Learning Objectives. Coming Out of the DARC: Improving CDI and Coding Alignment

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1 1 Coming Out of the DARC: Improving CDI and Coding Alignment Kathy Dorich, RN, CCDS, CPHQ, System Manager CDI Kelly Tarpey, RN, MS, CPHQ, System Director CDI Advocate Health Care Downers Grove, Illinois Kelly Tarpey, RN, MSN, CPHQ System Director, Clinical Documentation Improvement Advocate Health Care Kathy Dorich, RN, CCDS, CPHQ System Manager CDI Advocate Health Care Susan Bittner, RHIT,, CCS (Key reference) Clinical Data Manager Advocate Health Care 2 Learning Objectives At the completion of this educational activity, the learner will be able to: Understand the impact of the CDI/coder relationship and interdependence Develop a multidisciplinary CDI/coding team to build alignment in practice and share ongoing learning opportunities Explore tools that help create alignment between coding and clinical criteria for complex diagnoses (e.g., Advocate s Document Alignment Reference Card DARC ) 3 1

2 4 CDI/Coding Relationship Tammy Combs, RN, MSN, CDIP, CCS, CCDS, Director and lead nurse planner of HIM Practice Excellence for AHIMA; April 27, 2017 blog Journal of AHIMA Background: Advocate Health Care Faith based, not for profit health system based in Downers Grove, Illinois More than 250 sites of care 12 acute care hospitals 3 academic medical centers Children s hospital with two campuses and the state s largest integrated children s network Named one of the Top 5 large health systems based on quality by Truven Analytics Six Advocate hospitals have earned Magnet Recognition from the American Nurses Credentialing Center (ANCC) One hospital National Baldrige winner 2 additional hospitals winners of Illinois Performance Excellence awards (state Baldrige) 5 Advocate Program Size and Scope CDI Staffing ~70 CDSs located at 10 acute care hospitals Salaried professional nurses Inpatient record reviews; all payers Structure Report through care management System director CDI 5 system CDI managers new 2017 Site care management director (varies) CDI Shared Governance Committee Standardized structure, workflow, metrics System & site physician advisors Coding Staffing ~130 coders, mostly working remotely Hourly professional coders Structure Report through revenue cycle System executive director HIM Site HIM/coding leader Coding Committee Standardized metrics, workflow structure pending centralization

3 7 Polling Question On a scale of 1 to 5, how would you rate your site s current CDI/coding relationship? 1: Always aligned 2: Usually aligned 3: Sometimes aligned 4: Rarely aligned 5: Never aligned 8 ICD 10 Impact So much new learning for everyone! New ICD 10 concepts Glasgow Coma Scale Post procedural respiratory Pressure ulcers Procedure coding 9 3

4 10 Kelly & Kathy s 7 Principles The past is in the past! We will actively choose to manage our relationship with care and respect CDI and coding professionals think differently aren t we lucky! We can learn so much from each other Because we think differently, we sometimes communicate & make decisions differently We commit to leading with facts & transparency not opinions and assumptions Kelly & Kathy s 7 Principles We have different viewpoints and metrics, yet we have aligned goals We want the care & resources used in patient care to be accurately reflected in the documentation & final code assignment We have a shared responsibility to help our physicians bridge documentation gaps Coding guidelines are the law of the land (even if they just don t make clinical sense) Most conflict between our professional groups exists in the gray areas between clinical care and coding guidelines we can actively manage this better with aligned decisions & approaches shared across our teams 11 Building Our Structure Opportunity: Needed a system level forum for CDI & coding problem solving Members personally selected and invited Characteristics of members Professionally knowledgeable Good problem solving & communication skills Transparent influencers Kickoff meeting Share our principles & expectations for the work group Role model alignment Start some action: Develop mission statement/next steps 12 4

5 13 System CDI/Coding Alignment Team What is it? Team of 3 coding and 3 CDI leaders + system CDI and coding leaders Meet twice monthly Structured agendas/minutes with action items/owners Key expectations Champions of this shared new vision Represent all CDI and coding colleagues at all sites Fact based decision making whenever possible Creative, productive, professional discussion is welcome! As we leave, we have one voice in all decisions made Mission statement We are one team of CDI and coding professionals actively working together to develop a culture of learning and collaboration that is transparent, factbased, and constantly evolving. Our shared goal is to ensure that the care and resources used in patient care are accurately reflected in the documentation and final code assignment. CDI/Coding Alignment Log Opportunity: Method for site CDSs & coders to identify objective sources of conflict at their sites What is it? Excel log Located on organization s intranet site (All CDSs & coders have access) Encouraged to place unresolved questions or topics on their site Frequent mismatch conversation topics; knowledge gaps; areas of confusion How it s used Identification of key issues for CDI/coding alignment team Prioritize & sort topics Assign needed action to the topics: DARC/coding pathway/training Communication tool to point to key references and answers As topics are addressed, the resolution is added to log Outcome Issues are transparent! 14 CDI/Coding Alignment Log Key columns: Patient # Site Name of logging associate Coding question to verify CDI/coding alignment recommendations (after review) Legend To be addressed Completed/more information Work in progress Coding FAQ review We can't do right now 15 5

6 16 Site CDI/Coding Team Meetings Connecting the dots: Site CDI/coding meetings already occurring at each hospital Recently formalized with CDI standardization Meeting at least monthly, using agendas and minutes Address site specific trends, challenging cases, and mismatch topics Opportunity: Finding resolution to unresolved conflicts CDI coding alignment log is now the place to escalate challenging topics Documentation Alignment Reference Cards (DARC) Opportunity: Reference tools needed to help align gray areas of practice What is it? Templated tool created by CDI/coding alignment team to clarify key coding references, key clinical indicators, and CDI tips for complex diagnosis/topics How it s used Coding references all in one spot Concurrence on relevant clinical indicators Identification of query opportunities Reference to use in physician training Resource for teaching new associates Assists in writing appeals for denials (clinical foundation) Outcome Decreased mismatches Increased alignment between CDI & coders at individual sites and across the system 17 Key headings: Code Assignment Coding References Key Clinical Findings CDI Implications Clinical Documentation References 18 6

7 19 DARC Template Code Assignment: Published coding guidelines and relevant issues of Coding Clinic Key Clinical Findings: Evidence based practice, Advocate clinical protocols and practice guidelines CDI Implications: Tips, query opportunities, key reminders Coding & Clinical Documentation References: Fact based decision making shows our work, adding credibility to recommendations Document Alignment Reference Cards CCA = CDI/coding alignment team 20 DARC 3 Month Review Process Incorporates learning from the first 3 months of use Site CDI team leader in charge of collecting site feedback from CDI, coding, & physician advisor site feedback Alignment team reviews every piece of feedback from sites Revisions made as appropriate Formal feedback provided to sites Revised DARC published Site Recommendation DARC Reference Card Feedback (3 month review) CDI/Coding Alignment Notes DARC CARD Name: DARC CARD Number: DARC CARD Owners: DARC Change Made? (yes/no) DATE OF REVIEW: 05/04/2016 Rationale Key columns: Site Recommendation DARC Change Made? (yes/no) Rationale Site That Made Recommendation Site/s 21 7

8 22 Completed DARC References Cerebral edema Excisional debridement Glasgow Coma Scale Pressure ulcers Respiratory failure Malnutrition (with and without dietitian consult) Type II NSTEMI Document Control Goal is to ensure the most recent info is published and used in decision making All cards receive: Title Document # Initial publication date Most recent review date Last revision date All key CDI/coding alignment information is housed on intranet All old documents are archived Standard review process Cards evaluated with code changes 23 Our Alignment Journey Never Ends! Always looking for better ways to quantify mismatches found in reconciliation process EMR changes are providing an opportunity to reevaluate our integrated CDI and coding workflow Continue to mature our site CDI/coding meetings 24 8

9 25 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 9