cdijournal Get ready for a new level of specificity New MS-DRGs add increased demands for CDI specialists FEATURES

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1 cdijournal October 2007 Vol. 1 No. 1 FEATURES Case study 4 n Take a look at a first-year clinical documentation improvement (CDI) program ACDIS advisors 6 n Meet the ACDIS advisory board Succeed with data 10 n Use a numbers-driven approach to get physicians on board with your CDI program Congestive heart failure 12 n Dr. Robert S. Gold explains the clinical conditions to help CDI specialists obtain the right diagnosis Get ready for a new level of specificity New MS-DRGs add increased demands for CDI specialists In August, CMS finalized its plans to move ahead with a new Medicare Severity DRG (MS- DRG) system and a corresponding documentation and coding adjustment, or phased-in payment cut as detailed in the inpatient prospective payment system (IPPS) final rule. The new system took effect on October 1. The changes occurred despite some protests from influential organizations and groups, including the House of Representatives, who on July 19 voted in favor of an amendment to prevent CMS from implementing the payment cut, and also to delay implementation of MS-DRGs for one year. In a press release issued with the rule, CMS Acting Deputy Administrator Herb Kuhn stated that Medicare payments for inpatient services will be more accurate and better reflect the severity of the patient s condition. CMS said it adopted MS-DRGs to prevent abuses under the current system. Under the old DRG system (with payments based on broad averages) incentives could lead hospitals to cherry pick the practice of treating only the healthiest and most profitable patients, CMS said in the release. However, the replacement of the current DRG (CMS-DRG) system relatively stable since its 1983 inception with MS-DRGs means that times are a-changing for clinical documentation improvement (CDI) specialists. The bottom line with the new system is that CMS is looking for specificity [CDI specialists] will have to go into further specificity of the diagnosis codes, says William Haik, MD, director of DRG Review, Inc., in Fort Walton Beach, FL. The documentation has to support the coding, and the only way that can happen is for doctors to specify the diagnosis. This means that documentation specialists either must educate the attending physician, query the physician, or both. Some good news with MS-DRGs The rule creates 745 new MS-DRGs to replace the current 538 DRGs. It also expands the familiar complication/comorbidity (CC) classification to include CCs and major CCs (MCC), which are conditions that require double the additional resources of a normal CC. The good news with the new MS-DRG system, says James S. Kennedy, MD, CCS, director continued on p. 2

2 Welcome to ACDIS and our premiere issue of CDI Journal! It s a pleasure to present this first issue of CDI Journal to all of our charter members of the Association of Clinical Documentation Improvement Specialists (ACDIS). Since announcing the formation of this one-of-a-kind association, we ve received dozens of queries wanting to know more about ACDIS and what it offers. The resources and benefits that you will find at your disposal include the following:» Biweekly tips, news, and strategies in our e-newsletter, CDI Strategies» In-depth stories and case studies about building successful clinical documentation improvement (CDI) programs in our quarterly electronic journal, CDI Journal» An opportunity to network with peers in our talk group, CDI Talk, as well as in quarterly conference calls» Helpful forms and tools from our electronic library» Access to e-learning courses and an opportunity to obtain coding, nursing, and case management continuing education credits» A featured article of the month» Discounts to the annual ACDIS conference and other related products» And coming soon, CDI Blog, a Web site in which you can read and comment about your colleagues posts about anything and everything related to CDI I hope you will take advantage of the many benefits and resources ACDIS offers and visit our Web site often ( To make the most of the resource center, please take the time to share your best tips, policies, and forms with other members. Use our talk group, ask lots of questions, and feel free to talk and comment freely. Remember that ACDIS members range from those who have an established CDI program to others whose facilities are just now getting a program off of the ground. Best regards, Brian Murphy bmurphy@hcpro.com MS-DRGs continued from p. 1 with FTI Healthcare in Brentwood, TN, is that coders will still report ICD-9-CM codes using the same principal/ secondary diagnosis and procedure coding conventions as before. That means the working DRGs CDI specialists often assign as part of their role will remain largely the same. The base DRGs, for all practical purposes, remain the same, although they ll have different numbers and there s some consolidation, says Kennedy. This shouldn t necessarily change the way coders assign codes, but they will have to be more cognizant of capturing every CC and more specific diagnoses, adds Shannon McCall, RHIA, CCS, CPC, director of health information management/coding for HCPro, Inc., in Marblehead, MA. Also, just like under the old system, it still takes only one CC or one MCC to change a DRG. CDI specialists will be pleased to find that CMS restored five CCs and four MCCs that were previously deleted, including acute blood loss anemia (285.1) and trifascicular block (426.54), among others. For example, coma (780.01) is now an MCC. I do think on a more positive note, [MS-DRGs] will positively affect those hospitals that do have a more severe case mix index, says McCall. But this could cause problems for physicians because it will require them to give coders even more specific information than they do now. And some bad news with MS-DRGs The bad news is that CMS is implementing a corresponding 4.8% payment cut over a three-year period, including a 1.2% reduction for fiscal year (FY) 2008 and proposed October HCPro, Inc.

3 1.8% reductions for FYs 2009 and This reduction is to offset the improved documentation and coding and therefore, payment CMS believes providers will adopt, based on past data. In other bad news, Kennedy says that revisions to the CC/ MCC table will result in fewer MS-DRGs reported with a CC: 41.1% of MS-DRGs providers report will be without a CC, whereas providers today only report 22.34% of CMS-DRGs without CCs. Of the remaining 58.8% that will be CC/MCCs under MS-DRGs, 22.2% will be MCCs and 36.6% will be CCs. Kennedy says that CMS did not correct some of its logic errors in CC/MCC designation errors that will ultimately reward nonspecific physician documentation. For example, CMS classified malnutrition, not otherwise specified, as a CC, whereas mild/moderate malnutrition is not a CC. It pays for hospitals to not be specific with malnutrition, which I think is wrong, he says. Also, CMS did not differentiate between sepsis and severe sepsis it classifies both as MCCs. Get your program up to date The bottom line is that hospitals that do not have a CDI program one that engages medical and coding staff to cooperatively document and report illness severity using ICD- 9-CM terminology should strongly consider implementing one now, Kennedy says. Given the 1.2% documentation and coding adjustment, and the complete revision of the CC/ MCC structure, hospitals that don t implement such a clinical documentation program will be left behind, he says. If your hospital already has a CDI program, the next step is to get physicians up to speed about their new requirements under MS-DRGs. This will prove to be a difficult challenge, Haik says, especially if you ask physicians to just document better. When clinical elements in the medical record suggest a more specified diagnosis, such as aspiration pneumonia, the documentation specialists may query the attending physician for further specificity, Haik says. However, the physician may answer nonspecifically, with comments such as really severe pneumonia. Haik says that CDI specialists will have to:» Schedule large meetings with physicians to provide education regarding the new system» Break down the documentation requirements of individual service lines (e.g., cardiology, pulmonary, gastrointestinal) and educate physicians in department-specific sessions» Teach by means of osmosis pose queries to physicians every day about clinical elements until they are familiar with the new requirements The only time that physicians will learn and that goes for everyone else in this world is they have to understand, when it comes to code reporting and chart documentation, that their skins are in the fire, he says. H Editor s note: You can read the IPPS rule at the CMS Web site: a257.g.akamaitech.net/7/257/2422/01jan / edocket.access.gpo.gov/2007/pdf/ pdf. Getting more specific: An example Under the current CMS-DRG system, congestive heart failure (CHF) unspecified ICD-9-CM code is a complication/ comorbidity (CC), and if a physician documents it in the record, and a coder assigns it, it affects the DRG assignment. But under the new system, CHF is not a CC. However, if the physician further specifies CHF as either diastolic (428.30) or systolic (428.20) in nature, it is a CC. Further, if a physician specifies CHF as acute diastolic (428.31) or acute systolic (428.21) in nature, it qualifies as a major CC. But the catch, as always, is that physicians must get very precise with their documentation. Those words have to be in the chart diastolic or systolic congestive heart failure, and acute to toggle you up to a CC or a major CC, says William Haik, MD, director of DRG Review, Inc., in Fort Walton Beach, FL. You can see that that level of specificity makes an enormous difference in the potential on DRG impact. Because a clinical documentation improvement (CDI) specialist might have to ask as many as two or three questions of a physician to arrive at the right diagnosis, the value of a real-time CDI program cannot be overestimated, Haik says. That s why it s important to do these queries concurrently, while the patient is still in-house, he says. This makes the concurrent documentation specialist even more valuable HCPro, Inc. October 2007

4 Case study: A CDI program looks back at year one Editor s note: Each quarter, CDI Journal will offer a case study of a clinical documentation improvement (CDI) program. For our premiere issue, we ve chosen the program at St. Luke s Episcopal Hospital in Houston. In 2006, St. Luke s Episcopal Hospital in Houston decided that the facility had room to improve its clinical documentation. Soon after the initiative began, the task of running the program fell on the shoulders of Judy Ostrow, RN, BSN, manager of the clinical documentation department at St. Luke s. We talked about the complexity of the patients we treat, and our high acuity, but our documentation and the indicators we looked at didn t always support that, Ostrow says. St. Luke s selected a vendor 3M Health Information Systems in May 2006 and embarked on a program to improve its indicators, severity of illness, and risk of mortality. A team approach St. Luke s first step was to form a CDI team, with Ostrow running the department. The hospital brought in seven RNs to perform concurrent reviews of physician documentation. The CDI team made a point of working closely with health information management (HIM) from the beginning. Our assistant manager of HIM/coding has been invaluable in providing support, and she comes to all of our staff meetings, Ostrow says. 3M provided coaching throughout the process, which included three weeks of training for both coding and CDI staff members. They also involved the IT department to help incorporate an electronic documentation tool, because all the hospital s coders work remotely and the CDI analysts document on an electronic record. Then we hit the road, Ostrow says. Questions? Comments? Ideas? Contact Senior Managing Editor Brian Murphy Telephone: 781/ , Ext bmurphy@hcpro.com At St. Luke s, clinical documentation analysts are assigned to specific units and obtain a list of the targeted population for that unit. The documentation analysts are expected to see all new patients within 24 hours of admission, and follow up with subsequent reviews every hours during their length of stay. The analysts query the physicians on a concurrent basis to clarify the principal diagnosis, confirm a secondary diagnosis, or request greater specificity of a diagnosis, which is used for accurate DRG assignment and profiling. The analysts then assign the patient a working DRG. During this process, the analysts have the ability to the assistant HIM/coding manager for help with any ICD-9/DRG questions they may have. She s very supportive with helping the [CDI analysts] understand how the records get coded to the final DRG and what coding rules apply, says Ostrow, of St. Luke s assistant coding manager. I don t see how you could have success with a program without help from your HIM department. Focused efforts The CDI team focused on the following objectives:» Concentrated their efforts on Medicare discharges.» Focused on achieving greater specificity and accuracy in the documentation that clearly reflects the highest appropriate Nominate a colleague for outstanding CDI contributions Do you work with a colleague who has helped launch a successful clinical documentation improvement (CDI) program in your hospital? Do you know of a peer who has made outstanding contributions to the field of CDI? If so, we want to hear about it. Once each year, ACDIS will recognize a CDI specialist who has demonstrated a high level of success in the field. We will celebrate his or her accomplishments in an article appearing in our quarterly publication, ACDIS Journal. If you d like to submit a nominee for consideration, please include his or her name and contact information, and a brief list of his or her accomplishments to Senior Managing Editor Brian Murphy at bmurphy@hcpro.com. October HCPro, Inc.

5 level of severity. This supports the resources used related to patient care. For example, if a physician simply documented anemia, he or she was asked to specify whether it was an acute blood loss anemia, acute versus chronic, etc.» Queried physicians for diagnoses when they order medications.» Examined lab values. Lab results provided opportunities for physician query and documentation improvement. For example, some physicians used up and down arrows in the record instead of documenting proper terminology. Ostrow says the team s overall goal was to get the physicians to document with greater specificity. If they were treating the patient, we wanted to make sure the documentation showed the true picture of what was going on, she says. Physician feedback When St. Luke s CDI analysts leave a query for a physician, they are required to follow up the next day to determine the physician s response. Improved communication and education is the goal. Trying to catch the physicians to talk to them when possible is important, she says. Ostrow and her team also provided quarterly feedback to physicians. Every quarter, Ostrow met with the medical sections and services to present and discuss data and results. She also attended two quarterly medical staff meetings to provide updates. Measurable results The overall goal for the program is ensuring accurate and specific physician documentation in the record to obtain the correct severity of illness, risk of mortality, and DRG assignment. So far, Ostrow says the data show that the program is meeting those objectives. 3M sent monthly progress reports, as well as quarterly reports related to severity of illness/risk of mortality. After the program s implementation, the reports showed that documentation practices contributed to an improvement in risk of mortality and a 2% baseline increase in St. Luke s overall severity of illness score. Medical capture rates of complications/comorbidities climbed 4.11%, and surgical capture rates improved by 10.3%. The program also improved physician s response rates and agree rates to queries. We ve seen some good measurable results, with some good outcomes as a result of this [program], Ostrow says. Room for improvement Despite seeing good results, Ostrow has buoyed her optimism with realism. She hopes for continued gains in the second year of the program and beyond. Whenever you start a new program, you generally see improvement, she says. But the biggest question is: Can you sustain it? There are still improvements that we need to make, and we re learning and making changes as we go. H Would you like your hospital featured in CDI Journal? We re looking to publish case studies of CDI programs. For more information, please send your inquiries or questions to Brian Murphy at bmurphy@hcpro.com HCPro, Inc. October 2007

6 Meet our panel of experts the ACDIS advisory board Dear Reader, Following you will find brief biographies of the advisory board members of the Association of Clinical Documentation Improvement Specialists (ACDIS). These are professionals who have volunteered their time and expertise to help make ACDIS a success. Cindy Basham, MA, RN, CPC, CCS Senior Regulatory Specialist HCPro, Inc. Marblehead, MA CBasham@hcpro.com Basham serves as a senior regulatory specialist for HCPro and is an instructor for the Certified Coder Boot Camp Original Version (covers physician and outpatient hospital coding) and Certified Coder Boot Camp Inpatient Version (covers inpatient hospital facility coding). Currently, she serves as the lead developer and instructor for the Interventional Radiology Boot Camp. Basham works with hospitals, medical practices, and other healthcare providers regarding a wide range of coding and documentation-related issues with a particular focus on coding, billing, revenue cycle, chargemaster, and compliance reviews/audits. Basham has extensive experience relating to coding and billing of both physician and hospital services. Prior to joining HCPro, she worked for a large hospital system as a compliance auditor. Her duties included monitoring and performing audits for coding, billing, chargemaster compliance, and documentation. She also worked extensively with reorganization of clinical departments. She has also previously worked as an independent consultant focusing on coding, documentation, billing, revenue cycle, chargemaster, and compliance relating to hospital inpatient services with particular emphasis regarding intensive, cardiovascular, and ER care. Her clinical experience includes directorship over intensive inpatient cardiovascular surgery, interventional cardiology, coronary care, and ER departments. She was appointed to and served a two-year term on the Texas Healthcare Information Council. Gloryanne Bryant, BS, RHIA, RHIT, CCS Catholic Healthcare West Corporate Director Coding HIM Compliance San Francisco, CA gbryant@chw.edu With more than 28 years of experience in the health information management (HIM) profession, Bryant currently is the corporate director of coding HIM compliance for Catholic Healthcare West (CHW), located in San Francisco. In this role, Bryant has responsibility for the coding and documentation compliance of 40 acute care facilities and a variety of other nonhospital-based healthcare entities (e.g., outpatient settings, skilled nursing facilities, and rehab) in three states. She has the charge of developing, implementing/setting and maintaining system-wide coding policies and creating an internal coding compliance auditing and monitoring team and process. She is also responsible for maintaining ongoing continuing education to the CHW coding and charging staff and providing specific documentation-related education to physicians, case management, and other ancillary clinicians. In addition, she works closely with senior management and those involved with the Charge Description Master, severity/acuity, and risk of mortality statistics via all patient refined DRGs. During the past three and a half years, she has been a guest speaker about compliance issues for several regional, state, and national educational programs and associations. Bryant has given presentations about planning and implementation of ICD-10 during the past four years and provided testimony in support of ICD-10 implementation for the House Ways and Means Committee in April Jean S. Clark, RHIA Service Line Director for HIM Roper St. Francis Hospital Charleston, SC Jean.Clark@RoperSaintFrancis.com Clark is the service line director for HIM at Roper October HCPro, Inc.

7 St Francis Healthcare in Charleston, SC. She also serves as the system s accreditation coordinator. At Roper St. Francis Healthcare, Clark is responsible for all HIM services, the clinical documentation program (which she started in 2005), and Joint Commission (formerly JCAHO) and other regulatory compliance. She has served on the JCAHO Standards Review Task Force and the expert panel for the Information Management chapter, which resulted in sweeping changes for the accreditation process beginning in January Clark is a past president of the American Health Information Management Association (AHIMA) and a past president of the International Federation of Health Record Organizations. She is a well-known author and speaker about topics related to accreditation. Her books include the HCPro bestseller Ongoing Records Review: A Guide to The Joint Commission Compliance and Best Practice and The HIM Director s Handbook, also published by HCPro. She also served as technical editor for Documentation for Acute Care, published by AHIMA in Clark has received several awards during her healthcare career, including the President s Award, CareAlliance Health Services, 2002; Distinguished Member Award, AHIMA, 2000; National Volunteer Award, AHIMA, 1998; and Tribute to Women in Industry Award, YMCA of Greater Charleston, Inc., Wendy De Vreugd, RN, FNP Western Regional Director of Case Management Kindred Healthcare, Hospital Division Orange County, CA wdevreugd@ca.rr.com De Vreugd is senior director of case management, West Group (West and Midwest regions, 12 states, 44 facilities), for Kindred Healthcare LTAC hospital system. Currently, she is helping implement a clinical documentation improvement (CDI) team across all of its facilities. De Vreugd has 36 years of clinical nursing experience in the areas of advanced clinical nursing practice, acute hospital management and strategic planning programs, quality management, risk management, infection control, acute and ambulatory care level case management, managed care development and shared risk contract management, disease state management programs, and legal nurse consulting. Proficient at Medicare, Medicaid, HMO, and managed care coordination, and NIPAC regulatory auditing of medical groups, De Vreugd is thoroughly familiar with The Joint Commission, Title 22, NCQA, and other regulatory agency requirements. Colleen Garry, RN, BS Clinical Documentation Manager Medical University of South Carolina Charleston, SC garrycf@musc.edu Garry is the clinical documentation manager for the Medical University of South Carolina in Charleston. She implemented and has managed the clinical documentation improvement department at the Medical University of South Carolina since its creation in Garry graduated from Marist College in Poughkeepsie, NY, and has a baccalaureate in business and marketing as well as an RN license. Garry has a varied background in nursing with more than 16 years work experience as a critical care nurse, transplant coordinator, ESRD educator, and outpatient program director. Prior to her career in healthcare, her business resume included employment in marketing at IBM and NBC television in New York City. She has been recently published in HCPro s Medical Records Briefing and is soon to be published in The Business of Caring, copublished by HFMA and AONE. Robert S. Gold, MD CEO DCBA, Inc. Atlanta, GA DCBAInc@cs.com Dr. Gold has more than 40 years of experience as a physician, medical director, and consultant. A graduate of Hahnemann Medical College in Philadelphia, he trained continued on p HCPro, Inc. October 2007

8 Advisory board continued from p. 7 in general surgery in the U.S. Navy, where he spent his professional career as a practicing surgeon. Since leaving the service, he has worked as a consultant in the fields of managed care medicine, locum tenens, home health, hospital accreditation and licensure, and, most notably during the past 15 years, in the education of physicians, nurses, and HIM professionals regarding DCBA for healthcare services. Dr. Gold is known nationally for his education regarding the clinical orientation of coding in AHIMA teleconferences and at national conferences about aspects of clinical coding. He has spoken at national and state-level HFMA and HCCA meetings about the participation of medical staff members in programs of documentation improvement. His monthly articles in HCPro publications have enjoyed success with all who read them. Dr. Gold is a cofounder of DCBA, Inc., a consulting company that provides physician-to-physician programs in CDI for the purposes of properly reflecting disease processes in inpatient and outpatient medical records. William E. Haik, MD Director DRG Review, Inc. Fort Walton Beach, FL Behaik@aol.com DRGreview@aol.com Dr. Haik is director of DRG Review, Inc., in Fort Walton Beach, FL, where he has practiced medicine since He has received board certification in internal, pulmonary, and critical care medicine. Dr. Haik s past professional accomplishments include serving as chief of internal medicine, director of respiratory care services, board of trustees at his local hospital, president of the Okaloosa County Medical Society, and representative of the Government Liaison Committee for the American College of Chest Physicians. Dr. Haik s coding background includes AHA s Editorial Advisory Board and Expert Advisory Panel of Coding Clinic for ICD-9-CM and participation in the preparation of the original CCS examinations. He also served as the expert consultant to the U.S. Department of Justice regarding pneumonia coding fraud and abuse. Since 1988, Dr. Haik has served as the director of DRG Review, Inc., a physician-directed hospital coding consultative service. Tamara Hicks, RN, BSN, CCS Manager of Care Coordination North Carolina Baptist Hospital Winston-Salem, NC thicks@wfubmc.edu Hicks currently serves as manager of care coordination at North Carolina Baptist Hospital in Winston- Salem. In this role, Hicks manages and facilitates quality practice within the department of care coordination, identifies and implements changes that enhance effectiveness of patient care delivery, and ensures compliance with regulatory agency standards. Hicks is also responsible for staff member management and development, and the environment of the department including the oversight of case managers, social workers, medical management specialists, clinical documentation consultants, and support staff members. Prior to assuming her current role, Hicks served as Baptist s coordinator of clinical documentation management. Pam Lovell, MBA, RN Senior Director of Case Management and HIM Kindred Healthcare, Hospital Division Louisville, KY Pam.Lovell@kindredhealthcare.com Lovell is the corporate senior director of case management for the hospital division of Kindred Healthcare. She supports the case management and HIM management programs of Kindred s 84 long-term acute care facilities in 26 states. In this role, Lovell ensures that the case management program provides for and makes certain that appropriate and cost-effective medical and October HCPro, Inc.

9 medically related social services and behavioral health services are identified, planned, obtained, and monitored for individuals eligible for long-term acute care hospital services. Lovell oversees divisionwide medical centralized coding, medical records, and transcription services. She also monitors compliance with applicable regulatory requirements related to medical coding and HIM activities. In the past three years at Kindred, Lovell has been part of significant evolution in the case management program, particularly with the development of the CDI specialist role. Shannon McCall, RHIA, CCS, CPC Director of HIM/Coding HCPro, Inc. Marblehead, MA McCall serves as the lead instructor for HCPro s Certified Coder Boot Camp Inpatient Version and as an instructor for HCPro s Certified Coder Boot Camp Original Version. In her consulting practice, McCall works with hospitals, medical practices, and other healthcare providers regarding a wide range of coding-related issues with a particular focus on coding reviews and audits. McCall has extensive experience with coding for both physician and hospital services. Prior to joining HCPro, she worked for Per-Se Technologies, a national, medical practice management company, where her duties included serving as instructor for Per-Se s in-house coding training and certification program. McCall also previously worked for Lexicode Corporation as a coding consultant focusing on hospital inpatient services. She successfully completed Lexicode s rigorous in-house consultant training program. McCall is accredited as a registered health information administrator and a certified coding specialist by AHIMA. She is also accredited as a certified professional coder and is an approved instructor of the Professional Medical Coding Curriculum by the American Academy of Professional Coders. Lynne Spryszak, RN Coordinator, Clinical Documentation Management program Alexian Brothers Medical Center Elk Grove Village, IL spryszal@alexian.net Spryszak has spent the past five years as a documentation specialist, with the past two as program coordinator of the Clinical Documentation Management Program at Alexian Brothers Medical Center in Elk Grove Village, IL. Spryszak finally achieved her dream of becoming a nurse when she received her associate degree of nursing from the College of DuPage in Glen Ellyn, IL, in Her nursing career has included working on a medical/ oncology unit as a staff nurse, as a home hospice nurse, a certified case manager, and, most recently, as a clinical documentation specialist. As the coordinator of the Clinical Documentation Program at Alexian Brothers, Spryszak s goal is to inspire her team to cement strong relationships with the physician staff, the nursing staff, and her coding staff, without whose experience and expertise the program would be lost. Heather Taillon, RHIA Manager, Coding Compliance St. Francis Hospital Beech Grove, IN Heather.Taillon@ssfhs.org Since 2005, Taillon has been manager of coding compliance at St. Francis Hospital in Beech Grove, IN. In that role, Taillon has assisted with the implementation of a document imaging system, developed a home coding program, and provided oversight of the hospital s clinical documentation program. Prior to taking her position at St. Francis, Taillon served as health information manager at Westview Hospital from 2002 to At Westview, she oversaw implementation of a new transcription system with electronic signature and a hospitalwide computer system. Taillon currently serves as secretary of the IHIMA Executive Board, a role she has held since H 2007 HCPro, Inc. October 2007

10 Show them the data, and better documentation will follow Physicians respond to hard numbers As clinical documentation improvement (CDI) specialists know, achieving physician buy-in is critical to the success of any CDI program. Unfortunately, getting physicians to want to document better is far easier said than done. After all, physicians aren t driven by the same monetary stakes as hospitals they aren t reimbursed via DRG, but rather their own fee schedules. So, given that the hospital s financial well-being isn t the best motivational tool, how do you get physicians to improve their documentation practices? The answer, says Colleen Garry, RN, BS, clinical documentation manager in the health information services department of the Medical University of South Carolina (MUSC) in Charleston, is to show them the data. Physicians, for the most part, are very data-driven people, Garry explains. If you can present data to them, as far as their past performance, mock it up with before and after program comparisons, and can show trends and benchmark against other facilities, that is how you can speak to them. Using numbers is a great way to get physicians involved in your CDI efforts, but there are many other methods you can use to arrive at the same goal, says Jean S. Clark, RHIA, service line director for health information services at Roper St. Francis Healthcare in Charleston, SC. For more tips and strategies about achieving physician buy-in, see Other motivational ideas for achieving physician buy-in on p. 11. Gathering and using data You can gather data relevant to your hospital from a number of sources. Garry recommends the following Web sites:» Medicare Provider Analysis and Review (MedPAR): 05_MedicareProviderAnalysisandReviewFile.asp» University Health System Consortium database: Program for Evaluating Payment Patterns Electronic Report (PEPPER): Check your quality improvement organization s Web site. Using the above resources, Garry recommends CDI specialists prepare reports using the following data:» Case mix index (CMI)» Complication/comorbidity capture rate» Severity of illness profile CMI is the tried-and-true statistical measure with which all CDI specialists should become familiar. It remains an effective benchmark to measure your hospital with other hospitals, with one caveat you must compare like facilities. If not, the data are meaningless. For example, PEPPER reports compare a hospital with all other hospitals in its state, regardless of the hospital s type. This can paint an inaccurate picture if you work at a specialized facility. If you re an academic medical center, and most of your hospitals in your state are not, you ll think you re performing much better than you really are, Garry explains. On the other hand, Garry recommends PEPPER reports to help you measure how well your physicians and coders capture specific diagnoses e.g., complex versus simple pneumonias, ratio of urinary tract infections to sepsis, etc. Presenting the data After you ve gathered your data, the next step is presenting them. Getting physicians to set aside enough time to attend a data presentation can be problematic. Garry has found success by ing the chair of the service line/ division of the physicians to whom she wishes to present, setting up a time to present the data to the chair individually. The chair, then, will add Garry to his or her group s monthly staff meeting agenda. These meetings often have 50 physicians gathered in a room. Garry and MUSC s other CDI specialists have a limited time (i.e., minutes) to present their data, so organization is key. They use a formal PowerPoint presentation and end the session with time for questions and answers. These question and answer sessions often help direct Garry s future data mining efforts. For example, physicians will often ask her to identify their top five cardiology DRGs, their average length of stay, and top reported diagnoses. From their questions, you can see what data they are looking for, she says. We try to tie some of that into their outcomes performance. H 10 October HCPro, Inc.

11 Other motivational ideas for achieving physician buy-in In addition to gathering and presenting data, you might want to try these other tips and techniques to achieve physician buy-in of your clinical documentation improvement (CDI) program:» Introduce your program as a partnership with the medical staff members to improve documentation for patient care and the quality of the medical record. We used this approach, rather than This will have a financial impact down the road, says Jean S. Clark, RHIA, director for health information services at Roper St. Francis Healthcare in Charleston, SC.» Involve your medical executive committee with your program. Introduce your CDI specialists to the committee, provide them with an overview of the program s objectives, and tell them what CDI specialists do on a day-to-day basis. Physician leaders are an essential asset to a CDI program, and getting them on board is key, says Clark.» Focus your efforts. It can be daunting to ask physicians to improve their documentation for all patients across the board, so Clark recommends that CDI specialists consider narrowing their focus to Medicare patients, for example, or specific problematic DRGs. You ve got to focus either on DRGs that you have some opportunities to improve or a certain type of patient population, she says. Eventually you can add new patient groups, and improved documentation in one type of patient will usually trickle down to others.» Network with peers. The new Association of Clinical Documentation Improvement Specialists hopes to fill this role, but one-on-one peer relationships with CDI specialists outside of your organization are a must for survival. They can share motivational techniques that you may not have otherwise been able to develop on your own.» Enlist a physician champion(s). This does not necessarily have to be a single physician; it can be a group interested in improving documentation hospitalwide. In order for a program to be successful, you have to have a key group of physicians that you can go to with clinical questions or a clinical diagnosis, says Colleen Garry, RN, BS, clinical documentation manager in the health information services department of the Medical University of South Carolina (MUSC) in Charleston. For example, MUSC has a handful of supportive physicians who will help with an occasional troublesome record that needs review. Don t let the physician champion(s) take on too much of the documentation work, however; they should help educate, not complete records. You ll never change your process that way, Garry says. Roper St. Francis vice president of medical affairs (also a physician) gets involved if a physician is reluctant to participate. We ve had very strong support from administration, senior leadership, and medical staff leadership, Clark says.» Enlist new physicians as they start. MUSC s CDI specialists have a training program for new residents who start at the hospital. The new residents start in July, so we asked to be on the calendar as part of their core orientation, Garry says. The CDI specialists hand out pocket cards, or tools that prompt the new residents as to what type of documentation the CDI specialists need. We show them what our query forms look like and what the medical director s expectations are.» Encourage physicians to teach coders. South Carolina s quality improvement organization hosts coding roundtables, a popular feature during which physicians present to coders about anatomy, disease processes (e.g., sepsis), procedure techniques, and more. Most physicians love to teach by nature, so if you can involve the physicians in having them teach to the coders, that can be helpful it helps them feel that they have a piece to contribute, says Garry. This also has the secondary effect of helping coders capture complications/comorbidities and secondary diagnoses. If [coders] read documentation that s not in codable format, but they can understand it clinically, it allows them to query the physician, Garry says. When physicians field questions from coders during the roundtables, it helps them to understand the specific information coders need to do their jobs and leads to improved documentation, he says HCPro, Inc. October

12 Don t fail to account for changes to CHF Documentation of acute and chronic crucial in 2008 By Robert S. Gold, MD As a writer for various HCPro publications for the past six years, I want to welcome you to the Association of Clinical Documentation Improvement Specialists (ACDIS). Yours is, indeed, a very important job in today s medical practice an age of medical informatix and statistics. As you know, all severity-adjusted statistics come from the codes that appear on CMS bills. If the chart has the right words and the coders assign the right codes, the bill will tell the story of the patient. Unfortunately, a bill that tells the story is rare in facilities that don t have a strong clinical documentation improvement (CDI) program. Why? Young doctors are influenced by their mentors, their textbooks, their peers, drug reps, and the terminology du jour words taken from yesterday s medical literature that have no benefit whatsoever to help with the ability to assign proper ICD codes. So, welcome to the club assigned with righting these wrongs. Let s use it as a springboard to mutual success. Let s share our information, our techniques, our successes, and our failures, and help one another. CHF and the need for specificity For the past two years, CDI specialists and coders have had to identify patients with heart failure based on the concepts of :» Acute» Chronic» Systolic dysfunction» Diastolic dysfunction The information CDI specialists and coders provide is supposed to help physicians identify patients with heart failure due to chronic systolic dysfunction, the primary reason for the existence of the CMS/Joint Commission (formerly JCAHO) heart failure core measure initiative. The American College of Cardiology (ACC) and the American Heart Association (AHA) wrote an article in 2001, titled Guidelines for Identification and Management of Chronic Heart Failure [CHF], that identified the patients at risk of sudden cardiac death as those with heart failure due to chronic systolic dysfunction, which they defined as patients having an ejection fraction under 40%. Unfortunately, CMS and The Joint Commission have only asked us to identify that a patient s ejection fraction is under 40%, and do not require physicians to include the terms chronic or systolic. Personal discussions with both the ACC and The Joint Commission have led to promises that this will change. Also, certain DRG assignments depend on physicians to properly identify patients who have an acute myocardial infarction (MI), heart failure, or shock as a principal diagnosis. These DRGs have a higher relative weight than the corresponding DRG assigned to patients without these conditions. Under CMS Medicare Severity DRG (MS-DRG) system, which takes effect on October 1, secondary diagnoses of acute diastolic or acute systolic (or acute diastolic and systolic) heart failure are considered major complications/ comorbidities (MCC). CMS identifies secondary diagnoses of chronic diastolic or chronic systolic (or diastolic and systolic) failure as complications/comorbidities (CC). And 12 October HCPro, Inc.

13 many other descriptors, such as CHF won t count for a hill of beans neither a CC nor an MCC. This concept of severity and heart failure is of massive importance from a quality and a reimbursement perspective. If CDI specialists are to help the medical record truly reflect what is wrong with patients with words that can be translated into the proper codes, they must be able to identify acute, chronic, systolic, and diastolic conditions. Important terminology to know To identify these conditions in the patient s chart and ensure appropriate reimbursement under MS-DRGs, familiarize yourself with the following terms. Left heart failure: This is a situation in which stroke volume i.e., the amount of blood leaving the left ventricle with every contraction cannot supply the body with sufficient nutrients to function normally. When the left ventricle cannot meet this burden, the heart fails. Left ventricular systolic dysfunction: This is a situation in which the heart cannot supply enough stroke volume due to contractility problems. During systole, the left ventricle is so weak it cannot produce enough emptying to provide an acceptable stroke volume. If one has a left ventricular muscle that has been weakened by ischemia, it can dilate and not be strong enough to supply a good stroke with the next systole. This occurs as a result of alcoholic cardiomyopathy, toxic effects of adriamycin therapy, or other reasons that weaken or kill heart muscle cells. Over time, the left ventricle dilates and ejects only a small portion of what goes into it. This inability to empty adequately during systole is called systolic dysfunction. Left ventricular diastolic dysfunction: This is a situation in which the left ventricle cannot fill with enough volume during the relaxation phase. Despite the fact that it is strong, it doesn t have enough filling to put out enough volume with the next contraction. If the left ventricle hypertrophies due to hypertensive disease (i.e., working harder against higher pressures downstream causes muscles to hypertrophy and become muscle-bound and unable to relax when they should relax) or due to aortic valvular disease (i.e., working harder against a narrower exit opening causing hypertrophy and inability to relax at the end of diastole), it develops diastolic dysfunction i.e., it cannot fill enough during diastole because the volume of the left ventricle is smaller (with a hypertrophied muscle), and it cannot relax at the end of diastole to let blood into its smaller cavity. Modeling: Chronic left ventricular systolic and diastolic dysfunction develop over long periods of time. Dilation and left ventricular hypertrophy are conditions called modeling. This means that the shape of the left ventricle changes over time due to chronic issues, either systolic or diastolic. When the stroke volume is less than desirable, failure occurs. The ACC/AHA article establishes a 40% ejection fraction as being the lower level of normal systolic function. Therefore, when a left ventricle has an ejection fraction under 40%, that is systolic failure. When a CHF patient has a normal ejection fraction or a sustained ejection fraction, the patient has diastolic failure. A patient with an ejection fraction under 40% (i.e., systolic failure) can also have diastolic dysfunction. In addition to downstream pressures or hypertensive disease or narrowing of the aortic valve, a heart may be troubled with diseases that stiffen its muscle or deposit abnormal chemicals between muscle fibers, making the left ventricle stiff and unable to relax during diastole. Such CHF chart Four phases of diastole: (1) isovolumic relaxation, (2) rapid filling, (3) diastasis, (4) atrial contraction. continued on p. 14 Source: Chart courtesy of Robert S. Gold, MD, Atlanta, GA HCPro, Inc. October

14 Changes continued from p. 13 conditions include amyloidosis of the heart or glycogen storage causing stiffness or chronic constrictive pericarditis causing inability of the left atrium and the left ventricle to relax completely during diastole. The most common presentations of patients with chronic diastolic failure are respiratory signs and symptoms (e.g., dyspnea, cough), although they may be minimal when things are otherwise stable and the patient is controlled with medication. The most common presentations of patients with chronic systolic failure are fatigue and weakness. Acute diastolic dysfunction: This condition can occur with a basically normal heart or with a heart that has chronic systolic or diastolic problems. This is represented by the patient who comes in with acute shortness of breath and often with x-ray findings of pulmonary edema. Acute diastolic dysfunction occurs due to an acute change in the heart s ability to fill the left ventricle during diastole. The chart on p. 13 represents one heart cycle, starting with left ventricular contraction on the left side of the chart at a pressure of approximately mm Hg. The pressure change first closes the mitral valve. Then the pressure builds until it exceeds the pressure in the aorta during diastole, and pop the aortic valve opens. Pressure builds in both until the contraction of the heart is over and the pressure in the left ventricle starts to drop. Then the aortic valve closes. Pressure drops during Phase 1 of diastole until the pressure in the left ventricle drops lower than the pressure in the left atrium and the mitral valve opens. During Phase 2, there is rapid filling of the left ventricle. Then a short period of rest (Phase 3) until the left atrium contracts and the last little spurt of volume gets into the left ventricle in Phase 4. This time period during diastole is necessary so that the left ventricle can fill. If suddenly the heart rate rises to 140, 160, 220 beats per minute, there is no time for diastole to take place. With no time to fill the left ventricle during diastole, the patient instantly develops massive decreases in stroke volume due to acute diastolic dysfunction and experiences an acute diastolic heart failure. Treatment must include dropping the heart rate. When the rhythm is restored, the heart returns to where it was prior to the acute event and there may be no chronic component at all. Acute diastolic dysfunction is caused by acute volume overload, acute pericardial effusion, salt intake, not taking medication (noncompliance with treatment), or acute MI. Acute diastolic failure: This condition occurs in a patient that has:» Symptomatic acute diastolic dysfunction» Pulmonary edema» Elevated serum brain natriuretic peptide levels Acute systolic failure: This occurs due to an acute MI, or an acute rupture of a chorda tendinae or papillary muscle of the mitral valve. These conditions cause immediate mitral regurgitation and inability of the left ventricle to empty itself into the aorta and it backs up into the lungs. Take-home points for CDI specialists The following is a checklist you should run through for every acute heart failure patient: 1. Find out the cause of the acute failure, or whether the patient has any chronic conditions. 2. If a physician indicates any notation of left ventricular hypertrophy, dilated cardiomyopathy, or history of CHF, find out the cause of the patient s CHF state. For example, a patient may have acute diastolic failure due to ventricular tachycardia on top of chronic systolic failure due to ischemic cardiomyopathy. 3. Require the physician to give you the reasons for the acute and chronic conditions whenever they exist. 4. When forming a query or asking a question, talk the physician s language. Talk pathogenesis of disease. 5. Don t forget. Patients with CHF states are at risk of chronic kidney disease, especially if related to hypertensive disease. Patients with acute heart failure are at risk of acute respiratory failure or acute renal failure. Don t miss those additional diagnoses when they exist as they can affect severity. Now, you be careful out there. H Editor s note: Dr. Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in CDI. The goals are data accuracy, profile management, and compliance, either in the inpatient or outpatient arenas. He can be reached by phone at 770/ or by at DCBAInc@cs.com. 14 October HCPro, Inc.