July/August 2015 CDI Journal by ACDIS

JULY/AUG 2015 Vol. 9 No. 4

Focus on Physician Engagement

an Association of Clinical Documentation Improvement Specialists publication www.acdis.org

Discover how breakthrough technology and a coordinated CDI program can strengthen your performance. Leveraging our clinically-based algorithms and LifeCode NLP technology, Optum CDI 3D reviews 100 percent of your records to identify those with the greatest opportunities for improvement. With review concurrent to the patient stay, CDI 3D enables more timely documentation improvement. Ultimately, this streamlines the CDI process, enhances compliance, and most importantly, allows for better quality of care. ®

™

See how our CDI solutions enable cutting-edge performance. Visit: optum360.com/CDI3D Call: 1-866-223-4730 Email: optum360@optum.com

CLINICAL DOCUMENTATION IMPROVEMENT

Our customers double their CDI productivity

Our customer support is rated #1

$ Our customers see a return on investment in just a few months

ONLY CHARTWISE 2.0 OFFERS THE TOTAL PACKAGE: Better documentation tools, greater efficiency, improved outcomes and a fast ROI.

Advanced User Interface

ICD-10 Made Easy

Unmatched DataScan Reporting

Go Beyond CDI

Give documentation specialists the tools to do their job efficiently and accurately.

Work in ICD-9 and simultaneously see the results in ICD-10— and vice versa.

Unrivaled reporting and management dashboards let you dig deeper into your data.

Notify your Case Management and Quality teams within minutes and improve outcomes.

IF IT’S TOO GOOD TO BE TRUE, IT MUST BE CHARTWISE 2.0! STILL DON’T BELIEVE US? Visit www.ChartWiseMed.com to request a demonstration Contact us at (888) 493-4502 to learn more.

CONTENTS FEATURES 8 Redefining physician query response types Understanding how different professionals define physician agree and disagree rates could dramatically affect overall program results.

12 Engaging physicians: Survey results and helpful tips A recent survey from the American Hospital Association shows CDI programs are still struggling to gain physician support.

17 ICD-10 for complication code clarifications In ICD-10-CM, complication codes are structured very differently. Instead of grouping the codes in one chapter, ICD-10-CM places complication codes near the end of each body system–specific chapter.

DEPARTMENTS 5 Associate director’s note Rewarding physicians for their CDI support goes a long way to earning their buy-in, but helping them understand how their documentation matters within the larger reality of healthcare delivery might have a greater effect.

JULY/AUG 2015 Vol. 9 No. 4

6 Note from the Advisory Board Karen Newhouser, RN, BSN, CCDS, CCS, CCM, explores how present on admission and hospital-acquired condition reviews can be a simple first-step foray into CDI quality expansion.

10 Physician advisor’s corner Trey La Charité, MD, offers reasons for CDI interest in hierarchical condition categories.

20 In the news The AMA hopes to earn a delay in ICD-10 payment penalties and get a seat at the table with existing ICD Cooperating Parties. ACDIS Director Brian Murphy offers his take on this latest ICD-10 wrinkle.

21 Meet a member Fran Platt, BSN, RN, came from a career start in hospice care and rose to the rank of CDI manager at Southampton Hospital in New York.

OPINIONS & INSIGHT 14 Take a holistic documentation approach Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, explains how CDI professionals can adapt the concept of clinical bundles to their record review and query practices.

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, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $165/ year for membership to the Association of Clinical Documentation Improvement Specialists. • Copyright © 2015 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.

4 CDI Journal | JULY/AUG 2015

ASSOCIATE DIRECTOR’S NOTE Everyone wants a gold star. As a personal friend often puts it, “Wouldn’t it be nice to get a pat on the head and a cookie every once in a while?” It’s true. It’s as true for her and me as it is for you, your children, your parents, your coworkers, and yes, your physicians. Generally speaking, CDI professionals know this social dictum pretty well. They’re experts at the “thank you for answering my query” cookie delivery, they excel at the thank-you card in the physician’s mailbox, and they have their two-minute elevator speech selling their CDI program’s efforts down pat. What’s more, CDI professionals—typically creative types— often come up with ingenious ways to communicate with physicians beyond the official confines of the concurrent query or clarification form. They hit the local craft store for poster board and glitter pens, research clinical and coding guidelines for commonly under-documented diagnoses, and come up with clever ways to bedazzle the heck out of even the most recalcitrant physician. Ultimately, CDI professionals’ jobs rest on their ability to engage, educate, and win over physicians—but it’s not just to placate their egos. It’s to convince the physicians that the documentation of their clinical thinking is what matters.

to stroking a physician’s pride, the real buy-in comes from truly understanding the role one plays in the overall scheme of things. The child who earns a good grade needs to ultimately understand and love the process of learning. Throughout this edition, you’ll hear experts explore avenues of physician engagement and explain why physician documentation matters to physicians. ACDIS Advisory Board member and this year’s CDI Professional of the Year award winner Karen Newhouser discusses how quality metrics can further the physician-CDI dialogue. In the article “Redefining physician query response metrics,” experts explore the intent behind physician agree and disagree rates, advising programs to regularly review team expectations. Readers can also hear how Tennessee-based physician advisor Trey La Charité, MD, believes expansion into hierarchical condition categories can show physicians how documentation matters not only at the inpatient bedside, but within their own clinics as well.

EDITORIAL Director Brian Murphy bmurphy@acdis.org Associate Director Melissa Varnavas mvarnavas@acdis.org Membership Services Specialist Penny Richards, CPC prichards@acdis.org Editor Katherine Rushlau KRushlau@hcpro.com Associate Director for Education Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer cericson@hcpro.com Director of Sales and Sponsorships Chris Driscoll cdriscoll@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

Hopefully readers will come away from this edition of CDI Journal armed with additional CDI selling points—but remember, everyone loves a pat on the head and a cookie from time to time.

While bulletin boards of “gold star” documenters go a long way

CDI Journal | JULY/AUG 2015

NOTE FROM THE ADVISORY BOARD What is all this fuss about quality? by Karen Newhouser, RN, BSN, CCDS, CCS, CCM

The typical pay for performance (P4P) program provides a bonus to healthcare providers if they meet or exceed agreed-upon quality or performance measures. Quality. If I had a dollar every time that “buzzword” was used in the healthcare reform discussion, I would be wealthy. But money isn’t everything (either for me or for the healthcare industry— emphasis on healthcare rather than industry, folks). While the CDI profession was built on a financial platform—it’s how CDI programs got in the door during the early years—now, the focus in healthcare is quality. Quality is the theme in so many healthcare initiatives that it may seem as if such measures just surfaced, but in many cases these reimbursement models have been on the scene for decades. For example, pay-for-performance (P4P), the umbrella from which all modern-day quality indicators stem, emerged in the early 2000s after deficiencies in quality were highlighted in two major reports by the Institute of Medicine (To Err Is Human: Building a Safer Health System in November 1999 and

Crossing the Quality Chasm: A New Health System for the 21st Century in March 2001). These reports recommended a sweeping redesign of the healthcare system. In this context, P4P emerged as a way for payers to focus on quality, with the expectation that doing so would also reduce costs. As stated, P4P programs can give bonuses to providers for striving toward quality or performance measures, but they can also impose financial penalties on providers that fail to achieve specified goals or cost savings. P4P programs can be broken down into both private-sector and public-sector initiatives. The largest and longest running (since 2001) is California’s program. Within the public sector, CMS established value-based purchasing (VBP) programs to provide incentives for physicians and providers to improve the quality and efficiency of care. Most of these programs focused on quality with little, if any, cost consideration. P4P evolved and grew, and the Affordable Care Act further encouraged improvements in quality while addressing the subject of cost. Due to CMS’ continuous updates to its inpatient prospective

ADVISORY BOARD Donald Butler, RN, BSN CDI Manager Vidant Medical Center Greenville, North Carolina dbutler@vidanthealth.com

Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, IQCI, MBA Director Case Management University of California Irvine wdevreug@uci.edu

Wendy Clesi, RN, CCDS Director of CDI Services Huff DRG Review wendy.clesi@ huffdrgreview.com

Cheryl Ericson, MS, RN, CCDS, CDIP CDI Education Director HCPro Danvers, Massachusetts cericson@hcpro.com James P. Fee, MD, CCS, CCDS Vice President Huff DRG Review james.fee@drgreview.com

6 CDI Journal | JULY/AUG 2015

Sylvia Hoffman, RN, CCDS, CCDI, CDIP President and CEO Sylvia Hoffman CDI Consulting Tampa, Florida sylvia@sylviahoffman.com Walter Houlihan, MBA, RHIA, CCS Baystate Health Springfield, Massachusetts walter.houlihan@ baystatehealth.org

Thomas W. Huth, MD, MBA, FACP Vice President of Medical Affairs Reid Hospital & Health Care Services Thomas.Huth@ reidhospital.org

Michelle McCormack, RN, BSN, CCDS, CRCR Director, CDI Stanford Hospital and Clinics Palo Alto, California mmccormack@ stanfordmed.org

Mark LeBlanc, RN, MBA, CCDS Clinical Documentation Manager HCMC Minneapolis, Minnesota mark.leblanc@hcmed.org

Karen Newhouser, RN, BSN, CCDS, CCS, CCM Director of CDI Education MedPartners karenmpu@ medpartnershim.com

Judy Schade, RN, MSN, CCM, CCDS Clinical Documentation Specialist Mayo Clinic Hospital Schade.judy@mayo.edu Anny Pang Yuen, RHIA, CCS, CCDS Corporate Director of CDI University of Pennsylvania Health System Anny.Yuen@uphs.upenn.edu

payment system rules, the public needs to watch for changes associated with VBP, with the Hospital Readmission Reduction Program, and with the Hospital Acquired Condition (HAC) Reduction Program. Let’s take a closer look at the HAC program and its counterpart, the present on admission (POA) status indicator. Generally speaking, if the patient did not come to the hospital with a particular condition, then he or she acquired it in the hospital. Remember, POA assignment is not limited to a “Y” (Yes) or “N” (No) determination; a provider may also state that he or she is unsure or unable to determine whether the diagnosis was POA. Such a determination would receive a POA indicator of “W,” which CMS considers equivalent to a “Y” indicator and exempts the condition from being identified as a HAC. Similarly, a fourth indicator of “U,” which essentially states that the documentation is insufficient to determine whether the condition was present at the time of inpatient admission, equates to an “N” indicator where a HAC is identified. Note the words “documentation is insufficient” in the above explanation of the “U” indicator. For coders and CDI specialists, these words represent a neon sign to query the physician to obtain sufficient documentation and make an accurate POA determination.

We all realize that the patient entering the hospital today is much sicker than the patient who entered the hospital 20 years ago. The role of the CDI specialist is to ensure that the medical record reflects that fact, that each individual’s record accurately identifies an appropriate principal diagnosis, and that all significant reportable secondary conditions match the care delivered and resources consumed. We, as CDI specialists, are charged with carrying forward the story of each patient’s encounter. We are, in essence, the editors of a nonfiction story. As we move toward a personal health record in our mobile age, it is imperative that we advocate for patients and appeal for a complete, accurate account of their health status. That’s what the fuss is all about in relation to CDI and quality of care efforts. Our patients are depending on us. We won’t let them down. While it isn’t all about money, I would be remiss in not recognizing the role that money plays in all of the above. However, I leave you with this thought: Quality doesn’t follow money; money follows quality. Editor’s note: Newhouser is the director of CDI education for MedPartners CDI in Tampa, Florida, and the 2015 winner of the CDI Professional of the Year award. Contact her at KarenMPU@medpartnershim.com. This article originally appeared in the CDI Horizons newsletter and on the ACDIS Blog.

For many CDI programs, expanding review efforts into POA and HAC measures means a simple, small step into the quality arena—and another small step to help ensure the accuracy of the medical record. CDI staff members also need to understand that many quality-related reimbursement initiatives are risk-adjusted and that many public reporting agencies (such as Healthgrades, U.S. News and World Report, Hospital Compare, etc.) have their own risk-adjusted methodologies, most of which are proprietary. CDI specialists need not learn the intricacies of how each method works or how one report compares to the other—don’t get overwhelmed. What is relevant is that all these methodologies use factors such as chronic and comorbid conditions to determine the degree of risk. The greater the number of (and/or the more significant) the chronic and comorbid conditions, the higher the risk.

CDI Journal | JULY/AUG 2015

ASSESSING CDI SUCCESS

Redefining physician query response types It’s a scenario many CDI specialists face: After spending hours reviewing a physician’s documentation and carefully crafting query after query, the physician responds with “unable to determine” or “clinically insignificant.” It may seem frustrating to get an answer like this. After all, 98.5% of CDI programs nationwide—according to a survey conducted by the American Hospital Association and Executive Health Resources—say they struggle with physician documentation and engagement, and a vague response can sometimes make you feel like you’re being ignored. (Read a related article on p. 12.) Some facilities even debate tracking queries answered with “unable to determine” or “clinically insignificant,” as non-responses. Sure, the physician may have responded to the query, but is it fair to track such

8 CDI Journal | JULY/AUG 2015

responses in the same way as a more specific answer? According to ACDIS’ 2013 Physician Query Benchmarking Report, to determine the success of the query, 70.6% track the final DRG, 69.9% track the financial impact of the query, and 69.1% track whether the response to the query was positive or negative. Most respondents (56.1%) also monitor for leading queries; many keep tabs on missed query opportunities (52%) and clinical support (46.8%). CDI specialists need to take care when tracking physician query response rates and responding to such, says Laurie Prescott, MSN, RN, CCDS, CDIP, CDI education specialist at HCPro in Danvers, Massachusetts. There are a few steps, she explains. First, pay close attention to query response trends over time to identify whether a particular physician always responds with

“unable to determine” or a similar option, or always responds in this manner when a particular diagnosis or CDI specialist is involved. Program staff members need to know whether a problem exists before it can be solved. While “unable to determine” and similar query response choices can serve as a back door or escape route for the physician, Prescott warns against tracking such responses as non-responses. The physician did take the time to respond and, most likely, simply chose the best answer available. “Physicians who legitimately use these options and support CDI efforts should not receive any negative feedback for that use,” she says. Query response tracking requires a more nuanced approach these days, says Donald Butler, RN, BSN, CDI manager at Vidant Medical Center in Greenville, North Carolina. Tracking

only three options—agree, disagree, and no response—is no longer best practice. Organizations need to decide, and then define for the entire team, how responses should be categorized if their software system only allows three options. The response “clinically insignificant” does not equal “clinically undetermined,” Butler cautions. It actually means “the physician does not feel that the queried condition was significant enough during this particular episode of care to be reported as an existing (additional) diagnosis. The CDI specialist may feel differently, but we must always respect the physician’s expert opinion.”

What options mean That’s why CDI specialists need to consistently review their own processes and query definitions—to make sure everyone on the team has the same understanding and goals—but also why CDI staff need to consistently communicate those definitions of terms with physicians during regular interactions. Open communication with hospital staff is a good way to identify problems within the query process, Butler says. Discern how the medical staff (or a particular physician) typically employs certain query responses. At Vidant, hospitalists often responded with “clinically undetermined” when they assumed the appropriate consulting physician would subsequently clarify the condition. Instead, the CDI program simply tracked the response as “clinically undetermined”; upon

analyzing query data, the program found an alarming rate of such responses. So Butler and his team talked with the medical staff, identified the problem, and worked to have hospitalists request the query be forwarded to the consultant, surgeon, etc. to more accurately reflect the situation.

as determined by the quality of the medical record, among other factors. Help them understand the value of the CDI program from the physician’s perspective, and be empathetic and willing to help. If the physician is struggling with a particular diagnosis, focus on that and adjust your education accordingly.

Facilities need to look at how they define “agree,” says Butler. “Is it when the CDI specialist obtained the expected documentation and it was coded? Or is it when there was a clear, clinical response to the query regardless of coding or other impact? The ability to split agree responses into ‘agree with coding change’ and ‘agree with no coding change’ is also helpful.”

If the pattern continues, or if you find the responses are targeted at one or two particular CDI specialists, consider bringing the matter to the attention of your CDI department manager, physician advisor, chief medical officer, etc., says Prescott.

He also suggests a “clinically insignificant” response be categorized as a response, but as a “disagree.” His personal preferenceis to track clinically undetermined as an altogether separate response category. “Certainly a rise in that percentage rate would be a trigger for further investigation by the CDI or coding departments,” says Butler.

Corrective action If an “abuser” is identified, Prescott suggests developing a method to address the issue up front. This could initially include physician education, specifically looking at why CDI specialists are asking questions and why specificity is needed to assign the most appropriate codes. Put it in perspective for physicians—show them websites like Healthgrades, where physicians are ranked based on their performance

The goal for tracking queries should not be only to identify abusers, but rather to improve query practices and processes overall, says Michelle McCormack, RN, BSN, CCDS, CRCR, director of CDI at Stanford Health Care in Palo Alto, California, and an ACDIS Advisory Board member. She suggests analyzing trends within queries with a “disagree” response to determine appropriate next steps. It is also helpful to look at the structure of the queries to determine if revision may facilitate improved responses. A potential outcome of analysis is identifying diagnoses in need of better organizational definitions, says McCormack. Work with medical staff specialists to draft and approve clinical criteria for these definitions and ensure buy-in. “You may be able to identify opportunities to educate providers, coders, and/ or CDI staff on certain diagnoses, required documentation, and coding guidelines.”

CDI Journal | JULY/AUG 2015

PHYSICIAN ADVISOR’S CORNER

Outpatient efforts: What your primary care physicians need to know about CDI by Trey La Charité, MD

The field of CDI traditionally focused on the inpatient environment. However, as healthcare reform gains momentum, that view has dramatically changed. Wise organizations have already seen the writing on the wall and know that CDI is equally important for outpatient providers. Unfortunately, even though primary care physicians (PCP) need CDI expertise, many remain unaware of how the medical landscape around them has changed, and many more simply do not believe that their practice has to change. If the PCPs in your network are reticent, the following information might persuade them to embrace the changes necessary to implement CDI principles in their practices.

Consumer pressures The two basic reasons for expanding CDI efforts to the outpatient arena are the same as those that influenced our inpatient efforts: Will patients want to see our providers for their medical care? and Will they be allowed to see our providers? When prospective patients search for a new PCP, they will choose the one who has better performance metrics readily available from online reviews and data resources—they will want to see the better-rated doctor. Increasingly, insurance carriers (or employers paying for the health insurance) steer new patients to a particular group of PCPs based on those same performance metrics—they won’t be allowed to see a provider deemed inferior. If a patient wants to see a physician outside his or her insurance carrier’s network, that patient will have to pay to do so. As with inpatient CDI, providers achieving equivalent or superior performance metrics and outcomes on patients who are clearly sicker than their competition will be rewarded by both of these mechanisms. Providers that

10 CDI Journal | JULY/AUG 2015

do not achieve favorable results will experience reduced patient volumes. Therefore, the goal of CDI in the outpatient environment remains the same: to make sure that the patient’s medical record accurately reflects the severity of the illness treated by the physician. However, there is a less widely known reason for our PCPs to embrace outpatient CDI efforts. While not a new phenomenon, utilization justification may be the most important factor in determining a PCP’s success. All insurance carriers (Medicare, Medicaid, and commercial) monitor the practice patterns of every PCP in their network. While carriers certainly care about the obvious performance metrics, such as the percentage of mammograms completed on eligible beneficiaries or the average hemoglobin glycosylated test (HbA1c) of the diabetic beneficiaries in a practice, they are particularly concerned with cost-effectiveness. The carriers want to see that a PCP spends an appropriate amount of the limited healthcare dollars available on the patients in his or her charge. What does “appropriate” mean? The obvious answer is that it depends on how sick the patient is. Cost-effectiveness is measured by a simple formula: the amount of money spent on a given beneficiary for a given calendar year divided by the amount of money that was expected to be spent on that beneficiary for that calendar year. Expressed as a percentage, this utilization ratio, also known as the Medical Expense Ratio or Medical Loss Ratio, is perhaps the single most important yardstick by which PCPs are judged. The amount of money spent on a patient for a given calendar year is easily and accurately obtainable by the carriers from their claims data. Calculating the amount of money that was expected to be spent on a beneficiary for a given calendar year varies by carrier. Regardless of carrier, though, the calculation is documentation dependent: The more accurately a provider reports a patient’s (pr patient population’s) severity of illness, the higher the

amount of money the carrier will expect the provider to need to treat that patient or population. While Medicare’s hierarchical condition categories (HCC) system is the most widely known methodology for obtaining this forecast, every carrier has a similar system. Explaining HCCs is beyond the scope of this article; however, I suggest that your PCPs learn and incorporate the system’s intricacies into their documentation patterns. If they can master HCCs, they will likely obtain high marks regarding their publically reported quality data as well as within their various payers’ risk stratification methods. What should a PCP’s utilization ratio actually be? With the passage of the Affordable Care Act, insurance carriers became obligated to spend no less than 80% (individual and small group plans) to 85% (large group plans) of collected premiums on actual medical care for their beneficiaries. This means that out of every dollar collected, $0.80 to $0.85 must go to medical services and benefits for a carrier’s patients, leaving only $0.15 to $0.20 for the administrative costs of the carrier and its potential profit margin. Therefore, since most of our PCPs will be dealing with large group plans, a utilization ratio somewhere around 85% should be the PCP’s goal.

Hypothetical case in point Let’s assume that PCP A’s utilization ratio is 110% for a given year. This means the insurance carrier would have spent $1.10 on PCP A’s patients for every $1.00 it collected, making that PCP look expensive. However, if PCP B’s utilization ratio were only 86%, the insurance carrier would have spent only $0.86 for every $1.00 collected, potentially generating a little profit. Assuming equal patient outcomes, PCP B looks more cost-efficient. For PCP A to improve (i.e., decrease) his utilization ratio, he must either reduce the amount of money spent on his patients or increase the amount of money that was expected to be spent on his patients. Reducing the amount of money PCP A spends means ordering fewer lab tests and/or radiological studies, making fewer specialist referrals, or seeing his patients less frequently in the office. However, increasing the amount of money expected to be spent on his patients merely requires accurately portraying within the medical record how sick the patients really are.

The first strategy requires the PCP to change his practice patterns; the second strategy requires only a change in documentation patterns. Needless to say, suggesting that a colleague limit or reduce patient care is not a strategy or conversation I intend to pursue. Going forward, denominator management is the clear choice.

Insurer options What will an insurance carrier do if a PCP’s utilization ratio stays consistently high? First, the carrier can drop certain carrier-specific care designations for the expensive providers from its network websites. Alternatively, if the carrier employs a ranking system (such as adding a variable number of stars next to each provider’s name, with a higher number of stars indicating a better provider), it may reduce the expensive provider’s number of stars in relation to his or her peers. When presented with more than one choice, a prospective patient will select a PCP that has the carrier-specific care designation or that has the most stars. As yet another option, the carrier can charge higher copays to see the expensive providers. Again, when presented with two options, prospective patients are more likely to choose the one that costs less. Lastly, insurance carriers can invoke what I call the “death penalty.” They can completely drop or exclude the expensive-appearing PCP from one or all of their network products. Rest assured that any of these will result in fewer patients being steered towards your PCPs’ offices. Traditional word-of-mouth referrals will continue to dwindle as technologically savvy patients do their homework on the Internet. These patients will choose their PCP based on the information and data they discover. Therefore, a PCP’s documentation is paramount in ensuring a flow of new patients. Ultimately, your organization’s future may depend on what the publicly reported information and data says about your PCP network. A reduction in patients for PCPs means a reduction in referrals for your hospital—and empty hospital beds result in closed hospital doors. Editor’s note: La Charité is a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center (UTMC) in Knoxville. comments and opinions do not necessarily reflect those of UTMC. Contact him at Clachari@UTMCK.EDU.

CDI Journal | JULY/AUG 2015

Physician documentation and engagement CDI specialists are told to keep physician engagement and education at the forefront of their efforts. Without physician buy-in, it can be challenging to run a CDI department at all, let alone achieve success. Yet physician engagement, or rather the lack thereof, is something most CDI programs struggle with on a daily basis. A recent survey conducted by The American Hospital Association and Executive Health Resources (EHR) found that 98.5% of participants reported that their physicians could improve their documentation practices. Only 5% of respondents—out of over 1,000 surveyed nationwide, mostly CDI specialists— said their physicians were highly engaged, with no barriers preventing

12 CDI Journal | JULY/AUG 2015

engagement in CDI. (Note—only 2% of the respondents were physicians.) When asked about the root of their physician engagement challenges, respondents identified a number of issues, says Ginny Balla, MBA, documentation services manager at EHR in Newtown Square, Pennsylvania, who spoke about the survey findings and physician engagement in a webinar on April 16. The survey revealed three top barriers prohibiting physicians from being effectively engaged in CDI. Essentially, it pointed out that physicians are lacking certain things: ■■ An understanding of the

importance of strong documentation. Physicians tend to document from the clinical perspective, Balla says,

while the coding perspective is much more technical. CDI specialists exist to bridge that gap and help physicians understand how their turns of phrase translate to codes (and why it matters). However, the method by which CDI currently communicates with and educates physicians may not be the most successful. “[We need to be] working with physicians and educating why documentation is important for the physician themselves.” ■■ Time. Physicians are often

focused on delivering care to the patient, and stopping to get documentation into the record isn’t always a top priority, says Balla. Moreover,

physicians are focused on their current patients, and handling queries regarding a patient from 30 days ago can be frustrating. ■■ Interest—maybe. Many CDI

specialists feel physicians are against CDI programs. But is the central issue lack of interest, or simply lack of awareness? “One of the things we hear over and over about CDI,” Balla says, “is that physicians view CDI as a hospital initiative, rather than something that the physicians need to be engaged in.” The answer to these difficulties is to think like a physician and empathize with them, says John Zelem, MD, FACS, senior director of audit, compliance, and education at EHR. Appeal to your physicians’ strengths and weaknesses. Some of the most common educational approaches hospitals use to educate physicians—including posters, emails, and lectures—were deemed ineffective, the survey showed. Physicians document and think from a clinical standpoint. The trick is to look for solutions outside of the status quo, says Zelem. For example: ■■ Educate physicians in a way

that works—not the way you’ve always done it. The survey found that real-time, patient-specific conversations are the most effective educational strategy to help physicians understand how they can improve their documentation.

■■ Acknowledge the limited time

that physician resources can allocate to CDI. Physicians are busy, and very few physician advisors for CDI focus solely on CDI program effectiveness. Know the limits your facility has and adjust your strategies accordingly. ■■ Make sure physicians know

there’s room for improvement across the board. No physician likes to be singled out, so it’s important that they understand improvement opportunities are a universal theme in CDI. ■■ Get a physician advisor on

board, if you can. They can help bridge the gap between physicians and CDI specialists, and can be more effective at getting physicians to work with CDI programs, Zelem says.

Technological trouble Technology also seems to contribute to physician engagement challenges, says James P. Fee, MD, CCS, CCDS, vice president for Huff DRG Review. “The physician’s biggest complaint is ’I just want to take care of patients,’ ” says Fee. “Time spent in front of computer is exceedingly disrupting the coveted physician-patient relationship and bedside care.” CDI professionals sometimes view technology as less of a barrier in preventing proper documentation than physicians do. The reality, Balla says, is that EHRs do not engage physicians but simply

automate the documentation process. Some EHRs turn a patient encounter into an exercise in physician data entry. A system aimed at organizing physician notes may actually encourage erroneous copy and paste, not quality documentation. From the CDI perspective, EHRs standardize required details and stratify clinical information; from a physician standpoint, however, the technology does not elevate documentation standards or modify physicians’ thinking. As a result, physicians ask CDI specialists to tell them what to say or what boxes to check, Balla says. While relatively new in healthcare, EHRs still aren’t tailored for the physician as the end user, says Karen Chase, MS, BSN, RN, CCDS, assistant director of CDI for Stony Brook Medicine. Eventually this will change—EHRs are currently being modified to include forms that will engage physicians and help provide the proper language needed for documentation, as well as make use of computer-assisted coding to look at clinical indicators and push forward diagnoses that are important to the patient. But as of now, they’re considered a hindrance to physicians. “There is a frustration element,” Chase says. “Physicians say, ‘I’m doing everything I can and you still want more. Why don’t you build the system to help me?’ Once developers do that, they’ll get more physician engagement.” As for technology, try getting physicians involved in creating templates

CDI Journal | JULY/AUG 2015

and improving the electronic record system, says Sharme Brodie, RN, CCDS, CDI education specialist for HCPro in Danvers, Massachusetts. An overwhelming number of physicians feel that there are too many hard stops and soft spots they have to answer; that there are way too many drop-down menus and check boxes. By giving physicians an opportunity to get involved, CDI specialists hear from them directly regarding what they want and need from the EHR. “I do think they’d respond and want to get involved—physicians love to teach,” says Brodie. “It’s all in your approach. Make it seem like the end result will be something both CDI and physicians will benefit from. I think generally physicians want to help out.” In summary, physicians will respond to direct communication. By adjusting CDI efforts to fit their needs and strengths, physicians, in

turn, will be more apt to work with CDI specialists. Here is an example of a documentation review process that incorporates effective physician discussions: 1. Review: Determine if greater specificity is needed. 2. Substantiate: Clarify if a query is valid or needed. 3. Engage: Interact directly with physicians one on one to gain clarification in the documentation and provide case-specific education and feedback. If your program does not currently have a physician advisor, consider working with management staff to hire one. Make sure to follow ACDIS/AHIMA query guidelines and recommendations to avoid leading the physician. 4. Document: Provide a written summary of the physician

conversation so that all queries—even verbal ones—are tracked effectively. Facilities can improve physician support for CDI efforts by engaging them from the get-go, communicating directly with them, employing their assistance in EHR and query efforts, focusing on their clinical needs, and simply asking them how they prefer to be communicated with. Physicians are humans too. Empathetic CDI specialists just need to engage them to make sure educational efforts and review processes work for everyone involved. Physicians face numerous daily challenges, not least of which include caring for their patients. Therefore, CDI can become a lower priority for them, says Zelem. “I believe that most physicians really do want to do the right thing,” he says—and CDI staff need to be there to help them do that.

CLINICAL BUNDLES

Take a holistic documentation approach by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI

Some common disease processes require certain types of care. Healthcare specialties often create such standard care intervention checklists to increase efficiency in overall treatments, and to drive notable decreases in morbidity and mortality while decreasing costs and increasing value. These “bundles of care” exist for serious disease processes with tendencies toward greater mortality rates; the Surviving Sepsis Campaign, for

14 CDI Journal | JULY/AUG 2015

example, defines bundles as “a selected set of elements of care distilled from evidence-based practice guidelines, [which], when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone.” CDI programs can adapt a similar “bundle” concept to help change physician behavior patterns. CDI bundles can be part of an effective strategy to enhance communication of patient care because

bundles, by their very nature, expand the CDI program focus beyond strict reimbursement (or CC/MCC) capture.

■■ Estimated time frame (length of stay) for the

Let’s consider the following components as representing integral parts of a clinical CDI bundle:

■■ Progress notes—reflecting the actual progress of

■■ Chief complaint and nature of presenting prob-

lem—an accurate and complete recording of why the patient seeks healthcare, in his or her own words. ■■ History of present illness (HPI)—a chronological

description of the development of the patient’s present illness from the first sign and/or symptom to the present. (This is vital to establish medical necessity, regardless of whether care is provided on inpatient, observation, or outpatient status.) ■■ Physical exam—commensurate with the nature

of the presenting problem and HPI, and congruent with the chief complaint and review of systems. ■■ Medical decision-making—reflecting the physi-

cian’s thought processes and including data that supports the amount of work needed to establish diagnoses and select management plans for the patient. Documentation should clearly outline the physician’s clinical reasoning and judgment for what he or she currently understands the patient’s condition to be and where he or she plans to go with the treatment defined. It should include the following: ■■ The clinical significance of available diagnostic

tests and their relationship to provisional and established diagnoses. ■■ The clinical rationale of ordering additional tests

and/or therapeutic treatment, and linkage to provisional or established diagnoses. ■■ Definitive diagnoses (as well as provisional diag-

noses associated with symptoms if definitive diagnoses are not currently known at the time of admission), all recorded with associated clinical specificity (i.e., acute, acute on chronic, etc.).

patient’s workup and treatment. ■■ Postacute care discharge plans.

the patient. The continuity of documentation in the progress notes needs to outline the patient’s response to treatment, changes in diagnosis, and clinical stability. ■■ Discharge summary—clearly encapsulating the

patient’s hospital admission, including: ––

Reason for hospitalization

––

Significant findings

––

Procedures and treatment provided

––

Patient’s discharge condition

––

Patient and family instructions (as appropriate)

––

Attending physician’s signature

CDI limitations CDI programs, operating much like any other healthcare business, must be self-sufficient and self-supporting when it comes to expenses and measurable revenue creation. Nevertheless, our present focus on CC/MCC capture, DRG optimization, and fiscal return on hospital-focused reimbursement is simply not sustainable. The need for complete, accurate, and effective documentations extends well beyond reimbursement. At the crux of this is efficient, cost-effective healthcare with a strong emphasis on preventive medicine and population health management. An integral component of these new healthcare delivery models is ensuring the right care at the right time for the right reason in the right venue with the right (supportive and appropriate) clinical documentation. Securing documentation of diagnoses for reimbursement purposes without regard for documentation of clinical context (i.e., establishment of medical necessity for the service ordered) is counterintuitive. Consider the sheer number of inpatient cases denied by Medicare contractors due to lack of documentation for medical necessity. In June 2014, Palmetto GBA—the

CDI Journal | JULY/AUG 2015

Medicare Administrative Contractor for North Carolina, South Carolina, Virginia, and West Virginia—released a presentation, “Spotlight on Physician Querying and Coding Specific Diagnosis Related Groups,” which highlighted the top 25 MS-DRGs billed in their region and the associated claims denial rate percentages. Two high-volume DRGs in North Carolina with large claims denial rates include DRG 291 (heart failure and shock with MCC) and DRG 292 (heart failure and shock with CC). The claims error rate for DRG 291 was 89%. Of those, 99% of denials were related to medical necessity. The error rate for DRG 292 was pegged at 93%. Again, 99% were due to medically unnecessary services. Palmetto GBA found similar results in its other three jurisdiction states. The fiscal year (FY) 2014 Comprehensive Error Rate Testing (CERT) program paid claims error rate increased to 12.7%, representing $45.8 billion in improper payments, compared to the FY 2013 improper payment rate of 10.1% or $36 billion in improper payments. Inpatient admissions accounted for a 13.8% improper payment rate, with 50.6% of the improper payments attributable to medical necessity issues, according to the supplemental appendixes for the Medicare Fee-for-Service 2014 Improper Payments Report. The numbers for the first quarter CERT 2015 improper payments demonstrate the same results.

16 CDI Journal | JULY/AUG 2015

Clearly, facilities need help demonstrating medical necessity within the medical record for services provided. The National Quality Forum Safe Practice #15, Discharge Systems, discusses discharge summaries, and the Society for Hospital Medicine has proposed checklists for these summaries. Learn more about the recommended content of discharge summaries by reading “Documentation of Mandated Discharge Summary Components in Transitions From Acute to Subacute Care” and “Creating a Better Discharge Summary,” which appeared in the March 2009 ACP Hospitalist magazine.

Final words CDI programs need to recognize that their present efforts may, in fact, contribute to increased medical necessity denials. Embracing clinical documentation “bundles” and engaging physicians in an open, active discussion of these various documentation elements may prove essential for transitioning into value- and performance-based healthcare delivery models. The status quo of focus on CC/MCC capture and case-mix index is destined for eventual extinction, the way of industries such as movie rentals and chain bookstores. Editor’s note: Krauss is an independent contractor with multiple years of experience in CDI management, review, auditing, and compliance. Contact him at glennkrauss@earthlink.net.

IT’S COMPLICATED

ICD-10 offers opportunities for complication codes In ICD-9-CM, almost all of the complication codes are in one chapter—the 900 series. Specifically, categories 996 through 999 capture complications of medical and surgical care that are not classified elsewhere in ICD-9-CM. Note that the term “complication” as used in ICD9-CM does not imply that a problem has been caused by improper or inadequate care.

■■ Nature of complication, such

Coders first refer to the main term for the condition and look for a subterm indicating a postoperative or other iatrogenic condition. If they can’t find an entry under the main term for the condition, they look under the term “complications” and then look for an appropriate subterm, such as one of the following:

To be considered a complication, the condition in question must be more than a routinely expected condition or occurrence. However, just because something is referred to as “expected” doesn’t prevent it from also being a complication, depending on the type of procedure.

as foreign body, accidental puncture, or hemorrhage ■■ Type of procedure, such as

colostomy, dialysis, or shunt ■■ Anatomical site or body sys-

tem affected, such as respiratory system ■■ General terms, such as

mechanical, infection, or graft

Complications in ICD-10-CM In ICD-10-CM, complication codes are structured very differently. Instead of grouping the codes in one chapter, ICD-10-CM places complication codes near the end of each body system–specific chapter, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts. Within the last few categories of the chapter, coders will find a category that indicates intraoperative and post-procedural complications. “When it comes to those complication codes, they’re going to be about complications that affect that particular body system,” McCall says. Some will be

CDI Journal | JULY/AUG 2015

combination codes, such as I97.710 (intraoperative cardiac arrest during cardiac surgery). Many of these complication codes will identify the specific type of surgery, McCall says. “It basically will tell you whether you’re operating on the same body system the complication occurred or if you’re operating on a different body system.” This is a significant improvement over ICD-9-CM for research statistics and mortality data, as complications that occur within a different body system are likely to have more significance because they are less likely to be expected, says Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director for HCPro. Code I97.710, for example, indicates the patient suffered cardiac arrest while the surgeon was operating on the heart. If the patient suffered cardiac arrest during a different type of surgery, coders would report I97.711. Anything other than a cardiac surgery will fall under the code I97.711 for cardiac arrest during other surgery, McCall says. Some of the complication codes are not stand-alone codes, McCall cautions. For example, say a patient suffers an intraoperative cerebrovascular infarction during another surgery, meaning the physician wasn’t operating on the nervous system. Coders would report I97.811 (intraoperative cerebrovascular infarction due to cerebral artery occlusion during other surgery) to show that the patient suffered a stroke during the procedure, as well as an additional code to identify the specific

18 CDI Journal | JULY/AUG 2015

infarction site. For example, if the infarction occurred because of an occlusion in a cerebral artery, coders would report I63.50, which is an MCC, as well. “Remember that when it comes to any of these codes, you need to pay close attention to the instructional notes,” McCall says. “Some of them are not stand-alone combination codes, but rather may necessitate multiple codes.”

Quality and documentation CMS wants to pay for quality of care and is using coded data, which it refers to as administrative data, as a surrogate for this purpose, says Ericson. “That’s one of the things that’s going to make our role as CDI specialists and coders increasingly difficult,” Ericson says. “We already know there’s a lot of frustration in properly assigning complication codes in ICD-9.” The good news is ICD-10-CM includes more complication codes. The bad news is the industry still doesn’t have a consensus of when and how to use these codes appropriately. “There’s a lot of differences regarding when people feel comfortable using a complication code versus when they don’t,” Ericson says. Remember, coding conventions included in the Tabular List and Alphabetic Index supersede coding guidelines. After that, refer to AHA’s Coding Clinic for ICD10-CM/PCS for additional advice to clarify the Official Guidelines for

Coding and Reporting and the coding conventions. CDI specialists need to recognize when there is the possibility of a relationship between the care provided and the unexpected outcome and to remember that a complication does not imply the physician did something wrong, Ericson says. Physicians are sometimes reluctant to document an unexpected outcome as a complication, says Trey La Charité, MD, physician advisor for the University of Tennessee Medical Center at Knoxville’s clinical documentation integrity program, coding, and RAC response. CDI specialists can explain to the surgical staff that complication rates are averages, and that one isolated complication will not ruin a physician’s reputation or destroy his or her perfect report card. “After all, some baseline surgical complication rate is expected—a surgeon who has never had a complication has not performed enough surgery,” he says. Additionally, complication rates are risk-adjusted. A sicker patient with additional documented comorbidities has an increased likelihood of a complication occurring, La Charité says. When an unexpected outcome does occur, “if the code set doesn’t already take us to a complication code, we would have to query the provider to find out if there is a cause-and-effect relationship,” says Ericson. “Did this surgical intervention cause the ensuing condition, or did the condition cause this

outcome regardless of the medical intervention?” Coders and CDI specialists need to pay careful attention to present on admission (POA) status, Ericson adds. One CMS quality initiative specifically focuses on identifying preventable hospital-acquired conditions (HAC). A HAC is a condition that occurs during the admission as opposed to being POA, which is why that POA status is so important.

“With” and “due to” Coders and CDI specialists often get confused by the terminology “with” versus “due to.” The term “with” can link two ideas, but it does not demonstrate a

cause-and-effect relationship, says Ericson. “This is when you need the physician to say ‘due to,’ to show causality, which is how it is specified within the code set. They could also use phrasing like ‘from’ or ‘secondary to.’ ”

relationship exists that could affect the coding of the record, then query the provider for clarification, Ericson says.

For example, say the provider documents “the infection was due to the urinary catheter” instead of “the patient has a urinary tract infection (UTI) with an indwelling catheter.” In the latter case, “that doesn’t tell the coder that the indwelling catheter caused the UTI,” Ericson says.

“It’s your responsibility to query,” she adds. “The physician has the freedom to disagree, but if you see a high prevalence of disagreement amongst certain physicians, then that’s something you might want to escalate to your compliance department. We want to make sure the coding accurately reflects the events of the health record rather than worrying about whether it’s going to hit a quality metric or not.”

The best practice would be to look at the totality of the health record. If the possibility of an undocumented

Editor’s note: This article was originally published in our sister journal Briefings on Coding Compliance Strategies.

Tips to resolve tricky anemia documentation troubles Anemia is a tricky condition from a diagnostic standpoint because as many as one-third of patients in the U.S. could have some type of anemia, says Cesar M. Limjoco, MD, vice president of clinical services for DCBA, Inc., in Indianapolis. If a patient with acute bleeding loses enough blood to become anemic, the diagnosis of acute blood loss anemia is appropriate, says Richard D. Pinson, MD, FACP, CCS, of HCQ Consulting in Chattanooga, Tennessee. This definition also encompasses patients who have preexisting anemia and become more anemic due to bleeding. If the physician just documents “anemia,” he or she is not capturing the patient’s severity of illness, Limjoco says. Coders will report ICD-9-CM code 285.9 when the physician does not specify the type of anemia. Physicians can be much more specific when documenting anemia, Limjoco says. For example, the physician can document acute blood loss anemia (285.1), chronic anemia secondary to chronic kidney disease stage IV or V

(285.21), chronic blood loss anemia (280.0), or iron deficiency anemia (280.9). Physicians don’t document acute blood loss anemia well, says Timothy N. Brundage, MD, CCDS, medical director of Brundage Medical Group in Redington Beach, Florida. Acute blood loss anemia can be linked to a hemorrhagic process, such any procedure or surgery, fracture, or GI bleed. “This should be documented separately from its cause,” Brundage says. If a patient experiences post-procedural bleeding, the physician should document whether it is expected—for example, in an elderly patient who fractures her hip, the anemia could be an expected occurrence depending on fracture type, Brundage says. Even if the amount of blood lost following surgery is expected and routinely associated with the procedure, acute blood loss anemia is still present if anemia occurs, Pinson says. Editor’s note: This article originally appeared in JustCoding.com.

CDI Journal | JULY/AUG 2015

IN THE NEWS

Latest AMA ICD-10 proposals get it half right by Brian Murphy, ACDIS Director

The AMA, aware that the national tide has turned in favor of ICD-10, has made what seems to be one final, desperate push for a delay—not of the implementation of the new code set, but of its impact. Physicians at the 2015 AMA Annual Meeting in June passed a policy that calls for CMS to put a two-year moratorium on payment penalties for physicians as a result of ICD-10 coding mistakes. You can find the full article on the subject at www.ama-assn.org/ama/ama-wire/post/ doctors-call-two-year-grace-period-icd-10-penalties. Alongside this comes a more interesting policy—the AMA wishes to join CMS, the National Centers for Health Statistics, the American Hospital Association, and the American Health Information Management Association as a fifth Cooperating Party. The Cooperating Parties, as most know, are the group in charge of updating and managing the ICD code set. ACDIS does not support the concept of implementing a code set halfway. Holding hospitals, but not physicians, accountable to the ICD-10 codes they report only deepens the divide between these two parties at a time when CMS is attempting to unify the professional/facility divide through bundled payments and other initiatives. It would also likely result in bad statistical data that would have ripple effects for years to come. ICD-10 has already been delayed several times at the behest of the AMA. There are a number of free ICD-10 training resources available at the disposal of physician practices from CMS and others. Furthermore, early claims testing has proven remarkably successful. And

20 CDI Journal | JULY/AUG 2015

as many have pointed out, the ICD-10 code set is not the monster it is made out to be: The rhetoric of “four times as many codes” is a smokescreen, as most physician practices will be using a far smaller subset of codes. Hospitals, at the behest of CMS, have been preparing for years, at enormous cost. The time is now to implement ICD-10 to the hilt, including for claims processing and payment. However, the AMA’s case to become a fifth Cooperating Party is a much stronger proposal. Physicians deserve an equal voice at the table when new codes are developed. Codes need to be 100% clinically congruent to the practice of medicine, not the other way around—as anyone familiar with the quirks of ICD-9 can attest. While there are physician representatives among the four current Cooperating Parties, they are in the minority. More to the point, the critical work of the Cooperating Parties lacks transparency—try to find a website detailing their work or membership roster, for example—and there is no readily available method for groups affected by ICD changes to have their voices heard. In summary, let’s move forward with full implementation of ICD-10 on October 1, 2015, both for hospitals and physicians. But let’s also see a more transparent application process for the Cooperating Parties, allowing physicians/clinicians full representation at the table. While that physician group may not ultimately be the AMA, the time has regardless come for more input on the ICD codes from those at the center of healthcare delivery. Editor’s note: This article originally appeared on the ACDIS Blog.

MEET A MEMBER

From hospice care to Southampton CDI Fran Platt, BSN, RN, is the CDI manager at Southampton Hospital in New York. Though she says she’s new to CDI (she’ll be celebrating her two-year anniversary in the field this coming September), she says learning and continually growing in the CDI profession has kept her motivated. Platt is also involved with the Suffolk County (Long Island New York) ACDIS chapter. Married, with four daughters and one son ranging in age from 13 to 31, Platt enjoys staying involved with her family’s many activities. Her two oldest daughters live in nearby Brooklyn and Manhattan; her 18-year-old daughter graduated high school this year and will be attending Fordham University; her 15-year-old daughter is a sophomore in high school; and her son will be entering 8th grade in the fall.

“They all have a ton of interests and keep me very busy,” Platt says. CDI Journal: What did you do before entering CDI? Platt: I was an East End hospice nurse. I absolutely loved hospice work. Working there kept me grounded and reminded me to be grateful for each day. From there, I worked on the units, including radiology, here at Southampton Hospital, and moved on to case management doing utilization review and discharge planning. CDI Journal: Why did you get into this line of work? Platt: Our CDI nurse was moving on to become a nurse manager, so the position became available. I was really excited, and thought it would be a good change and an opportunity to learn something new. CDI Journal: What has been your biggest challenge? Platt: Physician buy-in. It’s an ongoing challenge to have physicians understand what CDI is and why we’re there. I’ve been jokingly called the “chart police” and “the enemy” [by physicians]. I hope a full [electronic medical record] will help make the query response process easier for the hospitalists and residents. I want them to understand that I’m not there to make sure their T’s are crossed and I’s are dotted, and that I am a resource for them. I’m lucky enough that we are a small hospital, and I know just about all the physicians personally. CDI Journal: What has been your biggest reward? Platt: My biggest reward has been learning what CDI is all about and having the opportunity to continually grow in the field. My goal is to eventually become a Certified Clinical Documentation Specialist. Being a CDI nurse, I have the pleasure of working with many of the departments in my organization, including medical staff, residents, nursing, HIM, case management, etc. I love that part of my job. CDI Journal: How has the field changed since you began working in CDI?

CDI Journal | JULY/AUG 2015

Platt: I’m not sure how much it has changed. After two years, I still consider myself “new” because there’s still so much to learn. ICD-10 will be a big change for CDI, but I’m definitely looking forward to the challenge.

you get the summers off—I could then work in my garden and go to the beach every day.

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

Platt: My first job was working as a clerk at the naval base in Kitsap County, Washington. I remember back then that my high school counselor encouraged me to take typing. I learned on an electric typewriter and I thought it was so technologically advanced. Never in my wildest dreams did I ever think I would be working as a CDI specialists with so much technology.

My biggest reward has been learning what CDI is all about and having the opportunity to continually grow in the field. My goal is to eventually become a Certified Clinical Documentation Specialist. Platt: I don’t just have a few—I have a ton of things that I take from ACDIS via the website and also through my local chapter. I’m on [the website] every day and try to read as much of the information as I can. I also use it for my reference during my day-to-day work. My colleagues from the Suffolk County ACDIS chapter are also a wealth of information. I look forward to our meetings because I’m sure to learn something new when I attend. I leave thinking of ways to implement or use the information shared at our meetings [in my facility]. I also recently attended my first ACDIS conference in San Antonio and I found it to be highly informative, and [everything I learned will] certainly be helpful in my own scope of work. I absolutely encourage CDI specialists to attend their local chapter meetings and to take advantage of everything ACDIS has to offer.

CDI Journal: What was your first job (what you did in high school)?

CDI Journal: Tell us about a few of your favorite things: ■■ Vacation spots: Guam (where I was born and

raised) and Costa Rica. ■■ Hobby: Reading, trivia, Words With Friends (the

app). ■■ Non-alcoholic beverage: Water. Tons of it. ■■ Foods: I love all kinds of food! The spicier the

better! ■■ Activity: I love spending time with my family, swim-

ming, and going to the beach. I also absolutely love the New York Yankees and going to games at Yankee Stadium! Editor’s note: CDI Journal introduces an ACDIS member in each issue. If you would like to be featured, or know someone who would, please email ACDIS Editor Katherine (Katy) Rushlau at krushlau@acdis.org.

CDI Journal: What piece of advice would you offer to a new CDI specialist? Platt: Don’t give up! The amount of information to learn is very daunting, but keep striving, and when you feel it’s too overwhelming, take a step back and breathe. CDI Journal: If you could have any other job, what would it be? Platt: I would love to be an elementary school teacher. I am always amazed at how kids love to learn, and how proud they are when they do learn something new. Plus,

22 CDI Journal | JULY/AUG 2015