cdijournal Chart reviews: Best practices from three perspectives

Transcription

1 cdijournal October 2008 Vol. 2 No. 4 FEATURES Director s note 3 n ACDIS director Brian Murphy talks about the growth of local chapters. Case study 4 n This quarter features Mercy Medical Center and the challenges facing long-term CDI programs. Dedicated to the ED 8 n Learn the benefits of adding a dedicated CDI specialist or case manager to this critical department. Physician advisors 10 n Two doctors share their thoughts on their roles within a CDI program. Respiratory failure 12 n William E. Haik, MD, explains the clinical indications and sequencing guidelines. Chart reviews: Best practices from three perspectives It s difficult to pin down an average number of charts that you can expect CDI specialists to review per day. Experts say the biggest factor that influences productivity is whether CDI specialists are dedicated to chart review and which medical record data the CDI specialist is expected to review. For example, some specialists review only principal and secondary diagnoses for CC and MCC capture. Some review all diagnoses for severity. Others also review data for quality measures. The following are three perspectives to consider: Melinda Tully, MSN, senior vice president of clinical services and education at JA Thomas in Smyrna, GA. Tully says best practice for all hospitals is to employ dedicated CDI specialists. We ve found through the years that if you integrate [CDI] into case management, that discharge planning supersedes the need to query or clarify documentation, she says. We know that one of the critical success factors is to dedicate the nurse or medical record professional to that role. If your CDI specialists are dedicated specifically to the task of CDI, Tully recommends that they do the following: Review 80% 100% of charts Individually review new charts each day She emphasizes that these standards apply only to dedicated, well-trained specialists. These standards do not apply to those who also perform utilization review or case management functions. A methodical review includes the following: Emergency department (ED) documentation. Reviewing the ED record can reveal why the patient presented to the ED and why he or she was admitted. That s an important distinction patients come to the ED for one reason, but may get admitted for another, Tully says. Chart reviews really come down to your program s goals and expectations and how much you re responsible for looking for. Heather Taillon, RHIA History and physical. Consults. Laboratory tests. Reviewing laboratory information can reveal underdocumented CCs or MCCs and support clarification of the correct principal diagnosis. Radiology (e.g., echo/mri/x-ray) findings. Orders. Many times, physicians will place a STAT or standing order (e.g., vasoactive support) without specifically documenting it, and nursing staff members will carry out and document the treatment. It s another clue or insight into the clinical picture, Tully says. Another example pertains to pneumonia, she says, explaining that physicians might delineate the type of pneumonia in the standing orders with a nonmatching antibiotic treatment, which provides a basis for query. Tully recommends that CDI specialists review a record within hours of admission. This helps prevent overwhelming the CDI specialist continued on p. 2

2 Chart reviews continued from p. 1 with too much information. She says JA Thomas does not recommend that specialists target specific DRGs. However, if a hospital isn t fully staffed and must prioritize, she says best practice is to analyze the following: Top-volume DRGs (e.g., heart failure, pneumonia, gastroenteritis, and dehydration) that represent the best change for additional CC/MCC capture and financial effect. Symptom-code DRGs (e.g., chest pain, syncope, and back pain). These are not delineated with a CC or MCC, but for severity of illness and report cards, it s important that symptom DRGs are better explained clinically with a suspected or can t rule out diagnosis, Tully says. Symptom DRGs are also being targeted by recovery audit contractors [RAC], so you want to make sure that medical necessity is met. Surgical DRGs. Medicare classifies virtually 100% of surgical DRGs as with CC or MCC. Regardless of chart type, Tully says specialists should initiate a global review, balancing compliance, reimbursement, and patient safety. They should also assist with core measures documentation and help ensure that the documentation can stand up to RAC or Quality Improvement Organization review. If specialists must limit their review to certain payers, Tully recommends starting with Medicare and learning its regulations. Once the program grows and you can add staff members, add other payers. Our philosophy is that all payers should be reviewed for documentation improvement, Tully says. But once you learn Medicare, you should be able to handle other payers requirements. Tully also recommends that hospitals analyze their admission patterns to determine whether a CDI specialist should staff at least one weekend day. Tamara Hicks, RN, BSN, CCS, manager, care coordination, and Trish Flippin, RN, BSN, supervisor, clinical documentation management at North Carolina Baptist Hospital in Winston-Salem. North Carolina Baptist Hospital, an 821-bed facility, has a nine-year-old clinical documentation management program (CDMP) under which its clinical documentation consultants (CDC) review 100% of records. Initially, its CDCs only reviewed Medicare claims. Gradually, the program expanded to Medicaid, and three years ago, it grew to include all private payers. There was a shift in focus institutionally to look more broadly at severity of illness and not just DRG assignment, Hicks says. She says the hospital uses the expected mortality rate and the mortality index as benchmarks for the CDMP program s success. The program uses the University HealthSystem Consortium ( to measure its scores. Our mortality index was over 1, and in a few short months, we were able to get it under 1, Hicks says. As a result of that, Editorial Board Group Publisher: Lauren McLeod, CPC-A Executive Editor: Ilene MacDonald, CPC ACDIS Director: Brian Murphy, CPC bmurphy@hcpro.com Cindy Basham, MA, RN, CPC, CCS Senior Regulatory Specialist HCPro, Inc. Marblehead, MA CBasham@hcpro.com Gloryanne Bryant, BS, RHIA, RHIT, CCS Corporate Director Coding HIM Compliance Catholic Healthcare West San Francisco, CA gbryant@chw.edu Wendy De Vreugd, RN, FNP Senior Director of Case Management Kindred Healthcare, Hospital Division Orange County, CA wdevreugd@ca.rr.com Colleen Garry, RN, BS Clinical Documentation Manager NYU Medical Center New York, NY Colleen.Garry@nyumc.org William E. Haik, MD Director DRG Review, Inc. Fort Walton Beach, FL Behaik@aol.com DRGreview@aol.com Tamara Hicks, RN, BSN, CCS Clinical Documentation Coordinator North Carolina Baptist Hospital Winston-Salem, NC thicks@wfubmc.edu Shannon McCall, RHIA, CCS, CPC Director of HIM/Coding HCPro, Inc. Marblehead, MA smccall@hcpro.com Lynne Spryszak, RN Coordinator, Clinical Documentation Management Program Alexian Brothers Medical Center Elk Grove Village, IL spryszakl@alexian.net Jean S. Clark, RHIA Service Line Director for HIM Roper St. Francis Hospital Charleston, SC Jean.Clark@RoperSaintFrancis.com Robert S. Gold, MD CEO DCBA, Inc. Atlanta, GA DCBAInc@cs.com Pam Lovell, MBA, RN Senior Director of Case Management and HIM Kindred Healthcare, Hospital Division Louisville, KY Pam.Lovell@kindredhealthcare.com Heather Taillon, RHIA Manager of Coding Compliance St. Francis Hospital Beech Grove, IN Heather.Taillon@ssfhs.org CDI Journal (ISSN: ) is published quarterly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 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 Copyright 2008 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/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Visit our Web site at 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. October HCPro, Inc.

3 we have a huge focus of reviewing the records of patients who do die. The program began with seven dedicated CDCs and a manager. When specialists began to review Medicaid claims, the hospital decided to employ another specialist. When the program expanded to all payers, the hospital added three more specialists, bringing the total number of full-time chart reviewers to 11. On average, North Carolina Baptist s CDCs review 10 new cases per day. They also re-review all their active cases every other day. Adding together active and new cases, Flippin estimates that an average CDC reviews as many as 50 charts per day. CDCs conduct prebill reviews of certain charts for compliance after they have been final-coded. These include continued on p. 4 Local clinical documentation peer groups popping up in ACDIS wake The CDI profession is still quite new and there are few signposts pointing the way to success. CDI professionals have questions about staffing, querying, reviewing records, data gathering, and more questions for which ironclad answers are difficult to find. Each hospital has, through trial and error, found out what works and what hasn t. We launched ACDIS for many reasons, foremost among them to form a national network of peers to help find solutions and offer advice for these and other challenges. But a large national association is no substitute for meeting locally in small, face-to-face groups. If you haven t been on CDI Talk lately (and you should; our talk group is a benefit of ACDIS membership and there are lots of great ideas being shared there), one of the hottest topics of discussion is local/regional groups. Members are posting every day to find one another and gather together. One Illinois-based group has started to take off, thanks to the efforts of Nancy Sikorski of Central DuPage Hospital, Linnea Thennes of Northwest Community Hospital, and Lynne Spryszak of Alexian Brothers Medical Center. Spryszak received a call from Sikorski earlier this year asking if she d like to help start up a local group. Spryszak agreed, but found that it was difficult to get started. It required calling local hospitals and asking whether they had a clinical documentation program, which meant repeated questions for case management, HIM, or quality departments (or wherever the CDI department happened to be housed). It was a time-intensive thing, and nobody had time to do it, Spryszak says. But the first few members hit on a great idea: Each was responsible for a single call to a local hospital to ask whether members of its CDI department were interested in joining. That hospital would then call the next hospital, and so on. The phone chain approach worked. The group met for the first time this past winter with 25 members. It started as a simple meet and greet, but it also generated some great discussion on physician advisors, Spryszak says. The group recently met for a second time, and its membership had grown to 35 members. They brought worksheets, query forms, and posters to help encourage physician participation and shared them among each other. They talked about the role of physician advisors and challenges that they faced on the job. The group plans to continue to meet quarterly for roughly three hours and rotate the meeting place at participating hospitals. It s kind of like a local ACDIS all the reasons we created ACDIS, but at the grassroots level, Spryszak says. Spryszak s advice for others wishing to start a similar group is to use CDI Talk or start making calls to hospitals. The phone chain approach can quickly build momentum. Don t be afraid to start. And know that, as we grow, ACDIS will be working to help foster and grow local and regional chapters. Take care, Brian J. Murphy, ACDIS Director bmurphy@hcpro.com 2008 HCPro, Inc. October 2008

4 Chart reviews continued from p. 3 complex pneumonia and sepsis cases. CDCs also perform a second review of certain DRGs (e.g., simple pneumonia, urinary tract infection, or chronic obstructive pulmonary disease) to determine whether they have missed any opportunities. They review charts for which the working DRG assigned by the CDC does not match the final DRG reported by the coder. These get filtered into the number of reviews they do on a daily basis, Hicks says. Hicks and Flippin do not recommend targeting certain cases. However, if the hospital must do this, they recommend that specialists focus on general medicine patients, because these patients have the greatest potential for DRG change. For example, some of North Carolina Baptist s physicians document renal insufficiency when the patient has clinical indicators of acute renal failure. Malnutrition is another target, as dietitians document the condition in their notes, but the attending physician does not. When reviewing established records, Flippin recommends making operating room notes a priority, particularly for excisional debridement procedures. It s a big push to make sure these are coded appropriately, she says. Hicks adds that present on admission is another focus when specialists review established patient s records. If we see something come up on day two or three that might have been present on admission, we ll ask about it, she says. Heather Taillon, RHIA, manager, coding compliance for St. Francis Hospital in Beech Grove, IN. Each of St. Francis three clinical documentation specialists (CDS) review approximately 24 charts per day. Taillon says specialists are also responsible for several other duties aside from documentation review. These additional responsibilities include database entry, following up on queries with individual physicians, and performing back-end queries. They must also attend the inpatient coding meetings that Taillon conducts for her coding staff. Chart reviews really come down to your program s goals and expectations and how much you re responsible for looking for, she says. Taillon says her department has been approved to hire another CDS. However, based on a 24-chart-per-day review, St. Francis volume warrants five full-time employees dedicated to reviewing records. This shortage requires Taillon to prioritize. Currently, specialists review only DRG payers, which account for approximately 70% of St. Francis total volume. Surgical, orthopedic, cardiac, and geriatric floors are a priority. Taillon also performs quarterly audits of 34 charts per CDS. She looks for the appropriateness of each query from a clinical perspective, whether the CDS missed any opportunities, whether the query was leading in nature, and how the physician responded. H Clinical documentation as a marathon, not a sprint Mercy Medical Center succeeds with long-term approach Julie Doy, MSN, RN, director of clinical documentation at Mercy Medical Center in Des Moines, IA, followed a winding road on her way to becoming a clinical documentation specialist. Doy had been the manager of Mercy s endoscopy unit before returning to school to obtain her master s degree. When the hospital decided to implement a clinical documentation program in January 2003 and needed a director to lead the program, Doy was intrigued by the position and applied for it. It sounded really interesting and up my alley, and, luckily, I was hired. But I really didn t know what I was getting into, Doy says. After accepting the position, Doy found that her path was strewn with obstacles. She knew very little about documentation requirements and nothing about coding. But perhaps the biggest obstacle was the fact that Mercy s physicians were treating conditions without documenting them. It s the same as everywhere in the country, Doy says. For example, physicians did not document types of pneumonia or anemia, which led to nonspecific diagnosis assignment. Our coding supervisor was very instrumental in getting the whole thing started, because she saw the need. She knew the documentation could be better, she says. October HCPro, Inc.

5 Fortunately, Doy received a lot of help from a clinical documentation firm that the hospital engaged to help get the program off the ground. In the ensuing five and a half years a span in which Doy says her staff has reviewed approximately 57,000 records and written 9,300 queries she has learned a lot about how to run a successful program. Biggest challenge: Getting physicians involved Doy says the most difficult challenge is getting physicians to buy in to a clinical documentation program in the beginning stages and on an ongoing basis. Many physicians don t care how documentation affects their profiles they only know that it adds work to their day, she says. Although some queries, such as those for urosepsis and acute blood loss anemia, have declined since the program s inception, most physicians still require continued queries on the same diagnoses. They re so busy, and it is more important for them to take care of the patient than to remember specific documentation requirements. We just ask that they answer our queries, Doy says. Consider the following solutions that Doy says are effective ways to ease the burden on physicians and reduce the number of queries: Establish good relationships. Doy says her clinical documentation specialists have established strong relationships with physicians and feel comfortable asking direct and simple questions. She says another tactic that has worked is to remind physicians that their patients come first and that the specialists are there to help them understand the documentation rules. A recent article Doy read likens the work of a clinical documentation specialist to a tax attorney in the sense that, like an attorney who knows all the Mercy Medical Center: Fast facts 970 beds, 500 staffed 13,000 14,000 Medicare discharges annually Launched clinical documentation program in January 2003 Employs eight full-time clinical documentation specialists IRS rules and can help clients submit their taxes, a documentation specialist knows the ins and outs of clinical documentation and can help physicians meet documentation requirements. Doy encourages her specialists to incorporate this approach into their daily work. Create diagnosis definitions sheets. With input from the medical staff, Doy and her staff developed definitions of sepsis, heart failure, pathological fractures, and other frequently queried diagnoses. They place these definitions on easy-to-read worksheets. When a clinical documentation specialist posts a query, he or she places the definition sheet alongside the query in the record. It s so that they [physicians] know why we re asking the question that we re asking, Doy explains. (See p. 7 for an example of a respiratory symptoms definition sheet.) Develop preprinted progress notes. These include a list of all applicable ICD-9-CM codes for conditions such as congestive heart failure (CHF) and chronic kidney disease (CKD), as well as information on body mass index and the present-on-admission (POA) indicators. For example, physicians can simply check off the stage of CKD or whether a diagnosis was POA. [Preprinted progress notes] have made it so much easier for us to get the physicians on board, because physicians can see why we re asking what we re asking, Doy says. In addition, Doy has implemented a rigorous auditing program to ensure that her staff s queries remain compliant and effective. The program focuses on the following: Physician query peer audits. Doy requires her CDI staff members to examine one another s queries, including those that are well written or appear confusing or in need of improvement. The nurse who examines the query then gives it back to the nurse who wrote it. Clinical documentation staff members must then attend a meeting held every other month, during which they explain the rationale behind writing the query. That helps us stay on the right track and write compliant queries, Doy says. There are no accusations. External review of nonmatching DRG assignments. Doy says she reviews claims on a monthly basis to filter for ones in which the working DRG that the CDI specialist assigned continued on p HCPro, Inc. October 2008

6 Mercy Medical Center continued from p. 5 does not match the final DRG that the coder reported. A department secretary compiles s from the coding staff explaining why the DRG assignment differed, and Doy shares some of the more widely applicable s during the two-hour monthly meetings. This helps to educate CDI specialists about coding requirements. Doy also looks at long-length-of-stay cases that don t include a CC and asks the nurses to review these cases and assign a DRG. She also asks them to identify any conditions for which they could have queried. Doy keeps tabs on Mercy s clinical documentation progress with vendor software that tracks: How many records staff members reviewed What types of records (i.e., Medicare versus non-medicare) staff members reviewed Percentage of Medicare charts reviewed Queries written Queries that physicians answered Correction The July CDI Journal stated that Nancy Taylor Ward, director of case management for Tampa (FL) General Hospital, passed away in Taylor Ward passed away March 14, We regret the error. Although Mercy reviews all of its DRG payers, it places a special focus on Medicare. Mercy has a low surgical-to-medical ratio and a high volume of OB patients, which has resulted in a relatively low case-mix index (CMI) compared to hospitals of similar size. But the data show that the records Mercy s clinical documentation specialists review increases the average CMI of the case by Our emphasis is on compliance and accuracy. We track the dollars, but I couldn t tell you how many queries we write that move the DRG versus how many we write for severity, Doy says. If you get that severity captured, the dollars will follow. Although Mercy s clinical documentation program does not directly address core measures, its specialists assist indirectly with their collection. For example, the specialists review all CHF cases in which CHF is the primary diagnosis. Specialists determine whether CHF is a valid principal diagnosis for a patient who reports to the ED with shortness of breath, is given a dose of Lasix, and is sent home. We ll do a secondary clinical review and, if necessary, query to get it accurate, Doy says. Our core measures are fabulous, especially for CHF. In addition to her role managing and overseeing the clinical documentation program, Doy assists specialists by performing prebill reviews of patients who are admitted Friday through Sunday and discharged Saturday through Monday. This helps us see as many Medicare patients as we can, she says. Doy s message for specialists in newer CDI programs is to not assume that physicians are going to learn all of Good relationships with coding staff members ensure success Julie Doy, MSN, RN, director of clinical documentation at Mercy Medical Center in Des Moines, IA, credits her program s success to a dedicated coding staff. Mercy s coders work from home and communicate with the clinical documentation department via . Because Mercy has a hybrid electronic health record that does not allow staff members to perform electronic queries and because its coding staff is completely off-site the clinical documentation specialists perform all the queries. However, Doy says the coding staff is always available to answer questions and serves as a constant, helpful resource for the documentation specialists. For example, coders let the specialists know when they change a DRG in the abstract, and they let specialists know when the patient had a procedure or when they code a different principal diagnosis. When a conflicting DRG assignment requires more explanation, the coder s the specialist. To prevent repeated s regarding coding rules and DRG assignments, which can tax the coding staff, Mercy uses a folder on a shared drive with documentation of complex coding regulations. October HCPro, Inc.

7 Medicare s documentation requirements. To think that physicians are going to incorporate these strategies into their daily practices is a mistake. They don t do it, she says. For example, she says specialists might have to reiterate the fact that although coders can code chronic obstructive pulmonary disease exacerbation, they cannot code chronic diastolic heart failure exacerbation. Instead, coders need the word acute for proper ICD-9-CM code assignment. Doy says the true strengths of Mercy s program are the nurses who have the knowledge and temperament to perform the job. They have to have a strong clinical background and excellent critical thinking and communication skills, she says, adding that they must also be able to accept that the certified coders have the final say in the code assignment. I now bring a prospective [clinical documentation specialist (CDS)] in for a meeting and explain the ups and downs of the job and make sure they really understand what it takes; probably 50% decide it s not for them, she says. It s a more difficult job than many realize. Doy says she hopes to develop additional preprinted progress notes for acute renal failure versus insufficiency, malnutrition, and severe sepsis or septic shock. Mercy s physicians frequently document sepsis syndrome, she says. The CDSs also need to continue to work on POA documentation, especially now that CMS has added three new hospital-acquired conditions for It s all part of the continued tweaking that long-term CDI programs need to perform if they re to stay fresh and effective, Doy says. H Documentation clarification worksheet for respiratory symptoms Respiratory distress, dyspnea, and hypoxia are symptoms. What is the etiology of the symptoms? If the etiology is uncertain or is under study, what are you treating and investigating? For inpatients, use words such as Possible Probable Suspected If you have a definite diagnosis, please be sure to either confirm or rule out the possible diagnosis. Respiratory distress, hypoxia, dyspnea, shortness of breath, or cough Common underlying causes of respiratory distress: Pneumonia COPD exacerbation Asthma Bronchitis CHF ESRD with fluid overload AMI CVA Sepsis Trauma Head injury Overdose/poisoning Please document all conditions you are treating. If appropriate, please document: Signs and symptoms O2 sat <90% RA or <95% on O2 Tachypnea Use of accessory muscles Air hunger Cyanosis Acute Respiratory Failure Definition: Inadequate exchange of O2 and CO2 by the lungs. Life threatening, requires close monitoring and evaluation, with aggressive management. ABGs: ph <7.35 or >7.45 po2 <60 or 10 below norm if COPD pco2 >50 or 10 above norm if COPD Treatment pattern may include: O2, nebulizer treatment, close monitoring, urgent treatment of underlying cause, bipap, ventilator Julie Doy, Mercy Medical Center, Des Moines, IA. Reprinted with permission Source: Julie Doy, MSN, RN, Mercy Medical Center, Des Moines, IA. Reprinted with permission HCPro, Inc. October 2008

8 Recognize the value of a specialized CDI specialist/case manager ED documentation specialists can make a world of difference for your program The emergency department (ED) is, in many ways, the financial lifeline of a hospital. Not only are patients admitted through the ED, but it s also a place where physicians establish admitting diagnoses and present-on-admission (POA) status. But an ED is also a point of extreme vulnerability. The hectic reality of an average ED creates a host of problems that can come back to haunt a hospital, including inappropriate admissions and ED documentation that does not allow coders to report specific diagnoses or POA status. Recognizing a soft target, the Recovery Audit Contractor (RAC) program is focusing its efforts on inpatient admissions. In fact, 85% of overpayments that RACs collected were from inpatient hospitals. Of the $828.3 million that Medicare improperly paid to inpatient hospitals, approximately 36% was due to incorrect coding. Forty-one percent of improper payments were due to a service being rendered in a medically unnecessary setting, according to The Medicare RAC Program: An Evaluation of the Three-Year Demonstration. Donna Turtle, associate vice president of Quorum Health Resources (QHR), LLC, in Tampa, FL, says the front-end/ admitting process at most hospitals is not equipped to meet the demands of CMS admission requirements. ER staff members are motivated to treat and street (discharge) or treat and bed (admit) without true knowledge of the regulations, Turtle says. We on the inpatient side can understand what is going on, but for the most part, the admitting, registration, and ER staff don t understand what the word RAC means or the fines that can result, she says. To bridge this gap of opportunity and vulnerability, hospitals should place a dedicated clinical documentation specialist and/or case manager in their ED, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, senior coding and chargemaster consultant at QHR. What to document For example, to support an inpatient stay for a chest pain patient, Turtle says dedicated case managers/clinical documentation specialists should focus on obtaining the following: Evidence of failed outpatient treatment Acuteness of the onset of chest pain Coexisting comorbidities A physical description of the patient s pain Diagnostic information (e.g., troponins) Background information and assessment Regarding background information and assessment, specialists should ask the following questions: Has the patient seen his or her internist in the past 30 days? When was the patient s last hospitalization? Is the patient taking any new medications or participating in any new therapies? Has the patient experienced a change in lifestyle? [RACs] are looking at making sure hospitals don t admit a patient without a good assessment, Turtle says. With good queries, you can build a case for an inpatient stay. Documentation in the ED determines medical necessity, along with the doctor s history and physical, Krauss adds. It paints the picture of what the doctor is thinking and what he knows at the time the order is written. A [CDI specialist] needs to get the physician s thought processes on paper. Often, physicians document the following entries for a typical admit case, Krauss says: Troponin 1.1 EKG changes equivocal October HCPro, Inc.

9 No ST changes Diagnosis: Acute chest pain This level of documentation won t support an inpatient admission, Krauss says. However, if the physician documents that the patient is 72 years old, presented last week with the same signs, and needs a total workup, and that there s an inherent risk in sending him home, this documentation may support a short stay. A few sentences go a long way, Krauss says. It also supports a higher-level E/M for the physician. Where to document Many hospitals use templates to capture ED diagnoses and procedures, but these templates are often preprinted forms that leave little room for the brief but detailed narrative documentation necessary to describe diagnoses and assessments that support inpatient stays. However, creative use of these forms can go a long way, Krauss says. For example, many physicians use the T System, a well-known documentation system used to capture clinical disease processes/symptoms and help physicians document their professional ED services. Although the system allows physicians to quickly and easily arrive at the appropriate E/M code by providing prompts, it doesn t leave much free space for documentation. The T System and other clinically structured documentation systems allow physicians to specify whether they ordered a test; however, these systems often do not have a place for the physician to document his or her medical decision-making for example, a place where the physician can write, I looked at these tests, which are indicative of an MI, but for reasons X, Y, and Z, I m not comfortable letting the patient go home, so I m admitting him. However, Krauss says most of these forms contain a small narrative box that physicians can use to provide succinct, important documentation to support inpatient stays and diagnoses. It just has to be a couple of sentences linking lab values to the diagnosis and noting that they re concerned about the patient s risk factors and the reasons why the patient requires more than 23 hours of observation, he adds. If your hospital has its own check-off sheets, create a space for free-flow documentation or dictation, Krauss says. You can also insert this documentation into RAC appeal letters, which makes for much more compelling cases. H How to finance an ED specialist Although an emergency department (ED) case manager can pay for him- or herself tenfold, many hospitals can t implement this solution because of financial constraints, says Donna Turtle, associate vice president of Quorum Health Resources (QHR), LLC, in Tampa, FL. Some hospitals attempt to split an ED specialist s role so that the specialist spends half of his or her time dedicated to the ED and the other half dedicated to a unit or units. However, this approach isn t always successful, Turtle says. It may work for a smaller hospital, but to do a really good job of ED case management, you have to be available and accessible for a good 12 hours a day, seven days a week, she says. Hospital administration will likely not allow specialists to focus solely on the ED unless you can back up the need with hard data, Turtle says. Build your case with the following plan: Conduct a data analysis of your patient-level database to determine your peak ED volume and which days have the most admissions. Turtle recommends taking a strategic approach to determine when your dedicated ED specialist will be on duty. Examine your one-day trending volume during the previous 12 months. If these cases are consistently increasing even by a few per month this might indicate the potential for recovery audit contractor review, Turtle says. Emphasize ancillary financial benefits. A dedicated CDI specialist and/or case manager in the ED can realize other significant benefits, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, senior coding and chargemaster consultant at QHR. For example, many CT scans in the ED (e.g., for minor head trauma) are denied because physicians don t adequately document medical necessity. A dedicated specialist who reviews all cases can help get these and other outpatient claims paid. If you get one CT covered, that can pay that person s salary for the day, Krauss says. Emphasize other ancillary benefits. A dedicated CDI specialist can also assist with data to support inpatient and outpatient quality measures and Hospital Compare scores, Turtle says HCPro, Inc. October 2008

10 CDI physician advisors: Two MDs share their experiences A good physician advisor/champion is a boon for any CDI program. An advisor can provide credibility and a much needed physician-to-physician dialogue to help get reluctant doctors on board with a program. But finding the right physician advisor isn t easy. It s critical to define clear expectations for physicians who are busy practicing medicine. Below, two physician advisors provide their experiences and position descriptions. Feeling an obligation When Trey La Charite, MD, a hospitalist who specializes in internal medicine and physician advisor for the CDI project at the University of Tennessee (UT) Medical Center at Knoxville, was asked to assume his current role as physician champion eight months ago, he already had many of the desired prerequisites for the job. It helps that I already happen to be so anal-retentive in my documentation that I already write more in the chart than most people to begin with, La Charite says. I m sort of notorious for my note-writing. La Charite says he accepted the position because he felt an obligation to the hospital and wanted to give something back. As far as I m concerned, UT made me the physician that I am, he says. Selling the benefits UT selected FTI Consulting to implement the clinical documentation program. FTI recommended La Charite for the role of physician advisor, provided training, and scheduled several meetings, during which he could meet with various physician groups in the hospital to spread the word about the program. La Charite provided lectures on how physicians could improve their documentation and demonstrated the benefits of doing so, including how it improves the following: Publicly available quality reporting data Physician pay-for-performance data Facility funding, which in turn provides benefits for physicians, including better equipment and workspace and more staffing La Charite explains to physician groups that documentation is a patient-care issue. In the middle of the night, when someone crashes, you need to be able to pick up the chart and immediately glean what is going on with this patient at baseline, he says, adding that many physicians don t do this. Making a time commitment La Charite s role as a physician advisor requires approximately 40 hours per month and includes: Developing educational lectures/powerpoint materials. La Charite says he tries to tailor his presentations to certain physician groups to make them more effective. Creating pocket cards. These provide physicians with definitions of various diagnoses and appropriate language that coders need to report specific ICD-9 codes, as well as CDI golden rules, La Charite says. It helps that I already happen to be so anal-retentive in my documentation that I already write more in the chart than most people to begin with. Trey La Charite, MD Fielding questions from CDI specialists. UT currently employs three nurse clinical documentation specialists who review Medicare claims only. When they have a question regarding a query or receive denials from physicians, La Charite assists them. Participating in weekly meetings. La Charite meets with the nurse specialists, the head of medical records, and the coding manager every Wednesday morning to discuss opportunities and difficulties. The meetings are an important part of sustaining the program s momentum, he says. La Charite is a salaried UT physician and receives an hourly rate for his physician advisor role. He says his time commitment has been significant in the early stages due to choosing a program direction, creating lectures, and rolling it out. Each month, La Charite and the rest of the CDI team receive a CDI dashboard that lists UT s case-mix index (CMI) and CC/MCC capture rates. La Charite says the results have been promising. A year ago at this time, UT s CMI was In a May report, UT s CMI had grown to October HCPro, Inc.

11 Overcoming obstacles Despite the programs early successes, La Charite continues to encounter physicians who are reluctant to adopt the program. He says physician documentation is specialtydriven: Physicians who already write reasonable notes in the chart (e.g., internal medicine, family practice, nephrology, and medicine-related subspecialties) are generally amenable to a CDI program and can buy in to better documentation practices. However, surgeons are much more difficult to recruit because their documentation is often minimal or nonexistent. The general obstacle I ve seen so far is surgical services, La Charite says. Not only are you asking them to change what they re writing in the chart, you re asking them to document at all, which they don t even do in the first place. La Charite says he hopes to have more speciality-specific data down the line to educate surgical physicians and to show the benefits of documenting additional, appropriate documentation that demonstrates the severity of patients illnesses. The most effective way to get physicians on board is to show them what they documented in each chart versus what they could have documented based on the patient s clinical indicators, La Charite says. Including the monetary and profiling effects of any secondary diagnoses also helps support the need for more specific documentation. Physicians are completely result-driven, and a lot of times, you don t get responses unless you affect their wallet, he says. Surgeons, in particular, are very concerned about their report cards, whereas medicine specialists don t really care. In general, surgeons tend to document only the main problem for which the patient presents for surgery, and they ignore secondary diagnoses and complications, La Charite says. One idea is to work around surgeons, when possible. For example, UT s neurosurgeons and orthopedic surgeons rarely document in the chart; however, they almost invariably consult with medicine specialists. This latter group has proven receptive to the program and often provides the necessary documentation for the surgical patient s chart. Finding the right advisor For existing CDI programs that don t currently employ a physician advisor, La Charite recommends finding a candidate who has the facility s best interests in mind which isn t easy, given the current hospital/physician dichotomy. Unfortunately, I think there s still a lot of that old mentality where people say, The hospital be damned. I don t care if the hospital makes money as long as my patients are taken care of, which is an outdated attitude, he says. In fact, a hospital where La Charite used to work officially closed its doors. La Charite also recommends finding a physician who is relatively recently trained, aggressive in his or her patient care, and respected by the staff. La Charite says clinical documentation supervisors who employ a physician advisor should not expect that the advisor will be a magic pill for the program. The bottom line is that not everyone is going to come on board, and you need to pick and choose where you are going to place your efforts, he says. Taking a physician-first approach James Pappas, MD, MBA, is vice president of quality and patient safety for Loma Linda (CA) University Medical Center. An internist and clinical pathologist, Pappas became medical staff president five years ago. Midway through his tenure, the hospital s CEO put out a request for a vice president of quality and patient safety. Pappas was interested and left his med staff presidency to take the position. In late 2007, a new recruit under Pappas who had a previous successful experience as a clinical documentation specialist asked Pappas about starting a program at Loma Linda. With help from a consulting firm, Pappas helped sell the program to physicians (not hospital leadership) as a quality initiative. Loma Linda s authority rests with a dean who was extremely supportive of the CDI program a critical first step in the newly launched program s development. That was probably the single most important thing because then he gathered his chairs and said, This is required. You must go to this, and your attendings must go to this, Pappas says. Nearly 400 physicians turned out for the initial training. The program, which has been in place at Loma Linda since April, was also pitched as a safety issue. Framing the program in this way helped garner support because the diagnoses that physicians had documented were making them continued on p HCPro, Inc. October

12 Physician advisors continued from p. 11 look poor on paper, as well as on Web sites such as www. hospitalcompare.com, which compares expected versus observed rates of mortality. What hit the physicians was when we saw that you could go to the Internet and pull up various Web sites, and compared to other physicians in the same community, we didn t look very good, when in fact we knew they were darned good physicians, Pappas says. Serving as a champion Loma Linda is a four-hospital system, so Pappas placed a physician champion in each hospital, including two in the university hospital. Each champion, referred to as a multidisciplinary quality committee chair, attended a daylong training session that included coding and documentation education. Part of Pappas role is to follow up with reluctant ordering physicians who don t respond to queries. It can be a yes or a no response, but what you don t want is a nonresponse, he says. For those departments whose physicians don t respond to queries, Pappas develops solutions to increase their response rate. For example, surgery hasn t had nearly as much success as medicine, and Pappas is currently working to help educate that group. We had to do that [additional work] with surgery because surgery didn t get their residents to the education sessions, he says, noting that Loma Linda s residents issue 90% of the orders. Pappas says the hospital also employs a large group of residents who began their residency in July. Newly employed residents can pose a challenge, he says, because they are unfamiliar with the CDI program. Any place with teaching residents is going to have to reteach that group every year, he says. Pappas says a physician champion should be someone who is respected, influential, and well-known in the institution. It s not necessarily any particular specialty, it s more person-dependent, he says. That s what works here really well. Pappas says his role as physician advisor was initially timeconsuming due to several kickoff meetings when the program began. However, he opened a clinical documentation section within the quality improvement department and has since received assistance from a clinical documentation nurse specialist who provides most of the physician education. [The time commitment] varies, based on the size of your institution and how well-functioning your CDI department is, Pappas says. At first, it was a sizable chunk of my day, but now, it s starting to take off on its own. Pappas is salaried by the hospital as its vice president of quality and patient safety, a position that includes his duties as a physician champion. The other four hospital-specific physician champions are paid 40 hours per month of their particular specialty s hourly pay. Loma Linda s three CDI specialists review 60% 70% of all Medicare claims. The hospital has also given approval for the addition of a fourth specialist due to the early successes. The financial benefits have been profound in the shortterm, Pappas says, noting that the cost of the consulting firm has already been paid for. H Respiratory failure: Recognize clinical indicators and query opportunities to capture this difficult diagnosis by William E. Haik, MD Respiratory insufficiency. Hypoxemia. Respiratory distress. Its names are numerous and, unfortunately, often result in nonspecific codes and inaccurate DRG assignment. The offender: respiratory failure. Respiratory failure is problematic for CDI specialists and coders for several reasons, including the following: Definition (confusion about what constitutes respiratory failure) Sequencing (when to sequence respiratory failure as a principal diagnosis) Documentation (how to combat insufficient or nonspecific documentation that includes terms such as respiratory insufficiency, hypoxemia, and respiratory distress) 12 October HCPro, Inc.

13 Define respiratory failure carefully Respiratory failure confuses specialists and coders because the term originally appeared in Chapter 16 ( Symptoms, Signs, and Ill-Defined Conditions ) of the ICD-9-CM Manual. This placement meant that the condition was viewed as a symptom, and coders could not report it as a principal diagnosis. In 1987, the National Centers for Health Statistics assigned a new code for acute respiratory failure, , which resulted in the movement of the diagnosis from Chapter 16 of the ICD-9-CM Manual to Chapter 8 ( Diseases of the Respiratory System ). Subsequent to this change, the confusion centered on how to define respiratory failure and in what circumstances coders could report it as the principal diagnosis. In an effort to qualify all remaining questions regarding respiratory failure, multiple articles appeared in the AHA s Coding Clinic for ICD-9-CM. continued on p. 14 Sequence acute respiratory failure correctly Properly sequencing acute respiratory failure has gotten considerably easier over the years; however, there are several Coding Clinic references of which CDI specialists and coders should be aware. The ICD-9-CM Official Guidelines define a principal diagnosis as that condition established after study as being chiefly responsible for occasioning the admission of the patient to the hospital for care. Report acute respiratory failure as a principal diagnosis under the following circumstances: When the respiratory failure is associated with another acute condition that is equally responsible for occasioning the patient s admission to the hospital and there are no chapter-specific sequencing rules (see below). When this is the case, apply the guideline regarding two or more diagnoses that equally meet the definition of principal diagnosis in this situation. For example: Respiratory failure secondary to aspiration pneumonia. Sequence either acute condition as the principal diagnosis, depending on the circumstances of the admission. Acute respiratory failure secondary to cardiogenic pulmonary edema in a patient with an acute anterior wall myocardial infarction. Sequence either acute condition as the principal diagnosis, depending on the circumstances of the admission. When respiratory failure is an adverse reaction to a drug. When this is the case, follow the coding rule for coding an adverse drug reaction, which specifies to sequence the respiratory failure first, followed by the appropriate external cause code for the drug (E code). For example: Respiratory failure secondary to aspirin taken as prescribed. Respiratory failure is the principal diagnosis. When the cause of the respiratory failure is not identified. This might occur when the patient expires or is transferred shortly after admission. Do not report acute respiratory failure as the principal diagnosis when there is a chapter-specific coding guideline (e.g., sepsis, obstetrics, poisoning, HIV, newborn) or an alphabetic index or tabular directive that takes precedence over the general respiratory failure guidelines and examples. For example: Acute respiratory failure secondary to Pneumocystis carinii pneumonia in a patient with HIV. Report HIV (code 042) as the principal diagnosis. A patient is admitted with acute respiratory failure secondary to Valium overdose. Report the Valium overdose as the principal diagnosis. A patient is admitted with aspiration pneumonia with associated sepsis and acute respiratory failure. Report the sepsis as the principal diagnosis. Coders and CDI specialists typically choose respiratory failure as a principal diagnosis when it is associated with another acute condition that is equally responsible for occasioning the patient s admission to the hospital. However, certain underlying respiratory conditions have a higher weight than respiratory failure (e.g., aspiration pneumonia) and would likely be sequenced first. Sources: AHA s Coding Clinic for ICD-9-CM, third quarter, 1988, p. 7; second quarter, 1990, pp ; first quarter, 2005, pp. 3 8; second quarter, 2005, pp ; fourth quarter, 2007, pp ; first quarter, 2008, pp HCPro, Inc. October

14 Respiratory failure continued from p. 13 In summary, Coding Clinic articles state that you can suspect respiratory failure based on the following facts: Respiratory failure is a condition categorized by inadequate exchange of oxygen and/or carbon dioxide by the lungs. Respiratory failure is a life-threatening disorder that requires close patient monitoring and evaluation with aggressive management. To treat it, physicians place the patient in a monitored bed and initiate aggressive respiratory therapy and/or mechanical ventilation. Treatments can include frequent oxygen level checks, nebulization of bronchodilators, antibiotic treatment, and intubation. A patient with acute respiratory failure usually presents with evidence of increased work of breathing. Typical symptoms include a rapid respiratory rate and use of accessory respiration muscles (e.g., intercostal muscle retraction, paradoxical breathing, or cyanosis). Specialists can identify respiratory failure in a patient whose lungs were previously normal (i.e., no preexisting lung disease) by using the following criteria: P O2 < 60 mmhg P CO2 > 50 mmhg However, most patients who present to the hospital in acute respiratory failure do not have normal lungs. These patients typically have a chronic disease of the lung with an acute insult (e.g., pneumonia or bronchitis) that leads to respiratory failure. Specialists can identify acute respiratory failure in a patient with previously abnormal lungs using either of the following criteria: ph < 7.35 with a P CO2 > 50 mmhg A change in the P O2 < 60 mmhg representing a drop of 15 mmhg from the previous normal P O2 The arterial blood ph (rather than the P CO2 ) is generally more useful for determining respiratory failure for patients who have chronic lung disease. Patients with chronic lung disease Note that patients do not have to be intubated or on mechanical ventilation to have respiratory failure. Physicians can treat respiratory failure using noninvasive methods such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP). These treatments involve a face mask strapped to the patient s mouth to provide oxygen, keep the lungs open, and prevent lung collapse. Neither CPAP nor BiPAP require the patient to be intubated; however, both can indicate respiratory failure. Of course, patients who are on mechanical ventilation are in respiratory failure. Don t forget to look at lab values CDI specialists should review laboratory notes for evidence of respiratory failure. For example, the following arterial blood gas determinations (a process whereby a needle is inserted into the artery to measure oxygen and carbon dioxide levels, as well as the alkalinity/acidity of the blood) are helpful in determining acute respiratory failure. Note that lab values for respiratory failure differ between a patient whose lungs were previously normal versus one whose lungs were previously abnormal, such as a patient who is suffering from chronic obstructive lung disease. 14 October HCPro, Inc.