CDI input helps EHR implementation succeed

Transcription

1 cdijournal April 2012 Vol. 6 No. 2 Director s note 4 n Can CDI/coding staff survive computer-assisted coding efforts? Meet a member 5 n Martha Stanley, RN, MSN, CCM Chapters give back 6 n ACDIS chapters offer philanthropic opportunities. Clinical clash 7 n Trey La Charité, MD, reflects on regulatory vs. clinical focus for physicians. Ask ACDIS 9 n Advisory board looks at pulmonary hemangioma. Clinical corner 10 n William E. Haik, MD, FCCP, tackles documentation for diagnostic bronchoscopic procedures. Case study 12 n Solving malnutrition documentation deficiencies. ICD-10 prep 15 n Look to available ICD-10 guidelines to prepare staff. ICD-10 benchmarking 17 n 2012 survey results illustrate increase in ICD-10 training efforts. CDI input helps EHR implementation succeed On March 7, CMS announced Stage 2 Meaningful Use requirements' proposed rule for Medicare and Medicaid electronic health record (EHR) incentive payments. On the table for eligible hospitals is a potential $2 million base payment for EHR implementation. In order to obtain the potential dollars, hospitals must demonstrate that a number of specific EHR measures have been met. It is a process involving numerous staff members and multiple resources. In facilities that currently have, or plan to have, CDI programs, it makes perfect sense that CDI professionals participate in the implementation discussions, otherwise facilities risk purchasing electronic systems that fail to integrate documentation improvement needs. We saw the EHR train as it was whisking by. We were shouting Wait! Wait! What about CDI? says one CDI specialist. They didn t know CDI existed. The [implementation team] hadn t thought about us and how we interact with the record or what we might need from an electronic system. So now we re trying to play catch-up and do the best we can with what we ve got. Finding meaning in meaningful use CDI specialists probably think phrases like interoperability and meaningful use need not cross their minds EHR implementation belongs in the hands of the IT or HIM department, right? The answer to that question is yes and no, says Barbara Hinkle-Azzara, RHIA, Vice President of Operations for Meta Health Inside: ICD-10 Benchmarking Survey According to an ACDIS survey, 40% of facilities have conducted a formal assessment of ICD-10 readiness. Read more findings from the survey on p. 17. Figure 1: Has your facility conducted a formal assessment of its readiness for ICD-10 implementation? No 23% 37% 40% Don t know Yes Technology in New York City. The individual end-user (i.e., the CDI specialist reviewing medical records on the hospital floor) may not need to be involved in checking off the boxes to certify meaningful use is met, but certainly adapting to an EHR and adhering to meaningful use requirements affects the information CDI professionals review and how they will ultimately perform their jobs. EHR systems will change the CDI specialists experience, she says. Defining electronic components An EHR refers to the overall record of patient care. While many use the terms EHR and electronic medical record (EMR) interchangeably, EHR is typically used as a global term encompassing all electronically generated components of a hospital or facility computer-based patient record.

2 EMR, on the other hand, typically describes only the components of the record used in the physician, professional, or clinical realms. (A list of e-record terms and definitions, is available on the ACDIS Blog at Both EHR and EMR are overarching terms used to describe many of the major systems typically created and supported by Epic, McKesson, 3M TM, and Allscripts TM, among others. The EHR is a repository of documents and data to which all these other systems and software needs to attach, says Jonathan Elion, MD, FACC, founder of ChartWise Medical Systems, Inc., in Wakefield, RI. A number of different systems can be incorporated into the EHR and add to its practical functionality for documentation and coding purposes, including computer physician order entry (CPOE), computer-assisted coding, and even electronic physician query systems, Elion says. However, for those components to work effectively, facilities first need an effective overarching EHR. Call it a catch-22, but it's a conundrum for which CDI specialists can provide valuable insight and suggestions. Adapting new technologies Most CDI specialists perform their initial record review on the floor, looking over a hybrid record and leaving paper queries for the physician to answer. FHN in Freeport, IL, works with a hybrid record and won t be completely electronic until two years from now, says Tamar Gorenyuk, MBA, RHIA, director of HIM and Resource Management. It s been more than a year since FHN implemented its CPOE system, and it's still managing the transition. Physicians are used to having nurses manage their order sets and provide the documentation, she says, so the new system which puts the responsibility back on the providers is a real leap. She sometimes wonders whether implementing CPOE first instead of coordinating a system for electronic notes was the right decision. Is it a lot for the physicians? Sure, but we are moving forward. Waiting isn t going to help. You have to start somewhere, Gorenyuk says. Facilities approach the transition to electronic systems differently, says Hinkle-Azzara. Physician order entry or results reporting may be the first component implemented, Advisory Board ACDIS Director: Brian Murphy, CPC bmurphy@cdiassociation.com Associate Director: Melissa Varnavas, CPC mvarnavas@cdiassociation.com Publisher: Lauren McLeod Susan Belley, M.Ed., RHIA, CPHQ Project Manager 3M HIS Consulting Services Atlanta, GA sebelley@mmm.com Timothy N. Brundage, MD Physician Champion Kindred Hospital North Florida District St. Petersburg, FL DrBrundage@gmail.com Cheryl Ericson, MS, RN Manager of Clinical Documentation Integrity Medical University of South Carolina ericsonc@musc.edu Robert S. Gold, MD CEO DCBA, Inc. Atlanta, GA DCBAInc@cs.com Robin R. Holmes, RN, MSN Manager, Clinical Documentation Improvement DCH Health System Tuscaloosa, AL rholmes@dchsystem.com Fran Jurcak, RN, MSN, CCDS Director, CDI Practice Huron Healthcare Chicago, IL fjurcak@huronconsultinggroup.com James S. Kennedy, MD, CCS Managing Director FTI Healthcare Brentwood, TN james.kennedy@ftihealthcare.com Glenn Krauss, BBA, RHIA, CCS, CCSP, CPUR, FCS, PCS, C-CDIS, CCDS Independent Consultant Madison, WI glennkrauss@earthlink.net Trey La Charité, MD Physician Advisor University of Tennessee at Knoxville Knoxville, TN Clachari@UTMCK.edu Gail B. Marini, RN, MM, CCS, LNC Manager, Clinical Documentation South Shore Hospital Weymouth, MA Gail_Marini@sshosp.org Dee Schad, RN, BSN, CCDS Director Care Coordination and CDI Clark Memorial Hospital Jeffersonville, IN dee.schad@clarkmemorial.org Donna D. Wilson, RHIA, CCS, CCDS Senior Director Compliance Concepts, Inc. dwilson@ccius.com Lena N. Wilson, MHI, RHIA, CCS, CCDS HIM Operations Manager Clarian Health Indianapolis, IN lwilson9@clarian.org Previous ACDIS board members: Cindy Basham, MHA, MSCCS, BSN, CPC, CCS ( ) Shelia Bullock, RN, MBA, CCM, CCDS ( ) Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS ( ) Jean S. Clark, RHIA ( ) Wendy De Vreugd, RN, BSN, PHN,FNP, CCDS ( ) Garri Garrison, RN, CPUR, CPC, CMC ( ) Colleen Garry, RN, BS ( ) Robert S. Gold, MD ( ) William E. Haik, MD ( ) Tamara Hicks, RN, BSN, CCS, CCDS ( ) Pam Lovell, MBA, RN ( ) Shannon McCall, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS ( ) Lynne Spryszak, RN, CPC-, CCDS (founding member) Colleen Stukenberg, MSN, RN, CMSRN, CCDS ( ) Heather Taillon, RHIA ( ) CDI Journal (ISSN: ) is published quarterly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, 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 3049, Peabody, MA Copyright 2012 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 website 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. 2 April HCPro, Inc.

3 but I ve also heard of some facilities beginning with the progress notes, and then following with electronic medication reconciliation, and so on. Some electronic components have been around for a long time. Consider the grouper, Gorenyuk says it automatically translates ICD-9-CM codes into Diagnosis Related Groups which have been in existence since the mid-1980s. By the mid-1990s, almost all facilities had a grouper. Even today, with one-stop EHR vendors, there are still separate electronic systems available for laboratory and radiology orders and reports, charges, ancillary services, medication reconciliation, and so forth, she says. Facilities typically buy these tools incrementally and implement them in phases, over time, says Hinkle-Azzara. These disparate systems may not all be integrated into a central system, so the CDI specialist will need to be able to navigate and review the different documents in all these systems, to see the complete picture of the patient s care, she says. Involving CDI perspective CPOE implementation presents several problems for CDI professionals, Hinkle-Azzara says. For example: Incomplete drop-down menus could potentially lead physicians to pick inappropriate diagnoses Lack of robust documentation modules could eliminate much of the nuance of physician s interpretative analysis typically associated with patient care Copying and pasting of preceding documentation as a shortcut may result in progress notes that do not reflect a patient's daily condition accurately In particular, CDI professionals need to educate themselves on the dangers of the copy-and-paste functionality and ensure that physicians truly document their patients' progression from day to day without simply copying yesterday s assessments into today s progress notes, warns Marion Kruse, MBA, RN, director at FTI Healthcare. Other hazards include compliance concerns associated with drop-down menus that include a hard stop or system freeze, forcing the physician to choose one diagnosis over another, Kruse says. For example, suppose that a diagnosis of congestive heart failure has 10 possible options in a drop-down menu. A physician may not scroll through all the options to find the most accurate one. AHIMA-recommended options for not otherwise specified or unable to determine might not be included, Kruse says. Or, even if all options are included, a physician may simply not scroll through all the options to find the most accurate one. We need to make sure [the computer program is not] leading the physician the same way we need to ensure that the CDI specialist querying the physician isn t submitting a leading query, says Hinkle-Azzara. The individuals involved in designing the EHR may not be aware of the requirements for physician querying. This is the perfect example of the importance of having the CDI manager or specialist involved in the EHR planning. The CDI expert s knowledge will contribute to ensuring that these tools are designed and used appropriately. Last fall, John Pettine, MD, FACP, CCDS, CDI director at Lehigh (PA) Valley Health Network, formed a steering committee to tackle CDI concerns related to ICD-10. The multidiciplinary group included IT staff, coding and HIM, finance, physicians, and others. But the group focused first on software adaptation and reviewed 10 different potential vendors, presenting their findings to the chief medical officer. Obviously, not all institutions have a setup like ours with cooperation from the top down, says Pettine. Nevertheless, it is the responsibility of the CDI physician champion or director to insert him- or herself into the process to get the ear of the decision-makers and to have the CDI perspective heard, he says. We, as CDI professionals, know how critical CDI programs are to an institution, but sometimes other key decision-makers are not aware of that importance. A CDI program director or physician champion can play a pivotal role in the implementation of initial and ongoing assessment efforts for EHRs and their components, Pettine says. CDI staff should get involved and do it now before it is too late. Otherwise, CDI professionals are at the mercy of decisions made without their input, which can be tragic to the success of the program going forward into ICD-10, he says HCPro, Inc. April

4 Director s note Finding the human element: Determining the benefit of flesh-and-blood CDI vs. computer-assisted coding I received an interesting question following the last ACDIS Quarterly Conference Call about the impact of new technology on the CDI profession. It read: Do you think computer-assisted coding (CAC) will reduce or eliminate CDI jobs? Several members of the ACDIS advisory board formulated answers worth sharing. Fran Jurcak said, Although these programs may change work flow and process for CDI specialists, physician understanding of the theory behind the practice is still necessary, and the CDI specialist is the primary person to be able to share the rationale with physicians. Although these programs may assist with the low-hanging fruit queries, they certainly cannot identify and analyze the clinical indicators of conditions that are not accurately being documented. CDI specialists need to embrace this new technology and be creative in their approach with physicians as they adapt to the everchanging world of clinical documentation. Glenn Krauss noted, CAC is designed to improve coding efficiency by having the computer scan the record and identify ICD-9 codes. However, the accuracy of CAC is predicated upon complete and accurate clinical documentation in support of patient acuity and treatment. The introduction of CAC does not negate the requirement for effective clinical documentation supportive of the physician s clinical judgment, medical decision-making, patient acuity, severity of illness and outcomes, assessments, and interventions. In short, the advent of CAC makes the activities of CDI that much more important. Finally, Cheryl Ericson added, My organization is in the process of implementing CAC. I think most organizations are seeing CAC as an opportunity to increase productivity rather than to eliminate or reduce coding or CDI [staff]. I see it as more of a tool like dynamaps and other tools that automatically collect vital signs this reduced the nurse s need to manually collect the vital signs, but they still needed to monitor the vital signs, and the task of manually obtaining vital signs was replaced with other nursing tasks. Basically, CAC may allow CDI departments to relinquish basic querying (i.e., type of [congestive heart failure] CHF, type of anemia, type of malnutrition, etc.) so they can focus on more complex query opportunities. As such, I agree with your observation of it replacing some of the grunt work. Here s how I feel about CAC. It can be a valuable tool in the box of a CDI specialist, like a hammer or saw, but it does not replace the CDI specialist. At times I too react to new technologies with skepticism and defensiveness, wondering if this or that new gadget will sound the death knell for my own job. But machines will never replace the human element. In short, summarizing what Fran, Glenn, and Cheryl said: As long as physicians require education as to why accurate, complete, and legible documentation is important, CDI will be here to stay. As long as doctors respond to a face instead of an electronic prompt, CDI will be here to stay. As long as medicine remains part art and part science, CDI will be here to stay. In short, CDI is not going anywhere anytime soon. View these new technologies as a new and exciting challenge to master, not as an enemy to fear.what do you think about CAC and the impact it will have on CDI? Send me an with your thoughts. Take care, Brian D. Murphy, CPC bmurphy@cdiassociation.com , Ext April HCPro, Inc.

5 Meet a member Move to CDI career a rewarding change for Martha Stanley Martha Stanley, RN, MSN, CCM, is a CDI specialist at San Juan Regional Medical Center in Farmington, NM. Farmington is in the high desert near the famous four corners the place where New Mexico, Arizona, Colorado, and Utah meet in perfect unison. Featured member CDI Journal: How long have you been in the CDI field? MS: Three years. CDI Journal: How did you get into this line of work? MS: I was a nurse for 12 years and was looking for a change. I spent the next eight years as a case manager. Three years ago, there was an opening for a CDI specialist and I applied. Since I joined the CDI team, there have been some good changes in our program. We have gone (almost) paperless. We moved to the HIM department to work closely with our coding supervisor. Our manager staggered our shifts and encouraged us to interact more with the physicians, which increased our response rate tremendously. We also assign a working DRG, which helps the quality department identify core measure patients and helps case management with the geometric length of stay. ACDIS is our best resource for staying up to date with the latest in CDI! My husband and I moved to this beautiful area 14 years ago. He was a commercial pilot at the time. Now he is looking for a new career and is almost finished with school studying coding and billing. I am very happy that we now have similar careers and someday may work together. CDI Journal: What has been your biggest challenge? MS: Like most CDI professionals, the biggest challenge is working with the doctors and explaining what we do. We educate them and sell ourselves and the program. Sometimes we are well received, sometimes not. CDI Journal: What has been your biggest reward? MS: I learn as I work. When I have to submit a query, the research I do helps me learn new things, and that helps us make sense of the patient s case. CDI Journal: What advice would you give someone entering the CDI field? MS: If you are a nurse, learn about coding. You will understand the CDI role so much better. A few of Martha s favorite things Family: Martha lives with her husband, David, and their 6-year-old daughter Esperanza (her name means hope in Spanish). As the mother of a first grader, Martha is busy with soccer games, birthday parties, Spanish, and sign language classes. Vacation: Martha says her family s favorite vacation was a trip to the Grand Canyon. Hobby: Relaxing, reading, and a good movie. Most recently Martha viewed Fireproof and Courageous. Non-alcoholic beverage: Coke. Food: Mexican. Be sure to keep an eye out for Martha Stanley at the 5th Annual ACDIS Conference in San Diego in May. To be a featured member, Member Services Specialist Penny Richards at prichards@cdiassociation.com. Courtesy photo Martha Stanley with her husband David and daughter Esperanza HCPro, Inc. April

6 Networking focus ACDIS chapters extend a helping hand to charities It was a simple challenge: Reach out to a local charity with your CDI and HIM coworkers and send a photo and description of your charitable accomplishments back to the leaders of the North Carolina ACDIS chapter. You never know how your actions are going to affect someone. Giving back, trying to make a difference is really what the heart of our profession is all about. Sequana Webb, RN, CCDS We wanted it to be an easy thing for chapter members to do. It was the holiday season, and we assumed that most people already do some form of charitable giving in their own lives or in their own facilities. So we just asked them to send a photo of themselves to us. We felt as if we, as a local chapter, could provide an extra measure of encouragement, says Leah Taylor, RN, CCDS, CDI specialist at Iredell Memorial Hospital in Statesville and president of the North Carolina ACDIS chapter. For Vicki Davis, RN, CDI manager at Alamance Regional Medical Center (ARMC) in Burlington, that meant sharing the details of a number of charitable events taking place at her facility. In October 2011, the ARMC CDI team joined with its HIM coworkers to celebrate breast cancer awareness month. The group made pink ribbon pins, beaded dangles for their name badges, pink hair bows, and a slew of pink snacks that they sold, donating the proceeds to the Pink Ribbon Foundation at ARMC ( foundation-funds). As the holidays approached, Davis and her team turned their attention to a new endeavor: coming together to fill shoeboxes with children s toys to benefit the Samaritan s Purse charity Operation Christmas Child ( We have a number of events we do here at our facility, Davis says, pointing to regular blood drives to which CDI staff are encouraged to donate, and recent fundraisers for the critically ill child of a coworker. Volunteer efforts have an added side benefit for the chapters: They prove to be effective team-building exercises, says Davis. Working on nontraditional tasks helps us work together, to see each other outside of our traditional roles, to view each other with new eyes, and to see each other as individuals with concerns, gifts, talents, and worries beside those we d typically see in our daily interactions, she says. Courtesy photo Vicki Davis (at bottom right) and other members of the CDI and HIM departments at Alamance Regional Medical Center in Burlington, NC, don pink clothing during their Breast Cancer Awareness event held in October Courtesy photo The Virginia ACDIS chapter launched its ACDIS Gives Back initiative at its inaugural meeting in April HCPro, Inc.

7 Virginia chapter embraces giving, too When Virginia ACDIS chapter leader Sequana Webb, RN, CCDS, CDI specialist at the University of Virginia Health System in Charlottesville, heard about local chapter charitable initiatives, she was excited about the idea. The Virginia ACDIS group was about to hold its first meeting, and Webb thought it would be great to incorporate the act of giving from the very beginning. The Virginia group is informal in nature, rotating its events to host facilities throughout the state on a quarterly basis. The host for each meeting gets to pick the charity and lets participants know how they can help once the meeting agenda is finalized. Typically, hosts choose area food banks and invite meeting participants to bring a non-perishable item from their home to donate. Since Webb s facility hosted its most recent meeting, she chose The Haven, a Charlottesville nonprofit day shelter that, among other services, provides meals, showers, shelter, and computer access to the region s poor and homeless ( The idea [of giving back] has really been well received, says Webb. People really do participate and seem to feel good about doing so. It really isn t too much to ask them to grab something out of the cupboard on their way to the meeting, and it can really make a difference for some of these charities. By providing an opportunity for local chapter participants to give back to the community, Taylor and Webb say they are responding to an inherent trait of CDI professionals. Typically, we re nurses who chose to be nurses because we wanted to help people, to serve people, Taylor says. When you step back from bedside care to become a CDI professional, you really tend to miss that interaction, that immediate awareness that you ve had an impact on someone s life. This allows us to feel that a little bit. You never know how your actions are going to affect someone, say Webb. Giving back, trying to make a difference is really what the heart of our profession is all about. A physician's perspective The clash of clinical vs. coverage/payment concerns by Trey La Charité, MD An emergency department (ED) physician diagnosed a patient with pneumonia. He was concerned about a possible nosocomial etiology given the patient s recent hospital discharge for problems related to atrial fibrillation. Because the patient s Pneumonia Severity Index score was 4 and his CURB-65 score was 2, the ED physician wanted to admit the patient to the hospital for treatment with broad-spectrum intravenous antibiotics. However, after discussion with the ED physician, the admitting hospitalist denied the admission on the grounds that the patient did not meet either InterQual or Milliman criteria for inpatient admission. According to the hospitalist, the patient had a normal white blood cell count, was not tachypnic or tachycardic, had a normal temperature, and had an oxygen saturation of 98% on room air. While the patient had an extensive past medical history, the only new objective abnormality was an obvious infiltrate on the chest x-ray. The patient looked fine on paper, at least healthy enough to be sent home, the hospitalist said. After discussion, the ED physician agreed and discharged the patient. I am the hospitalist in this tale. What should I have done? Should I have: Admitted the patient to the hospital, risking the future inpatient denial and the subsequent exhausting appeal process? Placed the patient in observation status, trusting that the patient would be discharged in a timely manner and knowing that reimbursement from the payer would not cover the cost of the care provided? Discharged the patient home with oral antibiotics and close outpatient follow-up with either his primary care provider or through a return visit to our ED? 2012 HCPro, Inc. April

8 Because the patient clinically looked good according to the ED physician, I made the suggestion to try outpatient treatment first. The patient received an initial dose of broadspectrum intravenous antibiotics in the ED and was discharged home with 10 days of oral antibiotics, with a return visit to the ED scheduled in two days time. I d like to report that the patient returned drastically improved. He didn t. When he returned 48 hours later he was floridly septic. Fortunately, the patient responded very well to aggressive treatment; two days after the initial admission to an intermediate care unit, he was medically stable for transfer to a general medicine ward. He was eventually discharged back home with home health care. My gravest concern is that I made a decision I would not have made a little over a year ago. In hindsight, it is blatantly obvious that I allowed my medical judgment to be negatively impacted by my recent experiences fighting medical necessity denials in my role as a physician advisor to CDI and coding. In the aggressive post-discharge auditing environment where I now find myself practicing medicine, I and my colleagues are subject to heavy scrutiny by CMS and private insurers. Observation versus inpatient status review is the new focus of these nonclinician auditors and has become the reason for the vast majority of my facility s denials. This new auditing pressure we all face stems from the completely noble idea that reductions in fraud, abuse, and improper payments will preserve resources for those who truly need medical care. Sadly, as with many commendable aspirations, the execution is poor and often produces a dismal result. As the physician advisor for CDI, I have been diligently educating every physician at my institution about ensuring the medical necessity of our inpatient admissions. But while CMS asserts that the admitting physician is solely responsible for status selection (i.e., inpatient, outpatient, or observation status), admission status for the physician has no clinical relevance. Physicians do not recognize conditional or partial admissions, which observation status implies. As far as physicians are concerned, their patients either medically need something or they don t. Physician education focuses on the development of skills that allow one to discern whether a patient can be safely sent home. The rules concerning inpatient versus observation status selection are not newly created; CMS vague guidelines for appropriate status selection have been around for years. The difference is that CMS and other payers suddenly discovered that they can extend their existing financial resources by enforcing those rules. Payers and their related auditing agents have traditionally avoided the question of whether a patient actually needed the medical care that was provided. Instead, they simply point to inappropriate status selection and deny the associated claim. The issue is whether physicians should be contemplating a patient s admission status at all. I have always prided myself on the belief that I do what is best for the patient before me. I never look at the patient s registration sheet because I do not want to inadvertently be prejudiced by his or her insurance status. Yet the admission judgment I made for the patient described in this introduction was affected by my recent experiences with medical necessity denials. As a society, do we really want our physicians to be faced with these simultaneous worries? Should nonclinicians be influencing my bedside practice patterns? I am concerned that other physicians will face this same scenario in the future. Is this what we want from our healthcare system? Is this what I want for my family s medical care? I understand that financial resources for medical care in this country are finite. I understand that not all care provided in this country is medically necessary and that some individuals take advantage of the current system. However, most entities caring for patients in the United States are simply doing the best they can to comply with today s regulatory environment while still trying hard to provide the high-quality medical care that their patients trust them to deliver. One day, I will be a patient, and I hope that the physicians taking care of me at that time do what is in my best interest as opposed to having their clinical judgment influenced by nonmedical considerations such as government audits, threats of fraud, or worries about reimbursement. Editor s note: La Charité is a hospitalist and physician advisor for CDI and coding at the University of Tennessee at Knoxville. Contact him at Clachari@UTMCK.EDU. 8 April HCPro, Inc.

9 Ask ACDIS Pulmonary hemangioma, VAT/wedge resection as principal What is the correct principal diagnosis in the following case? A 59-year-old male with history of (h/o) bladder cancer and failure to follow up was admitted for video-assisted thoracic surgery (VAT) for pulmonary nodules found on imaging. The patient had the VAT procedure and a pulmonary wedge resection with a three-day length of stay. The discharge diagnosis stated h/o bladder cancer with pulmonary nodules, path pending. The pathology report stated small pleural nodule with features of cavernous hemangioma with partial thrombosis and benign hyalinized parenchymal nodule. The coder queried post-discharge if the surgeon wish[ed] to add these as a possible/probable diagnosis to this patient s clinical picture? The surgeon replied: Diagnosis: pulmonary hemangioma. The record was coded with a principal diagnosis of (hemangioma, any site; of other site). With the VAT and wedge resection, the DRG is 982 (extensive OR procedure unrelated to principal diagnosis). If we used a principal diagnosis of (benign neoplasm of bronchus/lung), the DRG with the VAT/wedge resection is 165 (major chest procedure). Which principal diagnosis is more appropriate: or 212.3? Or is there another diagnosis that is more appropriate in this case? It just does not seem logical that it would end up in DRG 982. If the provider s final diagnosis upon query was , then that s what should be assigned, despite the DRG designation. There is not a specific code for pulmonary hemangioma. ICD-9-CM code (hemangioma, any site; of other sites) is the correct code to use to report this diagnosis. It does result in a non-married DRG, but it is what it is. A neoplasm is a growth the diagnostic statement indicates that this is not what the patient has. According to the article Benign Lung Tumors published in Medscape: Solitary pulmonary nodules are found at a rate of 1-2 per 1,000 chest radiographs. About 30% of these nodules prove to be malignant. Of the rest of the nodules, benign tumors of the lung make up about 2-5% of primary lung tumors. Benign lung tumors are a heterogenous group of neoplastic lesions originating from pulmonary structures. A benign neoplasm/tumor is the broad category of pulmonary nodules, whereas a pulmonary hemangioma is a more specific identification. You should always report the more specific diagnosis when provided, in lieu of using the unspecified category. One comment to add: Make sure that the surgeon clearly indicated that the VAT resection was performed to ensure that the pulmonary nodules were not malignant metastasis from the history of bladder cancer. While the hemangioma is the principal diagnosis in this case as presented, your facility likely runs the risk of a medical necessity denial. Any time you report a DRG of procedure unrelated to principal diagnosis, you subject yourself to much more intense auditor scrutiny. The facility doesn t need someone questioning why the patient was subjected to a highly invasive procedure for just a hemangioma. An auditor may take the position that the VAT didn t need to be done at all because the path report was so benign. If you receive denials based on the position that the PTCA with stent didn t need to be done and hospitals are receiving these types of denials it is not a far stretch to imagine what else the auditor might question. Editor s note: Lynne Spryszak, RN, CCDS, CPC, independent HIM consultant based in Roselle, IL, and ACDIS advisory board member Trey La Charité, MD, hospitalist and physician advisor for CDI and coding at the University of Tennessee at Knoxville, collaborated to answer this question HCPro, Inc. April

10 Requirements for diagnostic bronchoscopic procedures by William E. Haik, MD, FCCP There has been a considerable amount of confusion regarding physician terminology, documentation requirements, and subsequent coding of various diagnostic bronchoscopic lung procedures. Because the current MS-DRG structure categorizes some of these as operating room procedures, each procedure carries with it different reimbursement; therefore, they are frequently the targets of third-party reviewers. While CDI specialists do not typically clarify documentation for procedures, diagnostic bronchoscopic lung procedures are an exception. Following are thumbnail descriptions of these procedures to aid the CDI specialist when clarifying physician documentation for correct code assignment. The most commonly documented diagnostic bronchoscopic procedures include the following: 1. Transbronchial biopsy of lung 2. Endobronchial bronchoscopic biopsy (bronchial biopsy) 3. Brush biopsy of lung or bronchus 4. Transbronchoscopic needle (Wang) biopsy of lung 5. Bronchoalveolar lavage 6. Transbronchoscopic (closed) needle aspiration of a mediastinal lymph node As with all ICD-9-CM codes, the coding and reporting of a diagnostic bronchoscopic procedure completely depends on accurate and specific physician documentation. Let s review a few possible documentation trouble spots for these procedures. Transbronchial biopsy of lung (33.27) A potential coding conflict occurs when the physician merely documents a transbronchial biopsy and does not specify it as being of the lung, rather than the bronchus. Because the 2012 ICD-9-CM Manual, Volume III Tabular Index separates a transbronchial biopsy of the lung (33.27) from that of the bronchus (33.24), an error commonly occurs when a hospital assigns due to the fact the physician has not documented the specific structure biopsied (lung versus bronchus). However, from a clinical perspective it is redundant for a physician to document both a transbronchial biopsy and a transbronchial lung biopsy, since lung tissue surrounds the bronchus and is the only structure that is obtainable via transbronchial biopsy. Although a second-level appeal to a physician reviewer will typically overturn the initial adverse determination, CDI specialists should query the attending physician regarding the specific pulmonary structure that was biopsied (lung versus bronchus) to avoid the burdensome appeal process. Clinical elements that may be present in the health record to support a physician query for further specification of a transbronchial lung biopsy are as follows: 1. Use of fluoroscopy 2. Non-visualization of the biopsied lesion endobronchially via the bronchoscope 3. Pulmonary infiltrate or solitary peripheral lung nodule as the indication for the biopsy 4. Alveolar (lung) tissue on pathological examination 5. Resultant pneumothorax Consider the following sample multiple-choice query format employing the above clinical information: Dear Dr. Haik, It is noted in the impression of the history and physical examination that the patient has a diffuse left lower lobe pulmonary infiltrate. The operative report notes that a transbronchoscopic biopsy was performed under fluoroscopy with the resultant pathology report revealing multiple granulomata with surrounding normal lung parenchyma. Can you identify the tissue biopsied via the transbronchoscopic biopsy as being: 1. Lung 2. Bronchus 3. Some other tissue 4. Undetermined Note that according to AHA s Coding Clinic for ICD-9-CM, 3rd Quarter 2011, p. 6, it is not necessary for lung tissue to be present on a pathology report to substantiate the physician s documentation of a transbronchial biopsy of the lung. 10 April HCPro, Inc.

11 It is not uncommon for tissue samples to be inadequate or inconclusive; therefore, this does not mitigate the reporting of the extent of the procedure (even if failed). Also, in a related issue, physicians may merely document a bronchial biopsy of left lower lobe, which may be incorrectly assumed to mean a transbronchial biopsy of the lung. When this documentation occurs, query the physician to determine the specific type of tissue biopsied (lung versus bronchus) so that a coder may assign the correct ICD-9-CM procedure code. Endoscopic (bronchial) biopsy (33.24) This biopsy is usually performed with forceps and occurs when a bronchial lesion is sited through the bronchoscope lying within the tracheobronchial tree. Therefore, the physician performs this procedure under direct visualization of the lesion. This is different from a transbronchial biopsy of the lung where the lesion is not sited directly through the bronchoscope. When an endobronchial biopsy is performed in conjunction with a transbronchial lung biopsy, a coder assigns both and 33.27, respectively. Brush biopsy of lung or bronchus (33.24) This type of biopsy is performed by inserting a firm bristled brush into a bronchus or extending the brush into the lung via a small bronchiole to collect cellular material. Regardless of the site of the transbronchial brush biopsy (lung and/or bronchus), a coder assigns ICD-9-CM code based on the 2012 ICD-9-CM Manual, Volume III Tabular Index. Assigning to represent this procedure is incorrect and will result in adverse determination by a third-party reviewer. Transbronchoscopic needle (Wang) biopsy of lung (33.27) and bronchus (33.24) Revisions to the 2012 ICD-9-CM Manual, Volume III, clarified the coding of a bronchoscopic needle biopsy. A bronchoscopic transbronchial needle biopsy of the lung is usually performed for sampling an isolated parenchymal lung lesion, providing a cellular sample for microscopic examination. This procedure is performed by passing a thin-walled needle out of the tip of the bronchoscope through the bronchus into the surrounding lung parenchyma. Although the 2012 ICD-9-CM Manual revisions also listed a code for a transbronchial needle biopsy of the bronchus (33.24), this procedure is rarely performed as a transbronchial procedure and would result in going through the bronchus into the lung for sampling a lung lesion and not solely for sampling a bronchial lesion. However, a needle biopsy solely of a bronchial lesion may be performed, and in this instance, would be appropriately assigned. Bronchoalveolar lavage (33.24) Also sometimes referred to as a liquid biopsy, this procedure is performed by infusing saline into a bronchial subsegment of the lung, which is subsequently suctioned to retrieve a cellular sample. This procedure is differentiated from a whole-lung lavage (33.29), which is usually performed therapeutically in the treatment of alveolar proteinosis. Transbronchoscopic (closed) needle aspiration of a mediastinal lymph node (40.11) Based on AHA s Coding Clinic for ICD-9-CM, 1st Quarter 2010, p. 9, the appropriate code assignment for this procedure is This new guidance resolves previous confusion surrounding the code assignment for this procedure. This procedure involves the insertion of a small gauged needle via the bronchoscope through the tracheobronchial tree into the mediastinum for the sampling of a mediastinal lymph node, which is usually enlarged and suspected of being invaded by a pathogenic process. In general, all personnel involved in the documentation and coding of bronchoscopic procedures would find AHA s Coding Clinic for ICD-9-CM, 3rd Quarter 2011, pp. 6 9 a useful clarification of previous Coding Clinic for ICD-9-CM publications. I recommend obtaining a copy of that publication and sharing it with your coding staff. Editor s note: Dr. Haik is the director of DRG Review, Inc., in Fort Walton Beach, FL. In addition to maintaining his own clinical practice, Dr. Haik has served on the AHA s editorial advisory board and expert advisory panel of the AHA's Coding Clinic for ICD-9-CM, and was a founding member of the ACDIS advisory board. Contact him at drgreview@aol.com HCPro, Inc. April

12 Case study Dietitian involvement resolves malnutrition query quandary While most CDI specialists know to query for conditions related to malnutrition, such as obesity and cachexia, programs frequently ignore dietitians documentation and keep dietary professionals out of the coding/querying conversation when they should be partners at the table. This was the situation at Carondelet Health in Kansas City, MO. CDI specialists queried for malnutrition specificity only when documentation warranted it, rarely flipping through to the dietary notes. It turned out the physicians weren t reviewing those notes either, says Joann Agin, RHIT, regional director of data quality for Carondelet Health, St. Joseph Medical Center in Kansas City, MO, and St. Mary s Medical Center in Blue Springs, MO. Even though the dietitians were documenting in the electronic part of the record, the physicians admitted that they didn t look over in the dietary section of the notes because they didn t get prompted to do so, Agin recalls. When you move to a hybrid or electronic record, if there isn t something right in front of the physician they may forget about it. (See related article regarding electronic health records on p. 1.) During a 2009 dietitian s conference in Boston, Melinda Hamilton, RD, LD, assistant director of patient services at Carondelet Health (contracted with ARAMARK), learned about the difficulties related to malnutrition documentation and coding and became energized to investigate the problem. She connected with Agin, who leads Carondelet s CDI program, and the two began work on a new malnutrition tool (see p. 14). The first step to take, says Hamilton, is to evaluate what's being done to document malnutrition at your facility. CDI professionals should reach out to dietitians and/or coding staff to determine whether there is currently a process in place for tracking malnutrition. Then use the information to start a dialogue between departments regarding potential improvements (read the checklist below). If there isn t enough data to make this determination, Checklist to initiate malnutrition program This checklist was developed by Joann Agin, RHIT, regional director of data quality and Melinda Hamilton, RD, LD, assistant director of patient services at Carondelet Health, to help other facilities assess their malnutrition documentation needs. Evaluate what is currently being done Determine the current process for reviewing malnutrition documentation/coding Identify stakeholders (CDI/dietitians/coders) Determine rate of current malnutrition documentation Contact team responsible for coding process Introduce registered dietitian roles in malnutrition coding Develop meeting schedule with coding team for implementation Review malnutrition criteria Establish biweekly staff meetings to review case studies Review physical appearance of malnourished patients Examine laboratory assessment standards and guidances Discuss potential subjectivity of disease states Develop malnutrition diagnostic tool Ensure justification for all diagnostic criteria if asked and provide references Involve physician/medical staff participation/feedback Revise tool, as needed, based on physician feedback Obtain medical records approval Educate physicians, nurses, unit secretaries, and coders Establish benchmarks for success Create a timeline for program review Establish success criteria (e.g., increase in CC/MCC capture, increase in malnutrition as secondary diagnosis, etc.) Review potential documentation pitfalls and program difficulties Implement program 12 April HCPro, Inc.

13 conduct a random audit of your facility s top 10 DRGs for the past year, selecting every fourth record per DRG in a given month. Review the records for malnutrition clinical indicators and determine whether those indicators were pulled forward to a clinical diagnosis and appropriately coded. With this information you can extrapolate the effectiveness of the current program and set expectations for improvement. Next, develop a meeting schedule and include primary stakeholders (e.g., physicians, coders, dietitians, and CDI specialists) to work through the logistics of possible improvements. During their meetings, Hamilton says her team: Reviewed the DRG process and the dietitians potential role Discussed malnutrition coding requirements and relevant AHA Coding Clinic for ICD-9-CM guidance Reviewed current clinical malnutrition criteria Reviewed malnutrition case studies from within the facility Discussed diagnosis ambiguity and the potential for changes in clinical criteria Developed a malnutrition diagnostic form Creating the draft of the diagnostic form took about a week, Hamilton says, but the remainder of the team s work took quite a bit longer. There was definitely a coordination of care concern, and we really had to spend a lot of time trying to understand each other s roles and engaging in a lot of open communication, she says. A slight tug-of-war ensued between the various departments as stakeholders debated who would own responsibility for the form and who would ensure that physicians used it. Should it be a dietary form or a CDI query? In the beginning, the real questions were around who was going to do this and when, etc. You just have to push through that and determine the best fit for your own program, Hamilton says. The team decided dietitians would own the form, that it would be an assessment tool akin to a wound care nurse documentation form. Since the dietitians owned this stage of the process, Agin says it was important not to call the form a query or clarification, since the dietitians were documenting conditions and physicians were essentially signing their agreement or disagreement. The team then turned its attention to enlisting support from the medical staff. It had to go through our clinical effectiveness team, where it went through a number of revisions, Hamilton explains. Once it earned approval there, the HIM department worked to incorporate it into the medical record. Agin s CDI team set out to educate the physicians about the process and its importance to accurate documentation and patient outcomes. It has been a wonderful endeavor, says Agin. We had physicians stating that they didn t get that much education on malnutrition [when they were in school], so many of them were happy to have the extra information. With all the tools and process finalized, Agin and Hamilton began their educational campaign by: Including information in physician newsletters Developing a poster of the new form Posting information in the physician lounge Presenting information at physician and nursing meetings The team even arranged an educational blitz aimed at the nursing staff and unit secretaries, Hamilton says, and made themselves available for physicians with problems or questions. The only concern left to tackle was tracking the team s success. They wanted to know how much of an impact the new form had, so they looked for malnutrition coding that was prompted by the dietary staff first. Then they went deeper into the data to see the effect of the new process. In 2009 there were 873 cases with malnutrition documented. In 2010, that number rose to 1,247. In fiscal year 2011, malnutrition documentation prompted by the new dietary form brought in more than $350,000 in potentially lost reimbursement, says Agin. Now, as physicians awareness of the importance of malnutrition documentation increases, they are beginning to document within the record on their own and look to the dietary notes without using the form. While that means statistically the number of malnutrition cases caught by the dietary staff may start to go down, clinicians are beginning to capture malnutrition as a comorbid diagnosis early on. That s the thing we focus on, Hamilton says, the impact of malnutrition on risk of mortality and severity of illness. And appropriate documentation of that fact could help the physician s profile and the facility s reimbursement, Agin adds HCPro, Inc. April

14 Malnutrition form Patient Label Diagnosis: Marasmus Cachexia Criteria: 1 Intake 2 #2 and #3 MUST be present Chronic poor energy intake #2,3, and 4 MUST be present Severe proteincalorie malnutrition #2 and #3 MUST be present Inadequate intake for >7days Malnutrition of moderate degree Any two must be present Malnutrition of mild degree Any two must be present %IBW <80% <60% 60-75% 75-90% Weight loss > 10% in 6 months >5% in 1 mo. >7.5% in 3 mo >10% in 6 mo. >10% loss from usual within 6 mo % from usual body wt 5-10% from usual body wt Unspecified proteincalorie malnutrition Any two must be present Inadequate intake for >7 days BMI <16 Albumin* >3 <3.5 < <3.5 g/dl 3 Prealbumin >10 <15 < >15 <15 mg/dl Overt fat tissue Overt muscle and skeletal Overt muscle wasting and muscle mass wasting with no prominence Depletion of fat wasting, Wasting may or Muscle wasting supporting lab of the body tissue and including 4 Appearance may not be becoming measures, skeleton, skeletal muscle temporal and apparent apparent delayed wound esp. in chest mass boney healing, stress and prominences, factors extremities poor wound healing *Serum albumin should not be used as sole indicator of visceral protein status when the following conditions are present: liver disease, immediate post-operative states, infection, nephrotic syndrome, fluid imbalance, trauma. Nutrition note: Registered dietitian signature: Date: Time: Please see RD nutrition assessment in Meditech for comprehensive assessment. Physician comments:!agree with assessment, patient meets criteria for diagnosis specified above.!disagree with assessment because: Physician signature Date: Time: MALNUTRITION DIAGNOSTIC TOOL Form # (rev 9/10) Source: Melinda Hamilton, RD, LD, assistant director of patient services at Carondelet Health in Kansas City, MO. Reprinted with permission. 14 April HCPro, Inc.

15 ICD-10 preparation Expect uncertainty in ICD-10 s early days by Lynne Spryszak, RN, CCDS, CPC The American Hospital Association (AHA) does not plan to convert past issues of Coding Clinic for ICD-9-CM into new issues for ICD-10-CM/PCS, the AHA confirmed in a CMS teleconference held in November This decision caused concern among coders and CDI specialists, who for years have relied on the guidance published in Coding Clinic to help resolve coding concerns. Everyone, from CDI specialists and hospital-based coders to physician office billing staff members, is wondering where to turn for coding advice when ICD-10-CM/PCS takes effect on October 1, (See related article on p. 17 regarding potential delays to ICD-10 implementation.) CDI specialists and coders who already completed training in ICD-10-CM/PCS are now identifying coding challenges under the new system. However, the AHA has not made any formal decisions regarding when it will begin publishing a separate Coding Clinic for ICD-10, according to Nelly Leon-Chisen, AHA s director of coding and classification, who spoke during the November CMS national provider call. The coding and CDI community expressed concern about the ambiguous timeline of the new publication. Based on past history, this concern is neither unprecedented nor without basis. ICD-9-CM was implemented in the United States in 1979, yet the first issue of Coding Clinic for ICD-9-CM was not published until 1984 meaning there was a five-year lag between ICD-9-CM code implementation and when the AHA first issued advice regarding the use of that code set. Coders had to become accustomed to reporting codes using the Official ICD-9-CM Guidelines for Coding and Reporting, the only guidance that was available at that time. In short, the conversion to ICD-10-CM/PCS and the challenges that this transition represents closely resemble the difficult situation coders had to face with ICD-9-CM in Guidance varies regarding cause-and-effect The 2012 ICD-10-CM Official Guidelines for Coding and Reporting contains advice regarding the proper application of diagnosis codes from specific code categories. One example is how to correctly code a case in which the patient has both osteoporosis and a current pathological fracture. Currently, there is not an assumed cause-and-effect relationship in ICD-9-CM between an acute (i.e., new) fracture and osteoporosis; in other words, the terms fracture and osteoporosis documented on the same record do not equate to a diagnosis of pathological fracture. A physician must clearly document this cause-and-effect relationship with terms such as osteoporotic fracture, fracture due to/associated with osteoporosis, or similar language. Without this link, the CDI specialist or coder must query the physician. In ICD-10-CM, however, this cause-and-effect relationship is assumed, supported by the following guidance from the ICD-10-CM Official Guidelines for Coding and Reporting (I.C.13.d.2): Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. This guidance clearly directs the coder to assign the code for pathological fracture, supporting an assumed causeeffect relationship between fracture and osteoporosis. This represents an echo of previous Coding Clinic advice, and coders and documentation specialists will no doubt welcome this explicit direction in the Guidelines because it averts the need for a provider query HCPro, Inc. April