of looking for weighting comorbidities for severity of illness and comorbidities that meet qualifying conditions for compliance,” Johnson adds. Speech therapists also come in handy for query purposes, Johnson says. While she doesn’t directly query the speech therapists, she does review their documentation and speak to them about their patients. The clinical indicators from that documentation can, in turn, support her queries to the physicians. For example, “vocal cord paralysis is a high-level impairment,” she says, necessitating thorough documentation from the whole team. Though there are significantly more cooks in the kitchen, CDI specialists venturing into the rehab setting can take heart on one crucial component: physician engagement. While many CDI specialists have horror stories about problematic physicians, Johnson’s experiences have largely been smooth. The atmosphere allows her to reach out to the physicians as another team member, not a meddling outside force. “I’m just one more person they hear from,” she says. “The rehab physicians are used to taking care of their patients in a team environment, so they hear you.”

CMS IMPAIRMENT CRITERIA FOR REHAB FACILITIES CMS sets out 13 impairment criteria for which patients can be admitted to an inpatient rehab facility. In order for a facility to receive reimbursement from CMS, 60% of the facility’s patient population needs to meet one of the criteria from the list. For items 10–12, the criteria are based upon significant functional impairment of ambulation and other activities of daily living that have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings. The 13 impairment criteria are: 1. Stroke 2. Congenital deformity 3. Spinal cord injury 4. Amputation 5. Brain injury 6. Major multiple trauma 7. Hip fracture 8. Burns 9. Neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson’s disease 10. Active, polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies 11. Systemic vasculidities with joint inflammation 12. Severe or advanced osteoarthritis involving two or more major weight bearing joints with joint deformity and substantial loss of range of motion, and atrophy of muscles surrounding the joint 13. Knee or hip joint replacement, or both, during an acute hospitalization immediately preceding the inpatient rehabilitation stay Each of the impairments also needs to be linked with an etiology code from ICD-10. Out of that pairing, either the impairment of the etiology code must show improvement to be compliant. To read the complete breakdown of impairment groups, visit the CMS website.

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RADIO RECAP

CDI in critical access hospitals wear multiple hats “Working in a critical access hospital (CAH) lets you get your feet wet in a lot of different areas,” said Ellen Shriver, RN, CCDS, then a CDI specialist, RAC coordinator, inpatient coder, and auditor for Boone County Health Center in Albion, Nebraska, on the April 26, 2016, episode of ACDIS Radio. While Boone County Health Center has only 25 inpatient beds, Shriver has no problem keeping busy. At the beginning, seven years ago, Shriver’s goal was to “help utilization review in regards to increasing documentation to help support medical necessity,” she said. As the role matured, however, she found herself picking up other tasks along the way. One such task was inpatient coding. After watching and working with coders for years, she started coding herself in fall of 2015. This allows her to catch documentation opportunities by sending a retroactive query. “There’s less of a chance to miss things when you can see a patient from start to finish,” she said. Though Shriver does send retrospective queries, most of her query efforts are concurrent and verbal. Because CAHs typically have a low patient population (and therefore a lower number of charts),

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CDI specialists can get to know the patients’ records intimately and interact with the providers more closely, she said. “Since we’re small, I can go to the floor every morning,” Shriver said. “I pretty much do the same things as most CDI specialists do. I look for the potential diagnoses that are missed, I look at labs, radiology reports, the medications ordered without a covered diagnosis, and of course any clinical indicators for any conditions that are not documented,” she said. Since the patient population is small, however, Shriver reviews all patients regardless of payer—a practice not common in larger facilities. For Boone County Health Center (and nearly all CAHs), though, patients are billed under a costbased structure. This means that the hospital gets paid the price for the actual services it provides, rather than an adjusted rate. Just because the facility is paid through a cost-based system, it doesn’t mean CDI has no effect— rather, its influence might show up in less-expected areas. “I might not increase any revenue on the front end, but accurate and complete documentation hopefully

prevents any takebacks,” Shriver said. As with any CDI specialist, physician engagement in the CAH setting can be a challenge. Since Boone County is so small and in a rural area, none of its physicians are even listed on websites like Physician Compare, Shriver noted. Shriver suggests focusing on good patient care and medical necessity. These two avenues have been the most helpful in getting the Boone physicians on board. CDI specialists often feel like they work in a silo—even more so in the CAH setting because there aren’t many specialists working there. Shriver suggests joining ACDIS and attending conferences whenever possible. Once the initial adjustment of working in CDI has subsided (for Shriver, this took about a year), Shriver encourages CDI specialists in CAHs to keep in good humor. “There’s really a lot of fun to be had in CDI,” she said. Editor’s note: To listen to the ACDIS Radio episode from April 26, 2016, click here. To read a related article from a past edition of the CDI Journal, click here. Shriver currently works as a CDI specialist at Sarasota Memorial Hospital in Sarasota, Florida.

PHYSICIAN ADVISOR’S CORNER

Addressing cardiac concerns in pediatric CDI By Daniel E. Catalano, MD, FACOG

As Robert S. Gold, MD, co-founder of DCBA, Inc. and founding ACDIS Advisory Board member, was fond of saying, “Pediatric medicine is not adult medicine for little adults.” Indeed, while pediatric medicine has most of the same subspecialties as adult medicine, some pediatric specialties don’t exist in the adult world. The pediatric-specific specialties often find their basis in the study of diseases with genetic, metabolic, or structural origins and are frequently the cause of medical care needs in childhood. Unfortunately, from the CDI perspective, the ability to communicate pediatric severity of illness (SOI) is complicated by the fact that pediatricians have a lexicon that is not well captured in ICD-10-CM. This is slowly improving, but the lack of pediatric terms in ICD-10 remains a roadblock to accurate coding and capture of SOI and risk of mortality. Pediatric cardiology is a great example of this problem. Providers in this clinical field, much like in the adult world, are fond of using “chronic heart failure” to cover all types of heart failure. CDI specialists thus have the well-known difficulty of getting providers to document heart failure as acute or chronic, and systolic or diastolic (or any combination

Unfortunately, from the CDI perspective, the ability to communicate pediatric SOI is complicated by the fact that pediatricians have a lexicon that is not well captured in ICD-10-CM. thereof). However, pediatric CDI professionals face an additional challenge: Many pediatric physicians want to stay away from the “heart failure” diagnosis altogether. Pediatric physicians know that a layperson will hear the term heart failure and misinterpret its meaning, associate

it with diseases of the aged and not their own child when the similarity between the condition in an adult patient and a pediatric patient is in disease name only, not pathogenesis. Pediatric providers prefer the term “cardiomyopathy,” which they explain as a “disease of the heart” and leave it at that. The obvious problem, from a CDI point of view, is that cardiomyopathy is a nonspecific diagnosis. There are children with cardiomyopathies on the playground today, and there are children with cardiomyopathies who are in the cardiovascular intensive care unit awaiting a heart transplant. How are we to capture accurate SOI in these cases? Many pediatric heart failure specialists encounter another terminology difficulty with their patients. They have a hard time defining “systolic” and “diastolic” heart failure in children with congenital anomalies that defy traditional definitions. Instead, they may prefer to use terms such as “low cardiac output syndrome,” which codes to “heart failure, unspecified”—bringing us back to square one. Another popular diagnosis, “pulmonary overcirculation,” is a statement of function of the heart, and while it may have significant pulmonary manifestations, it has no code in ICD-10. This condition may lead to heart failure with an overworked heart, but it isn’t the same as heart failure. There are many other examples of cardiovascular diseases in children that present difficulties in capturing accurate SOI due to the pediatric lexicon, such as diseases that are most commonly “primary” in adults but “secondary” in children (and therefore represented by a different code and possibly severity). Suffice it to say that the job of pediatric CDI specialists is easier if they have a background in that specialty and are familiar enough with the providers to have an honest discussion about these pediatric documentation concerns.

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How do we convey these CDI concepts to those who have difficulty understanding the import of our words? First, we must make the case that what we do is relevant. Physicians need to understand that coding is much more than billing. They need to understand that how they look to the world—their success rates, mortality rates, length of stay, etc.—depends on the words they use to describe their patients. In addition, children’s hospitals that do this type of cardiac work are generally members of the Children’s Hospital Association (CHA). The CHA compares its members to each other and provides statistics that result in rankings, which most institutions and academicians care about. Also, while its use is rightfully declining, “reputation” has always been a part of the scoring for the annual U.S. News and World Report rankings.

Another way I hear this—a complaint familiar to most CDI specialists—is, “How come we have to change how we document? Why can’t they change how they code?” Is it possible to achieve change in the current coding system? This question comes up often, especially following the conversion to ICD-10-CM and use of electronic medical records, thanks to the increased awareness providers have regarding the specific codes that result from their documentation. Another way I hear this—a complaint familiar to most CDI specialists—is, “How come we have to change how we document? Why can’t they change how they code?”

and that will capture the true severity associated with pediatric heart failure pathology as opposed to adult heart failure. For now, my conversation with the pediatric cardiology specialists relies on very low-tech definitions of diastolic and systolic heart failure: “Diastolic failure is failure of the fill or flow” and “systolic failure is failure of the pump itself.” If I can get the specialists to agree on those simple definitions, I then show them information from their own pediatric cardiology textbooks that describe one or the other, or both, in relation to all types of pediatric cardiac disease. The textbooks either use those very words in describing the pathophysiology present, or describe the disease process that causes the failure, which physicians can identify as a “fill or flow” issue or a “pump failure” issue. This approach isn’t always successful, but it does move many physicians to use diagnoses they know are present but were previously reluctant to employ. While very few providers cared about what was in ICD-9 in 1979, a great number care about what is in ICD-10 today. They need to understand that they can get changes made. The best way to do this is for the real clinical experts to work together as clinicians within their specialty organizations, along with documentation and coding experts. In doing so, they can come up with not just complaints about ICD-10, but solutions that are evidence-based and fit the clinical picture they wish to paint.

The answer is that the codes can change—and change they have. Witness the 2017 addition of codes for hypertensive crisis conditions, forgotten or left out in the conversion from ICD-9 to ICD-10 for 2016, or the addition of the root operation “Creation” in ICD-10-PCS.

This is part of the process that resulted in the addition of the “Creation” root operation to ICD-10-PCS. If they go this route, they will enable the ICD-10 system to speak for them rather than work against them. It is possible.

We have started a network of pediatric heart failure specialists to work on pediatric definitions of heart failure that can be presented to the Cooperating Parties in a request for new codes—ones that define pediatric heart failure along lines that physicians can agree on,

Editor’s note: Catalano is the president of SMRT Doc Consulting, Inc. He has over 30 years of experience as a physician, CMO, and consultant. He has implemented or re-tuned more than 30 CDI programs, and developed expertise in pediatric-specific issues while working with CDI programs at 15 (and counting) stand-alone children’s hospitals.

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A new frontier: Finding profiles in pediatric CDI

s with any profession, many unique individuals make up the pediatric CDI field. Since pediatrics represents a relatively new area for CDI, ACDIS spent some time chatting with “the proud and the few,” as Leah Savage, RN, MSN, CDI specialist at Norton Children’s Hospital in Louisville, Kentucky, calls pediatric CDI specialists. Regardless of setting, CDI efforts shouldn’t operate in silos; however, when a program starts out, CDI specialists may feel alone. Hearing other people’s experiences and advice helps to broaden perspectives, especially when forging a path into a new area like pediatrics.

From adults to children “When I first started, I had to sit myself down and self-educate,” says Savage about her transition from an adult-focus to a pediatric one in February 2016. Norton Healthcare is a multi-facility system comprised of four adult, one children’s, and one outpatient

It’s still a work in progress. There’s no perfect way to do it. I try to get as much done as I can with what little I have. –Leah Savage

children’s facility. The children’s facility has 250 beds, more than 100 of which are in the neonatal intensive

care unit (NICU). As the sole CDI specialist for the pediatric facility, Savage has no problem keeping busy. Norton Healthcare began its CDI efforts in the pediatric intensive care unit (PICU) and then expanded outward. Savage reviews 100% of the PICU patients and all the patients on the heart floor, regardless of payer, and then all the Medicaid payers on the other floors. Where inpatient programs principally begin record reviews for Medicare patients, pediatric facilities frequently start by targeting Medicaid recipients’ records. According to the Kaiser Family Foundation, Medicaid covers nearly 30 million children. To narrow her review focus, Savage specifically looks at patient

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records that have a length of stay greater than two days. “It’s still a work in progress. There’s no perfect way to do it. I try to get as much done as I can with what little I have,” says Savage.

definitions—likely, the physicians and the CDI specialists are both swimming in uncharted waters, says Savage. Malnutrition poses a complicated diagnosis for adult patients; it’s even more complex for children.

Though she had some pediatric nursing experience prior to moving into the CDI realm, Savage was not strictly a pediatric nurse. Norton Healthcare, however, deemed it crucial to have an experienced CDI specialist take over the pediatric hospital’s CDI initiatives.

Rather than imposing her own opinions, Savage brought the facility’s dietitian on board. The dietitian helped develop and distribute facilitywide definitions and clinical indicators for malnutrition, giving physicians concrete details on what to look for and how to effectively document.

“You’re likely not going to find an experienced pediatric CDI nurse,” says Savage. While pediatric nurses are readily available, as are experienced CDI specialists, the number of people with experience in both settings is

Pediatric providers do not appreciate being asked questions they perceive to be about adult medicine. Children may have the same diagnosis, but they get to it from a completely different pathway. –Daniel E. Catalano

small. Many pediatric CDI programs are still in their infancy, so CDI specialists without pediatric-specific experience need to lean on experts from the broader hospital staff. “You have experts all over the hospital. Use them,” Savage advises. Others’ expertise can also be valuable in the realm of clinical

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While the development of malnutrition definitions is still a work in progress for the pediatric facility, it has been successful on the adult side. “The doctors want to do it right, but they have a hundred other things on their plates. You have to be patient with them. The more clinical information you have, the easier this role will be,” she says. To help provide this type of information to physicians, Savage places flyers about accurate documentation, clinical indicators, and other CDI concerns throughout the hospital—specifically in bathrooms and physician workrooms. Her efforts place CDI front and center in physicians’ minds. If they have questions, Savage encourages the physicians to call her for help.

From chief medical officer to CDI consultant Since starting his CDI consulting company, Daniel E. Catalano, MD, FACOG, physician consultant at

SMRT Doc Consulting, Inc. in Lake Mary, Florida, has worked with more than 20 pediatric programs. He frequently works with large university medical centers, including several listed as top 10 children’s facilities nationwide. Interacting with physicians tops Catalano’s favorite things to do. “When you come into a room, the physicians may be angry they have to be there. But, as you get going, they eventually start asking questions and become engaged,” says Catalano, who started his career as an OB/GYN, then specialized in pelvic reconstructive surgery, and eventually became a CMO for a division of a large not-for-profit hospital company, where he became acquainted with CDI. CDI specialists coming from the adult side of the house, Catalano warns, may run into a few snags with providers due to the differing clinical definitions for children. “Pediatric providers do not appreciate being asked questions they perceive to be about adult medicine,” he says. “Children may have the same diagnosis, but they get to it from a completely different pathway.” A couple diagnoses come up repeatedly in the pediatric population as documentation integrity opportunities. Like Savage, Catalano lists malnutrition near the top of the problem-diagnosis list. “We don’t miss [documenting] the problem,” he says; “we miss the diagnosis that counts. Instead, other words are used, such as ‘failure to

thrive,’ ‘underweight,’ ‘unexplained weight loss,’ etc. While there may be codes for some of these diagnoses, they don’t convey severity.” Literature in the dietetics world estimates that up to 50% of children in stand-alone children’s hospitals are admitted with some degree of malnutrition, but only about 10% of children’s records actually list malnutrition as a diagnosis, Catalano says. Respiratory conditions, sepsis, and intellectual disabilities also pose a problem for those working in pediatric CDI programs. In Catalano’s opinion, however, cardiac conditions present the biggest challenge. ICD10-CM/PCS offers greater code specificity than previous code sets, but the specificity pertains to adult conditions, not pediatric ones. One such example is congenital cardiac anomalies that result in heart failure. CDI specialists transitioning to the pediatric population should seek additional, pediatric-related, clinical education. In Catalano’s opinion, it may be easier to train a pediatric nurse to be a CDI specialist than vice versa. Specifically, he recommends ICU nurses as the best choice; they’ve already weathered high-stakes situations and highly stressed physicians, so “they are not intimidated by the hardest-nosed providers.” No matter where the CDI specialist comes from, however, both clinical and coding teams need to value the specialist’s expertise. Catalano recommends CDI specialists round with the physicians,

enabling on-the-spot documentation improvement opportunities. “When they’re perceived as the expert on the team, it’s great to watch,” Catalano says. For academic hospitals, the return on investment from pediatric CDI reviews may come from the hospital’s public standings rather than from reimbursement improvements. “From the management perspective, pediatric hospitals are now judged on the value-based purchasing and quality model, as are adult hospitals,” Catalano says. “It’s not just about ‘front-end money,’ but now penalties and withholds that also affect the bottom line. When a facility addresses incomplete and inaccurate documentation, the payers and those who compile rankings get an accurate picture of what the facility actually does.” While in the process of implementing a CDI program at a pediatric facility, Catalano harps on physician engagement more than anything else. “Don’t forget your physicians,” he says. With continued learning, the physicians get a better picture of why they should care about documentation integrity. Just as Savage points out, being a resource to the physicians—rather than a hindrance—aids engagement tremendously. If a physician constantly feels attacked by a CDI specialist’s documentation urgings, that physician is much less likely to respond to the queries placed in his or her charts,

especially if the physician doesn’t really understand what CDI is all about. Ultimately, reminding physicians of the end goal of CDI will help engage them, thereby giving the CDI program an additional head of steam. “We’re trying to get to the truth—not more than the truth and not less than the truth,” Catalano says.

From year one to year 10 Prior to working in the CDI program, Jackie Touch, RN, MSN, CCM, worked as a case manager for about eight years at CHOC Children’s in Orange, California, so she knew the lay of the land. When the pediatric CDI program took flight, Touch became one of its founding team members. CHOC has a little bit of everything, from a quaternary-level NICU, to cardiac surgeries, to oncology, to research—more than enough to challenge its three full-time CDI specialists (and one per diem specialist).

We’re trying to get to the truth—not more than the truth and not less than the truth. – Daniel E. Catalano

A teaching hospital with just over 200 beds, CHOC’s CDI program took advantage of opportunities to sow the seeds of proper documentation early for its residents and fellows. “It’s a seedling that can grow while in their residency,” Touch says.

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Though the CHOC CDI team holds the lofty goal of training new physicians in their infancy, interns (first-year residents) can be difficult to reach, Touch says. Interns receive a barrage of new information every day, so CDI efforts can get lost in the shuffle. The residents in their second and third years, however, prove the most receptive audience for CDI efforts. “They know they’re going to be moving on and they won’t have the attendings to help them out soon,” says Touch, so they depend heavily on the CDI staff.

If you work in a silo, you’ll never learn anything. Find the experts and have them speak to you. It’s very helpful. –Jackie Touch

Touch also touts the value of education, but through a different method. “We’re not able to provide housewide education to the care team right now, but rounding with the physicians offers a great opportunity,” she says. Touch focuses most of her time on the PICU because of the high level of acuity available for capture.

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After rounding, conducting reviews, and querying in the PICU, Touch uses those charts and the severity of illness/risk of mortality (SOI/ROM) information for education with the intensivists. As other CDI specialists have found, bringing concrete examples, data, and case studies can help garner physician support and increase understanding. Outside of education, the CDI team focuses on APR-DRG payers specifically (or as many as they can get to, she says). When the program first began, the team brought in a consulting company to help with the training, but that company only used MS-DRGs. Eventually, the CDI program made the shift to APR-DRG because, even though it’s “more labor intensive, it’s a more accurate representation of the patient population,” Touch says. “We’re trying to forge a path for entirely different diseases, disorders, etc., in a world established for adults.” Since the CDI staff focus on APRDRG payers, they primarily look to improve SOI/ROM scores. Developmental and intellectual disabilities pose big query opportunities for Touch. Many physicians simply document “developmental delay,” but

that’s a nonspecific term that does not affect the SOI/ROM. “I also struggle a lot with cystic fibrosis,” Touch says. “When patients get admitted with what they call a ‘tune-up,’ it’s really challenging to clarify if there’s an active infection or another condition that more accurately reflects the level of care provided.” A cystic fibrosis tune-up refers to admissions where the physician’s primary goal is preventive care. Typically, this includes a combination of intravenous antibiotics and respiratory therapy. The cystic fibrosis documentation shortfall primarily affects the pediatric population, according to Touch, so CDI specialists need to keep their eyes open for these opportunities. Whenever Touch sees a troublesome diagnosis or repeat documentation problem, she finds a colleague and talks through it. The ACDIS Forum includes a pediatric section, which she says helps connect her with others outside her CDI department. “If you work in a silo, you’ll never learn anything,” says Touch. “Find the experts and have them speak to you. It’s very helpful.”

Establishing effective remote CDI takes planning The 2017 ACDIS Physician Queries Benchmarking Survey uncovered a number of tidbits about the query process, but the survey also probed the state of remote CDI programs. While 40.8% of respondents cited having some sort of remote CDI option, 36.03% of respondents reported having some sort of hybrid between on-site and remote, and only 4.5% stated that their CDI team is completely remote. While this disparity might appear striking initially, beginning and sustaining a remote CDI program can be a challenge for even seasoned professionals. Traditionally, CDI specialists put in varying amounts of face-to-face time with the physicians. Ideally, that in-person interaction makes the physicians more

open to CDI efforts. However, many remote CDI programs and individual specialists have found creative ways around this face-to-face time. “Technology and mobility has changed physician workflow, and remote communication is likely the

“By being remote, we are working with physicians on their own time, not interrupting them at their busiest time of day.” —Kara Masucci, RN, MSN, CCDS

future of CDI,” says Lara Faustino, RN, BSN, CCDS, a CDI specialist at Boston Medical Center (BMC).

Remote program structure For Cooper University Health (CUHC) in Camden, New Jersey, the CDI program existed solely on-site for eight months before branching out. The facility still has four CDI specialists on-site, but now there are eight remote CDI specialists as well. “CDI has changed a lot over the years. It used to be paper charts and tracking down the physicians in the hospital, but that’s just not how it is anymore,” says Rebecca R. Willcutt, RN, BSN, CCDS, CCS, director of the CDI program at CUHC. The decision to have some remote CDI specialists stemmed from the need to hire new staff without

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spending additional resources training and taking up hospital real estate. “When I hire a CDI specialist remotely, I can hire the best from anywhere in the country. They can hit the floor running and demonstrate a return on investment within a matter of hours, not months,” Willcutt says. For this reason, she hires only certified CDI specialists who have experience with the program strategies and software used at CUHC. Also, Willcutt requests that her staff obtain the CCS or CRC credential within one year of hiring as “these credentials demonstrate a level of dedication and competence in both CDI and coding, fostering a high level of personal achievement and success for each CDI specialist.” When BMC began transitioning to a totally remote CDI team, Faustino was hired as a part-time remote CDI specialist. Quickly, however,

“If you’re going to go through the transition, it takes some time to adjust. You have to have the confidence to succeed. It can be done.” —Lara Faustino, RN, BSN, CCDS

her role transitioned to four days at home and then eventually to full-time remote. The other CDI specialists on the team had similar transition experiences. The change doesn’t happen in the blink of an eye, though. “If you’re going to go through the transition, it takes some time to adjust,” Faustino says. “You

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have to have the confidence to succeed. It can be done.” Although the BMC CDI team now works 100% remotely, their training sessions still take place on-site. They try to hold about two on-site meetings per month, often early in the morning so they can book a conference room in the facility. These meetings help the team brainstorm new educational angles in the world of CDI, Faustino says. Conversely, CUHC does not hold any regular on-site education. Instead, they work together online, asking questions; using instant messaging, WebEx meetings, and email; and sharing education resources. The entire team is on-site for one week each summer to give them a chance to strengthen their bonds in person. Willcutt herself works remotely, making frequent trips to CUHC; the team lead works on-site. This combination allows Willcutt to address the concerns of both on-site and remote staff members.

Physician engagement “With every query, there comes education,” Faustino says. When physicians have questions regarding a query or about CDI in general, Faustino encourages them to call or email her about it. In response, she advises remote CDI specialists to “supply physicians with data and resources they respect and support.” This could be anything from medical journals to industry thought leadership. “I don’t shy away from emailing or calling the physicians with

a question,” says Kara Masucci, RN, MSN, CCDS, a member of Willcutt’s remote team at CUHC. In her experience, a simple phone call to the physician can be an opportunity for education. CDI specialists may fear that being remote will mean the physicians can ignore them easily. This may be true for some situations, but there are ways to leverage the benefits of remote work. “By being remote, we are working with physicians on their own time, not interrupting them at their busiest time of day,” Masucci says. The process at CUHC helps ameliorate frustration and stress for the physicians in responding to queries. If physicians are busy when a query or email comes in, the physicians know they can respond at their convenience. “When you’re in a hospital, you have to be assertive about queries because you only have a few moments of opportunity to catch the physician, and usually those moments are bad ones for them. When communication is electronic, though, it’s on the physician’s time and in their terms when they’ve had a chance to decompress,” Willcutt says. Of course, physician engagement is never quite a tiptoe through the tulips. “You can’t motivate everyone to engage in the query process,” Faustino says. With particularly difficult physicians, she touts the benefits of an escalation policy. “I think what makes or breaks the CDI program is having leadership support.”

That administrative suppor t helped Cooper’s CDI team achieved a 100% query response rate. “We also have a fabulous medical director who helps with the physicians who aren’t responding to queries,” Masucci says. “The administration initiated a zero-tolerance policy for no responses and made it clear that we do not expect a 100% agree rate, but we do expect a 100% response rate,” Willcutt says.

Productivity standards and expectations According to the 2017 Physician Queries Benchmarking Survey, those working 100% remotely average 11–20 new reviews per day. In contrast, those not working remotely average 6–15 new reviews per day. BMC does have a productivity standard in place for its remote CDI specialists, Faustino says, but it is less than the average reported in the survey. The CDI specialists are expected to complete 20 reviews per day, 10 of which are new reviews. “I was able to proceed through my daily workflow quickly due to less office distractions when I switched to remote. Now, I have more time to self-educate, research best practice methodology, and assist in improving processes,” Faustino says. “ Pro d u c ti v i t y ex p e c t ati o n s depend on the size and type of institution you work at, what service line or institute you review, and the purpose of the CDI program. CC/MCC capture is pretty fast,

whereas quality measures, checking admission type and source, trauma activation, performing mortality reviews, reviewing for SOI/ ROM, and querying for Hierarchical Condition Categories take a lot longer,” says Masucci, who reviews specifically for Patient Safety Indicators (PSI). A further benefit of CUHC’s hybrid model is that CDI specialist

“It’s not the kind of position where everything is handed to you in a cute little folder,” says Masucci. CDI specialists need to be willing to selfstart and take initiative. Also, being tech-savvy is a must, says Masucci. “I haven’t hired anyone who I haven’t worked with or previously trained, unless someone on the team recommends them highly,” Willcutt says. “We’re very particu-

“CDI has changed a lot over the years. It used to be paper charts and tracking down the physicians in the hospital, but that’s just not how it is anymore.” —Rebecca R. Willcutt, RN, BSN, CCDS, CCS

coverage is easy. For example, in the event that it’s a light PSI day, Masucci can “jump in where I’m needed since everything is within the EHR,” she says. Those working in an office can develop tunnel vision in their cubicles, but remote staff get used to making themselves available to each other with a quick email or call. “I feel just as connected to my colleagues now as I did before going remote,” Masucci says.

Building a remote CDI team Since not everyone is suited for remote work, CDI programs moving in that direction need to set expectations early. A facility should reserve the right to revoke a newly remote CDI specialist’s telecommuting privilege at any time, Faustino says. This (hopefully) ensures that the remote staff take their positions with the proper gravitas. A remote CDI specialist needs a particular set of traits and strengths.

lar about who we choose for these highly coveted positions, not only from a knowledge and work ethic standpoint, but also based on how they will fit into our [professional] family dynamic.” The facility or CDI manager also needs to set policies for power outages and the like. For example, backup generators and a mobile hot-spot device may be a necessity for remote staff members if they live in an area with frequent outages. “The good news is that if the power goes out in one area, you’re not going to lose all your staff at once if you have remote coverage,” Willcutt says. The bottom line is that not just anyone can cut it in the virtual office. “Remote isn’t for everybody. You have to look at your team and the qualities needed for success, including independence, creativity, critical thinking, and confidence,” says Faustino.

CDI Journal | MAY/JUNE 2017

CODING CLINIC FOR CDI

2017 Coding Clinic advice from first and second by Sharme Brodie, RN, CCDS

Many CDI and coding professionals let out a sigh of relief when the First Quarter 2017 edition of AHA Coding Clinic for ICD-10-CM/PCS arrived—it’s only 52 pages long, a novella compared to the voluminous tomes of previous editions. I looked at it from two perspectives: “Great, maybe there aren’t as many changes!” and “Bummer, maybe they didn’t answer as many questions.” For the purposes of this article, we will focus on items that deal with inpatient-related concerns. However, as the CDI profession moves into the outpatient arena, those working in that setting should stay informed about all of Coding Clinic recommendations.

COPD One of the areas covered in this Coding Clinic relates to coding and sequencing chronic obstructive pulmonary disease (COPD) with other respiratory diagnoses. Let’s start with COPD and pneumonia. The instructional note at code J44.0, chronic obstructive pulmonary disease, with acute lower respiratory infection, states “use additional code to identify the infection.” Coding Clinic says this note does not apply to aspiration pneumonia, and explains that in ICD-10-CM the code for aspiration pneumonia does not fall under the “respiratory infection” codes. Code J69.0, pneumonitis due to inhalation of food and vomit, comes under the section titled “Lung diseases due to external agents.” Aspiration pneumonia is an inflammation of the lungs caused by the inhalation of solid and/or liquid matter. When a patient has both COPD and pneumonitis, the codes assigned would be J44.9, chronic obstructive pulmonary disease, unspecified, and J69.0, pneumonitis due to inhalation of food and vomit. Sequencing of the two conditions would depend on the circumstances of the admission. Another type of pneumonia that does not fall under “respiratory infection” is ventilator-associated pneumonia (code J95.851), which

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falls under the section title “Intraoperative and post-procedural complications and disorders of respiratory system, not elsewhere classified.” Let’s switch gears and talk about coding COPD and asthma. Coding Clinic says that if the specific type of asthma is documented, assign an additional code for the type of asthma. If the type of asthma is not further specified, do not assign code J45.909, unspecified asthma, uncomplicated. The instructional note under category J44, Other chronic obstructive pulmonary disease, states “code also type of asthma, if applicable (J45-).” “Unspecified” isn’t a type of asthma. If the documentation in the health record is unclear, query the provider for clarification. One last note: An exacerbation of COPD does not automatically make the asthma exacerbated; the severity of the asthma and code assignment would be based on provider documentation. To finish up with respiratory advice, Coding Clinic tells us that when referencing respiratory distress in the

No pun intended, but encephalopathy and the coding of encephalopathy can be a bit confusing. Alphabetic Index, there are subentries for both adult and child, and both lead to code J80, acute respiratory distress syndrome. Coding Clinic instructs us to only use code J80 when the provider states acute respiratory distress syndrome, otherwise we would use code R06.00, dyspnea, which also has subentries for adult and child.

Additional considerations There are a few more Coding Clinic items that are particularly relevant to CDI. One question relates to the documentation of body mass index (BMI) when the documentation is provided as a fraction of a whole number—for example, a record that indicates a BMI of 19.5. The instruction states we would assign code Z68.1, BMI 19 or less, adult, for an adult BMI documented as 19.5.

This surprises me, as I would have thought to do the opposite. No pun intended, but encephalopathy and the coding of encephalopathy can be a bit confusing. The advice confirms how a toxic encephalopathy related to a medication should be coded. When the medication was properly administered, we would assign code G92 for the toxic encephalopathy as well as the code to identify the toxic agent, in this case a medication from the T51– T65 grouping. This would follow the sequencing rules of an adverse reaction, with the encephalopathy sequenced first. A second question confirms also that if the toxic encephalopathy was the result of a poisoning, the T code or the code identifying the toxic agent would be sequenced prior to code G19 for the toxic encephalopathy. Another common focus for CDI professionals is the presence of an ileus postoperatively. The question notes that an ileus does not always involve an obstruction and asks whether a diagnosis of postoperative ileus should be assigned code K91.3, postprocedural intestinal obstruction. Coding Clinic tells us to query the physician as to whether the ileus is a postoperative complication. If the answer is yes, assign code K91.89, other postprocedural complications and disorders of the digestive system. We would then assign code K56.7, ileus, unspecified, as an additional diagnosis to describe the complication. If the provider does not state that the ileus is a postprocedural complication, only code K56.7 would be assigned. Lastly, if the ileus is described as being an obstructive ileus and a complication, code K91.3, postprocedural intestinal obstruction, would be assigned. Thus, the record must be very clear in differentiating the presence of an obstruction as well as stating whether the ileus is a complication. The documentation of myocardial infarction (MI) is always a CDI focus, as we look to capture the type of MI (non-ST-elevation myocardial infarction [NSTEMI] versus STEMI), the location of the MI, and whether the MI was initial or subsequent. This Coding Clinic offers direction related to the documentation of a Type 2 myocardial infarction. Coding Clinic states this would be assigned

code I21.4, describing an NSTEMI, unless it is otherwise documented as a STEMI. Therefore, if your physicians are describing an MI as a Type 2, you can assume they are stating the MI is an NSTEMI. Lastly, a question asks whether code Z51.5, describing an encounter for palliative care, can be listed as the principal diagnosis when the reason for the encounter is to receive palliative care. According to Coding Clinic, yes, this is appropriate, although the editors note that such an admission would be rare. This instruction may indicate the need for a query if such a patient is admitted and the reason for the encounter is not entirely clear within the documentation.

Second Quarter concerns The Coding Clinic Second Quarter, 2017, touches on diagnoses related to neurology such as Parkinson’s disease, encephalopathy, and stroke, some of which previously lead to discrepancies amongst auditors. Parkinson’s is a neurodegenerative brain disorder that progresses slowly. Although not fatal, most individuals diagnosed will die from complications related to the disease. While the disease is sometimes known by other names, including Parkinsonism, parkinsonism is a general term that refers to a group of neurological disorders that cause movement problems like those seen in Parkinson’s but it is attributed to toxins, drugs, brain injury or infection, or neurodegenerative disease. This Coding Clinic clarifies that indexing included in the ICD-10-CM manual could cause incorrect code assignment, and indicates that the Centers for Disease Control, is aware of the situation and is considering updates to the code set. So, for now, Coding Clinic recommends assigning code G20, Parkinson’s disease, and F02.81, Dementia in other diseases classified elsewhere with behavioral disturbance, for a patient with Parkinson’s dementia exhibiting aggressive behavior. As always, we encourage you to review each edition so that you can apply its recommendations to your specific focus. Editor’s note: Brodie is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, please visit www.hcprobootcamps.com.

CDI Journal | MAY/JUNE 2017

MEET A MEMBER

Former Army nurse knows CDI in veterans’ healthcare Robert S. Hodges, MSN, BSN, RN, VHA-CM, CCDS, acting VISN 10 clinical documentation improvement program lead and currently works as a quality, safety, and value RN/CDIS at the Aleda E. Lutz VA Medical Center in Saginaw, Michigan. He will soon be moving to a new position as the clinical lead for the VISN 10 documentation improvement program for the 11 VA medical centers in Indiana, Michigan, and Ohio. CDI Journal: What did you do before entering CDI? Hodges: I spent my first 15 years in nursing as an Army Nurse Corps officer serving in a variety of Army hospitals in the United States and the Republic of Korea. In the Army I worked as a medical-surgical nurse, charge nurse, head nurse, preceptor, acting chief nurse, infection control nurse, and informatics nurse. After the Army, I worked for a while as a patient care supervisor and then as a case manager and manager supervising case management and social work at a local hospital. CDI Journal: Why did you get into this line of work? Hodges: I was looking for a way to get back to serving veterans, and this was the opportunity that was presented to me. I joined the CDI team at Aleda E. Lutz VA Medical Center in 2008, and in truth have been having way too much fun ever since. It is great to be able to have an impact on the healthcare of our veterans by working to ensure that the documentation in their health records is as complete and precise as possible. The Veterans Health Administration is probably the largest integrated healthcare system in the country, and we have a fully integrated health record. Since our veterans may seek care at any VA Medical Center, it’s critical that the documentation in the health record reflect exactly what is going on with them, since the record literally does follow them wherever they go.

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CDI Journal: What has been your biggest challenge? Hodges: Convincing people that it’s more than just about money. A lot of people see CDI as a moneymaker, and I won’t deny that. But that’s not what it’s all about to me. For me, it’s about ensuring that the documentation accurately and completely reflects the high quality of care being delivered. This supports quality measures, resource utilization, and—most importantly for the patient—enhances the continuity of care. Any financial impact to me is the cherry on top of a very large sundae. If the documentation is there, the money follows. CDI Journal: What has been your biggest reward? Hodges: The opportunity to work with some really great people all over the country. I have made some great friends and have had the opportunity to work with some people who are a lot smarter than I am, so learning from them is a bonus for me. I’ve also enjoyed becoming a certified fellow mentor in the Veterans Health Administration and being able to mentor CDI specialists at other VA medical centers to help them learn what it is to be a CDI specialist in the VA. In my current role, I get to do a lot of teaching and mentoring, which means I get to share what I know— but I also learn from the CDI specialists I’m helping and mentoring. CDI Journal: How has the field changed since you began working in CDI? Hodges: I think in the beginning the industry focused a lot around financial impact and RAC avoidance—two things I didn’t really have to worry about since the VA is RAC-exempt. I see the shift now to be more on the quality of the documentation and its impact on quality measures and away from the revenue cycle. Sure, the revenue cycle is important, but as I said before, if the documentation is right, the money follows.

CDI Journal: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues through ACDIS? Hodges: I wish they were gold nuggets—I have gotten so many, I would be able to retire to a private lake by now! But I think the biggest single thing that caught my attention was when I attended the ACDIS Conference in San Antonio in 2015 and listened to the presentation by Dr. Cesar Limjoco and Kelli Estes on “Go After the Truth, the Clinical Truth—That’s What Matters at the End of the Day!” This really struck me as the heart and soul of CDI. We really are seekers of truth in the health record, weeding out what is not clinically supported, and identifying and bringing forward those things which are hiding or not specific but which support more precise documentation. I find this to be absolutely amazing, and it’s something I now preach every day to my mentees and providers. Our job as CDI specialists is to ensure that the health record is a truthful representation of the care the patient receives, without embellishment. As Joe Friday from Dragnet would say, “Just the facts.” CDI Journal: What piece of advice would you offer to a new CDS? Hodges: Never be afraid to ask questions and expand your knowledge. Seek out opportunities to learn as often as you can—be it from your peers, coders, providers, or even finding a mentor. We all have opportunities to learn and share every day. That’s how we get stronger. Being a CDI can be a tough job, especially when dealing with a rather challenging provider, but you are there to do a job, and that job is to ensure that the health record is a truthful representation of the care the patient receives. And that is the reward.

Hodges: I delivered newspapers on bicycle (yes, I am that old). A few of Robert’s favorite things: ■■ Vacation spots: Any national park or historic site. ■■ Hobby: Fishing, hunting, reading, and movies. ■■ Non-alcoholic beverage: Iced tea—not sweet tea,

but sweetened. ■■ Foods: Venison, fish … almost anything, really,

especially if I get to cook it. ■■ Activity: Traveling and exploring. Being outside

when I can. I love driving the tractor at my in-laws’ and walking or riding through the woods. I also really enjoy going to the local A-ball baseball games, watching the Tigers on TV, and keeping up with University of Utah football, baseball, and gymnastics. ■■ Family: I’ve been married over 27 years to my wife

who I met in the Army (yes, she really has put up with me that long. Amazing, isn’t it?). She was an adult nurse practitioner when we met, and we were both captains at the time. I have two amazing daughters, both of whom are a lot smarter than I am. My oldest is currently working on her master’s degree in legal and forensic psychology, and my youngest is a manager at the store where she works. They are both very artistic and talented as well. I really am blessed.

CDI Journal: If you could have any other job, what would it be? Hodges: It sounds crazy, but a history teacher. I love reading history and I love teaching. As long as you do what you love, you never have to work a single day in your life. CDI Journal: What was your first job (what you did while in high school)?

CDI Journal | MAY/JUNE 2017