cdiJournal
April 2009
Save the date
Vol. 3 No. 2
Join HHS for ICD-10
implementation in 2013
FEATURES
Director’s note
2
CDI spotlight
4
Ask ACDIS
6
nM
oving
CDI into
hospital departments
such as pediatrics can
have added benefits.
nB
ryanLGH
Medical Center
shows how HIM can lead
a hospital’s CDI charge.
nD
etermine
whether
elevated D-Dimer levels
are related to a transient
ischemic attack.
Carrier enforces proper
documentation
7
nA
December bulletin
from CMS carrier Cigna
is demystified.
Tips to clarify “injury” 8
nW
e
offer advice for
documenting in tricky
situations, namely
chronic kidney disease.
ACDIS chapters
nU
se
these networking
tips to start or join a
local ACDIS chapter.
11
The whispers about ICD-10 implementation were worse than the buzz before a wedding.
“Have they set a date yet?” administrators asked.
Earlier rumors pegged the kickoff for 2011, a
timeline many called too quick to be successful.
The U.S. Department of Health and Human
Services (HHS) finally settled on October 1,
2013, as the deadline for implementation, according to the final rule released January 16.
“It certainly gives people plenty of time”
to change and test coding systems, says Dan
Rode, MBA, CHPS, FHFMA, vice president of
policy and government relations at AHIMA in
Washington, DC. “On the other hand, it’s not
a reason to think that we can sit by for a while
until we get closer to 2013.”
“People have a date, so they’re looking for a
place to start their preparations,” says Kathleen
Wall, MS, RHIA, CDI specialist at 3M Health
Information Systems in Atlanta.
CDI specialists aren’t merely guests at the ICD10 reception. The profession plays an important
part in the rollout of the new code set. Because
ICD-10 boasts more than 155,000 possible code
combinations (ICD-9 only has 17,000), the
increased number of codes allows ICD-10 to be
far more specific than its predecessor. Therefore,
the new code set requires more specific documentation to back it up. Since CDI specialists primarily aim to obtain the most specific documentation
for the medical record, facilities with CDI programs are primed for the ICD-10 conversion,
says Garri Garrison, RN, CPUR, CPC, CMC,
director of consulting services at 3M Health Information Systems and a member of the ACDIS
advisory board.
“The role of the CDI is to keep good clinical data. This will only help the whole transition to ICD-10,” says Gloryanne Bryant, BS,
RHIA, RHIT, CCS, ACDIS advisory board
member and senior director of coding and HIM
compliance at Catholic Healthcare West in San
Francisco.
Preparty prep work
Achieving implementation by 2013 still
seems daunting to many. Realization of the ICD10 goal requires juggling many pieces (such as the
particulars of a reception), and some healthcare
experts doubt the feasibility of code set execution.
Nevertheless, ICD-10 represents a turning
point for HIM, says Bryant.
“As we move toward more electronic medical
records and use the computer to help us with decision-making and even computer-assisted coding,
the move to ICD-10 is ideal,” she says.
To get the ball rolling, talk to your HIM councontinued on p. 3
Director’s note
CDI triumph discovered in pediatric unit
Many new CDI programs experience
success right out of the gate. Low-hanging
fruit such as urosepsis and unspecified
heart failure are easy documentation targets and often bring good early returns.
But what happens when that first fruit is
plucked? Susan Klein, RN, director of clinical documentation management at Saint Peter’s University Hospital in New
Brunswick, NJ, recently found some interesting and rewarding
documentation opportunities in an area many CDI specialists
overlook: the pediatric unit.
Some CDI programs have opted not to review pediatric records due to perceived nonopportunity. But where
hospitals have typically seen barriers, Klein and the CDI
staff members at Saint Peter’s have found improvement
prospects.
“Is the opportunity [in pediatrics] as big as the adult
population and the med-surg area? No, but there’s still
cash on the table,” Klein says. “It doesn’t matter whether
it’s a pediatric or geriatric population, the physician doesn’t
always write down all the diagnoses.”
Two years ago, Saint Peter’s recruited Klein, a former
DRG manager and reimbursement consultant, to help develop the hospital’s CDI program. Klein added staff members
to the CDI team and started looking for new opportunities.
Recently, she expanded to the pediatric unit and found the
following in the first week of dedicated review:
»»A Medicare-insured patient admitted for chemotherapy
in which the physician documented leukemia in remission, whereas the patient had acute leukemia in remission
»»Patients diagnosed with respiratory distress instead of
respiratory failure
»»Physicians documenting HIV instead of AIDS
»»Overlooked CCs such as pleural effusion
»»Diabetic patients with undocumented secondary diagnoses
»»Incorrect documentation of the principal diagnosis for a
patient with a history of congenital heart disease admitted
for “exceeding metabolic demands”
»»Patients admitted for “viral syndrome” instead of
dehydration
Klein credits a “clinically superior” team of CDI nurses, including a nurse manager with experience in high-risk
antepartum cases, a nurse manager with experience in critical care, a nurse manager with experience as an ER charge
nurse, and a surgical critical care nurse, for her program’s
successes. “I have an awesome staff,” she says.
Klein has also helped her cause by getting the pediatric nurse manager on board with the CDI program. Klein
frequently discusses complex cases with the nurse manager,
working to ensure that the clinical interpretation is correct
in this special population before she contacts the physician.
Educating the nurse manager regarding documentation requirements helps with compliance and information
dissemination, Klein says. “You have to work with your
nursing staffs and get their buy-in because they’re there
on the floor more than you. If there is an [advanced practice nurse] or [physician assistant] available, we will work
hand-in-hand with them,” she says.
For the next phase, Klein is planning a presentation
for Saint Peter’s pediatric physicians on documentation
requirements. She hopes to share her presentation with her
fellow ACDIS members via the Forms and Tools Library
on ACDIS’ Web site (www.cdiassociation.com).
One of the strengths of ACDIS of which I’m the most
proud is its role as a facilitator of innovative and unique
ideas. Klein’s work and willingness to share her success
story is proof of that.
Take care,
Brian J. Murphy, CPC
[email protected]
781/639-1872, Ext. 3216
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April 2009
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Save the date
continued from p. 1
terparts and make sure the C-suite administrators understand
the importance of the ICD-10 switch. The executive team
should establish an ICD-10 implementation committee to
spearhead the project. The team may consist of HIM, finance,
compliance, information technology (IT), and CDI professionals.
Many departments use ICD-9 codes, Wall says. Conduct
a hospitalwide inventory of external vendors and internally
developed/homegrown systems that currently use ICD-9.
Work closely with the IT department since any software
that incorporates ICD-9 codes will require revision, updating, and testing, Bryant says.
“What we don’t want to see when we go live [with ICD10 on October 1, 2013] is that, although coders are trained,
the systems don’t work well or the crosswalks haven’t been
checked,” Bryant says.
Think of it in comparison to IT challenges at the turn
of the millennium, Wall says.
“No one knew how the data would react,” she says.
Similar to the Y2K situation, data programs will need to
communicate with a new system to incorporate the new
language of ICD-10.
Administrators need to ask:
»»How will ICD-10 data be compared with ICD-9 data
when examining healthcare trends?
»»Will all vendors be ready for the change?
»»Is everyone in the organization aware of the change?
»»Does everyone know what to do?
Extending the invitation
Making a life-altering change is never easy, and an alteration of the ICD-10 magnitude makes many leery. In fact,
many CDI professionals suggest they may not last to see the
implementation date come to fruition. “There will always
On the Web
To view the ICD-10 final rule in the January 16,
2009, Federal Register, visit www.access.gpo.gov/
su_docs/fedreg/a090116c.html.
be those who say they’d rather retire than learn something
new,” Garrison says. “But that doesn’t represent the bulk of
the population.”
Keeping coders and CDI professionals informed as the
implementation team progresses may help allay staff members’ fears, Bryant says.
Communicate the implementation and training timeline
so everyone knows what to expect. Do not try to train staff
members on the specifics of ICD-10 until a few months prior
to the actual implementation date, Wall says. You don’t want
to fill staff members’ brains with information they can’t technically use for another three years, especially given the ongoing
documentation challenges with ICD-9, she says.
“As we move toward more electronic medical
records ... the move to ICD-10 is ideal.”
—Gloryanne Bryant, BS, RHIA, RHIT, CCS
More party prep work
Continued attention to documentation specificity and
quality data will illuminate areas to target with physician
education and CDI queries, says Bryant. Most experts suggest CDI staff members should intensify examinations of
unspecified codes.
“Today, ICD-9 unspecified codes aren’t reimbursed well,”
Garrison says.
“One place to look is unspecified coding,” Wall agrees.
She suggests looking at historically common diagnoses for
opportunities to improve specificity. Of the top 50 diagnoses at your facility, ask how many of them were unspecified.
For example, whereas an ICD-9 code permitted a simple
excision, ICD-10 excision codes now contain five terms.
The transition to ICD-10 may be the most sweeping change
that some healthcare professionals have experienced, says Bryant.
“Nevertheless, we really have some opportunities here,”
Wall says. If the CDI program already knows the troubled documentation spots, “you can educate on specific areas,” she says.
In fact, CDI professionals could use ICD-10 implementation as an opportunity to get physicians’ attention and illustrate the importance of specific, accurate documentation and
the role of various departments such as HIM and CDI on the
overall health of the healthcare industry.
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© 2009 HCPro, Inc.
April 2009
3
CDI spotlight
BryanLGH makes case for coders leading CDI
Like other professionals in her field, Kari Eskens, RHIA,
HIM coding manager at BryanLGH Medical Center
in Lincoln, NE, knows the benefits of CDI programs.
Clinical documentation captured at the point of care improves clinician communication, decreases reimbursement
denials, and in-creases appropriate reimbursement. Further,
Eskens saw CDI as an opportunity to increase awareness
among clinicians and leadership of the positive effects of
good documentation.
But to bring a CDI program to her hospital, Eskens
needed backing from her organization’s leadership. In July
2007, prompted by the pressing need to accurately capture
reimbursement and reflect case complexity and severity, the
coding managers and HIM director presented the idea for
the new program to their chief financial officer, who quickly
gave the group the go-ahead to start plotting the parameters
for the CDI program.
Gathering data
Eskens, in the role of CDI manager, joined the directors
of HIM, case management, and quality improvement to analyze the effect of the proposed CDI program on the facility.
The group conducted in-depth research, solicited feedback
from each department, analyzed work flow processes, identified documentation issues, and determined key areas for
improvement.
Members of the BryanLGH Medical Center CDI team at the Lincoln,
NE, center: From left to right are Kari Eskens, RHIA; Deb Beam, BSN;
Jane Hester, BSN; and Karen Everitt, RHIA, CCS.
An essential part of the process involved communication
with peers and outside organizations that already implemented a
CDI program. BryanLGH also hired HealthPort consultants to
conduct an inpatient audit. HealthPort identified documentation problems, analyzed their causes, helped determine criteria
for an appropriate query, and developed guidelines for reinforcing query principles. Based on HealthPort’s recommendations,
BryanLGH decided to house the new CDI program in the
HIM department.
Determining staffing needs
Initially, Eskens’ staff included two nurses as CDI specialists and a credentialed coding specialist to focus on DRGs,
coding, and reimbursement. Eskens’ responsibilities included
staff oversight, reporting, program evaluation, collaboration
with physicians, and conducting education and training.
Later, BryanLGH hopes to add a physician advisor to the
CDI team.
“Not surprisingly, approval for adding three new full-time
employees did not come easily,” says Eskens. “But we were
able to make a strong case that these positions were essential
to establish an effective program.”
Finally, the hiring process began—determining criteria for
CDI team members, writing job descriptions, posting positions, and conducting interviews to find the right combination
of experience and expertise. Recruitment proved more challenging than expected.
“Finding two RNs with three years of acute care experience, communication skills, people skills, and sincere interest
in doing this work was a tall order,” says Eskens.
And finding a credentialed coding person who was qualified and willing to step into a team position was even more
difficult. “Most coders want to remain in coding, where they
can work from home,” Eskens notes. Eventually, patience and
perseverance through a rigorous recruitment effort resulted in
a solid team.
Analyzing early results
Since establishing the program in 2007, Eskens has improved physician query response rates, raised the bar for
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April 2009
© 2009 HCPro, Inc.
improved documentation across the two-hospital system,
and created a multidisciplinary team of nursing and coding
professionals. (See “Take these six steps to implement a successful CDI program” below.)
In her new role, Eskens has had a significant effect on
many levels and led the way for other HIM professionals
to consider a CDI role as another step in their healthcare
careers.
Barely a year old, the CDI program has already received
accolades for its accomplishments.
“We’re in the infancy of an effective program,” Eskens
says. “But in addition to raising the bar for improved documentation, we’ve raised the bar for the HIM department
in terms of getting our name out to physicians and raising
awareness of what we do in HIM.”
Overall, Eskens is proud of her team’s achievements and
the successful transition to a new program. “We did our
homework. We were flexible, creative, and allowed ourselves
to think outside the box,” she says.
For Eskens, her role as CDI manager brings a new challenge, a different role, and an opportunity to drive improvement at her organization.
An additional benefit is that other departments now
recognize the expertise and experience of HIM professionals, she says. “Our leadership, combined with clinical and
coding knowledge, is essential for improving the clinical
record and capturing lost reimbursement,” Eskens says. “We
know coding, MS-DRGs, reimbursement, documentation
requirements. That’s why HIM leadership is vital for CDI
success.”
Take these six steps to implement a successful CDI program
– Should we house our program under HIM, finance, quality,
Kari Eskens, RHIA, HIM coding manager at BryanLGH
or case management?
Medical Center in Lincoln, NE, learned several lessons while
helping implement a CDI program at her hospital. Below,
– How many full-time staff members will we need?
she shares six critical steps to ensure CDI success:
– Will our organization support the addition of a physician
advisor or champion?
1. Get leadership support from the start. Show those in
the C-suite the effect of your CDI program. Obtain cost
4. Present to leadership. Explain your proposed program spec-
estimates from companies that help set up CDI programs.
ifications and budgetary needs to the facility management.
Convey the bottom line in financial terms. Show how better
Make your presentation simple and effective. Where possible,
documentation more accurately reflects severity of illness
combine anecdotal information with hard data. Present your
and the patient population, resulting in increased reimburse-
data clearly and effectively. Use PowerPoint presentations
and graphs when possible.
ment and better patient care.
2. Form a planning group. Include finance, medical records, care
5. Hire appropriately. Take your time during the hiring phase.
management, quality improvement, medical staff, and nursing.
Be selective. Do not compromise your program needs to fit
Network with other CDI programs and peers to learn what
the capabilities of the candidate. Involve the CDI manager,
worked best for them and consider implementing similar strat-
HIM, and a multidisciplinary team in the interview process.
egies in your own program.
Keeping the right person means hiring the right person.
3. Determine CDI needs. Consider a neutral third party to con-
6. Earn staff support. This can come from a physician cham-
duct an inpatient coding and documentation audit, evaluate
pion as well as your ongoing educational efforts. Conduct
current query processes, and update query policies and pro-
presentations with groups of physicians, attend their staff
cedures. Based on your audit findings and industry research,
meetings, and ask for their input. Similarly, build solid work-
determine the staffing and organizational needs of your CDI
ing relationships between your CDI and coding staffs by
program. Ask the following:
analyzing queries and difficult cases together.
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© 2009 HCPro, Inc.
April 2009
5
Ask ACDIS
Develop appropriate and credible physician queries
Our CDI program is a little over one year old and we
do not have a physician advisor or champion. I am
finding it difficult to write queries to obtain a specific
diagnosis.
For example, a physician documents in his progress
note that the patient’s D-Dimer is elevated much above
normal level and the syncope could be related to this.
It is possible that the patient had a transient ischemic
attack (TIA), but how do I write this query so as not to
offend the doctor or look like I am diagnosing the patient?
Previously, I wrote the query as follows: “Please relate the
syncope to the diagnosis when the workup is complete
(i.e., TIA, other).”
An elevated D-Dimer is a nonspecific test that may point
to thrombosis but, in the setting of syncope, does not
point to any one disease. A TIA rarely results in syncope
unless it involves the posterior (basilar) circulation, which is
very uncommon.
A pulmonary embolus usually has an elevated D-Dimer
and can result in syncope; however, the symptoms would be
dramatic. Given that D-Dimer and TIA have little direct correlation, the physician would be frustrated but not offended
by this question.
I suggest taking the following steps:
»»Get access to an electronic internal medicine reference.
You can use this to learn about the clinical indicators
of certain conditions, such as TIA and stroke. When you
see physician notes regarding these indicators, you can
document your reference (e.g., you can say, “I saw this in
Harrison’s Textbook of Medicine”) and query for the clinical
significance of that indicator.
»»Use this reference to learn about certain laboratory tests
or medications. This knowledge allows the CDI specialist
to ask open-ended questions such as “Please indicate the
condition the following pharmaceutical treated,” or “Please
indicate the clinical significance of the 102ºF temperature,
white blood cell count of 18,000, and hypotension in the
setting of the patient described to ‘appear toxic.’ ” Asking
questions in this manner allows the physician to present
additional information. It does not lead the physician to a
predetermined answer or suggest what he or she ought to say.
Regarding the specific D-Dimer question, I would query
the physician in one of the following manners:
»»“Please indicate the clinical significance of the elevated
D-Dimer level of ________ in this patient with syncope.”
»»“In light of the elevated D-Dimer, other laboratory studies, written patient history, and physical examination,
please indicate in the progress notes and discharge summary the likely cause of this patient’s syncope.”
Note that hospitals may code “possible,” “probable,” or
“suspected” diagnoses when the physician writes or dictates
them at the time of discharge (e.g., in the discharge summary).
You may also wish to create multiple-choice query forms
for the common situations that you run into.
Editor’s note: James S. Kennedy, MD, CCS, director of FTI
Healthcare in Atlanta, answered this question. E-mail him at james.
[email protected]. To learn more about him, visit www.
ftihealthcare.com, click on Professionals, and search for James S. Kennedy.
Upcoming event
April 14—Physician Advisors in CDI: Take a Team Approach
Poor documentation takes a toll on a physician’s report card
and a hospital’s quality scores. Avoid these problems by joining
ACDIS on Tuesday, April 14, 1 p.m. EST, for a live 90-minute
audio conference, featuring Mark S. Michelman, MD, MBA, of
Morton Plant Mease Health Care System, and Trey La Charité,
MD, of the University of Tennessee Clinical Documentation
Integrity Project.
For more information, visit www.hcmarketplace.com
and click on the Revenue Cycle tab, or call customer
service at 800/650-6787.
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6
April 2009
© 2009 HCPro, Inc.
News
Carrier bulletin enforces documentation habits
CDI specialists’ efforts to improve physician documentation of specific diagnoses received a boost from
one CMS carrier in December.
A Cigna bulletin states that the documentation of
the three elements of E/M (patients’ history, the physicians’ medical decision-making, and the exam itself) is
separate and distinct from the documentation of medical necessity.
According to the December 18, 2008, bulletin:
»»Medicare’s determination of the medical necessity of a service is
separate from the determination that the E/M service was rendered as billed or that the claim was billed correctly.
»»Medicare reviews claims for medical necessity largely through
the experience and judgment of clinician coders. The results
of the reviews are based on the documentation of the patient’s
problem(s) and what services the treating clinician performed, in
addition to the tools provided in [current procedural terminology]
and by the Centers for Medicare & Medicaid Services.
»»At audit, Medicare will deny or downcode E/M services that,
in its judgment, exceed the patient’s documented needs.
In other words, carriers will deny physician E/M payments for services such as initial and subsequent inpatient
visits if the services aren’t supported by good documentation demonstrating the medical necessity of those visits,
says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS,
PCS, C-CDI, senior coding and chargemaster consultant
at QHR in Brentwood, TN.
Many physicians have little motivation to participate
in CDI programs because they see them as a financial benefit only to the hospital.
But this bulletin—as well as the fact that Part A/B
Medicare administrative contractors (who review and
pay hospital and physician claims) are replacing the old
fiscal intermediary/carrier structure—underscores the
reality that good documentation of specific diagnoses
and reasons for treatment benefits the hospital and the
physician.
For example, during a recent audit, Krauss discovered that a physician had billed a level 3 subsequent
inpatient visit (99233) for a patient for whom he had
documented “failure to thrive,” a symptom code, as
the diagnosis. Chest pain is another common offender.
Neither diagnosis will stand up to carrier, fiscal intermediary, Medicare administrative contractor, or recovery
audit contractor scrutiny as a patient reportable diagnosis
or as a medically necessary reason to support a high-level
physician E/M code.
Krauss says common culprits that contribute to
physician E/M level downcoding and flat-out denials
include:
»»Inadequate physician clinical documentation to support
the physician’s initial clinical impression
»»Failure to document the reason for ordering a series
of diagnostic tests as part of the patient workup
»»Failure to document the final clinical impression
“The bottom line is that when we’re talking to physicians about documentation, particularly symptoms and
possibles and rule-outs, we need to be talking to them
about how their diagnosis supports medical necessity
for admission and continued E/M stays,” Krauss says.
“Encourage physicians to work with you to accurately
and effectively portray the patient’s acuity in the medical
record.”
The current financial challenges imposed by today’s
difficult economic climate mean that the time is ripe to
bring the message home to physicians that CDI programs
serve the mutual benefit of the physician and the hospital,
Krauss adds.
“The practice of medicine in and of itself cannot exist
without accurate and complete reporting of the physician’s
practice of medicine, facilitated by clinical documentation
improvement specialists,” he says.
Visit www.cignagovernmentservices.com/partb/claims/cert/
Articles/cope9014.html to read the Cigna bulletin.
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© 2009 HCPro, Inc.
April 2009
7
Tips to avoid adding insult to ‘injury’ documentation
by Robert S. Gold, MD
During the past few years, we have
seen the evolution of certain terms in the
medical literature, most of which have
evolved from recent professional writings. One of the most recent is the term
“injury,” which is causing headaches in CDI programs and
is hurting disease data streams.
Acute brain injury, acute lung injury (ALI), and acute
kidney injury (AKI) were introduced into the vocabulary
in an effort to help clinicians identify patients with mechanisms of organ damage that require study, treatment, and
intervention. Each one of these afflictions can have a wide
variance of reversible outcomes or result in total organ
destruction and death.
The problem is that the verbiage related to these “injuries” does not coincide with existing ICD-9-CM terminology, nor does it satisfy the desire of the Society and the
National Centers of Health Statistics to help track disease,
so the outcomes are becoming completely destructive.
Why? Because neither side—physicians or coders—recognizes that it speaks a different language. Both sides think
they are being helpful, but they aren’t helping at all.
Dialogue digression
Here’s an example: A coder recognizes the acronym CC
as a complication or comorbid condition. However, physicians recognize the same term as an abbreviation for the
patient’s chief complaint.
Both acronyms appear in medical records. Both are part
of documentation, coding, and billing for services. Each
participant in the dialogue knows what he or she is talking
about when using the term. But neither participant really
understands the implications of what the other party is saying. The dialects simply don’t jive.
Okay, maybe that’s a bit of a stretch. It’s somewhat
easy to see that a CC can mean different things. After all,
a pulmonologist refers to acute respiratory failure as ARF
and a nephrologist refers to acute renal failure as ARF, but
everyone can figure out what’s going on from the context
of the documentation, right? But what happens when an
internist uses the term ARF? In this case, it may be difficult
to determine what he or she is talking about without further
investigation.
Analogous affirmation
In critical care medicine, the term “injury” has been used
to describe intrinsic damage to an organ with reversible or
irreversible outcomes.
Almost all critical care studies have taken place in critical care units where the patients are already presumed to be
critically ill.
However, ICD is a system of pathogenesis—the path
and origin of a disease. Therefore, ICD does not necessarily
represent the same language used in critical care medicine.
These are different entities, and they do not talk to each
other.
ICD is a system whereby severity of illness and risk of
mortality can be computed based on etiology of a presentation of a healthcare concern. The term “injury” is descriptive
of presentation and has nothing to do with severity of illness
or risk of mortality—in fact, the severity of these injuries
can be anywhere across the board, and using the term with
the expectation of risk adjustment calculations derived from
statistics is ludicrous.
Yet the term “injury” is used in emergency departments,
med-surg nursing units, gastrointestinal labs, and outpatient
clinics, and these patients are not all presumed to be critically ill.
Typifying terminology
Physicians use the term “injury” based on writings in the
current literature and do not investigate alternative definitions.
But when original studies are performed in one environment
and the terminology is used in a secondary or tertiary environment, the terminology becomes distorted and data derived
from its use become inaccurate.
For example, when studies on the concept of ALI
involve patients on ventilators, then certainly we can classify all patients with ALI as having acute respiratory failure.
When all cases of ALI in critical care units have intrinsic
lung damage, causing the need for a ventilator, ALI implies
a critically ill patient.
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Fortunately, since the origination of the term ALI, further
studies have shown that all patients with adult respiratory
distress syndrome (ARDS) have ALI. (See “Documentation
specificity needed for ALI and ARDS” at right.) That reflects
direct damage to the lungs due to trauma, sepsis, or some process that directly damages respiratory tissue.
However, not all ALI patients have ARDS. Only 23%
of patients on ventilators because of acute respiratory failure
have ALI. The other 77% have primary heart disease rather
than primary lung damage, or brain trauma and not primary
lung damage, or many other causes that do not result in primary lung damage.
See what I mean? In this case, if the physician documented using the term “acute respiratory failure,” he or she
covers all the bases, accurately communicating the patient’s
condition. Conversely, documenting ALI or ARDS only
covers the patient population on ventilators because of acute
respiratory failure that have been defined as due to direct
lung damage.
My recommendation? Ask physicians to document
“acute respiratory failure due to sepsis-related ARDS” or
“acute respiratory failure due to acute lung injury from pulmonary contusion.” Then ask them to describe the outcome and the cause. Correct coding with ICD depends on
pathogenesis.
function within hours without measurable intrinsic damage
to the kidney parenchyma. It’s inappropriate to use AKI for
these patients.
The origination of the RIFLE criteria (i.e., risk, injury,
failure, loss, and end-stage kidney disease), with its three levels of severity of measurement of function and its two levels
of prolonged effect on renal function, was directed toward
the term “acute renal failure.” This term has always included
prerenal, intrarenal, and postrenal causes. When the Society
for Critical Care Medicine’s publications adopted the use of
the RIFLE criteria, they studied its effects and its potential
for mortality on critical care units where all of the patients
had intrinsic renal damage.
But not all patients with acute renal failure are on a critical care unit. Not all of them need to be on a critical care
continued on p. 10
Documentation specificity
needed for ALI and ARDS
Using the term “acute respiratory failure” covers all the
bases. Documenting acute lung injury (ALI) or adult respiratory distress syndrome (ARDS) only covers the patient population on ventilators because of acute respiratory failure that
have been defined as due to direct lung damage.
AKI controversy
A similar situation arises when CDI specialists review a
chart and encounter AKI patients on critical care units. If all
cases of AKI in critical care units have intrinsic renal damage
causing the concern and possible need for acute dialysis, then
AKI implies a critically ill patient.
However, AKI is also used for patients with problems other than intrinsic renal damage. For example, some
healthcare staff members use the term in reference to the
prerenal patient with excessive fluid losses who has decrease
in glomerular filtration but who has not suffered significant
enough intrinsic renal damage to be considered as acute
renal failure. It’s inappropriate to use the term AKI for
these patients.
We see physicians that document AKI in patients with
post-obstructive uropathy with elevations of creatinine who,
with insertion of a urinary catheter, revert to normal renal
Source: DCBA, Inc.
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April 2009
9
Documentation
continued from p. 9
unit. Also, many of them are not critically ill, particularly
those with prerenal and postrenal causes.
Finally, if a physician uses the term AKI when the patient
does not meet any of the RIFLE criteria, he or she could simply be stating that there was kidney damage or abnormalities
in renal function tests resulting from a different cause.
Go back to the days of yesteryear, when the term “acute
renal failure” implied just that—and if you want to go
further, identify the specificity of the cause when you can.
Describe the link of pathogenesis in such ways as “acute
renal failure due to severe dehydration from fluid losses in
clostridia enterocolitis,” or “acute renal failure due to AKI
from acetaminophen toxicity.” Let the term be the driving
force.
Resolving differences
If physicians in your hospital use the term AKI, what
should a CDI specialist do?
Determine chronic kidney disease by
glomerular filtration rate or creatinine level
GFR
Typical
creatinine
level (mg/dl)
CC/
MCC
Stage 1
>= 90
<1
–
585.2
Stage 2 (mild)
60–89
1–1.3
–
585.3
Stage 3 (moderate)
30–59
1.4–2.5
–
585.4
Stage 4 (severe)
15–29
2.5–4.5
CC
585.5
Stage 5
< 15
> 4.5
CC
585.6
ESRD
CKD w/chronic dialysis
N/A
N/A
MCC
585.9
CKD without staging,
chronic renal failure,
or chronic renal
insufficiency
N/A
N/A
–
ICD-9-CM
code
CKD
description
585.1
Sources: National Kidney Foundation, ICD-9-CM, and CMS.
Creatinine levels based on 65-year-old 170-lb. white male.
I’d suggest they encourage documentation of acute renal
failure, supply their physicians with the RIFLE criteria from
a publication that refers to it as “acute renal failure,” and
accept the fact that physicians might document AKI. The
CDI specialist should check whether the patient has met
the minimum RIFLE requirements before coders assign
584.9. If the patient’s renal function does not meet the criteria, coders should not translate AKI into 584.9 without
specific documentation by the physician stating why he or
she thinks the patient meets AKI. (See “Determine CKD by
GFR or creatinine level” at left.)
Acute brain injury is probably the only “injury” category in which the intrinsic brain damage (whether through
direct trauma or through indirect chemical damage such as
ischemia or circulating toxins) is the only way that damage
occurs with no corresponding “acute brain failure” to consider. Even here, the term “acute brain injury” does not tell
the story as needed by ICD, which is a system for pathogenesis and severity of illness.
When a patient has a concussion, cerebral contusion, intracerebral bleed, or subarachnoid hemorrhage due to parietal bone
skull fracture, the pathogenesis is key.
However, when the patient was comatose for an hour,
for 24 hours, or with no hope of recovering consciousness;
or when the patient has cerebral edema or herniation of the
brain or is being placed on comfort measures and withdrawal
of life support, it’s these other terms that tell the story for
severity.
What’s the bottom line? The term “injury” (except in
instances of trauma) is frequently misused, leading to misconception and mistakes. This affects everything from severity of illness to patient data and epidemiological tracking
capabilities.
Until we have injury stages and descriptive mechanisms—
something that even ICD-10 doesn’t yet include—I recommend using the standard terminology and linking the outcome to the cause.
Editor’s note: Dr. Gold founded DCBA, Inc., in Atlanta, a consult­
ing firm that provides physician-to-physician programs in CDI. The goals
are data accuracy, profile management, and compliance in the inpatient and
outpatient arenas. He can be reached by phone at 770/216-9691 or by
e-mail at [email protected].
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10
April 2009
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Tips for starting an ACDIS chapter
Many ACDIS members want to reach out to others in their
local community. We’ve heard from many of you. Others are
struggling to find CDI specialists interested in participating in a
local chapter. The following is some advice garnered from anecdotal information provided by our existing chapters on how to
get started in your area.
Generating interest
You’re a member of ACDIS, but you want to meet with
others face-to-face in your community. Wouldn’t it be great
to have a cup of coffee with a peer? The first step to starting a local ACDIS chapter requires a little bit of effort. But
don’t worry: ACDIS can help.
» Call your friends and neighbors. Look to the other
hospitals and healthcare facilities in your state. Call the facility’s main number and ask to speak to the clinical documentation specialist. You could be surprised by the energy and
enthusiasm on the other end of the line once you get through.
» Reach out to case management and HIM. Some facility operators may not know about their hospital’s CDI program, or the facility may not have a CDI program just yet. Ask
to speak to the HIM or case management director even when
there’s no evidence of an existing CDI program at the facility,
says Gail Marini, MM, RN, CCS, manager of clinical documentation at South Shore Hospital in Weymouth, MA.
Marini sent flyers with meeting information to area
hospitals. “Believe it or not, one of those flyers was spotted
by a CDI applying for a job in a hospital that didn’t have
a program, and now she is an active member of the [New
England] chapter,” she says.
“Unfortunately, CDI [programs] are hard to find,” says
Susan Tiffany, clinical documentation specialist at Guthrie
Healthcare System in Sayre, PA. “Most operators in these
facilities had no idea who I was asking for. So I suggest starting
with case management, then medical records, when calling.”
Tiffany took her efforts even further. She googled all
healthcare facilities within a 100-mile radius of her organization and began making phone calls. Although that may
seem daunting, it need not be a labor-intensive activity.
Just make one phone call per week to a facility and see
what happens.
» Let ACDIS know your interests. ACDIS wants to
facilitate networking opportunities for its members. Use the
list of attendees from the first ACDIS national conference to
reach possible chapter connections. ACDIS members have
access to this list for networking purposes only. You can
download the list from the Forms & Tools Library on the
ACDIS Web site at www.cdiassociation.com.
ACDIS maintains several networking and communication
tools, including “ACDIS Blog,” “CDI Talk,” and groups on
Facebook and LinkedIn. Each of these venues allows users to
post comments, concerns, and interests.
E-mail ACDIS Director Brian Murphy at bmurphy@
cdiassociation.com or ACDIS Associate Director Melissa Varnavas
at [email protected]. We can add you to our e-mail
lists and let other CDI members know you want to reach out.
» Collect contact information. As you begin to make connections, don’t forget to collect the contact information of your
new friends and file it in a convenient central location. It’s easy
to misplace e-mails or lose scraps of paper with phone numbers
jotted down on them. Ask those you connect with to share your
information with other CDI professionals they might know.
Establishing the first meeting
With enough interest from documentation improvement
professionals, you’re ready to hold your premiere event. All you
need to do now is set the date and let people know about it.
continued on p. 12
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April 2009
11
ACDIS chapter
» Identify roles and responsibilities. This may sound
continued from p. 11
too formal, but it’s a good idea for the host to pick someone
to be the official greeter, someone to take notes, and someone to run the meeting. This alleviates the pressure on any
one volunteer and helps the meetings run a bit smoother.
The official greeter should direct participants to a table
with a sign-in form and blank name tags, which Marini says
foster easier conversation and recognition. You may have
spoken over e-mail but never seen one another. Name tags
take the guesswork out of generating relationships.
The sign-in sheet should have space for participants to sign
in, provide their e-mail and postal mailing address, and list areas
of further interest. You can find a sample developed by the New
England chapter in the Forms & Tools Library on the ACDIS
Web site. This sheet helps move participants into the meeting
by providing them with a clear entry and action point. It also
gives the group additional ideas for future discussion topics.
Tips: You may want to print out two or more sign-in
sheets to avoid traffic jams at the doorway. To avoid additional hassles for the hosts, leave the name tags blank and
let participants fill in their names as they wish.
» Extend introductions. First meetings generally reflect
an air of informality. Foster that feeling. Spend the bulk of
the time letting people get to know one another.
» Set a meeting date. You’ve made contacts, and people
are interested. Now it’s time to set the time and location for
an initial get-together. Get permission from your facility to
host it and pick a time that’s convenient for you.
Alternatively, you could send an e-mail to your new
colleagues and ask for volunteers and votes for convenient
days and times. However, be forewarned that such a democratic approach takes additional time, and you’ll never please
everyone.
» Advertise the meeting. You don’t need to purchase
an advertisement in USA Today, but consider drafting a flyer
with the meeting date, time, location, contact, and possible
agenda to post at area hospitals and send to ACDIS and
other professionals. We’d be happy to post it as an attachment on the “ACDIS Blog.”
Welcoming CDI peers
Everyone’s attended a community meeting where they felt
awkward and out of place. A few simple steps can help ease
everyone into the gathering and make casual acquaintances,
even outright strangers, into longtime professional friends.
Editorial Board
ACDIS Director: Brian Murphy, CPC
[email protected]
Associate Director: Melissa Varnavas, CPC-A
[email protected]
Publisher: Lauren McLeod, CPC-A
Cindy Basham, MA, RN, CPC, CCS
Senior Regulatory Specialist
Wendy De Vreugd, RN, FNP
Senior Director of Case Management
William E. Haik, MD
Director
HCPro, Inc.
Marblehead, MA
[email protected]
Kindred Healthcare, Hospital
Division
Orange County, CA
[email protected]
DRG Review, Inc.
Fort Walton Beach, FL
[email protected]
[email protected]
Garri Garrison, RN, CPUR, CPC, CMC
Director, Consulting Services
Tamara Hicks, RN, BSN, CCS
Manager, Care Coordination
3M Health Information Services
Atlanta, GA
[email protected]
North Carolina Baptist Hospital
Winston-Salem, NC
[email protected]
Colleen Garry, RN, BS
Clinical Documentation Manager
Robin R. Holmes, RN, MSN
Manager, Clinical
Documentation Improvement
Gloryanne Bryant, BS, RHIA,
RHIT, CCS
Senior Director,
Coding/HIM Compliance
Catholic Healthcare West
San Francisco, CA
[email protected]
Shelia Bullock, RN, BSN, MBA, CCM
Manager, Clinical
Documentation Services
University of Mississippi
Medical Center
Jackson, MS
[email protected]
Jean S. Clark, RHIA
Service Line Director for HIM
Roper St. Francis Hospital
Charleston, SC
[email protected]
NYU Medical Center
New York, NY
[email protected]
Robert S. Gold, MD
CEO
DCBA, Inc.
Atlanta, GA
[email protected]
Shannon McCall, RHIA, CCS,
CCS-P, CPC, CPC-I
Director of HIM/Coding
HCPro, Inc.
Marblehead, MA
[email protected]
Lynne Spryszak, RN
Senior Consultant
FTI Healthcare
[email protected]
Colleen Stukenberg,
MSN, RN, CMSRN
Clinical Documentation
Management Professional
DCH Health System
Tuscaloosa, AL
[email protected]
FHN Memorial Hospital
[email protected]
Pam Lovell, MBA, RN
Regional Director, Clinical
Intake Team
St. Francis Hospital
Beech Grove, IN
[email protected]
Humana, Inc.
Louisville, KY
[email protected]
Heather Taillon, RHIA
Manager of Coding Compliance
CDI Journal (ISSN: 1098-0571) is published quarterly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $129/year for membership to the Association of Clinical Documentation Improvement Specialists. • Postmaster: Send address changes
to CDI Journal, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2009 HCPro, Inc. 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, Inc., 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 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.cdiassociation.com. • 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.
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April 2009
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When you call the meeting to order, welcome visitors and
bring the meeting to a start with a round of introductions.
As local chapter participation grows, this may not always be
possible. However, in the initial stages, this simple act adds to
individuals’ comfort level. Ask participants to state their name,
their facility, their location, and one professional problem area
they struggle with. This generates ideas for meetings as well as
conversation and solutions. During subsequent meetings, you
may want to leave about 15 minutes for people to take their
coats off and say hello to each other.
Determining chapter structure
There are several ways to keep your chapter organized.
The most important thing to remember is to make the meeting schedules and related responsibilities manageable.
» Meeting frequency. Everyone’s busy. How often your
chapter meets should reflect the needs of attendants. You can
meet as regularly or as infrequently as you need. Monthly,
bimonthly, quarterly, biannually, annually—it’s up to you.
Feel free to change this as your local chapter’s needs change.
You may be excited to meet monthly when you start, but by
month six decide a quarterly schedule better fits your needs.
“We set the ground rules at the first meeting,” says Linnea
Thennes, clinical documentation specialist at Northwest Community Hospital in Arlington Heights, IL. Participants voted
for Thursdays as the best day to meet and chose a quarterly
schedule to reduce the burden of time commitments. “These
meetings are a big time commitment, especially with adding the
drive time to get to the different hospitals,” Thennes says.
» Organize meeting hosts. Some CDI groups rotate
responsibility for hosting the meeting, establishing the discussion topic, and of course bringing the munchies. So, for
example, one time Varnavas Health might host, and the next
time Murphy System Health Care would take the lead.
At its first meeting, the Northern Illinois CDI Network
asked for volunteers to host meetings and planned its meeting schedule out about one year.
The host facility picks the meeting date, sets the agenda,
summarizes the meeting minutes, and communicates with the
rest of the group regarding its particular meeting, Thennes says. Try to establish a volunteer for your next meeting before
you adjourn your first session. The host of the previous meeting should stay involved and help the next host as much as
possible, Marini says. “This allows everyone to grow from the
experience so the group can be bigger and better,” she says.
Discussion topics and length depend on the interest
and needs of those in your group. You might consider best
query practices one month, and in the next plan a visit from
a physician advisor or champion. Use your sign-in sheets
and e-mail lists to generate ideas.
Having fun
Local professional meetings present a way for you to
reach out and help your fellow CDI specialists. Share what
you’ve learned during your professional experience and learn
from others in the field too.
» Take a group photo. ACDIS is a community, after all.
If you e-mail us your photo and the names of attendees, we’ll
post it on “ACDIS Blog.” We hope soon to have an entire
Web page dedicated to local chapters.
ACDIS award nominations open
Illustration by
David Harbaugh
“Still hallucinating?”
No need for daydreaming—nominate someone on your
team for the CDI Professional of the Year award. Simply visit
www.cdiassociation.com, click on the Annual Award button
on the left-side bar, fill out the form, and e-mail it to ACDIS
Director Brian Murphy at [email protected].
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April 2009
13
Local chapters: Meeting updates, search for starter members
Below is an alphabetical listing by state of specialists who
For information, contact Sue Tiffany at tiffany_susan@
are interested in or currently hosting local CDI meetings. Please
reach out to these generous individuals if you are interested in
joining them.
guthrie.org.
»» New York City: Deanna Holowczak at Riverside Health
hopes to put together a chapter in the New York City/
As always, feel free to contact ACDIS by e-mailing Melissa
Varnavas at [email protected] or calling 781/
Westchester County area of New York. Contact her at
[email protected].
»» North Carolina: The most recent meeting was held at Gaston
639-1972, Ext. 3711.
»» California: Two ACDIS members have expressed an interest
Memorial Hospital Friday, February 27. For information,
contact Leah Taylor, RN, clinical documentation specialist
in starting an organization in California. Contact Kim Digardi,
at Iredell Memorial Hospital in Statesville, at leah.taylor@
RN, clinical documentation specialist at St. Helena Hospital,
iredellmemorial.org.
»» Illinois: Started one year ago and meets quarterly. Cur-
at [email protected] or Mae Washington at maewash@
business1st.net.
rently includes 17 hospitals in the Chicagoland area.
»» Florida: Held its first meeting Friday, March 27. Contact
Next meeting is slated for Thursday, April 30, 12:30–3 p.m.,
Kimberly Richert, RN, CDS, lead clinical documentation
at Edwards Hospital in Naperville. For more information,
specialist at BayCare Health Systems in Clearwater, at
contact Linnea Thennes, clinical documentation specialist
[email protected].
at Northwest Community Hospital in Arlington Heights, at
»» Georgia: Donna Keith, RN, clinical documentation specialist
at Rockdale Medical Center in Conyers, hopes others from
[email protected].
»» Maryland: The Maryland Hospital Association Clinical
the peach-loving state will reach out to help her form a
Documentation Improvement Workgroup meets bimonthly
local chapter. For more information, contact her at dkeith@
on the third Friday of the month. Contact Denise Otto at
rockdale.org.
[email protected] or James Nagel at jen.01@
»» Louisiana: Join the New Orleans CDIS fun—for more
ex.uchs.org.
information, contact Melissa Mayer at melissamayer@ejgh.
»» Texas: Leticia Culbertson, MSPHN, BSN, RN, CCS, of Valley
org, Royceann Fugler at [email protected], or Lindy Sells
Baptist Medical Center in Harlingen, hopes to get an ACDIS
at [email protected].
chapter started in the Lone Star State. Contact her at leticia.
»» Oregon: Linda Haynes, RHIT, a documentation specialist
[email protected].
at Meridian Park Hospital in Tualatin, hopes to reach CDI
»» Washington: Joan Kloster, RN, clinical documentation
specialists. For more information, contact her at lhaynes@
specialist at Overlake Hospital Medical Center in Bellevue, is
lhs.org.
»» New England: The New England ACDIS group met Thursday,
February 26. For information, contact Gail Marini, MM, RN,
interested in starting a group. Contact her at joan.kloster@
overlakehospital.org.
CCS, at [email protected].
»» New Jersey: Deborah Gardner-Brown, RHIT, CCS,
C-CDI, hopes to foster interest for a chapter in the East
Brunswick area in time for a March meeting. Contact her
Questions? Comments? Ideas?
Contact Associate Director Melissa Varnavas
Telephone: 781/639-1872, Ext. 3711
at [email protected].
»» New York/Pennsylvania: Held its first meeting for networks
E-mail: [email protected]
in northeast Pennsylvania and southern New York state.
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April 2009
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