July/August edition of the CDI Journal by ACDIS

JAN/FEB 2017 Vol. 10 11 No. 14 JUL/AUG

SUMMER READING

Strategies for providing CDI training to a variety of stakeholders

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

cian i s y h P e c i t c a Pr

Revenue Cycle

Watch Revenue Shine in the Spotlight

AHIMA is heading backstage in Los Angeles, CA, this October to showcase strategies and solutions for increasing revenue through: - Educational tracks on CDI, revenue cycle, quality measures, informatics, and more! - Networking opportunities - Professional practice roundtable: Performance Review for Clinical Documentation Improvement Programs - 100+ exhibitors showcasing the latest technology and solutions - And much more!

Informatics

Inspiring General Session Speakers Viola Davis

Monday’s Point/Counterpoint Session on Healthcare featuring:

Award-Winning Actress Closing Keynote Address on Inspiration, Innovation, and Leadership Photo Credit: Brian Bowen Smith

Newt Gingrich

Former Speake r of the US House of Representa tives

Lorem

Barbara Box er

Former US

Senator

BOOK YOUR HOUSING NOW!

OCTOBER 7–11, 2017 | LOS ANGELES, CA AHIMA.ORG/CONVENTION | #AHIMACON17 2

956.17CDI

Journal | JUL/AUG 2017

CONTENTS FEATURES 8 Developing an onboarding process Not everyone approaches onboarding the same way, but a training plan streamlines the process.

11 CDI educator roles lend focused support Staying up-to-date in CDI can take valuable time away from daily record review duties and activities. One solution is adding a CDI educator.

18 Sweet provider education tips From chocolate to friendly competition, the ACDIS Advisory Board shares their tips for engaging physicians and ongoing education.

22 Breaking through the noise Physician engagement still ranks as the number one challenge for CDI. With a little creativity, CDI staff can break through.

29 Documentation training for physician residents Medical students aren’t often taught about CDI. Since they document in the record, adding resident education furthers the cause of CDI.

JUL/AUG 2017 Vol. 11 No. 4

21 Radio Recap When there are holes in documentation, denials fill them. Providing education and insight to the medical staff can limit the prevalence of denials.

25 Physician Advisor’s Corner Trey La Charité explains how money is a talking point for physicians and CDI.

32 Coding Corner Sharme Brodie reviews the answers in the newest AHA Coding Clinic for ICD-10-CM-PCS, Second Quarter 2017.

34 Meet-a-member Amy Sterner dove into CDI from coding. She urges to make the most of the time available.

OPINIONS & INSIGHTS 27 Physician Engagement Begins in Residency Lisa Dias and P. Roger DeVersa share findings from their recent survey of medical students’ awareness of CDI.

DEPARTMENTS

EDUCATION CREDITS

4 Associate Director’s Note

BONUS: Obtain one (1) CEU for reading this Journal

Ongoing training, education, and networking. Whether you’re brand new to CDI or a seasoned veteran, ACDIS can help.

6 Note from the Instructor Sharme Brodie shares her best advice for developing a CDI process for improving workflow.

10 Note from the Editor ACDIS Editor Linnea Archibald shares her onboarding experience with ACDIS and delves into the ever-changing world of CDI.

15 In the News The ACDIS Advisory Board discussed the leadership position paper during the quarterly conference call. The 2017 Physician Queries Benchmarking Survey keeps leaders informed.

3 CDI Journal | JUL/AUG 2017

ACDIS Members are entitled to one continuing education credit for reading the CDI Journal and taking this 20-question quiz. Vist the July/August Journal page on the website to take the quiz.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978-750-8400. CDI Journal (ISSN: 1098-0571) is published bimonthly by HCPro, 35 Village Road, Suite 200, Middleton, MA 01949. Subscription rate: $165/ year for membership to the Association of Clinical Documentation Improvement Specialists. • Copyright © 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 Expand summer reading to CDI education by Melissa Varnavas

Career advancement. It’s what most people look for when they join an association. Training, education, and networking are the tools to progress in your career. Whether you’re brand-new to the profession or a seasoned veteran looking for tips to help educate and train your CDI team, ACDIS can help.

California, confessed that, like most upon entering the field, she knew nothing about CDI, coding, or the revenue cycle when she spied an open CDI position. And, like most successful candidates, she did her research, found ACDIS, and absorbed as much information as she could to arrive at her interview armed with an awareness of the role and enough

We dedicate this entire edition of CDI Journal to the various forms of CDI education, with articles on working with residency physicians, tips for engaging providers, and providing ongoing education to the CDI team. We also explore the evolving role of the CDI educator and hear from educators themselves about their responsibilities, benefits, and difficulties.

knowledge to ask intelligent questions about job expectations.

While ACDIS has a wealth of information and materials for a wide variety of educational needs, the first steps—and often the most creative and important ones— come from you.

But what happens once you’re hired? The Clinical Documentation Improvement Specialist’s Complete Training Guide includes instructions and tips for managers on how best to onboard staff.

For example, back in 2015, ACDIS asked members to share insight on how to best get started in CDI. In “Six steps to help you join the CDI ranks,” Shiloh A. Williams, MSN, RN, CCDS, then CDI specialist at El Centro Regional Medical Center in Holtville,

For the new person on the team, the book provides insight into concepts central to CDI, test-yourknowledge questions, fun puzzles and online materials, as well as job shadowing activities. Many have used it to help build extensive mentoring programs.

4 CDI Journal | JUL/AUG 2017

Whether you’re brandnew to the profession or a seasoned veteran looking for tips to help educate and train your CDI team, ACDIS can help.

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

Educators often provide external training as well, either through ACDIS or a consulting firm. ACDIS offers a collection of online learning in its CDI Basics Online Boot Camp, as well as the CDI Essential Skills Online Learning Library. ACDIS Editor Linnea Archibald and the team put a lot of effort into each edition of the Journal, including the one you’re reading now, but the ACDIS website also includes an array of information on the ever-widening scope of CDI practice. Review the materials on the ACDIS website—much of it is free—and take lots of notes. Read the ACDIS Blog and the CDI Strategies email newsletter for timely tips and news updates. The ACDIS Resources pages and ACDIS Radio are also fantastic free options to learn about the field and the industry. Consider using these materials in group education activities as well. While your ACDIS membership is unique to you (no sharing passwords, please!), we encourage members to bring back news and information to share with the rest of the team. For example, the New Jersey ACDIS chapter once encouraged members to listen to ACDIS Radio and bring back tips from the broadcast for discussion at the chapter event. Why not incorporate a similar project with your team during regular monthly educational meetings? You could expand the scope and assign one team member to listen to Radio broadcasts, another to summarize Strategies, another to review the Journal, and so forth.

Members can leverage the ACDIS website for topic-based educational research as well. We often receive requests from members for help with research on physician engagement, outpatient efforts, or disease-specific documentation improvement opportunities. Your team can search the website and employ materials in a similar way.

While your ACDIS membership is unique to you, we encourage members to bring back news and information to share with the rest of the team. For example, if you’re looking to expand into outpatient or quality or are working on building physician education for a tricky diagnosis, consider entering some keywords into the site’s search bar. You’ll get recent news items, links to sample queries and order sets, Q&As with our boot camp instructors, columns from CDI experts offering insight on clinical definitions, and thought leadership and comprehensive discussion of the most recent coding and clinical information from the ACDIS Advisory Board. Sure, the kids are out of school for the summer and educational endeavors are likely far out of mind. I hope, though, that we’ve convinced you to expand your summer reading list to make room for CDI education.

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

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

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

Robin Jones, RN, BSN, CCDS, MHA/Ed Angie Curry, RN, BSN, CCDS System Director, Clinical Corporate CDMP manager Documentation Excellence CoxHealth Mercy Health Springfield, Missouri Cincinnati, Ohio angie.curry@coxhealth.com Katy Good, RN, BSN, CCS, CCDS RAJones@mercy.com CDI program coordinator Northern Arizona Healthcare Mark LeBlanc, RN, MBA, CCDS Flagstaff, Arizona Director, CDI Services kathryn.good@nahealth.com The Wilshire Group m.leblanc@ James P. Fee, MD, CCS, CCDS Vice President Enjoin james.fee@enjoincdi.com

thewilshiregroup.net Karen Newhouser, RN, BSN, CCDS, CCS, CCM Director of CDI Education MedPartners Tampa, Florida karenmpu@ medpartnershim.com Laurie Prescott, RN, CCDS, CDIP, CRC CDI Education Director HCPro/ACDIS Middleton, Massachusetts lprescott@acdis.org

Judy Schade, RN, MSN, CCM, CCDS CDI Specialist Mayo Clinic Hospital Mosinee, Wisconsin Schade.judy@mayo.edu Susan Schmitz, JD, RN, CCS, CCDS, CDIP Regional CDI director Southern California Kaiser Permanente Pasadena, California susanschmitz59@yahoo. com

Anny Pang Yuen, RHIA, CCS, CCDS, CDIP VP of Revenue Cycle R3 Health Solutions ayuen@r3healthcolutions. com Deanne Wilk, BSN, RN, CCDS, CCS Manager of CDI Penn State Health Hershey, Pennsylvania dwilk@hmc.psu.edu

CDI Journal | JUL/UG 2017

NOTE FROM THE INSTRUCTOR

Lean on your process: CDI workflow by Sharme Brodie, RN, CCDS

Many newer CDI specialists are trained on encoders right off the bat, often never using a DRG Expert until they seek certification. I’m going to show my age now by telling you that when I started, we all used a DRG Expert filled with notes in every available area on each page. I tell CDI specialists who are planning on taking the Certified Clinical Documentation Specialist (CCDS) exam to get a DRG Expert and start adding notes in all the margins. That way, when you are ready to take the exam, you’ll have your reference guide ready too. Most people don’t know until they fill out the application for the CCDS that you’re allowed to take your DRG Expert into the exam as long as there are no loose papers inside. Basically, if the proctor shakes your book and nothing falls out, you can take it in with you. Before settling in for the exam, become familiar with how to use the DRG Expert and all the resources found within. I advise everyone to take a few coded encounters and work through them manually using the DRG Expert. See how you do without the encoder! Make sure all the Major Diagnostic Categories (MDC) are tabbed along with the major appendixes like the Complications and Comorbidities/Major Complications and Comorbidities (CC/MCC) list, alphabetic listing, and numeric listings of diagnoses. These tabs will cut down on the time it takes to find things. I also suggest going through the CC/MCC lists and highlighting diagnoses that are common to the Medicare population. Again, the highlighting will save you time in the long run. Now, let’s go through a basic scenario. Try to follow along with me. Mrs. Jones has a history of congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). She is admitted with CHF exacerbation. What should be the first step? First, have a plan. Use a worksheet or a list until you are comfortable reviewing a chart. Follow a repeatable pattern to ensure nothing gets missed in the process of skipping around the medical record.

6 CDI Journal | JUL/AUG 2017

Determining the principal diagnosis is a major component of the first step. Knowing the definition per the Uniform Hospital Discharge Data Set (UHDDS) is vital. If you assign the wrong principal diagnosis, everything else could also be incorrect. This patient was admitted with CHF exacerbation, so what clinical indicators would support this diagnosis? To find the answer to this question, look at the diagnostic testing such as the echocardiogram, radiological testing, and labs. Remember what values fall into the clinically normal range. What if the patient had a brain natriuretic peptide (BNP) of 1575 and an ejection fraction (EF) of 30%? What do these results indicate? What MDC would this diagnosis be found in? Learning the various MDCs early in your CDI career will help narrow your search when exam time comes. As you learn each MDC, take a minute to look at all the principal diagnoses that are listed under each DRG. These lists are not all-inclusive, but they will let you know what to look for and where to look for it. The documentation indicates exacerbated CHF, so we need to know the type of CHF: systolic or diastolic. Normally, you would need to know whether systolic CHF qualifies as an CC or MCC. If the CHF is acute, it will be an MCC; if it is chronic, it will be a CC. To verify this categorization, look up these diagnoses in the CC/MCC list (found in Appendix B, in the back of the DRG Expert). Let’s move on to the next step. Are there any diagnoses documented by the provider that would, per the UHDDS, fit the definition for a secondary or other diagnosis? There are several definitions here that would be helpful to memorize. When looking at a patient with COPD, the CDI specialist needs to know whether the COPD is exacerbated. Look for clinical indicators that indicate exacerbation, such as IV solumedrol versus oral medication. If the clinical indicators are present, a query might be necessary to clarify the diagnosis. Before sending a query to the provider, you need to know the rules and guidelines pertaining to querying.

In 2013, AHIMA and ACDIS published “Guidelines for Achieving a Compliant Query Practice,” which was updated this year to reflect recent coding changes. Familiarize yourself with this practice brief to ensure your queries are compliant.

procedure was related to the principal diagnosis, then the patient stays in the same MDC (MDC 5 for circulatory). If, however, it was not related to the principal diagnosis, we would move to the MDC for DRGs Associated with all MDCs (often referred to as the “back of the book”).

If there are any secondary or other diagnoses that fit the definition per the UHDDS, you’ll need to determine if any are CCs or MCCs. There are four types of DRGs, three of which can be moved with a CC/MCC to a higher relative weight (RW) and length of stay (LOS). Think of it like climbing a ladder.

There are only four DRGs found in this MDC, all of which are surgical. Before assigning any of these DRGs, ask a few questions. First, is the procedure related to the prostate? If not, you can cross off DRGs 984–986. Second, is it considered a non-extensive O.R. procedure? To answer this question, review all the procedures found under DRGs 987–989. If you can’t find the procedure listed, the procedure would be considered an extensive O.R. procedure. The procedure should then be assigned to the DRGs 981–983, depending on the presence of a CC or MCC.

Let’s say, through querying the provider, we know that the patient has a principal diagnosis of acute systolic heart failure with an acute exacerbation of COPD as a secondary diagnosis. Where does that get us? Acute systolic heart failure as the principal diagnosis leads us to MDC 5: Diseases and Disorders of the Circulatory System. The DRGs found under this diagnosis are a triplet, meaning there are three ladder rungs to climb. The lowest rung is DRG 293—Heart Failure and Shock without CC/MCC, the second rung is DRG 292—Heart Failure and Shock with CC, and the top rung is DRG 291—Heart Failure and Shock with MCC. Next, when we look up acute exacerbation of COPD, we’ll find that it classifies as a CC. This information helps us climb to the second rung of the ladder. Once we’ve determined the principal diagnosis and any secondary diagnoses, we need to determine whether the patient had a reimbursable procedure or intervention during the stay. Based on the original documentation, the patient did not have any reimbursable procedures or interventions. To make the situation more interesting, however, let’s say that on day three of the admission, the CDI specialist reviewed the nursing documentation and saw that the patient has an unstageable decubitus ulcer requiring debridement. Now, we need to determine whether that debridement was excisional or non-excisional. An excisional debridement is considered reimbursable, whereas a non-excisional debridement is not. When a patient has an intervention or procedure performed, the CDI specialist also needs to determine whether it was related to the principal diagnosis. If the

You will actually find excisional debridement in every MDC. This means that you’ll never leave the MDC of the principal diagnosis when an excisional debridement is performed. This piece of information would be helpful to jot down in your DRG Expert. In this case, the final DRG would be DRG 292—Heart Failure and Shock with CC. The DRG won’t move until the patient’s ulcer is staged. The documentation stated that the patient would require an excisional debridement but did not state the debridement was completed. At this time, we would stay on the medical side of MDC 5. Once the patient undergoes the excisional debridement, we would move to the surgical side of MDC 5 under DRG 264—Other Circulatory System O.R. Procedures. DRG 264 is a single-tier DRG, meaning neither a CC nor an MCC can move it. Most of our patients are admitted with a laundry list of conditions. Each condition should be evaluated and clarified as needed. The process requires a lot of practice, so it may take some time to become fully comfortable with it. Once you do, however, you’ll be able to tackle even the most complex charts with ease—even without the help of an encoder. Editor’s note: Brodie is a CDI education specialist and CDI boot camp instructor for HCPro in Middleton, Massachusetts. For information, contact her at sbrodie@hcpro.com. For information regarding CDI boot camps offered by HCPro, visit www.hcprobootcamps. com/courses/10040/overview.

CDI Journal | JUL/UG 2017

Developing an onboarding process: Advice from the field

ave a new hire on the way? Without a set plan in place, the new staff member may end up with conflicting information or take significantly longer to train. Though not everyone approaches onboarding the same way, developing a transition and training plan streamlines the process, sets reasonable expectations, and ensures a smooth entrance for the new team member.

Methodist Health System in Omaha, about her training curriculum.

But how does one go about planning an onboarding process?

some programs may have a rotational training period where the new hire shadows each member of the CDI team in turn, Braun believes in having a single point person.

“I sort of just thought about the key points a CDI specialist needs to know and went from there,” says Erica Braun, MS, BSN, RN, CCDS, CDI manager at Nebraska

8 CDI Journal | JUL/AUG 2017

Braun’s plan involves two major components: one-on-one training with the team lead and a structured checklist of material to cover. While

can be hard for a new CDI specialist] when you’re shown four different methods right away,” she says. The time frame for the initial oneon-one education with the team lead varies according to the new hire’s

“You have to develop your own way to review the chart, but it’s hard when you’re shown four different methods right away.” Erica Braun, MS, BSN, RN, CCDS

“You have to develop your own way to review the chart, but [that

skill level and aptitude, Braun says. “Some need a bit more one-on-one time, and others are a bit more independent,” she says. No matter how much CDI experience they already have, all new hires need that initial personal education to ensure they’re on the same page.

Having a dedicated point person who trains each new hire also gives Braun focused insight into the hire’s progress. Rather than needing to ask each individual CDI specialist for impressions of the newbie, she can go directly to the team lead and get the whole rundown at once. “I’m in constant communication with the lead,” she says. Although the CDI team lead primarily takes charge of the new hire’s education, Braun still retains the controls and serves as the mastermind behind it all.

CDI SPECIALIST SKILLS CHECKLIST EXAMPLE To go along with the one-on-one education, Erica Braun, MS, BSN, RN, CCDS, CDI manager at Nebraska Methodist Health System in Omaha, developed a systematic checklist for identifying a new CDI specialist’s skills and abilities. Each item includes a checkbox that indicates the item needs review, a space for the date, and spaces for the supervisor and new hire to sign off on the completed training. The new hire’s checklist starts during the orientation period and goes into the specialist’s permanent record for review purposes. The checklist includes the following items as gauges of a new CDI specialist’s proficiency: ■■ Identifying principal diagnoses ■■ Identifying CCs/MCCs

And she’s developed a systematic approach to make education even more structured. First, the team lead reviews the basics (CCs/MCCs, DRGs, coding basics, queries, etc.). Then, “we take it by body system and nursing unit. We just take it one section at a time,” says Braun.

■■ Identifying missing documentation and the need for clarification

The second piece of Braun’s training program—the checklist—serves as a guide for the one-on-one education and lets her track the new team member’s progress.

■■ Demonstrating effective communication with providers

The checklist covers all the basics of a CDI specialist’s skill set, from identifying a principal diagnosis, to query formulation, to using Nebraska Methodist’s specific software. Before the training begins, the new hire and the CDI lead work through the checklist together and indicate whether the new hire needs review on the various items. Then, as the training progresses, the CDI team lead and the new CDI specialist each sign off on the individual skills.

■■ Demonstrating proficiency in reviewing a record within the electronic

health record (EHR) ■■ Demonstrating proficiency in sending and resolving queries within

the EHR ■■ Demonstrating proficiency in identifying query opportunities based

on clinical indicators or documentation ■■ Demonstrating effective communication with coders ■■ Completing the EHR computer-assisted coding education ■■ Completing an ACDIS CDI Boot Camp

The checklist process lets Braun, the team lead, and the new hire all see where the staffer stands in the

Some need a bit more one-on-one time and others are a bit more independent,” – Erica Braun, MS, BSN, RN, CCDS

educational process. When the skills checklist has been completed,

presumably the new hire can work independently. At the end of the day, the biggest advantage to having a set orientation plan in place, according to Braun, comes from the added consistency and support given to the new hires. “Before this, it was really inconsistent. The new staff have reported to me now that they feel supported,” says Braun.

CDI Journal | JUL/UG 2017

NOTE FROM THE EDITOR Onboarding lookback: An ACDIS journey by Linnea Archibald

It’s hard to believe my ACDIS journey only began six months ago. As anyone new to CDI will tell you, the mountain of information can be overwhelming. Lucky for me, I’ve never been tasked with reviewing a record and querying. Though I’ve learned a lot in the past months, the clinical side of the review would be almost entirely lost on me. (Have mercy on me, ACDIS friends, I possess but a limited understanding of medical abbreviations.) Anyone new to any job knows there’s a learning curve, but the path for those in CDI may be especially steep. My coworkers all told me it would be six months before I felt confident. They were right. While I certainly don’t know everything yet, my onboarding process made me confident about what I do and do not know. So, for those struggling in the trenches of CDI onboarding, gather around and listen to the tale of an English major’s ACDIS journey.

From confusion to limited understanding I can say with full confidence that none of the details of my first day at ACDIS imprinted in my memory—apart from it being jam-packed with meetings, reading, and research. Luckily, no one expected me to be particularly helpful that first day. Everyone I’ve spoken to about their own CDI onboarding process recounts similar feelings. The first week washes over you, leaving a overwhelmed impression. Then one day, it clicks. The words start to make sense. The lightbulb moment came early in the process for me, luckily. I credit this to the swaths of time I was able to devote to education. Director Brian Murphy, Associate Director Rebecca Hendren, Associate Editorial Director Melissa Varnavas, and CCDS Coordinator Penny Richards helped

educate me in all things CDI and ACDIS, emailing me bits of information or answering basic questions. Our CDI Boot Camp instructors took time to walk me through the CDI process—soup to nuts. In addition to resources, articles, books, and e-learning, several ACDIS members reached out to me offering help. Several even shared their stories, illuminating areas I hadn’t encountered. Though I did a lot of reading and studying, the most beneficial piece of my onboarding was conversation. Without those personal chats, I wouldn’t be where I am now.

Six months later, the onboarding continues Much like maturing CDI specialists widen their attentions from CC/MCC capture and DRG assignments, I’ve begun to move beyond the basics of my ACDIS duties and CDI knowledge. At the beginning, I had help with nearly every project I tackled. Slowly, though, I am tackling bigger projects. With new responsibilities, come more learning opportunities. For instance, for the last issue of CDI Journal, I dug into outpatient, inpatient rehab, ED, and pediatric CDI programs. Each one brought new challenges and lessons. As I researched this issue, I’ve found more areas outside my knowledge. CDI is a vast field, and I’ve only begun to scratch the surface. Though my initial onboarding is more or less over, I’ll never be done learning. Perhaps that’s why CDI is so exciting. Other jobs have a set onboarding period, but the CDI onboarding never stops. At least, that’s been my experience. If you’re feeling overwhelmed by the amount of CDI information to digest, try to think of it as an opportunity. You’ll never get bored. Editor’s note: Archibald is the ACDIS editor with responsibilities ranging from social media to crafting articles for its many publications. Contact her at larchibald@acdis.org.

CDI Journal | JUL/AUG 2017

CDI educator roles lend focused support

he amount of energy it takes to stay up-to-date on all the relevant CDI news can be overwhelming. It can take valuable time away from daily record review duties and activities. One relatively new solution to this conundrum is the addition of a CDI educator—an individual dedicated to the educational needs of the CDI team and, in some cases, even physicians. Not only does the presence of an educator give the CDI specialists the time to focus on their day-today tasks, but it allows for uniform

education across health systems, small or large. “We discovered a lot of variation across the system as to how [CDI concepts] were taught,” says Dee

“[Adding a CDI educator] provided a way to standardize work processes and workflows,” – Melinda Scharf, RN, BSN, CCDS, CCS

Ann Arellano, MS, BSN, RN, director of CDI at Banner Health System based in Phoenix, Arizona.

By adding two educators, Banner ensured that each of its approximately 80 CDI specialists received the same education, putting them all on the same page. Adding in-house educators also eliminates the need for outside help. “[The system leadership] wanted a way to educate staff and new employees without having to use consultants. Plus, this provided a way to standardize work processes and workflows,” says Melinda Scharf, RN, BSN, CCDS, CCS, regional clinical documentation

CDI Journal | JUL/UG 2017

integrity educator at St. Joseph Health in Irvine, California. Getting started can be challenging. In an effort to shed light on the murky process, ACDIS spent some time chatting with those already doing the job.

Structure and direction When Scharf first undertook her new role as a dedicated CDI educator, there was very little structure or direction attached to the role. The leadership essentially said, “Here: You’re an educator now. Go for it,” she says. To succeed, a new CDI educator must step back and assess the needs and responsibilities of his or her new role, then work with management to establish those parameters. For example, will the role require only training for new hires, freeing the educator up to conduct chart reviews when such services are no longer required, or will the role include weekly or monthly in-house training for all CDI staff? Will the educator be responsible for physician education as well, coordinating physician education newsletters, presentations, and the like? On what timetable? “One thing you should do right away is identify what exactly are priorities. Put a structure to that right at the beginning and then chip away at it,” recommends Scharf. Without concrete responsibilities, the new educator risks being pulled in different directions. It’s much easier to start with the essentials,

12 CDI Journal | JUL/AUG 2017

Arellano says. As the role matures, the educator can then take on more tasks. Arellano actually pushed her program to adopt a CDI educator role about four years ago, but without hard data or a project plan to support the request, the idea languished. So Arellano and her compatriots formulated a concrete business plan, including both tangible and intangible expected returns on investment, to present to the system’s leadership, leveraging data from Banner’s

“Gather your resources! Learn those coding guidelines and keep up with the updates.” Judy Cassetty, RN, BSN, CCDS

CDI software program. One crucial piece was to outline the negative consequences of not creating the educator position, Arellano explains in Banner’s 2015 ACDIS conference poster presentation. This is where variation in education comes into play. For example, a CDI specialist might think he or she understands the implications of a recent Coding Clinic release thanks to a close friend in coding. Perhaps the specialist changes his or her query practices based on that perceived understanding. Even if the CDI specialist’s perception is correct, he or she might no longer be sending the same message as the rest of the CDI team. Of course, if the CDI specialist’s perception is incorrect, he or she

could end up lowering coding and documentation accuracy, creating improper physician documentation habits, and damaging the trust between physicians and the rest of the CDI team. A dedicated CDI educator can avoid this situation by bringing information to the entire group at once, ensuring efficiency, effectiveness, and compliance.

The right candidate for the role Regardless of where the momentum comes from for the program, a CDI educator needs to be adequately equipped to help. To teach others, one must first obtain knowledge. Whether implementing the role as a step in the CDI program’s career ladder (promoting successful, energetic CDI staff from within) or looking externally for a competent individual to fill the role, a few qualifications should be kept in mind. First, the CDI educator needs to have an excellent understanding of the importance of the profession and exhibit not only competence in record review but advanced skills in working with a team, handling tricky situations, and delivering difficult information in a digestible way. Second, he or she needs to be a “self-starter,” understanding not only where to find relevant information but also which information needs to be passed along to which individuals. Third, the CDI educator needs to work well with administration to identify educational opportunities

and leverage programmatic data to make the case for change. Finally, the educator should be able to effectively argue for the additional resources needed to help the overall team. The educator’s ability to work well with coding/HIM is also crucial to a CDI program’s success, says Arellano. “This is a key, ongoing collaborative piece of the role that helps ensure we’re on the same page with understanding Coding Clinic advice and with our joint/shared processes.” “I think that the CDI educator needs the resources available to help the CDI specialists at the facility. Gather your resources! Learn those coding guidelines and keep up with

“There’s been some good feedback about some of our queries and things that are driving [the providers] crazy.” Melinda Scharf, RN, BSN, CCDS, CCS

the updates,” says Judy Cassetty, RN, BSN, CCDS, regional manager and CDI educator at Saint Joseph Health in Lubbock, Texas. The CDI educator and manager need to determine what additional resources to provide the team, such as newsletter or magazine subscriptions, association memberships, online or webinar-based learning, and live conferences. Once you’ve got the go-ahead, gathered your resources, and

set your priorities, you’re ready to embark on the CDI educator journey.

CDI specialist education: New hires A dedicated CDI educator also helps improve training for new CDI specialists. Even though an educator trains all the CDI specialists to a certain extent, he or she also has a unique opportunity to build the newest members of the team from the ground up. “Since we now have a much more structured program, we know they have the information they need to succeed. It enables them to get on board faster, feel more confident within the long learning curve expected, and be better aligned with the metrics expected of team members,” Arellano says. When Cassetty first started as an educator, she spent half of each day with one new hire, answering questions, reviewing compliant query practices, and teaching as necessary. “It was so neat to see the new staff blossom. These new hires could be top notch in six months, whereas it took me about two years after I started [to begin to really be comfortable in the role] without an educator’s help,” Cassetty says. Since most programs have few educators to go around, adding in a couple trusted, respected CDI team leads can be a great resource as well. At Banner Health, the educators hold “CDI classroom” programs

that last approximately two weeks. The first half of the program is spent reviewing Major Diagnostic Categories, select anatomy and physiology, coding-related information, and potential documentation improvement opportunities. The second half is spent practicing on real-time case reviews, implementing the CDI specialists’ newly gained knowledge. Query writing is also a major focus at Banner Health, according to Arellano. “[The CDI specialists] need to learn how to use appropriate ethical and compliant verbiage while supporting, in a concise manner, the key elements needed to support the clinically credible question being posed to the providers,” she says. “We’ll pull [new staff members] to a centralized area for one-on-one education with someone who’s experienced for the first month or so,” Arellano says. As they go through that focused training, the CDI team lead provides updates to the CDI educators about the new hire’s progress. If the lead sees an area where a new staff member could benefit from more education, the lead communicates with the CDI educator to provide the new staffer with additional materials and training. Having a point person for those new hires—whether that be the educator or an additional team lead— also helps take pressure off busy CDI specialists. “You see an immediate release of stress when you take something off their plates,” says Cassetty.

CDI Journal | JUL/UG 2017

CDI specialist education: Ongoing efforts To paraphrase Einstein, learning is a product not of school but of a lifelong attempt to gain knowledge. Even after a new staff member’s official onboarding ends, the education shouldn’t. CDI program managers need to understand how to leverage program data to identify education opportunities and work with both the team leads and the CDI educator to address those needs. For example, if one CDI specialist seems to have more unanswered sepsis queries than the rest of the team, the CDI manager might have a one-on-one discussion with that specialist or might check with the CDI educator to see if the entire team could benefit from a refresher. The CDI manager can also help connect the CDI educator with expertise from other departments to address a particular concern, such as reaching out to the HIM/coding group for review of a recent Coding Clinic or to case management/utilization review for help with medical necessity education. Each role—whether it be the educator, manager, or CDI specialist— should be clearly defined to allow the team to work together, rather than at cross-purposes, when it comes to identifying opportunities and providing education to meet those needs. For example, one sample job description included in the Resources section of the ACDIS website says that educators’ duties include:

14 CDI Journal | JUL/AUG 2017

■■ Working with program lead-

ership to plan, develop, and implement CDI education programs for both CDI specialists and providers ■■ Analyzing data to identify

areas for stronger education ■■ Mentoring and educating the

CDI staff ■■ Identifying areas of non-

specific documentation and improving documentation templates by working with the CDI specialists ■■ Collaborating with the CDI

manager and others to ensure the ongoing relevance of department-specific educational content

“If they [providers] are able to practice at our site, then we want them to know about CDI.” Dee Ann Arellano, MS, BSN, RN

While ongoing training is often less structured than new hire efforts, CDI educators do need to maintain a regular calendar of events. “We have a lunch and learn where a person from coding presents a case study and then they’ll go through how they would code it, and explain why/what they base their decisions on,” Arellano says. Bringing the two groups together on a formal, planned basis allows for greater collaboration and knowledge sharing. Educators can facilitate this

process well because it’s part of their dedicated job. Though the coders aren’t all on-site at her facility, Cassetty also uses group meetings as an educational platform. “We do several collaborative calls once a month with the hospital system, including all the CDI specialists and all the coders. We focus on one item and interact about it. During that meeting, they hear the roll-call and can put a voice to a name,” she says. In addition to these regular meetings, educators can provide resources to the CDI team throughout the week. “I do case studies with them every couple weeks and also send out weekly happenings that include clinical, coding, and process reminders,” Scharf says. Even when there’s no meeting on the schedule, this helps the CDI specialists stay abreast of any news or tips without spending their time digging for resources. Arellano says an educator’s days can vary quite a bit. First, no matter what’s happening, Arellano checks her email for any outstanding questions or problems from the CDI team. Having a designated point person for all educational needs lets the CDI specialists ask whatever they need to rather than floundering to figure things out on their own, according to Scharf. “The staff really likes having an educator,” she says. For Cassetty, much of the ongoing efforts take place on a case-by-case,

one-on-one basis. “The one-on-one interaction has been my greatest way to answer their questions. They don’t want the other CDI specialists to know what they don’t know,” she says.

While a CDI educator role does not eliminate the need for interaction between on-the-ground CDI specialists and physicians, providing physician education through a dedicated staff member takes even more

“Providers are much more likely to respond to the queries because they know what they are and specifically who they’re coming from,” – Dee Ann Arellano, MS, BSN, RN

Regardless of whether an educator is focusing on new-hire, ongoing, or provider education, the educator needs to be a pinch hitter for the team, Cassetty says. “On a whim, we’re answering our CDI specialists’ questions, trouble-shooting, and helping with anything else that may come up.”

Provider education Not all CDI educators provide physician education. At Saint Joseph, however, the CDI educator role proved so successful it evolved into a dedicated provider educator position. Cassetty, in fact, devotes part of her time to physician education while maintaining her CDI educator duties.

present the material to the physicians themselves. “Providers are much more likely to respond to the queries because they know what they are and specifically who they’re coming from,” Arellano says. “There’s been some good feedback about some of our queries and things that are driving [the providers] crazy,” notes Scharf.

pressure and responsibility off CDI specialists’ plates and transfers it to someone with more time to devote to the cause.

Even without the addition of a dedicated provider educator, the CDI educators can play a vital role in this area.

At Banner Health, the CDI educators participate with the facility’s CDI staff in developing physician educational presentations whenever the need arises, subsequently making them available to each CDI team within the system.

Though CDI educators develop physician education as the need arises, Arellano and her team have also developed a new-hire training presentation for physicians. This includes explaining the “what” and “why” of CDI, what’s in it for the providers, and how they participate.

By uploading the presentations to their shared intranet, every facility and CDI department has access to the same physician education resources. Even though the CDI educators provide a final review and approval of the presentations, the CDI specialists reviewing records

“If they [providers] are able to practice at our site, then we want them to know about CDI,” she says. “We let them know we’re their allies and a resource to help them with their documentation to best reflect a true, written portrait of their patient.”

CDI Journal | JUL/UG 2017

IN THE NEWS

In the news: ACDIS publishes new leadership position paper, physician query survey “Even if you don’t have a title, you can be a leader if you’re passionate and have a desire to change a process that’s not working,” said Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at the Mayo Clinic Hospital, on the May 18 Quarterly Conference Call. She spoke in regard to a new ACDIS position paper, “Developing effective CDI leadership: A matter of effort and attitude.” The paper addresses not only those in formal leadership positions within their CDI departments, but also leadership principles for average CDI specialists conducting dayto-day record reviews. Many CDI professionals feel frustrated when it comes to recognition, understanding, and support of their roles. In a January survey deployed to ACDIS members (“Present and future of CDI”), respondents were asked to identify challenges and opportunities for CDI efforts within their organizations. Some of the challenges expressed in the open-ended responses included lack of the following:

16 CDI Journal | JUL/AUG 2017

■■ Physician buy-in and

cooperation ■■ Upper leadership support ■■ Awareness and respect for

CDI ■■ Relationship with coders ■■ On-site CDI leadership ■■ Physician accountability

To clear these hurdles, CDI leaders can take advantage of many tools and their unique role as facilitators to transform their services and

“You really have to market yourself, you have to market your program, you have to share your passion with others because it’s contagious,” said ACDIS Advisory Board member Robin Jones, RN, BSN, CCDS, MHA/Ed, assistant vice president of revenue integrity and clinical documentation excellence at Mercy Health in Cincinnati, on the Quarterly Call. Effective leadership, according to the paper, isn’t the same thing as effective management—a minor but crucial distinction. Leadership

“Leadership is not a position; it is forward movement. CDI professionals have the power to create change on issues that they care about.” “Developing effective CDI leadership: A matter of effort and attitude”

departments, delivering even greater value. By doing so, they can align the focus of their department, meet the needs of their healthcare organization, improve their overall status, and remove any sense of powerlessness and isolation. As a result, the challenges outlined in the survey should improve noticeably. Of course, knowing where and how to start the process can be difficult.

has far less to do with authority and much more to do with setting a vision, mission, and strategy toward specific personal, professional, and programmatic goals, the paper states. “Leadership is not a position; it is forward movement. CDI professionals have the power to create change on issues that they care about. However, they need a robust purpose, an understanding of the value that they

bring, the knowledge to engage with their customers, and the patience to contribute to overall success,” the paper says. Whether CDI professionals consider themselves leaders or not, staying informed about changes in the industry helps them demonstrate their dedication to, and proficiency in, their role. One area of change and growth has always been queries. From following compliance recommendations to electronic health record templates, the world of queries has changed significantly since the early days of CDI. “The days of getting right in and out of the chart are way behind us,” says Shelia Duhon, MBA, RN, CCDS, A-CCRN, the national director for CDI education at Tenet Healthcare in Spring, Texas. In an effort to take the pulse of the query scene today, ACDIS recently conducted a new survey probing current query practices, nearly four years after its last survey on the topic. The 2017 survey received answers from 361 respondents.

clarification went down from 67.37% in 2013 to 51.93% in 2017. “The fact that we’re reviewing for primarily reimbursement is really going to put the industry behind the curve of value-based purchasing. We’re supposed to be looking at the bigger picture,” says Mark Dominesey, MBA, RN, CCDS, CDIP, CHTS-CP, the manager of excellence in clinical documentation at Children’s National Medical Center in Washington, D.C.

Encouragingly, however, 67.04% of respondents reported adherence to the ACDIS/AHIMA query practice guidance (up from 59.35% in 2013). However, anyone including reimbursement information on a query template may open themselves up to a world of difficulty, Duhon says.

Some respondents even still include pre- and post-query DRG information (2.27%) and DRG relative weights (1.42%) in their query templates.

“We’re just getting into an area where there’s so much auditing and so many compliance regulations, we have to make sure things are compliant and reliable. You have to assume that the queries are discoverable,” says Dee Banet, RN, CCDS, CDIP, director of CDI at Norton Healthcare in Louisville, Kentucky.

“It shocks me that some respondents include the relative weights. They’re asking to get themselves in trouble. Just wait till the Recovery Auditors get a hold of that,” says Duhon.

Editor’s note: To read the new position paper in its entirety, click here. To read about the hierarchy of authority among ACDIS resources, visit the FAQ section. ACDIS members can listen to the recorded May 18 Quarterly Call by clicking here. To read the 2017 physician query survey in its entirety, click here.

While the physician response rates rose significantly since 2013, with 22.84% of respondents reaching the 96%–98% response bracket versus only 15.64% reaching the same rate in 2013, other areas showed stagnation or even backpedaling. Notably, the percentage of respondents reviewing healthcare records for primarily financial impact rose from 20.8% in 2013 to 37.89% in 2017, and the percentage of those reviewing for any documentation

CDI Journal | JUL/UG 2017

More than chocolate? Sweet provider education tips

hocolate is a great motivator. Many a CDI professional has earned inroads with providers by rewarding good documentation habits through appealing to a sweet tooth or two. And yet, CDI specialists say that physician engagement and education represents their greatest daily professional challenge. While sugar helps, there’s a lot of other ways to gain, and keep, physician support for CDI efforts. Simple sincerity, openness, and helpfulness often serve to crack the toughest docs, says Laurie Prescott, MSN, RN, CCDS, CDIP, CRC, CDI education director for ACDIS in Middleton, Massachusetts, who once used Snickers candy bars as a “thank you” for providers who took time out of their busy day to talk with her, or for those who went above and beyond in a query

18 CDI Journal | JUL/AUG 2017

response or improved their documentation in some other way. “Make it fun,” Prescott says. “We’re always so serious. If you make it fun, it will make hard for physicians to run away.” Providers are busy, goal-oriented, achievement-driven individuals, often dealing with difficult patients all day long. A kind, friendly face offering a word of praise can easily make their day and earn the CDI program a friend in return, she says. “Anything to make them feel good and to make them smile,” says Prescott. “It is crazy how physicians respond to simple recognition.”

Simple recognition Awards or recognition for the best documentation can also motivate and reward providers. Some CDI programs secure a hospital bulletin board where they post examples of

effective notes, discharge summaries, etc. These bulletin boards can also be used to post documentation tips and reminders for physicians, says Tamara Hicks, RN, BSN, MHA, CCS, CCDS, ACM, director of clinical documentation excellence at Wake Forest (North Carolina) Baptist Health. While physicians look to see if they’ve been singled out for praise in a given month, they’re also picking up additional documentation information. Penn State Health’s CDI program puts helpful providers, residents, physician assistants, and nurse practitioners into a monthly drawing for a meal coupon, says Deanne Wilk, BSN, RN, CCDS, CCS, CDI manager at the Hershey-based hospital system. Even handwritten thank-you notes work well, says Sam Antonios, MD, FACP, SFHM, CPE, CCDS, chief

medical officer and medical director of information systems for Via Christi Health, Inc., in Wichita, Kansas. Sending similar notes to the provider’s boss is also effective, says Judy Schade, RN, MSN, CCM, CCDS. “I think it is very important to give feedback not only to the provider but to the department chairs/supervisors for excellent documentation. I had a resident tell me I made her day when I sent a message to the chair that she did an excellent job documenting on a case,” she says. Physician engagement in CDI efforts, however, takes more than just candy bars and thank-you notes. It takes clear effective communication, compliant query practices, ongoing education and collaboration, and regular, focused review related to program efforts and achievements. New CDI programs (and new CDI staff members) need to have a clear understanding of the mission and goals of their efforts first and foremost. Second, they need to effectively and compliantly communicate these tenets and employ them in their daily activities. That effective communication often begins with simple relationship building. Some programs create a one-sheet flier with the photos and contact information for the CDI team and send it to providers or post it in physician documentation areas, says Antonios. “Include a welcome letter and explanation about CDI in the new medical staff member orientation packet or new medical staff

officer orientation packet” too, he adds.

Data delivery After initial CDI program rollout, ongoing educational efforts need to leverage program data for targeted informational opportunities. Consider creating provider report cards that compare physicians’ scores to their peers based on several core measures and program goals, says Prescott. “Presenting physicians their metrics/statistics has always worked for me,” says Karen Newhouser, RN, BSN, CCDS, CCS, CCM, CDIP, education director for MedPartners based in Tampa, Florida, who suggests that CDI professionals also need to understand core data elements related specifically to their own physicians, hospital, and hospital system, as well as regional and national data. For example, University Healthsystems Consortium, now called Vizient, collects metrics of similar hospital divisions and shares that data. CDI programs can look to the Program for Evaluating Payment Patterns Electronic Report (PEPPER), published quarterly by CMS, to identify claims outliers and stay informed about auditor activities as documentation focus shifts. “Competition can be good, and the data can be a great motivator,” Newhouser says. Big-picture data helps illustrate to physicians their role in the larger healthcare system. Provide them with specific case study

scenarios—including examples of real medical record documentation (post-discharge and with patient and physician names excluded). This helps illustrate the specific effect of their documentation on a wide range of measures and metrics such as case-mix index, length of stay, risk adjustment, and so forth, says Wilk. In this way, CDI specialists demonstrate that their role is to help physicians “provide the highest severity for their patients to truly reflect how sick they are and the resources that are used for their care,” she says. “Providing physicians with their own data and own examples relevant to them and streamlining/ tailoring the education so that they can relate gets their attention very quickly,” agrees Anny P. Yuen, RHIA, CCS, CCDS, CDIP, vice president of revenue cycle for Intellis, based in Philadelphia. Leveraging metrics and statistics presents a challenge for those not fully versed in the nuances of that data, warns Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at Mayo Clinic Hospital, based in Mosinee, Wisconsin. “We need to be comparing apples to apples (using similar facilities in regards to patient populations and services); otherwise, the data may not be appropriate,” Schade says. “Additionally, in some cases, we may not know all the circumstances surrounding the metrics, so you need to be careful. We had a data coordinator pull stats and unfortunately selected the wrong variable, so the

CDI Journal | JUL/UG 2017

results were not correct. Again, there are times when the data should be verified if possible to avoid inadvertently giving incorrect information.”

Educational sessions CDI specialists can arrange to present this data one-on-one with providers or in group lunch-andlearn sessions. “You have no idea how much of a success this has been for us,” says Wilk. “If you can provide [physician continuing education] credits, all the better.”

ask physicians what they need help with and what they’d like more information about, then do the research and provide well-sourced education supporting their needs. “Providers like to see you taking an interest in their patients’ care, goals, and objectives,” says Wilk, who explains that lunch-and-learn sessions at her program have thus far included: ■■ Acute renal failure ■■ Blood loss anemia ■■ Congestive heart failure (CHF)

Because physicians love sharing their own knowledge, she suggests inviting providers to partner with the CDI team on presentations. Perhaps a nephrologist can assist with the clinical portion of a presentation on acute kidney injury, while a cardiologist helps with a presentation regarding myocardial infarctions.

■■ Clinical support/medical

Wilk also suggests having a CDI representative attend the providers’ educational sessions, especially resident education/training sessions. The rep can spread the word about the importance of documentation clarity, but also participate in and observe the lessons taught to providers. In doing so, CDI staff gain valuable insight into what physicians are being taught and how they learn, allowing the CDI team to pick up on themes from those sessions and reinforce concepts in their daily educational and query activities.

■■ Malnutrition

Attending education sessions also shows the CDI team’s dedication to, and interest in, providers’ needs. CDI programs need to also

20 CDI Journal | JUL/AUG 2017

necessity of diagnostic procedures ■■ Coagulopathy ■■ Evaluation and management

documentation and coding ■■ Stroke ■■ NSTEMI (stroke)

■■ Sepsis-3

Penn State Health created a clinical indicators committee that brings together physicians and CDI staff, says Wilk. During its meetings, the team pulls denial and query data to identify an area of documentation opportunity, then asks providers to discuss the clinical scenarios around those conditions. Wilk recommends taking these lessons further and conducting them during physician lunch-and-learn meetings to help get everyone on the same page. “I think everyone should have a clinical indicators committee,” she

says. “This brings them to you and has been really helpful for us.” Antonios suggests also creating “documentation days” during which CDI specialists essentially camp out near the physician lounge or documentation area with tip cards, instructions, and other information as reminders of the program’s focus. Others have suggested coupling these initiatives with a deep dive into a particular sub-specialty—pulling 30 or so records from the cardiology team and identifying query opportunities, then creating focused education for physicians while the CDI team sits outside their offices, so to speak. While much has been made of the increasing opportunity for CDI professionals to work remotely, many believe CDI programs need to maintain a physical presence on the hospital floor to provide on-the-spot assistance and visibly represent providers’ often-overlooked documentation duties. Hicks recommends engaging providers by attending daily rounds or huddles and providing documentation insight into broad-scope improvement opportunities as warranted. While many programs shy away from rounding, worried that CDI will get lost in the mix of priorities typically addressed during these sessions, others have found it immensely helpful in improving physicians’ respect for the CDI team. “Documentation is a part of the clinical care of that patient and should be regarded as such,” Newhouser says.

RADIO RECAP

Radio Recap: Denials and effective physician communication Where there are documentation holes, denials flood in. “It’s just amazing how infrequently the doctor is even aware of the denial. If they don’t know they even had a patient who was denied, then he or she can’t fix the documentation in the future,” said Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group and former member of the ACDIS Advisory Board, on the January 10 episode of ACDIS Radio, “Denials and effective physician communication.” “Everyone in the CDI world knows that we [CDI specialists] exist because documentation could and should be better,” Brundage said. When helping to defend a claim or prevent a denial, the first thing Brundage recommends is to walk through the medical record and identify the reason for the denial. “Most of the time, it’s truly about documentation,” he said. Once the issue has been identified, one of the biggest pieces of denial prevention, according to Brundage, is open communication between all parties. “When the denials come in and we write the appeals, we then take that record and create a documentation report card for the

physician,” said Brundage. “They like to be shown the two or so things that were actually taken from their own charts.” In addition to individual case-bycase education, Brundage recommends group education in the form of lectures. This method is especially prescient in a teaching facility. Try to “get those young physicians on board before their professors can teach them the ways of the oldschool doctor,” Brundage said. Clinical definitions and criteria can be especially helpful when conducting group education, Brundage said. In his own experience, using the Glasgow Coma Scale to support the diagnosis of encephalopathy or the Framingham criteria for heart failure have been helpful in giving a “concrete definition” to an otherwise “nebulous diagnosis.” Of course, it’s not just the physicians who need education on the denials process. “A lot of the time, the CDI specialists don’t even know the outcomes of the denials,” said Sharme Brodie, RN, CCDS, CDI education specialist with HCPro, on the program. CDI collaboration with the business side of the facility’s operation can be of particular help, according

to Brundage. Though it’s often difficult to bring the two groups together—business offices are usually off-site—an open line of communication is vital. “The business office is fielding a lot of information from the insurance companies, and that needs to get back to the CDI team,” said Brundage. Forming a denials management team with cross-departmental participation, representing physicians, CDI, coding, and the business side, helps keep the communication strong. Brundage recommends bringing the team together at least once a month to discuss the current denials and divide up the duties. Having that roundtable discussion brings all parties on board and to the same page. Though denial prevention and management can be multifaceted and challenging, the best method is communication and collaboration. “At the end of the day, it’s all about education, education, education,” said Brundage. Editor’s note: To listen to the complete ACDIS Radio show from January 10, “Denials and effective physician communication,” click here. To read the heart failure criteria referenced on the program, click here. To read a Q&A with Dr. Brundage following the program, click here.

CDI Journal | JUL/UG 2017

Breaking through the noise: Successful physician engagement takes creativity

espite CDI programs’ 10-plus years of existence, physician engagement continually ranks as the number one concern for CDI departments, according to the 2017 ACDIS Membership Survey. Part of this challenge may stem from the fact that, although some methods work better than others, physicians are individuals, so there’s no onesize-fits-all approach to get them engaged.

When the stress and difficulty of physician engagement and education mounts, it’s easy to get discouraged and lose hope. Instead, why not try viewing the difficulty as a

22 CDI Journal | JUL/AUG 2017

challenge to conquer? Often, strife leads to creativity.

reinforcements for the cause can go a long way.

If you’re struggling with your physicians, know this: You are not alone. Others have put their minds to the same problem, developed innovative and creative ideas, and conquered the issue. Take a page from their books and maybe even invent some new approaches of your own. Sometimes, problematic physicians require solutions and approaches that are just as unique as they are.

For facilities with private-practice physicians who maintain hospital privileges, the problem of physician engagement can be especially troublesome, says Barbara Eshleman, RN, director of CDI at Great Plains Health in North Platte, Nebraska. Since those physicians aren’t at the facility daily, they often lack the concrete CDI education others receive. To correct this issue, Great Plains Health assigned a registered nurse dedicated to working with the physicians.

Enlist help CDI specialists need to look outside of their own abilities and ask for help. Engaging physicians can be an uphill battle, and enlisting some

“The main reason [for this new position] was that the documentation

was lacking and physicians needed a liaison between the office and hospital to provide education and guidance one-on-one. Physicians look to her as a resource for all issues, from documentation, to process improvement, to removing barriers, to onboarding new physicians,” says Eshleman. “We’ve been able to collaborate with her and get better communication across to those physicians.” While the addition of the “physician buddy” at Great Plains Health may be less conventional, employing the help of a physician advisor presents a tried-and-true method for increased engagement. After some initial education through a vendor, Eshleman’s facility also placed a physician advisor on their team. Many physicians respond better to a fellow physician, but the physician advisor needs to be a particular type of physician—someone who can effectively educate across all physician groups. “Our advisor is an excellent communicator, non-threatening, and well respected,” says Eshleman.

For Karen Carr, MS, BSN, RN, CCDS, CDIP, CDI supervisor at Grand Strand Medical Center in Myrtle Beach, South Carolina, one of the biggest breakthrough moments came from a leadership change. With the addition of a new chief medical officer (CMO), the CDI department gained more clout with the physicians. “Our new CMO is very engaged with CDI. If we have an issue, he will address it with that physician in particular, or with all of them at once,” she says.

of their documentation from proper assignment of severity of illness, risk of mortality, and grading.”

Physicians without an engaged CMO like Carr’s or without a CDI program physician advisor like Eshleman’s can struggle to win engagement. In these instances, enlisting a few physician allies can be invaluable. Those one or two physicians can be the inroad needed for systemic change among the whole group, Carr says. Physicians often ask her team for help, and that creates the impetus for structured educational sessions. But, Carr cautions, “the physicians only asked for help after understanding the importance

When all the traditional methods of engagement and education have failed, a little creativity can go a long way, according to Carr. One of her team’s most effective tactics was to start wearing scrubs in the hospital. Every member of Carr’s team is a registered nurse, so wearing the scrubs provided a visual clue for the physicians regarding their knowledge and experience level in the clinical field.

With a little help from those outside of the CDI department, physician engagement and education becomes more of a team sport rather than a solo battle. “Really, it’s about bringing everyone in on the team. It’s just a big group effort,” says Tressi Wicker, BSN, CDS, CDI specialist at SRMC in Lima, Ohio.

Get creative

However, to ensure a unique visual identity, team members “don’t wear the same color as the

GAINING PHYSICIAN SUPPORT IN THE PEDIATRIC SETTING For CDI specialists across all settings, physician engagement is a looming problem. Many mature CDI programs have done a good job bringing their physicians into the fold. Any time a new CDI program takes flight, however, it seems that some physicians try to ground it again. “There used to be one physician who would literally turn around and walk away when he saw me coming,” says Claudine Hutchinson, RN, the sole CDI specialist at The Children’s Hospital at Saint Francis in Tulsa, Oklahoma. Over the past six years, however, Hutchinson has made significant strides toward physician engagement and even partnership. Enlisting the physicians’ expertise in developing facilitywide definitions of problem diagnoses helped ease the friction, though it’s still an ongoing process, Hutchinson

says. Over the next couple months, a new physician advisor will onboard at The Children’s Hospital. Part of his role will be to refine diagnoses and communicate to the rest of the medical staff. When a physician gives a CDI specialist trouble, Hutchinson says it’s important to remember that “it’s nothing personal. You’re there to help support the physician.” Offering rewards and recognition to the best-documenting physicians also helps smooth ruffled feathers. “I’ve even brought them cookies and chocolates,” Hutchinson says. When one physician receives recognition and accolades from the CDI specialist, it incites a bit of healthy competition with the other physicians, she adds.

CDI Journal | JUL/UG 2017

bedside nurses do,” Carr notes. “We wear purple scrubs because it matched the original paper queries,” which were printed on purple paper to make queries stand out from the rest of the information in the medical record. Purple became so synonymous with CDI at Grand Strand Medical Center that one physician took to calling the team the “purple paper people,” according to Carr. “We needed to brand ourselves as nurses,” she says, and that simple wardrobe change went a long way toward solidifying the team’s credibility with physicians. Fancy purple scrubs aren’t the only creative technique Carr’s team employs, though. “Once a month, we put an education tip [regarding a documentation concern] we see frequently in the newsletter. And then the documentation tip goes in the physician lounge on the TV with the announcements,” she says. “We really wanted a window into the lounge from our office so we could see who was in there, but they said no,” she jokes. It can also be helpful to approach a difficult issue as a game, creating a friendlier, fun environment to deliver education, says Wicker. She and her team presented a poster at the 10th annual ACDIS conference showing how they created a Candy Land– themed CDI game to illustrate the process of physician engagement and education—complete with physicians’ and CDI specialists’ actual pictures on the board. “When a pulmonologist sees himself on the board in the respiratory

24 CDI Journal | JUL/AUG 2017

section, he then asks about the other sections and sees the bigger picture,” Wicker says. The game board helps both the CDI team and the physicians see the connections between the various service lines, and how everyone’s documentation plays a part. Plus, just like a game of Candy Land, Wicker says the poster illustrates the fact that not everything turns out the way you want it to— whether that be with a query or with physician engagement in general. “If you’re the person rolling the dice, you might not get the number you want. But you can’t give up. You have to keep playing the game,” says Wicker.

Be a resource, not a hindrance Regardless of the method used to educate and engage physicians, CDI specialists need to remind the physicians they’re a resource, not a hindrance. “The most rewarding part of my job has been seeing [the physicians] succeed,” says Eshleman. “It’s rewarding to bring them over from the dark side.” Even though your aims may be obvious to you, the physicians may not see those efforts kindly. Reminding them of CDI’s true aim can be a valuable conversation. “We’re not trying to doctor. We’re trying to help them document what they’re doctoring,” says Wicker. With increased technological access, Eshleman says, it’s easier than ever to get ahold of physicians without disrupting their workflow. Rather than constantly chasing down non-responsive physicians, the CDI team at Great Plains Health

uses secure texting to message them regarding outstanding queries. “Now, even our most difficult physician has a no-response rate of zero,” says Eshleman. Sometimes, a physician may resist CDI efforts and require intervention from a physician advisor or CDI manager or other administrator, depending on facility policies and procedures. (If no escalation policy exists, consider working with the team to develop one as recommended in the 2016 ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” brief. See the Resources section of the ACDIS website for additional examples.) But even then, Wicker notes that sometimes physicians just need a day or so to absorb the information and reflect on the situation. “Respect the fact that the doctor is a person and they can have good days and bad days,” she says. Understanding a physician’s humanity can help CDI professionals remember their role as a resource and save them from feeling frustrated. Part of being a resource also requires the CDI specialist to understand the differences between various physicians and recognize their own strengths and weaknesses in communicating with them. While one CDI specialist may feel illequipped to deal with a particularly difficult physician, another will have no problem, Wicker says. “Just like our diversity [in the CDI department], the physicians are diverse too. We’re learning how to engage with them and make them part of the team,” says Wicker.

PHYSICIAN ADVISOR’S CORNER

Hit docs where it matters most—in their wallets! by Trey La Charité, MD, FACP, SFHM, CCS, CCDS

In the past, I have advised CDI professionals against promoting the monetary benefits of CDI adoption. If the medical staff thinks the program’s purpose is hospital revenue, they will likely rebel. Working in an academic institution, I have witnessed the laudable notion that patient care supersedes all other considerations. The unfortunate truth, of course, is that there is a business side to the practice of medicine. Sadly, many practitioners fail to realize that if the host hospital’s doors close, their vaunted ivory tower collapses. The bottom line is that to take care of patients, we must take care of the financial aspects of running a hospital. After years of promoting the concept that doctors and hospitals are closely aligned, I think it is time to readjust our strategy. While I still maintain that discussions regarding hospital revenues and CDI should be minimized, we need to highlight the idea that individual physician revenues are increasingly tied to CDI. Many physicians will state that they are not interested in the hospital’s wallet; however, their reaction will be very different when told that CDI has a similar effect on their personal finances. Try explaining to the medical staff how their lifestyle outside of the hospital’s walls will be directly impacted by their documentation inside the hospital or in their office. It may be the light-bulb moment you’ve been searching for. Let’s start with an example: General surgeons like a steady supply of gallbladder surgeries to keep them and their practices in business. And, since each patient has only one gallbladder to donate to the cause, surgeons require a steady stream of new patients with gallbladders that need to be removed. While the gallbladder itself does not care who removes it, the patients, their families, their insurance carriers, and their employers certainly do. First, as the patient population becomes more aware of providers’ publicly reported performance data, patients and families are incorporating that information into their

decision-making when selecting a surgeon. No prospective patient knowingly chooses a surgeon with high complication rates or poor outcomes. Second, as insurance carriers and employers have learned, surgeons with high complication rates and poor outcomes cost more than surgeons with good performance metrics. Surgeons with poor performance metrics will remove fewer gallbladders, because patients will see those metrics on the web and go elsewhere for their surgeries. As a result, those who are actually footing the bills (i.e., the insurance carrier or the employer) will allow fewer patients to have their gallbladders taken out by those poor-performing surgeons. No new patients means no new revenue. Let me share an example from my own healthcare environment. A primary care provider (PCP) from my network referred a patient to a general surgeon for a cholecystectomy. The PCP had been using this surgeon for years and was under the impression that the surgeon’s performance was satisfactory. After the insurance company reviewed the referral, however, it called the patient and said if the patient went to that surgeon, the patient would pay about $2,000 out of pocket. If the patient went to another surgeon in a different practice for the same procedure, though, the surgery would cost the patient nothing. Which surgeon do you think the patient chose? Obviously, the insurance company intervened in this case because the PCP’s chosen surgeon had high complication rates and/or poor performance metrics relative to cost. Was this avoidable? Absolutely. What your practitioners must glean from this lesson is: ■■ All provider performance metrics are risk-adjusted

in some fashion ■■ All risk-adjustment methodologies are primarily

based on how sick a given patient is ■■ How sick a given patient is depends on how

accurately and specifically all the disease processes affecting that patient are documented by the provider

CDI Journal | JUL/UG 2017

The moral to this story is simple: If a provider does good work on sick patients, he or she will get more business. Use this story to inform your medical staff that good documentation habits ensure long-term viability and prosperity. By doing so, you have demonstrated how CDI directly affects their wallets. You now will have their complete attention. Once providers know that their stream of new patients is directly related to their documentation habits, you can shift your educational focus to their individual reimbursements. Your medical staff may not be aware that bundled or episodic payments are coming or that the current fee-for-service system is slowly going by the wayside. This represents a tremendous shift in how providers are reimbursed for the services they provide, and they may not understand the magnitude of the changes. Under the current system, for any hospitalization or procedure, the patient receives two separate bills. One is for the hospital’s services, and one is for the doctor’s professional fees. In bundled or episodic payment models, a patient receives only one bill and submits only one payment. The two participants, the doctor and the hospital, are expected to decide who gets which portion of that check. Doesn’t that sound like a fun conversation? And while common sense would dictate that the single check would equal the two separate checks, this is not accurate. There will be significant value in maximizing the size of the solo check to ensure that both the hospital and the doctor receive what they deserve. So, how does one maximize the check size? All of the proposed alternative payment models incorporate some form of risk adjustment in their reimbursement calculations. This risk adjustment results in a larger single check for sicker patients and a smaller check for patients with fewer documented medical problems. In other words, the pie to be divided will be bigger for those consistently documenting their patients’ severity of illness. Here, again, you have my permission to instruct your medical staff that their future livelihood is going to be documentation-dependent. This paradigm shift is already occurring in the developing alternative payment models in East Tennessee. Our state Medicaid system recently transitioned to an

26 CDI Journal | JUL/AUG 2017

episodic model of reimbursement for things like chronic obstructive pulmonary disease exacerbations, cholecystectomies, and coronary stenting procedures. Under this system, a provider’s average cost per case is compared to all other providers’ average cost per case who provided that same service within the state. If a provider’s average cost per case is not significantly different from all other providers within the state, that provider is permitted to keep whatever he or she earns under the traditional fee-for-service system. If a provider’s average cost per case is lower than the others, that provider gets to keep 50% of the savings generated by his or her lower-than-average cost per case in addition to the fee-forservice reimbursements the provider has already earned. If a provider’s average cost per case is higher than the average for all other providers within the state, though, that provider must pay 50% of those cost overages back to the state as a penalty; that money comes out of the fee-for-service reimbursements already received. There is a significant risk adjustment built into how a provider’s average cost per case is calculated. Therefore, high-cost providers who consistently and accurately report their patients’ severity of illness keep themselves out of the penalty box. On the other hand, providers who exhibit poor documentation habits find themselves missing out on the shared savings since their patients’ severity of illness seems low. If the documentation is really abject, those bad habits could increase their average cost per case into the payback zone. With these real-life scenarios in mind, ask your medical staff which they’d prefer: taking their family to the beach for spring break or having a staycation? Tell them that the funding for their fun in the sun is tied to what they document in the record. If you’ve been having problems achieving buy-in from some of your providers, educating them on how their documentation directly affects their finances may elicit a new and improved response. Editor’s note: La Charité is a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville, a clinical assistant professor, and the medical director of UTMC’s CDI program. He is a past member of the ACDIS Advisory Board and the author of three books. La Charité’s comments and opinions do not reflect necessarily those of UTMC. To reach La Charité, email him at Clachari@UTMCK.EDU.

RESIDENT EDUCATION

Physician engagement begins with residency by Lisa Dias, MD, and P. Roger DeVersa, MD, MBA, FHM, CPE, CDIP, CHDA, CCS

Residency training typically serves as physicians’ first exposure to the CDI process, yet physicians have historically not had robust education during medical school on CDI or how it benefits patient care. Nevertheless, CDI education and discussions within this group are important for many reasons. Firstly, the Centers for Medicare & Medicaid Services (CMS) requires that hospitals and physicians participate in the CDI process. Accurate clinical documentation can lead to appropriate severity of illness (SOI) and risk of mortality (ROM) capture, thereby generating improved quality metrics. Secondly, appropriate documentation can help to ensure adequate resources are available to care for patients. We recently conducted a project to illustrate the experiences of a group of residents and fellows regarding CDI education, asking them to describe the benefits of improved CDI education, list typical barriers to successful physician education regarding the CDI process, and suggest methods to improve residents’ CDI education. We sent a cohort of residents and fellows (180 in total) currently training at the University of Tennessee College of Medicine a link to an online survey. They were not obligated to answer the survey, and no identifying information was retained from respondents. Questions included whether the respondent had heard of the term “CDI” or had received CDI education during medical school or residency. (See the list of questions asked on p. 27.) Our paper has some limitations. Results were limited by a low response rate (11%) and anecdotal data collection (physicians may have received CDI education that they did not recognize as such or did not remember receiving); no control was used; and our recommendations are based on qualitative data.

ASSESSING AWARENESS OF CDI Lisa Dias, MD, and P. Roger DeVersa, MD, MBA, FHM, CPE, CDIP, CHDA, CCS, wanted to understand how much residency students know about CDI efforts, so they created a 10-question online survey and sent it to more than 180 residents at the University of Tennessee College of Medicine. Questions included: 1. Have you ever seen the term “CDI”? 2. Did you receive education regarding the CDI process while you were a medical student? 3. Did you receive education regarding the CDI process at any time during your residency/fellowship program? 4. Did you receive education regarding CDI by a CDI nurse while caring for patients? 5. Did you receive education regarding CDI by an attending while presenting a patient to the attending? 6. Did you receive education regarding CDI in a didactic lecture? 7. Are you aware that CDI is an initiative of the Centers for Medicare & Medicaid Services in which physicians are required to participate? 8. True or false: A robust CDI process can ensure accurate expected mortality rate calculation. 9. True or false: A robust CDI process can ensure accurate actual mortality rate calculation. 10. True or false: I think I would benefit from more CDI education.

A future project might aim to compare CDI education and knowledge across different medical training programs and/or residencies.

CDI Journal | JUL/UG 2017

That said, our results do indicate that many residents and fellows are in need of CDI education—and in fact want more of it. For question 4, two trainees responded that they had not received CDI education. For question 5, one trainee responded that he or she had not received CDI education. For question 6, one trainee responded that he or she had not received CDI education.

so that education about CDI can start early in medical training.

For question 1, 40% of the respondents had never seen the term CDI. An impressive 80% of respondents indicated that they think they would benefit from more CDI education. Only 50% of respondents had received CDI education from a nurse, 50% had received CDI education from an attending, and 60% had received CDI education in a didactic lecture. These results underscore the need for structured CDI education for residents and fellows.

Editor’s note: Dias is a radiologist at University of Tennessee (Chattanooga) College of Medicine and DeVersa is a clinical assistant professor of internal medicine at the facility. Contact them at Lisa. dias@erlanger.org and pdeversa@tennessee.edu.

Historically, physicians are not educated to understand the full impact of clinical documentation on patient care. Physicians may not understand how the SOI/ROM are captured and calculated for patients. However, reimbursement for physicians and hospitals is tied to appropriate documentation. Therefore, physicians and hospitals literally cannot afford to allow suboptimal documentation to prevent them from receiving appropriate reimbursement. Documentation improvement works best with fully engaged physicians. Unfortunately, there are many barriers to CDI engagement. The first is competing responsibilities, including patient care, teaching, and research, all of which limit physicians’ available time.

We suggest incorporating the tenets of CDI in regular didactic lectures during medical school and residency. Finally, we suggest engaging the services of a CDI physician expert to educate physicians and residents about CDI.

CDI WEEK 2017 PREVIEW Each year, facilities nationwide celebrate the efforts of their CDI programs for one week in September. This year’s event takes place September 18-22. To help facilitate the festivities, ACDIS provides a number of resources throughout the week. This year’s theme is “The Wild West: New Frontiers in CDI” and ACDIS has a number of great things up their sleeve to keep the party going all week long. Some of the resources you should expect are: ■■ 2017 CDI Industry Survey results and analysis

from industry leaders ■■ Daily Q&As with CDI professionals on a variety

of topics ■■ Activity ideas to help take your celebration to the

next level

Secondly, CDI personnel may not be aware of physicians’ prior experiences regarding CDI, limiting their ability to provide appropriate education. As noted above, physicians may be unaware of the negative impact of suboptimal documentation and may not know how mortality ratios are calculated. As corroborated in our survey, CDI is typically not embedded in formal physician education.

■■ A poster illustrating the theme for your depart-

Finally, there is a lack of physician-to-physician education regarding CDI. A CDI physician educator may be able to uniquely relate to physicians on this important topic.

The ACDIS team is excited to celebrate with you this year! As ACDIS prepares, your help with the 2017 CDI Industry Survey would be greatly appreciated. To take the survey, please click here.

We recommend that the importance of CDI be discussed with thought leaders in physician education

28 CDI Journal | JUL/AUG 2017

ment to display with pride ■■ ACDIS and CDI themed swag ■■ Giveaways through ACDIS’ social media

channels ■■ A free webinar with two of ACDIS’ esteemed

Boot Camp instructors

In the meantime, stay tuned for all the latest updates. We can’t wait to hear about your plans!

Start ‘em early: Documentation training for physician residents Although documentation matters more and more in today’s world of ever-changing regulations, medical students often don’t receive any education on the topic. Approximately 40% of medical students have never even heard or seen the term “CDI,” according to a recent survey conducted by Lisa Dias, MD, and P. Roger DeVersa, MD, MBA, FHM, CPE, CDIP, CHDA, CCS, from the University of Tennessee (Chattanooga) College of Medicine. (To read a summary of the survey’s findings from the authors, turn to p. 27). So, CDI programs have begun to institute home-grown

documentation education for residents at their facilities. “When I first started getting interested in the topic of CDI, […] I asked my more senior colleagues and got blank stares,” says Joseph A. Cristiano, MD, an assistant professor of internal medicine at Wake Forest Baptist Health in Winston-Salem, North Carolina. Without the medical school faculty understanding CDI in the first place, there’s no way to pass the information along to the residents. With over 700 residents and fellows at Wake Forest Baptist Health coming to practice their clinical craft

every July, the CDI program partnered with Cristiano to provide a basic documentation overview that helps not only the program, but also the facility and the residents themselves. Fortunately, CDI specialists at teaching facilities likely already deal with resident documentation on a day-to-day basis. “The residents are the ones doing the actual documentation, so we spend a lot of time communicating with them anyway,” says Tamara Hicks, RN, BSN, MHA, CCS, CCDS, ACM, director at Wake Forest Baptist Health in Winston-Salem,

CDI Journal | JUL/UG 2017

North Carolina, and a current member of the ACDIS Advisory Board. Since the residents are documenting in the record that a CDI specialist reviews, adding in some resident education will further the cause of CDI. Educating the attending will not necessarily improve the documentation in the record if the residents are the ones physically documenting.

Obtaining administrative support Like any new project, first conduct some research to build the case for residency training. This could be done through an audit of past residents’ medical records and an extrapolation of potential future losses related to improper or inefficient records. Collaborate with coders to identify their top concerns. Medical directors and physician advisors or champions may also have their own list of documentation deviancies they wish could be addressed. The industry’s increasing focus on quality and pay-for-value can actually help get the administration on board with the prospect of CDI resident education, says Cristiano. At first, “the leadership for resident education was far more skeptical about devoting time for this education because there’s so many other things the residents have to learn,” he says. But, he notes, seeing how the documentation affects a facility’s quality scores and reimbursement can really help the cause. Armed with a cadre of concerns, next build out a timeline and scope

30 CDI Journal | JUL/AUG 2017

for residency education. Again, collaborate with the physician advisor and heads of residency training in the various service lines. They’ll be able to identify the best times for resident education, such as during orientation, in targeted informational sessions throughout the residency program, or via ongoing queries and one-on-one training.

“All the CDI nurses come and he introduces us to the residents and tells them, ‘If you see any of these women and have questions, they are here to help you,’ ” says Sherri Clark, BSN, RN-BC, CCDS, CCS, a CDI nurse at the University of Tennessee Medical Center in Knoxville. (To read La Charité’s “Physician Advisor’s Corner,” turn to p. 25.)

Asking for help builds an alliance between the residency program and CDI, says Karen Carr, MS, RN, CCDS, CDIP, the CDI supervisor at Grand Strand Medical Center in Myrtle Beach, North Carolina.

During that orientation session, approach the CDI conversation from the perspective of publicly reported quality data, Clark suggests.

Rather than forcing CDI education onto the new residents, Carr’s team sought out the leadership first. This fostered a collaborative environment for education to flourish. “Before we did anything, we asked the surgical director if we could talk directly to the residents,” she says. After gaining the director’s support, Carr worked with him to find the best time and place for education.

Scheduling troubles Residents (especially new residents) have extremely structured schedules, which can be a huge challenge for CDI to conquer. CDI specialists who use that schedule to their advantage will likely fare better than those looking for their own dedicated time slot. At the University of Tennessee Medical Center at Knoxville, physician advisor Trey La Charité, MD, FACP, SFHM, CCDS, extended his orientation resident education to two hours.

Tell residents that if they “correctly capture the complexity and acuity of the patient during the admission, that it helps show exactly how sick the patient is. When they hear that, boy, are they on board,” she says. (To read more about quality measures, read the March/April issue of CDI Journal.) An orientation session for new residents also extends CDI’s reach into specialty areas it may not otherwise cover. “When you do the resident orientation, you’re actually talking to a group that’s going to be responsible for 12 to 15 different service lines,” says Cristiano. When that information goes back with the residents to their service line, it’s “sort of a herd effect because they can then teach the attendings what we’re teaching them,” he says. The residents essentially become agents of the CDI department. Since that initial orientation session will likely be the first time these new physicians ever encounter CDI, however, residents may have more

questions than one might anticipate. Surgical residents were Carr’s test group. She slated just 15 minutes’ worth of education, but took another roughly 15 minutes responding to the residents’ questions.

Typically, residents focus on clinical topics during a “morning report” at Wake Forest Baptist Health before their rounds, Hicks says, but incorporating a monthly CDI training session into this time has worked well.

“I just gave them an overview of what we actually do and picked three or four things [such as debridement, staging decubitus ulcers, postoperative respiratory failure, etc.] we see a lot,” says Carr.

Prior to the morning report session, Hicks and the rest of the CDI team make concrete educational plans and goals.

Though it was a new endeavor, the residents responded well to Carr’s efforts, she says. “They don’t want the attending [physicians] to think they documented incorrectly. They want to do it right.”

“When we get ready to go see the residents, we always put our heads together and decide what we want to talk about,” she says. By picking some commonly missed diagnoses or topics beforehand, the Wake Forest Baptist Health team can make the most out

“They know they’re going to be moving on and they won’t have the attendings to help them, so they’re more receptive and appreciative.” Jackie Touch, RN, MSN, CCM

Fortunately, residents are accustomed to learning due to their recent time in medical school. While this frequently makes them more receptive to the new information, too much information early on can also lead to information overload, says Jackie Touch, RN, MSN, CCM, a CDI specialist at CHOC Children’s in Orange, California. Nevertheless, such CDI training is “a seedling that can grow while in their residency,” she says. Provided the CDI program has administrative support, there’s another existing time slot that’s perfect for CDI education—morning rounds, says Hicks.

of their monthly educational session. Additionally, the CDI team brings some physical takeaways for the residents—such as a case study or a tip card. Ultimately, residents need information, but they need a friendly resource just as much. The CDI specialists can serve as that resource. “Having been a resident here myself before even knowing about CDI, I can attest that the environment [the CDI team] built here was very positive and constructive. That goes a long way for residents,” says Cristiano. Regardless of the approach, however, getting in front of the residents early—even for a few

minutes—increases the chances for an ongoing conversation about documentation by giving the residents an opportunity to ask questions. When it comes to resident education, as Carr says, “getting them young is good.”

Ongoing education If information overload does set in, ongoing education can prevent residents from backsliding into poor documentation habits. How a CDI program approaches this, however, can vary depending on the facility and the program’s limitations. Providing resources to the residents throughout their time at the facility can ensure all the residents are on the same page and have the same materials, in addition to increasing the visibility of the CDI team, says Clark. Rather than just seeing a name at the bottom of the query, residents remember the CDI specialists as helpers who’ve provided them with tangible resources. “We created hospital-specific pocket cards for all the physicians that include common diagnoses. We would carry a stack with us at all times when we were on the floor and pull them out to reference the diagnoses on the card,” says Clark. Each resident at UTMC also receives one of the pocket cards during that initial orientation session with the program’s physician advisor. As with any other type of physician engagement, sometimes the help of a physician changes the landscape the most.

CDI Journal | JUL/UG 2017

“Teaching with the help of a provider is very effective,” says Hicks. Even if the CDI specialists also conduct resident education, identifying a physician who’s willing to disseminate the information will help smooth out the rough edges.

reluctant to share in front of a group or an attending.

“From my perspective, we’ve had an inpatient CDI program for about 18 years, but one area we’ve always been lacking in was having a good physician education program simply because we didn’t have a good physician advisor, leader, or liaison for us,” says Hicks. “[Cristiano] knows the language to speak and has helped us extend our reach.”

“I can say to [the CDI team], ‘I want a case that’s an internal medicine case that was written by a specific resident,’ and they can get it for me,” Cristiano says.

CDI specialists may also find more luck reaching the residents by answering individual questions as they advance through the program. This environment allows for more specific, case-by-case education. Plus, it allows the residents to ask any questions they may have been

At Wake Forest Baptist Health, the CDI specialists can also pull an individual resident’s files and see opportunities for continued education on a personal basis.

However, the simplest approach doesn’t involve formalized education per se, notes Carr, who adds that “the query itself can be a great education tool.” Residents are seeing queries for the first time in their careers, so CDI specialists can use those queries as a jumping-off point for teaching. “If they respond to my query right away, I know they understood what was being asked. If I do have an outstanding query, then I go talk with

them and help them through it,” Clark says. Even if a resident never shows up at your proverbial door asking for help, that resident’s response (or lack thereof) can give a CDI specialist the springboard he or she needs to do some in-person, one-on-one training. As the residents become more mature, they may also be more receptive to CDI training. “They know they’re going to be moving on [to their own practices] and they won’t have the attendings to help them, so they’re more receptive and appreciative,” Touch says. At the end of the day, even when it feels fruitless, educating residents will prepare them to leave the safety of the teaching facility. “I have a hard time understanding why you wouldn’t involve residents in CDI. The day they graduate from the program and go out into another facility, they’re not prepared for the challenge,” says Cristiano.

CODING CLINIC FOR CDI

New advice for neurology, stroke, heart attacks, and drug dependence by Sharme Brodie, RN, CCDS

One thing many new CDI specialists hear—and many experienced CDI specialists attest to—is that the CDI profession requires an incredible amount of knowledge in numerous areas, not all of which you may have experience in. One such area may be neurology. The newly released Coding Clinic, Second

32 CDI Journal | JUL/AUG 2017

Quarter 2017, touched on some information regarding diagnoses found within this specialty. Let’s start with the questions and answers given on pp. 7–8 of this Coding Clinic. Depending on which index entry is used, the coding instruction provided for dementia due to Parkinson’s disease and aggressive behavior seemed inconsistent, according to a question in this edition. So, Coding Clinic advised assigning code G20,

Parkinson’s disease, and F02.81, dementia in other diseases classified elsewhere with behavioral disturbance. There were also a few questions on pp. 8–9 regarding the coding of encephalopathy when the provider documents a specific cause versus an unknown etiology. In the first case, the cause of the encephalopathy was documented as being “sepsis-associated encephalopathy.” The question asked which code would be used: G94, other disorders of the brain in diseases classified elsewhere, or G93.41, metabolic encephalopathy? Coding Clinic advised using G93.41, and stated that G94 should only be assigned for those conditions with index entries that directly point to code G94 for certain etiologies. Otherwise, assign code G93.40, encephalopathy, unspecified, if the type of encephalopathy is not documented. The second scenario considered a patient with encephalopathy secondary to a cerebrovascular accident (CVA). The question sought clarification as to whether encephalopathy would be coded separately or be considered inherent to the CVA. Coding Clinic stated that the encephalopathy is not inherent to the CVA and would be coded separately.

Stroke concerns Another area covered in this Coding Clinic was in regards to the use of tissue plasminogen (tPA) therapy and hemorrhagic conversion. Hemorrhagic transformation is a frequent complication of acute ischemic stroke that is especially common after thrombolytic therapy. Per Coding Clinic, if the tPA is administered as prescribed, the cerebral hemorrhage would be coded as an adverse effect of the medication and code T45.615A, adverse effect of thrombolytic drugs, initial encounter, would be used, rather than a complication code. If per provider documentation the hemorrhagic conversion is not an adverse effect of the tPA, assign code I61, non-traumatic intracerebral hemorrhage, for the hemorrhagic conversion as an additional diagnosis.

Heart attack events

period. Coding Clinic said to assign code I23.3, Rupture of cardiac wall without hemopericardium as current complication following AMI. Code I23.3 indicates the patient had a previous MI; therefore, an additional code is not assigned for the previous NSTEMI. The term “within the 28-day period” is a non-essential modifier at category I23, certain current complications following ST elevation (STEMI) and NSTEMI myocardial infarction. The term’s presence or absence does not affect code assignment.

Drug dependence Lastly, let’s look at advice given on pp. 27–29 about drug dependence versus nicotine dependence. The first question asked about the coding difference between history of drug dependence and history of nicotine dependence. Coding Clinic stated that codes for drug dependence with remission and history of nicotine dependence are assigned based on how the condition is indexed in the classification. ICD-10-CM classifies a history of nicotine dependence differently than other types of drug dependence, and there is a unique code for “history of nicotine dependence.” This is an exception to drug dependence, Coding Clinic stated, as history of drug dependence is classified by “type of drug, in remission.” Coding Clinic further explained that index entries reflect the clinical differences between dependence on nicotine versus other types of drugs, and that the ICD-10-CM Official Guidelines for Coding and Reporting will be revised to state that the codes for drug dependence “in remission” should be assigned when instructed by the classification (as well as when the provider specifically documents “in remission”). Remember, only a provider can diagnose a patient as being in remission. Editor’s note: Brodie is a CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts. For information, contact her at sbrodie@hcpro.com. For information regarding CDI boot camps offered by HCPro, visit www.hcprobootcamps. com/courses/10040/overview. To read more about Parkinson’s sequencing and coding, click here.

A question on p. 11 concerned a patient with a recent non-ST-elevation myocardial infarction (NSTEMI) diagnosed with a myocardial rupture outside the 28-day

CDI Journal | JUL/UG 2017

MEET A MEMBER

The jump from coding to CDS was a natural one

Amy S. Sterner, CCS, CCDS, CDIP, is a Clinical Documentation Specialist at Hanover Hospital in Hanover PA, and a member of the Central PA ACDIS local chapter. She joined the Hanover CDI team as a certified coder when the program opened seven years ago, rounds on the units and handles a lot of the physician education. CDI Journal: What did you do before entering CDI? Sterner: I was an inpatient coder for 16 years. CDI Journal: Why did you get into this line of work? Sterner: I love coding and when the opportunity to work in CDI came about I jumped at it. I am always looking to learn new things and I realized how nice it would be for coders to have queries answered prior to discharge, so they can simply code the record. CDI Journal: What has been your biggest challenge? Sterner: My biggest challenge has definitely been physician engagement. Getting the physicians to understand

34 CDI Journal | JUL/AUG 2017

that it is not necessarily more documentation but better documentation. Attending hospitalist meetings has helped and taking concerns to our physician advisor has helped tremendously. I typically will electronic query first and if I do not get a response within a day or two, I will approach the physician and request a meeting to discuss the record. I have some physicians that actually seek me out and ask if they are missing any documentation. CDI Journal: What has been your biggest reward? Sterner: Earning my CCDS and CDIP and earning the respect of the physicians in our facility. CDI Journal: How has the field changed since you began working in CDI? Sterner: CDI has expanded so much, physician and facility buy in has increased greatly. CDI has definitely advanced from DRG focus to realty medical record integrity.

ÂŠ 2017 HCPro, an H3.Group brand.

CDI Journal: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on The ACDIS Forum or through ACDIS?

Sterner: Work together with the coders. There is a wealth of knowledge within them and it is not a competition.

Sterner: The Forum is awesome. I have learned better query writing, different ways to engage physicians, and most definitely that most CDS’ struggle with the same things!

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

CDI Journal: What piece of advice would you offer to a new CDS?

Sterner: Honestly this is going to sound cliché but this is my dream job. I love what I do. If I had to choose something else I guess it would be a something with helping people. CDI Journal: What was your first job (what you did while in high school)? Sterner: I worked for a local pizza shop making pizzas and subs and yes I could throw the dough in the air!

Amy and her husband Scot tackle a 5K run together

CDI Journal: Tell us about your family and how you like to spend your time away from CDI Sterner: I have been married to my high school sweetheart for 22 years and I have 2 children—our son is 19 and a college freshman and our daughter is 16 and high school sophomore. My time away from work is with them, whether at the soccer field, at the gym, in a boat or in a tree stand. My husband was diagnosed with retinitis pigmentosa a few months before we were married. He is now blind and we do everything together, including weight lifting, hunting, and fishing. His strength and courage amaze me every day. A few of Amy’s favorite things: ■■ Vacation spots: Beach ■■ Hobby: Hunting and fishing ■■ Non-alcoholic beverage: Diet Coke ■■ Foods: Pizza ■■ Activity: weight lifting/exercise ■■ Favorite saying: Time is precious, waste it wisely.

Don’t we all wish we had more time? In my rare downtime I enjoy reading.

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

CDI Journal | JUL/UG 2017