CMS releases IPPS proposed rule for FY 2013 Malnutrition codes proposed for CC status; for downgrade

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1 cdijournal July 2012 Vol. 6 No. 3 Value-Based Purchasing hits in October 4 ACDIS Comments on IPPS proposed rule 7 Director s note 8 Meet a member 9 How to get physician support for CDI 10 Malnutrition criteria 12 Ask ACDIS 14 ICD-10 prep 15 Multi-facility CDI management 16 Recommendations for creating system-wide CDI programs 18 Chapters get new leadership 20 CMS releases IPPS proposed rule for FY 2013 Malnutrition codes proposed for CC status; for downgrade Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 inpatient prospective payment system (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes. In addition, the IPPS proposed rule contains provisions to strengthen the Hospital Inpatient Quality Reporting (IQR) program and proposes new policies and measures for the Hospital Value- Based Purchasing (VBP) program. If the goal is to reward excellence, hospitals have to ensure that their coders are up to speed with appropriate identification of complications and with [present-on- admission] indicators as well as the over- documentation issues that could lead to financial penalties, says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. CMS also proposes a methodology to calculate the readmissions adjustment factor for inpatient hospitals that could result in a 0.3% decrease in overall payments to hospitals. Coding changes CMS did not propose any major changes to the ICD-9-CM code set, which affirms its commitment of minimal updates to ICD-9-CM until ICD-10 implementation, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc, in Danvers, Mass. Since the current proposal is to use ICD-9-CM until October 1, 2014, it potentially adds another year of limited updates, she says. (See related article regarding the still unsettled ICD-10 implementation date on p. 14.) For FY 2013, if a patient has a principal diagnosis of influenza with pneumonia (ICD-9-CM code 487.0) and a secondary diagnosis code from a specific list of pneumonia codes, CMS proposes assigning the case to MS-DRGs 177, 178, and 179 instead of MS-DRGs 193, 194, and 195. CMS proposes to make three additional codes CCs and change one MCC to a CC for FY It does not plan to add any MCCs or delete any CCs. CMS proposes adding the following diagnoses to the CC list: 263.0, Malnutrition of moderate degree 263.1, Malnutrition of mild degree 440.4, Chronic total occlusion of artery of the extremities It also is proposing to change the severity level of diagnosis code (acute kidney failure with other specified pathological lesion in kidney) from an MCC to a CC.

2 While I support many of their CC/MCC changes, such as making mild and moderate malnutrition a CC, I am saddened that CMS still refuses to make heart failure not otherwise specified a CC, says James S. Kennedy, MD, CCS, CDIP, managing director at FTI Healthcare in Brentwood, Tenn. IQR proposed changes The IQR program currently includes 72 quality measures. CMS has proposed reducing that number to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination. Hospitals choose to participate in the IQR program, but CMS reduces the annual payment update for those that do not successfully participate by 2%. CMS proposes adding perinatal care and readmissions, including overall readmissions and readmissions relating to hip and knee replacement procedures, to the IQR quality measures for FY In addition, CMS would also measure how well hospitals use a surgery checklist designed to reduce errors. VBP proposed changes Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments based on how hospitals perform or improve their performance on a set of quality measures. (Read the related article regarding the VBP program on p. 4.) For the FY 2014 VBP program, the proposed rule includes a new outcome measure that rewards hospitals for avoiding central line associated bloodstream infections that can develop during inpatient hospital stays. For the FY 2015 Hospital VBP program, CMS proposes grouping and scoring measures in four domains: clinical process of care, patient experience of care, outcome, and efficiency. CMS also proposes adding a total of four new measures to the list. Readmissions Reduction Program methodology In last year s IPPS final rule, CMS began implementation of the Readmissions Reduction Program for three conditions: acute myocardial infarction (i.e., heart attack), heart failure, and pneumonia. CMS also finalized its definition of readmission as occurring when a patient is Advisory Board ACDIS Director: Brian Murphy, CPC bmurphy@cdiassociation.com Associate Director: Melissa Varnavas, CPC mvarnavas@cdiassociation.com 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, Fla. 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 Fran Jurcak, RN, MSN, CCDS Director, CDI Practice Huron Healthcare Chicago, Ill. fjurcak@huronconsultinggroup.com James S. Kennedy, MD, CCS, CDIP Managing Director FTI Healthcare Brentwood, Tenn. james.kennedy@ftihealthcare.com Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS Independent Consultant Madison, Wis. glennkrauss@earthlink.net Trey La Charité, MD Physician Advisor University of Tennessee at Knoxville Knoxville, Tenn. Clachari@UTMCK.edu Gail B. Marini, RN, MM, CCS, LNC Manager, Clinical Documentation South Shore Hospital Weymouth, Mass. Gail_Marini@sshosp.org Dee Schad, RN, BSN, CCDS Director Care Coordination and CDI Clark Memorial Hospital Jeffersonville, Ind. 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, Ind. 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 ( ) Robin R Holmes, RN, MSN ( ) Pam Lovell, MBA, RN ( ) Shannon E. 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 Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , 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 July HCPro, Inc.

3 discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period [30 days] from the time of discharge from the index hospitalization. In the FY 2013 IPPS proposed rule, CMS proposes to codify the definition of excess readmission ratio as: a hospital-specific ratio for each applicable condition for an applicable period, which is the ratio (but not less than 1.0) of (1) risk-adjusted readmissions based on actual readmissions for an applicable hospital for each applicable condition to (2) the risk-adjusted expected readmissions for the applicable hospital for the applicable condition. In addition, CMS proposes defining base operating DRG payment amount under the Readmissions Reduction Program as the wage-adjusted DRG operating payment plus any applicable new technology add-on payments. CMS also proposes to exclude the difference between the hospital s applicable hospital-specific payment rate and the federal payment rate from the definition of base operating DRG payment amount. Additions to the HAC list CMS proposes adding two conditions to the list of HACs for 2013: Surgical site infection following cardiac implantable electronic device (CIED) Iatrogenic pneumothorax with venous catheterization Coding and documentation adjustment CMS expects the FY 2013 proposed documentation and coding adjustment (DCA) to net an aggregate increase of 0.2%. The DCA was originally established at the time CMS implemented MS-DRGs. It was thought that due to the increased need for specificity, facilities would focus attention on improvements to documentation. The shift in coding would not necessarily indicate that facilities were treating sicker patients than they had previously, only that they were now better able to capture that specificity. The last two years, the DCA has resulted in a payment offset of -2.0% and -2.9%. In good news, the documentation and coding adjustment actually works in the provider s favor this year, increasing reimbursement by 0.2%, Kennedy says. That s a substantial increase from previous years. Comments on the proposed rule CMS accepted comments on the proposed rule until June 25 and is expected to publish its final rule by August 1. (Read the ACDIS Advisory Board s comment letter to CMS on p. 6.) Editor s note: This article was written by Michelle Leppert, CPC-A, for HCPro, Inc. Inpatient facilities do not receive higher MS-DRG payments for patients with complications or major complications caused by the conditions on the HAC list. CMS also plans to add two codes to the existing vascular catheter associated infection HAC category: (bloodstream infection due to central catheter) (local infection due to central venous catheter) The addition of the surgical site infections from CIEDs seems to follow along with the inclusion of other site infections already on the HAC list, especially given an increased focus on ensuring sterile environments to avoid contamination of a primary infection at the time of placement of such devices, McCall says. The Lord giveth and the Lord taketh away HCPro, Inc. July

4 VPB hits hospital finances in October Documentation in today s records may affect payments in FY 2014, 2015 Some say it s all about the carrot and the stick, the penalty and the reward. Provide quality care at an appropriate cost to Medicare and earn the reward of incentive payments and better patient outcomes. Fail to reduce costs or fail to meet quality measures and your facility could lose out on those incentive payments a loss of up to 1% of all MS-DRG payments in FY 2013, and up to 2% by (See the related chart below, which illustrates the percentage of payments for Hospital Value-Based Purchasing [VBP], Hospital Readmissions Reduction Program, and hospital-acquired conditions incentives.) Others say the VBP program as outlined in the fiscal year (FY) 2013 inpatient prospective payment system (IPPS) proposed rule is just another government attempt to reduce payments to already strapped healthcare systems. (Read the related article regarding IPPS proposals on p. 1 and the ACDIS Advisory Board s comments on p. 7.) In an April press release, however, CMS Acting Administrator Marilyn Tavenner said [VBP] is part of a comprehensive strategy to use Medicare s payment systems to foster better care and better value in all settings, thereby reducing overall Medicare spending. 1 In July, CMS will provide eligible hospitals with reports explaining their estimated incentive adjustments via their QualityNet accounts. VBP basics The VBP program stems from the 2010 Patient 1 Downloads/ Message.pdf Value-Based Purchasing, Hospital Readmissions Reduction Program, and hospital-acquired conditions reimbursement incentives Source: Kristen Geissler, MS, PT, CPHQ, MBA, principal, clinical economics, Berkeley Research Group, LLC, Cockeysville, Md., presented during the 2012 ACDIS National Conference in San Diego. 4 July HCPro, Inc.

5 Protection and Affordable Care Act. It made its first appearance in the FY 2012 IPPS final rule. (Read more about the VBP core requirements in the July issue of the CDI Journal. 2 ) Essentially, the VBP program adopts performance measures under two domains : 1. Clinical processes, composed of 12 basic measures including heart failure, AMI, surgery, pneumonia, and healthcare-associated infections. These are elements which were previously identified under the Hospital Inpatient Quality Reporting Program or QualityNet, better known as Reporting Hospital Quality Data for Annual Payment Update. CMS weighs these measures at 70% of a facility s total VBP score and will measure the facility s performance (0 10) against a statewide threshold and benchmarks. It also will score how well a facility 2 improves its measures year-over-year (0 9). 2. Patient experience, as determined by data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. CMS will weigh these measures as 30% of the total VBP score. Again, facilities will be measured against statewide threshold/benchmarks (0 10) and on year-over-year performance (0 9). CMS will also factor in consistency based on the lowest of eight HCAHPS scores (0 20). Added measures In this year s IPPS proposed rule, CMS added a new measure for Medicare spending per beneficiary for both Part A and Part B payments, with related financial incentives set to take effect beginning in FY If approved, the measure would take into consideration costs per beneficiary from three days prior to an inpatient hospital admission Value-Based Purchasing performance measurement timeline Source: CMS Open Door Forum Wednesday, February 29, HCPro, Inc. July

6 through 30 days post discharge and would be risk-adjusted for the beneficiary s age and severity of illness. The proposed rule adds a central line associated bloodstream infection measure to the healthcare-associated infection lists, and adds measures for perinatal care. Readmission measures will be expanded from excess readmissions for heart attack, heart failure, and pneumonia to include readmissions relating to hip and knee replacement procedures. Staggered measurements The VBP also includes a staggered reimbursement method, which has drawn some criticism from industry professionals. (View a sample timeline from CMS on p. 5.) For example, the baseline measurements for the FY 2014 (calendar year October, 2013) mortality performance measure began July 2011 and ended on June 30, Monitoring of FY 2014 clinical performance measurements began in April 2012 and will end on December 31, 2012, according to a timeline presented by Donald Howard, CMS project lead for the office of clinical quality and standards in an Open Door Forum on February 29. (View the presentation on CMS YouTube Channel. 3 ) CMS will make incentive payments based on how well hospitals perform on each measure or how much they improve their performance as compared to their baseline assessments. A lot of people see the [timeline] and think they have time yet to worry about VBP measures. But the benchmark performance period for many measures already started. So facilities that haven t looked into this are already behind, says Susan Wallace, MEd, RHIA, CCS, CCDS, CDIP, director of compliance and inpatient consultant at Administrative Consultant Service, LLC, in Shawnee, Okla. CDI focus Some CDI professionals have expanded their scope of record reviews to incorporate VBP measures already, says Kristen Geissler, MS, PT, CPHQ, MBA, principal of clinical economics for the Berkeley Research Group, LLC, in Washington, D.C. But most have not. Those programs reviewing records primarily to capture CC/MCCs need to be digging deeper to ensure secondary 3 diagnoses are captured in the record and to start looking at mortality measures. Even if they just add capturing secondary diagnoses to their list of review priorities it could impact the risk adjustment model for these mortality measures, says Geissler. But adding VBP priorities to the CDI staff s work list could be problematic, says Wallace. Facilities are under the gun to show return on investment for the programs they implement, she says. Queries are easier to justify when they move the DRG assignment from A to B. Queries that help to establish the patient s severity of illness are just as important to reporting accuracy, but more difficult to quantify. The fact that VBP measures will be tied to reimbursement beginning October 1, 2012 should help draw additional focus on what CDI specialists can do to help capture and report clinical data, Wallace says. While CDI specialists need to review and query all documentation requiring clarity or added specificity, and not just diagnoses that affect CC/MCC assignment, coders also need to make sure they are appropriately reporting all these secondary conditions, says Geissler. They need to know it is important to code the secondary conditions even if those conditions do not affect the financial picture of that particular stay. Connection with quality Geissler admits that more staff members in the quality outcomes arena are likely to understand the implications of this shift in reimbursement focus, but CDI professionals need to reach out to ask how CDI can help, she says. It s not that CDI should lose its primary focus but rather that it can offer an insight and information exchange that both departments can benefit from. CDI can raise the level of the conversation, says Wallace. While other departments may be aware of VBP incentives and conducting their own efforts to address the issue they may not understand how CDI can help capture all the necessary information in the medical record in a concurrent, timely way. This isn t going away, says Geissler. The impact of VBP is only going to increase every year from now on. Many people want to hide and wait for the storm to pass but this storm isn t passing. 6 July HCPro, Inc.

7 ACDIS comments on IPPS proposed rule Editor s note: The following is an excerpt from ACDIS letter to CMS regarding the inpatient prospective payment system (IPPS) proposed rule for fiscal year (FY) 2013, sent on June 11, ACDIS is pleased to comment on the proposed changes to the Medicare Hospital IPPS and proposed FY 2013 rates, as published in the May 11 Federal Register (CMS-1588-P). Protein-calorie malnutrition We applaud CMS proposal to add these diagnoses to the CC list: 263.0, Malnutrition of moderate degree 263.1, Malnutrition of mild degree This proposal recognizes the increased costs of treating these patients. It also rewards hospital effort in properly classifying patients with different stages of malnutrition. Acute kidney failure with other specified pathological lesion in kidney ACDIS disagrees strongly with the proposal to change the severity level of diagnosis code (acute kidney failure with other specified pathological lesion in kidney) from an MCC to a CC. This downgrade penalizes hospitals willing to take on sicker patients since additional care is required to treat patients with this condition. It also hurts hospitals whose clinical documentation staff, in conjunction with providers, perform the additional work of identifying the underlying cause of the kidney failure. In its commentary last year regarding the 2012 IPPS proposed rule, ACDIS expressed its sincere disappointment that the ICD-9-CM Cooperating Parties chose not to expand the classification of acute kidney injury (AKI) into the three stages of severity outlined by the Acute Kidney Injury Network and advocated by the National Kidney Foundation at the ICD-9-CM Coordination and Maintenance Committee meeting in April We would again like to state that AKI stage 2, stage 3, or those patients requiring acute dialysis warrant resources that would qualify these as MCCs if there were more specific codes than to report them. We hope that CMS will use its influence as a member of the Cooperating Parties to expand these codes, even though the codes are frozen, given that the Kidney Disease Improving Global Outcomes (KDIGO) will soon release guidelines ( defining this disease, and will likely introduce the new term acute kidney disease for which ICD-9-CM and ICD-10-CM codes will be needed for proper classification and reimbursement. Influenza with pneumonia We support CMS proposal to reassign cases with a principal diagnosis code (influenza with pneumonia) to MS-DRGs 177, 178, and 179 instead of MS-DRGs 193, 194, and 195. This reassignment allows the capture of a more severe type of pneumonia that results in significantly higher average costs. FY 2013 MS-DRG documentation and coding adjustment (DCA) Even though the DCA results in a net positive revenue impact of 0.2% for hospitals this year, and is also ending this year, we believe that the DCA is unfairly punitive. ACDIS also believes that the DCA is a flawed metric that requires further analysis and/or greater transparency. For example, it does not appear to account for hospitals that may have added an expensive new surgical service line that increased its case-mix index (CMI). It also does not seem to recognize the fact that the increased trend toward treating patients on an outpatient basis and more rigorous standards for inpatient admissions has resulted in patients that are more severely ill on admission. These sicker patients have resulted in real changes to the case mix for hospital discharges, not artificial changes to the CMI as a result of better documentation and coding. We note that the American Hospital Association last year in its commentary ( letter/2011/ cl-fy12ippsprprule.pdf) to CMS on the 2012 IPPS proposed rule noted that CMS only analyzes a single year of claims to determine whether there is a change in documentation and coding practices relative to prior years. It is our sincere hope that CMS not consider restoring the DCA following the implementation of ICD HCPro, Inc. July

8 Director s note Case-mix index: Use with caution Many CDI managers use casemix index (CMI) as the primary metric for determining the success or failure of their program. If the CMI rises in a given month, the CDI staff is doing its job, appropriately querying physicians for the correct principal diagnosis and accompanying complications/comorbidities. If the CMI dips, CDI staff aren t getting physicians to respond, or aren t reviewing records thoroughly enough. Or so goes the common logic. But using CMI as your solitary or even principal metric for success is fraught with problems. Sure, CMI shows a good snapshot of the type of patients a hospital is treating. But as a cold piece of data in isolation it does not tell the story of what is going on inside the walls of a given facility. For example, what happens if a high-volume heart surgeon in your hospital takes two weeks vacation this summer? Your CMI will dip, perhaps significantly if you work in a small facility. What happens if your hospital adds an expensive new neurosurgery service line? Your CMI is going to climb. And both of these factors are out of the hands of CDI. Is this the measure you ultimately want to be judged against? Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS an independent revenue cycle consultant from Madison, Wis., and a member of the ACDIS advisory board, has uncovered another problem with CMI as a CDI metric: It doesn t account for takebacks from Recovery Auditors (commonly known by their original acryonym RACs), Medicare Administrative Contractors (MACs), and other audit entities. Krauss refers to CMI as the cost to buy the product. We should be using gross margin, instead of CMI. Gross margin is gross increase in case mix minus the take-backs. That s the net benefit. Krauss cites a New England hospital currently under scrutiny as part of an Office of the Inspector General study. An auditor is reviewing more than 100 records of DRG 252, Other vascular procedures with MCC. These records were selected primarily for the fact that they contained only one MCC. In many of these charts encephalopathy was written only once in the chart, and without the necessary consistency or continuity. Undoubtedly, these MCCs will ultimately be denied by the reviewer, Krauss says. The result is an artificially high CMI that will come back down. What is the net benefit if we don t solidify the chart to remain accurate? Krauss asks. Instead of declaring victory after a query results in documentation of a single shaky CC or MCC, Krauss says CDI specialists should pursue valid and explicit, wellorchestrated documentation throughout the chart. This solidifies the entire chart and ultimately results in a more accurate CMI. In short, CDI departments shouldn t ignore CMI. But if you do use it, make sure you account for other contributing factors. Deduct valid auditor recoupments from your numbers. And strive in your efforts to create a strong chart, top to bottom, that can withstand scrutiny. Doing so ensures that your CMI is a true reflection of severity of illness and not an easy auditor target. Take care, Brian D. Murphy, CPC bmurphy@cdiassociation.com , Ext July HCPro, Inc.

9 Meet a member Medical librarian learns tips from ACDIS Debra Debi G. Warner serves as the clinical librarian for Anthelio Healthcare Solutions, Inc., in San Antonio. She has a master s degree in library and information science and received her Academy of Health Information Professionals (AHIP) certification from the Medical Library Association. CDI Journal: How long have you been in CDI? DW: One year in July. This is a funny story. My boss asked me to attend a CDI training course with one of our nurses. It turns out this course is a natural for a librarian. The documentation and codes make sense because librarians use subject headings and classification numbers to catalog books in libraries. Medical librarians also have a long history with teaching physicians how to use technology. CDI Journal: What did you do before? DW: Many things (I m old!). I ve been a librarian in several hospitals, colleges, universities, and medical schools. I ve also been an instructional designer, a managing director for an EMR[electronical medical record] implementation team, and an IT relationship manager for physicians in a hospital. CDI Journal: How did you get interested in CDI? DW: My boss is the chief medical officer. She teaches physicians about CDI. She needed me to help with research and instructional design. CDI Journal: What is your biggest challenge? DW: Definitely understanding the clinical information in CDI. An RN would know that a blood pressure over 180/114 needs attention, but I don t. I have to look things up and learn. Fortunately, my husband is an RN and my daughter is an RN case manager, so I have some built-in reference sources in addition to my skills as a librarian. CDI Journal: What has been your biggest reward? DW: Teaching. I have had the opportunity to teach both documentation improvement and introduction to ICD-10 to physicians, office managers, residents, and midlevels, and it has been really fun. CDI Journal: Why would a clinical librarian join ACDIS? DW: I have so much to learn from ACDIS members. Because of my work with the CDI nurses in our company, it s the place for me to be. I can research answers, but listening to ACDIS members teaches me analytical thinking for CDI. I get new ideas, new viewpoints, and even new questions to ask from my interaction with ACDIS. At the conference I learned some neat tips for approaching and teaching physicians. CDI Journal: What was your first job? DW: You don t mean car hopping, right? My first real job after college was as a library assistant in a college library. That was before I earned my library degree. I made $4,700 for the whole year! Courtesy photo Debi Warner ( the real me as she describes herself), at the top of Haleakala Crater on Maui in Hawaii. A few other facts about Debi: Favorite vacation spot: I m a bird-watcher, so I d like to go anywhere there are birds I haven t seen yet. Favorite non-alcoholic beverage: Lemonade (sugar free I make my own and here is the recipe: 1/2 cup lemon juice, 1cup of Splenda, and enough water to fill a 2 qt container. Favorite foods: My major food groups include chocolate, peanut butter, and ice cream. Favorite activity: When I m inside, I cross-stitch. I ve done Christmas stockings for all five of my grandchildren HCPro, Inc. July

10 Get with the (CDI) program, doc! by Trey La Charité, MD We all agree: Better medical record documentation helps the patient, the physician, and the hospital. So why do we have so much trouble getting physicians to implement suggestions made by the CDI staff? If your facility is anything like mine, provider compliance varies greatly. What always amazes me and our CDI specialists here is which physicians participate and which do not. Let s look at some reasons why physicians choose not to adopt CDI goals and what remedies we might implement to gain wider acceptance of CDI principles. Recasting the financial focus First, the inescapable elephant in the room that must be effectively and decisively crushed is money. Unfortunately, the gut reaction of most doctors is that CDI is something that benefits only the hospital through an increased profit margin. While CDI professionals know this is not true, this initial reaction is understandable. After all, from where does the impetus for most CDI programs originate? The chief financial officer s (CFO) office, of course! And, frequently, the CFO has jumped onto the CDI bandwagon because he or she learned how another facility improved their case-mix index (CMI) by implementing CDI initiatives. Although the CMI is merely a reflection of how sick the patients are in a hospital, to a CFO, a higher CMI simply equals greater revenue. Unfortunately, this means that your fledgling CDI program may have a public relations problem before it ever gets off the ground. How do we remedy this problem? Education, education, education! The majority of doctors do not understand the increasing availability of their performance data to the general public, the insurance companies, and our government. Why is this important? Our government (via new Medicare payment rules) has embarked on a strategy of healthcare reform through forced competition between healthcare providers. The theory is that patients will choose the doctors and facilities that have better outcomes and fewer complications at a lower cost. Additionally, insurance companies and employers will intentionally steer their beneficiaries and employees toward the providers who display these same qualities. The ultimate question becomes whether new patients will want (after reviewing performance data on the Internet) or be able (through reduced copays to see the better providers) to be treated by your physicians in your hospitals. Yes, the probable short-term goal of any new CDI program is increased revenue at the CFO s behest. The longterm goal of all CDI programs is to ensure the flow of new patients through your doors through better performance data. Exploring new payment initiatives Let s look at the money issue from a different point of view. While this next line of reasoning casts physicians (my chosen profession, by the way) in a negative light, I have found that one sure way to modify physician behavior is to attack their wallets. When CMS instituted the DRG system in 1983, hospitals and individual physicians were suddenly no longer paid the same way. Hospitals now receive only one reimbursement check covering the entirety of the care provided during a hospitalization, no matter how long the patient remained in that hospital bed. Physicians meanwhile continue to submit daily E/M charges. Hospitals suddenly became concerned with patient length of stay while physician priorities did not change. Inevitably, conflict and friction ensued. I am sure that you have heard physicians say, I don t care about the hospital as long as my patient is taken care of. This mentality is the unfortunate result of the current non-alignment that exists between the hospital and physician reimbursement systems. Physicians need to be reassured that your program benefits them as much as the hospital. The solution to this component of the money issue requires realignment of physician reimbursement with their host hospitals. This will occur mainly via three mechanisms: 1. The various recovery audit programs (formerly called RACs) will increasingly demand that the physician fees be returned in addition to the hospital s MS-DRG reimbursement if the medical necessity of a given inpatient admission or procedure is successfully challenged and denied. 10 July HCPro, Inc.

11 2. Pay-for-performance initiatives and value-based purchasing programs are increasingly tying physician and hospital reimbursements to their performance data. For the providers, this means poor performance metrics will result in reduced reimbursement. 3. Bundled payments will eventually become a reality, ending the current system of separately paying the doctor and the hospital. In most proposed bundled payment system scenarios, there will be only one check and it will be written to the hospital not the physician. The hospital and the physician will then have to negotiate who gets what portion of that check. Imagine how compliant your interventional cardiologist will become if he or she suddenly has to scramble to make a monthly Porsche payment. When doctors realize that they have their own necks on the line, they too will willingly get on board the CDI bandwagon. Turning back the clock Another reason for physician resistance is time. Most physicians work far more today than they ever expected to when they completed their medical education. While no physician expects the medical profession to be without sacrifice, the simple fact is that there are not enough doctors for every person who needs medical care. Consider their ever- increasing patient load, coupled with the constant barrage of new government regulations, insurance company requirements, hospital process improvements, and the ever- increasing monstrosity of paperwork. You soon realize that time is one of a doctor s most precious resources. Today s physicians are pressed and stressed for time. The solution to push-back stemming from a physician s time deficit is to demonstrate the time neutrality of a new initiative. If CDI professionals can show physicians that they can document more in their charts but not negatively impact their time limitations, physicians are more likely to comply. My solution/sales pitch goes something like this: What s the one dictation that all physicians hate doing more than any other? Invariably, it is the discharge summary. If physicians take an extra minute or two to keep a complete and accurate problem list in their daily progress notes, they will dramatically reduce the time and frustration of the discharge summary dictation. How? With this process the physician simply reads the last day s problem list into the dictation machine at the time of discharge and they are done. This approach eliminates the need for the physician to spend precious time fumbling through the entirety of the medical record trying to figure out what went on with the patient while he or she was in the hospital. Imagine the time savings for a physician who dictates the discharge summary of a patient that he or she only took care of for the last one or two days of a 20-day hospital stay (a frequent occurrence I encounter as a hospitalist). Selling physicians on this approach demonstrates that additional documentation is both time neutral and stress reducing. While no physician expects the medical profession to be without sacrifice, the simple fact is that there are not enough doctors for every person who needs medical care. Passing over the noncompliant Lastly, and sadly, some physicians will never comply with what you ask regardless how great the benefit or consequence. My advice is to skip them. Move on to those whom you can positively influence. The recalcitrant ones will eventually retire or become the victims of their own obstinate behavior through the mechanisms previously mentioned. The effectiveness of a CDI program will ultimately be measured by its long-term contributions, not the immediate gains of just one or two charts. Unfortunately, most doctors do not recognize the rapidly changing healthcare environment they now live in. Ten years ago, medical knowledge needed to effectively carry out the practice of medicine and the newly developed technology available to practice that medicine changed at a whirlwind pace. In contrast, today s healthcare environment is changing more rapidly than the new medical knowledge or the advent of medical technology. The bottom line is that physicians need to take charge of their publicly reported performance data by accurately describing how sick the patients are in their care. If they don t, they face the possibility of not having enough patients to keep their offices or hospitals open. Editor s note: La Charité is an ACDIS Advisory Board member, a hospitalist, and the physician advisor for CDI and coding at the University of Tennessee at Knoxville. He is also a clinical assistant professor with the Department of Internal Medicine. Contact him at clachari@utmck.edu HCPro, Inc. July

12 New malnutrition criteria could help ensure consistent coding New clinical guidelines for malnutrition could help alleviate compliance challenges associated with coding the condition, which has never had universally accepted clinical criteria. New guidelines published in the May 2012 Journal of the Academy of Nutrition and Dietetics represent a consensus statement of the American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN). The Academy and ASPEN both advocate for provider use of a standardized set of diagnostic characteristics to identify and document adult malnutrition, says Jane White, professor emeritus in the Department of Family Medicine at the University of Tennessee in Knoxville. White also serves as chair of the Academy s adult malnutrition work group. The Academy and ASPEN say malnutrition should be diagnosed when at least two or more of the following six characteristics are identified: 1. Insufficient energy intake 2. Weight loss 3. Loss of muscle mass 4. Loss of subcutaneous fat 5. Localized or generalized fluid accumulation that may sometimes mask weight loss 6. Diminished functional status as measured by hand grip strength Don t fall into a compliance trap This all comes as good news for coders and providers who continue to struggle with third-party audits of CC and MCC conditions, including malnutrition, says James S. Kennedy, MD, CCS, CDIP, managing director at FTI Consulting in Atlanta. At a Maryland hospital employees allegedly used leading queries to add malnutrition as a secondary diagnosis. The Baltimore facility denied the accusations, but agreed to pay nearly $800,000 to resolve the False Claims Act violation allegations, according to a March 28 press release from the U.S. Department of Justice, available at com/d4j6hqy. If patients had truly had malnutrition, it wouldn t have been as much of an issue, says Kennedy. He attributes incorrect malnutrition coding to a lack of consistent clinical criteria and says that many CDI programs also incorrectly define malnutrition based solely on low albumin or prealbumin levels. Another facility in Redding, Calif., allegedly billed Medicare for treatment of more than 1,000 cases of kwashiorkor over a two-year period, according to a California Watch analysis of state health data. Kwashiorkor, a form of malnutrition that occurs when a diet lacks sufficient protein, is very rare in the United States, and is not something that coders encounter frequently, says Providers must assess these six characteristics in the context of an acute illness or injury, a chronic illness, or social or environmental circumstances to determine whether malnutrition is present and whether it s severe or non-severe (moderate). The article, available at provides a table with more detailed clinical criteria to which providers can refer when documenting severity levels for malnutrition. The Academy and ASPEN have asked the NCHS to adopt ICD-9-CM malnutrition codes that use etiologicalbased nomenclature, says White. If adopted, the ICD- 9-CM codes will better reflect the clinical presentations that providers encounter when assessing malnutrition, she says. 12 July HCPro, Inc.

13 Alice Zentner, RHIA, director of auditing and education at TrustHCS in Springfield, Mo. Physicians must specifically document the term kwashiorkor for coders to report it, she says. Although the ICD-9-CM index instructs coders to report code 260 (kwashiorkor) for unspecified protein malnutrition, Coding Clinic, Third Quarter 2009, p. 6 discourages assignment of this code when physicians document moderate or mild protein malnutrition, says Kennedy. Rely on helpful strategies Coders should remember and use the following strategies: Don t always assume documentation is correct. It may seem counterintuitive, but coders should question a diagnosis when it appears that no clinical evidence supports it, says Kennedy. For example, physicians often incorrectly diagnose malnutrition based solely on a low albumin or prealbumin, he says. Third-party auditors will challenge this diagnosis, and coders should also question it, he says. Coders must ensure that severe protein-calorie malnutrition an MCC is documented consistently and treated, says Zentner. If that code is on a record, it s certainly a red flag for a RAC to audit, she says. Malnutrition must also meet the definition of a reportable secondary diagnosis, says Zentner. Coders should also remember not to report cachexia, a wasting syndrome, as malnutrition instead, cachexia is denoted by a symptom code (799.4), she says. Hospitals should develop policies that explain how coders should address inconsistent and unreliable diagnoses, says Kennedy. Unreliable diagnoses are those that don t meet reasonable criteria established by the medical staff. Once identified, these diagnoses should be vetted by a coding supervisor, physician advisor, or CDI specialist, he says. Beware of leading queries. A malnutrition diagnosis often may not be documented when a patient does, indeed, have the condition. However, CDI staff cannot lead physicians when requesting clarification, says Kennedy. We are allowed, as coders [and CDI professionals], to ask providers for the clinical significance of abnormal labs or clinical findings, he says. Consider the following query based on the new criteria from the Academy and ASPEN: Dear Dr. Malnutrition The following clinical indicators are in the medical record: Current BMI Stress indicator (circled) Acute illness Chronic illness Social Energy intake over the previous days % Amount of weight loss over days % Loss of subcutaneous fat (circled) None Mild Moderate Severe Loss of muscle mass (circled) None Mild Moderate Severe Fluid accumulation (circled) None Mild Moderate Severe Measurably reduced grip strength present (circled) Yes No Please indicate what diagnosis best correlates with these findings: Cachexia without malnutrition Nutritional risk without malnutrition Malnutrition, severity unknown Malnutrition, non-severe (moderate) Malnutrition, severe, not otherwise specified Marasmus A specified severe protein-calorie malnutrition Kwashiorkor A specified severe protein malnutrition Another medical diagnosis Other (please specify) Cannot be determined Other clinical evidence in the record that might suggest malnutrition includes chronic disease, insufficient intake preor postoperatively, infection, malabsorption, muscle wasting, poor wound healing, or lethargy, says Zentner. Collaborate and educate. Ask CDI specialists to educate physicians about malnutrition clinical indicators, advises Kennedy. Also advocate for predischarge queries. The query for malnutrition is really best done in a predischarge environment in collaboration with dietitians, nutritional teams, and the CDI team, he says. Editor s note: This article originally appeared in the July issue of Briefings on Coding Compliance Strategies HCPro, Inc. July

14 Ask ACDIS MS-DRG assignment and cystic fibrosis I was interested in further discussion about cystic fibrosis coding. I am conducting an audit on MS-DRGs 177, 178, and 179, Respiration infections and inflammation with MCC, CC, and without CC/MCC. Cystic fibrosis with pulmonary manifestation charts can be tricky. I believe the correct and appropriate DRGs for these cases falls to They certainly command the respect of a higher-weighted DRG. However, AHA Coding Clinic for ICD-9-CM advice can be ambiguous. I believe Coding Clinic has been very clear in the sequencing of circumstances whereby a patient with known cystic fibrosis is admitted primarily to treat a pulmonary manifestation in light of the instructions in the coding manual s ICD-9-CM Index and in the Table of Diseases. First, let s look at the ICD-9-CM Table of Diseases. The only sequencing instruction for , Cystic fibrosis with pulmonary manifestation, is to use an additional code to identify any infectious organism present, such as pseudomonas (041.7). There is no requirement to code first if a patient is admitted with a pulmonary manifestation linked to cystic fibrosis. Second, let s look at Coding Clinic, Fourth Quarter 1990, p. 17, which states: In accordance with UHDDS requirements, the condition that occasions the admission to the hospital should be coded as the principal diagnosis. If a patient with cystic fibrosis is admitted due to a complication such as pneumothorax, 512.8; acute bronchitis, 466.0; acute cor pulmonale, 415.0; rectal prolapse, 569.1; gastroesophageal reflux, 530.1; the complication should be coded as the principal diagnosis and cystic fibrosis, 277.0x, reported as an additional diagnosis. If, however, the physician determines that the admission is due to the cystic fibrosis rather than a complication, cystic fibrosis should be assigned as principal diagnosis. This advice was reemphasized in Coding Clinic, Fourth Quarter 2002, pp with the institution of code in fiscal year It states: In accordance with UHDDS requirements, the condition that occasions the admission to the hospital should be coded as the principal diagnosis. If a patient with cystic fibrosis is admitted due to a complication or manifestation such as pneumothorax, acute bronchitis, acute cor pulmonale, the complication or manifestation should be sequenced as the principal diagnosis and cystic fibrosis reported as an additional diagnosis. If however, the physician determines that the admission is due to the cystic fibrosis rather than a complication, cystic fibrosis should be assigned as the principal diagnosis. The clinical example Coding Clinic used with acute bronchitis (which is an acute lung infection in the bronchus not involving the lung parenchyma) echoes this sequencing advice. It states on p. 46 of the same issue: Question: A 3-year-old patient with known cystic fibrosis is admitted to the hospital for treatment of acute bronchitis. How should this be coded? Answer: Assign code 466.0, Acute bronchitis, as the principal diagnosis since this condition meets the definition of principal diagnosis. Assign code , Cystic fibrosis with pulmonary manifestations, as an additional diagnosis. This is consistent with advice previously published in Coding Clinic, Fourth Quarter 1990, p. 17. The example used in Coding Clinic, Fourth Quarter 1990, p. 17 states: A 4-year-old patient was admitted due to chronic cough and lack of growth. Diagnostic workup and chest x-ray confirmed the diagnosis of cystic fibrosis. In this case the diagnostic workup was done to identify the underlying cause of cough and lack of growth. Therefore, cystic fibrosis (277.0x) would be the principal diagnosis. While bronchitis is not pneumonia, they are analogous. Therefore, I would think that if a patient with known cystic fibrosis is admitted primarily to treat pneumonia, the pneumonia would be the principal diagnosis, 14 July HCPro, Inc.

15 based on this explanation in Coding Clinic. This results in MS-DRG 193, Simple pneumonia with MCC. On the other hand, if the physician states in his or her discharge summary that the admission is primarily to diagnose cystic fibrosis rather than treat its complication, then is the principal diagnosis and 486 is the secondary, resulting in MS-DRG 177, Respiratory infections and inflammation with MCC. My guess, however, is that the cystic fibrosis has already been diagnosed and therefore would not be the principal, given that the circumstances requiring a patient to be an inpatient is to address the specified type of pneumonia treated. Patients with cystic fibrosis have a higher likelihood of pseudomonas as the causal agent. If their cultures are negative but the patient receives reasonable antipseudomonal therapy (e.g., IV pipercillin or oral ciprofloxacin) for a reasonable duration (e.g., over three or four days), and if the provider documented pneumonia probably due to pseudomonas at the time of discharge, then the coder can code pseudomonas pneumonia as the principal diagnosis, resulting in MS-DRG 177, Respiratory infections and inflammation with MCC ( would be the MCC). While this does not change the base DRG in APR- DRGs (pertinent to N.Y. Medicaid), it does increase the SOI and ROM that does impact reimbursement and mortality ranking. Editor s note: The ACDIS Quarterly Conference Call May 24 included discussion on sequencing cystic fibrosis vs. pneumonia when an individual with known cystic fibrosis is admitted with pneumonia, asking which diagnosis, either , Cystic fibrosis with pulmonary manifestations or 486, Pneumonia, organism unspecified, should be sequenced first when coding the inpatient admission. After the call, James S. Kennedy, MD, CCS, CDIP, managing director of clinical documentation and coding integrity at FTI Consulting in Brentwood, Tenn., provided the previous additional research and analysis. ICD-10 timeline still questionable Ramp up planning and implementation efforts nonetheless On April 17, the Department of Health and Human Services (HHS) released a proposed rule to delay the ICD- 10 code set implementation date from October 1, 2013, to October 1, The comment period on that proposal closed on May 17. As of the CDI Journal s publication deadline, CMS had not released a final rule with a final implementation timeline. The call for delay came after various provider groups expressed serious concerns regarding their ability to meet the initial 2013 compliance date; most notably, the AMA whose House of Delegates passed policy opposing the implementation in November At the AMA s National Advocacy Conference in Washington, D.C., CMS Acting Administrator Marilyn Tavenner initially indicated HHS inclination to consider the delay. In a letter to HHS Secretary Kathleen Sebelius 1, Dan Rode, MBA, CHPS, FHFMA, vice president of advocacy and policy for AHIMA, wrote that delaying ICD-10 implementation ignores both the efforts of the healthcare industry and the ability to use the much-improved data code sets to support the crucial data needed to move the nation toward an electronic health record (EHR) and exchange infrastructure that will improve the quality of care through more detailed data. There has been a lot of work already done in the healthcare industry in preparation for ICD-10, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, regional managing director of HIM, NCAL revenue cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, Calif. This work equates to monies spent already. The education and training timeline may need to be moved. Those that have already had some ICD-10 training may need refresher training now to retain the knowledge going forward. Despite the developments, ACDIS encouraged its mem HCPro, Inc. July

16 bers to stay the course with ICD-9 and ICD-10 documentation education, in a note from its Advisory Board published in the April 26 CDI Strategies. Hospitals continue to struggle with documentation and coding requirements under ICD-9; the best way to prepare for ICD-10 is to perform ICD-9 correctly and negotiate the differences between it and the new coding system, the letter states. Facilities should assess the readiness of their coding staff and evaluate current documentation procedures in relation to ICD-10 requirements. Although many facilities have implemented CDI programs in recent years in response to CMS payment initiatives many still have no documentation improvement efforts in place. Facilities need to craft strategies to manage any deficiencies in this area now before ICD- 10 implementation, Bryant says. Getting the additional specificity necessary under ICD-10 now is a good way to ensure a seamless transition to October 1, 2014, the ACDIS Advisory Board wrote. CDI specialists should use this time to improve their core competencies and knowledge base of ICD-10. All hospitals should continue with their education plans, says Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates in Plantation, Fla. Once we get a firmer foundation of what the date will be, you can always readjust the timeline. Hospitals can t sit in fear and become immobile. Editor s note: Portions of this article originally appeared in Briefings on Coding Compliance Strategies, Medical Records Briefings, and JustCoding.com. 1 on%204-17%20icd-10%20nprm_fin% pdf Four tips to tackle multi-facility CDI management It s Tuesday. For some CDI program managers that means jumping in the car and driving an hour or more to another hospital in their system to make rounds with CDI specialists there. For some, it s a routine that happens at least once a week; for others, once a month. Although the requirements of managing CDI programs and their staff at multi-facility hospital systems differ depending on a variety of factors, try the following four best practices for success. Standardize policies and procedures; then fine-tune for differences Meg McGill, RHIA, corporate director for HIM at Methodist Le Bonheur Healthcare in Memphis, Tenn., manages 19 CDI specialists across seven hospitals. In the beginning, McGill s primary role related to governing the overall direction of the healthcare system s CDI efforts. Each specialist reports directly to either the chief medical officer or performance improvement director at their facility and secondarily to McGill, whose primary job is to communicate CDI program data and effectiveness to facility and system management, she says. After little more than a year, Methodist Healthcare was ready to take the program to the next level, says McGill. We had to take a step back and take a deep breath to see where we wanted this program to go and how to get there. So they recently hired a CDI director, whose No. 1 task, will be to make sure all the processes are done consistently across all the sites, McGill says. Such overall consistency for program goals and processes matters, says Susan Tiffany, RN, CCDS, CDI program supervisor for Guthrie Healthcare System in Sayre, Pa. But flexibility matters, too, she says. A few of the challenges Guthrie faces include: One facility is in New York, the other in Pennsylvania. One is a small, rural community hospital and the other is a Level 2 trauma facility. One facility s CDI staff belongs to the nursing union; the other s doesn t. The New York facility has a large number of BlueCross denials; Pennsylvania does not. The Pennsylvania facility is also a teaching facility The New York CDI staff follows up on post-discharge queries; the Pennsylvania team does not. In the New York community hospital, a CDI specialist may see a physician in line at the lunch counter, casually ask how the road race went the previous weekend, and 16 July HCPro, Inc.

17 remind the physician about an outstanding query, Tiffany says. In the Pennsylvania facility, she says, it can be much more difficult to track the physician down. So while processes and governing policies at Guthrie s facilities mirror each other, each facility requires a specific focus and analysis, Tiffany says. When you assess your expectation for productivity, query response rates, and return on investment, you have to take all these factors into consideration, she says. I have to fine-tune the information to what is pertinent to each facility. Communicate consistently across hospitals CDI specialists working within a single facility often meet weekly to talk about any difficult records or problems with reviews. They also often sit near each other when not out on the hospital floors and may have team meetings or face-to-face interaction with each other daily. At Robert Packer Hospital in Sayer, Pa., it is easy to walk down the hall and talk to my staff, Tiffany says, but I have to remember that what I say to one group of individuals also needs to be communicated to the rest of my staff. To keep CDI staff on the same page, McGill holds monthly meetings for all CDI staff with the coding director and two lead coders who also attend. CDI specialists also meet monthly by facility with their immediate directors to discuss productivity, statistics, and facility concerns. Communication is definitely one of the big challenges, says McGill. You need to be sure you say the same thing individually that you say to the entire group. You have to have open communication and you have to get to know your staff. When concerns come up, they can talk to you one-onone, pick up the phone and call you, schedule an appointment, or send you an . Be sure to make time for that. But otherwise I really rely on . So does Bonnie Epps, MSN, RN, manager of CDI at Emory Healthcare in Atlanta. It is not often I get to meet face-to-face with each staff member, she says. We all work pretty independently. I trust them to do their best and we mostly communicate by . Staff members do meet monthly at individual facilities and quarterly for training and other meetings, with those from smaller facilities traveling to Emory s main campus. At Methodist Healthcare, however, McGill plans to have her new manager spend at least some time in every facility on a monthly or bimonthly basis. The better you know someone, the easier it is to communicate, she says. Know your staff Although absence may make the heart grow fonder, lack of communication can quickly turn fondness into indifference. You need to get to know your staff so they feel comfortable with you and you feel comfortable with them, McGill says. But long distances make face-to-face meetings difficult. It really took me about a year to get to that point because I never really get a chance to see them, she says. To resolve this dilemma Tiffany makes sure she reviews team members strengths and weaknesses, adds notes about developing abilities in their files, and regularly reviews and updates the information. I did not have any official managerial experience prior to taking this position, she says. My managerial experience stems from managing the care of multiple patients needs. Each patient has a different set of needs and each patient has a different set of capabilities. Managing staff is like that. You need to assess their individual skill levels and determine the best way to accomplish the goals at hand using those capabilities. Use available resources As a final tip, Tiffany encourages multi-facility managers to employ somewhat unconventional tools that they may not have thought of previously, and to avail themselves of ACDIS collective information. For example, fresh from the ACDIS conference in San Diego, Tiffany plans to develop an internal query audit program across both facilities. CDI staff will regularly audit each other s queries to make sure they are not leading or that they are not missing any potential query opportunities. And she recommends managers carry a digital recorder with them not to record conversations with noncompliant physicians, she laughs, but to help you focus and remember items you think of while between facilities. It can be a 45- to 60-minute drive, Tiffany says. That gives me a lot of downtime to shift my focus from the priorities of one program to the priorities of the other. It also gives me a lot of time to brainstorm new ideas. It could be as important as tracking a new metric, Tiffany says. And when inspiration strikes, you d better try to capture it HCPro, Inc. July

18 Multi-facility CDI management requires planning, communication by Fran Jurcak, RN, MSN, CCDS Implementing and monitoring a CDI program across a system with multiple hospitals is a complex and challenging experience. It requires a great deal of planning and attention to detail to ensure success. If you want to do it as seamlessly as possible, you must: Establish departmental policies and procedures Develop a process flow map Schedule educational sessions prior to the go-live date Although some minor changes in process may be necessary due to variances in facility size, physician service lines, and number of CDI staff, the variances in the processes from facility to facility as outlined in this article should be minimal. You can prevent miscommunication and identify barriers to a successful transition through careful planning (see the chart on p. 18 for a breakdown of recommended CDI program implementation activities). Once you implement the program and put your plans into effect, appoint a strong leader with the capability to ensure that processes are maintained across all facilities. This person should have the time, talent, and energy necessary to achieve this task. Plan first First, take the time to develop and establish policies and procedures that can guarantee consistency among facilities. The following is a process I recommend: Develop appropriate policies related to the CDI process. At a minimum, these should include communication of concurrent queries to the provider as well as reconciliation of unanswered provider queries prior to implementation. Implement a consistent set of tracking tools across all facilities. Complete your measurement methodology prior to the start date. Ensure consistent education and training of all staff, CDI specialists, and coders. Doing so provides all staff members with a common knowledge base to support the daily functions of the team. Establish a clear process flow map that supports staff in their daily work. This will go a long way to sustaining the goals of the program. Once this preparatory work is complete, you can deploy CDI across the system. Communicate second To ensure ongoing success of a multi-facility CDI program, you must be an effective communicator and establish a process of effective communication. Many CDI directors struggle to manage programs where the distance between facilities is too great to travel on a regular basis. In such situations, communication via conference calls and Web-based access work well. Still, face-to-face meetings create team cohesion and acceptance, so do not neglect at least annual visits to individual facilities. Aim for monthly or at least quarterly visits as a best practice. To that ensure clear and consistent communication occurs: Establish a network group Schedule monthly face-to-face team meetings and set clear agendas for those meetings Arrange one-on-one meetings between the CDI program manager/director and individual CDI staff members at least monthly Set regular site visits for each facility Share metrics regularly Make attendance mandatory at all virtual (telephone or Web conference) CDI team meetings. This measure ensures that CDI staff receive communication consistently. While consistency of goals and expectations is important regardless of the distance between facilities, the greater the distance, the more important this communication becomes. Make it a priority to speak regularly via phone with each CDI specialist when face-to-face meetings cannot occur. Communication should be delivered via a detailed agenda so that all team members receive the same information. Electronic data entry and Web-based tracking tools provide the most reliable method of monitoring metrics across a system. This also allows for live viewing of the data for evaluation of data correctness. 18 July HCPro, Inc.

19 Evaluate and enforce third Although I recommend that each facility monitor the same statistics/data points to ensure consistent evaluation of CDI program success, some situations make such applesto-apples comparisons inappropriate. For example, case-mix index, query rates, and CDI staff productivity may differ based on the size of the facility, its service line offerings, the percentage of its record that is electronic, and the number/ type of payers being reviewed. Although you may create reports for the system leadership using data collected from multiple facilities, you should create a separate report trending individual facility data. This enables you to evaluate an individual CDI specialist s performance. Query rates by facility may differ, too, due to physician acceptance and participation. Differences in physician buy-in/support for a CDI program impact the amount of time it takes an individual CDI specialist to review and query a given chart. Therefore, comparing CDI specialists statistics between a large teaching facility and a small general community facility in the same system is not reasonable. Instead, trend behavior over time and compare individual programs to like-sized facilities with similar service lines. Enforcement of system policies and procedures typically falls to the system CDI program manager/director with a dotted line of communication to facility leadership, such as the HIM manager/director or director of case management. This clear chain of command allows facility leadership to stay invested in the program while supporting the overall CDI mission of the entire system. Review and revise last Maintaining a cohesive and successful CDI program across multiple facilities requires constant attention to detail and establishment of clear pathways of communication. Remember to: Develop policies and procedures that allow for accurate work function and measurement of CDI metrics prior to system rollout. This will allow for identification of clear guidelines for success and openly detect process issues that may need refinement. Identify clear goals and expected outcomes and communicate them to the CDI team. This will allow for a successful transition to system accountability of a multi-facility CDI program. References Section III:6 System Implementation 177, NYS Project Management Guidebook: Keys to Successful System Implementation: Process Analysis, The Healthcare Informatics Associates Consulting Team: Process-Analysis.pdf. Editor s note: Jurcak is an ACDIS Advisory Board member and the director of CDI Practice for Huron Healthcare in Chicago. Contact her at fjurcak@huronconsultinggroup.com. Recommended activities for implementing CDI across a system Pre-implementation activities Implementation activities Post-implementation activities Develop system policies and procedures Schedule educational sessions for CDI Provide ongoing education team and physicians Develop system process flow map Utilize process flow map Review/update process flow map quarterly Identify measurement methodology Report metrics at system level Report metrics at local and system level Identify tracking tool Provide data entry Implement quarterly quality review to ensure data accuracy Schedule education Identify barriers to success at local and system level Transition ownership to local level Source: Huron Consulting HCPro, Inc. July

20 Volunteers step up to leadership roles in several chapters Editor s note: The following individuals were recently chosen to lead local ACDIS chapters in their areas. ACDIS currently has more than 40 local chapters across the country and is helping to facilitate additional networking efforts for CDI professionals in specialty areas. For more information, visit or for meeting information, visit our calendar page at acdis/calendar.cfm. California The California ACDIS chapter began in In the beginning, the state divided its networking efforts regionally into three groups covering the north, central, and southern regions. A year later, the groups consolidated in favor of monthly telephone conference calls/webinars, hosted by Dexter D Costa, MBBS, MHA, CRCR, regional director of clinical documentation integrity at NCAL Revenue Cycle, Kaiser Foundation Health Plan, Inc. & Hospitals, in Oakland. When D Costa took on additional duties requiring more responsibility, the time came to turn the reins of the group over to new leadership. ACDIS is proud to have the following individuals lead the CA ACDIS chapter for the coming year. Adriana van der Graaf, MBA, RHIA, CCS, CHP, HIM practice director for Jacobus Consulting in Rancho Santa Margarita, Calif., will serve as co-chair of the CA ACDIS chapter. She has more than 35 years of HIM and revenue cycle experience in facilities of all sizes, from 50 to 1,000 beds. She conducts ICD-10 assessment and remediation services, ICD and CPT coding audits, CDI program assessments and implementation, RAC management, HIM assessments, and operational redesign. She is a member of AHIMA, HFMA and HIMSS. Contact her at avandergraaf@ jacobusconsulting.com. Emily Emmons, RN, CDI specialist at Scripps Memorial Hospital in La Jolla, Calif., will also serve as co-chair of the CA ACDIS chapter. She has worked as a nurse in the emergency department and postanesthesia care unit, was a National Council Licensure Examination for Registered Nurses test-prep instructor, a clinical case manager, and a director of case management. She lives in San Diego and is currently working on her master degree in nursing at Point Loma Nazarene University. She earned her bachelor s degree from the University of Colorado Health Sciences Center in Denver, and is originally from Oklahoma City. She is looking forward to helping out with the CA ACDIS chapter and appreciates all the valuable information she learns from each meeting. Contact her at emmons.emily@scrippshealth.org. Michelle Limo, RN, MSN, MSMIT, CCDS, CCS, manager of CDI and coding compliance at Salinas (Calif.) Valley Memorial Hospital, will serve the CA ACDIS chapter by managing its membership lists and organizing its regular meetings. Her nursing experience includes telemetry/ medical-surgical units, outpatient surgery, and CDI, which she helped implement in Her favorite part of CDI is building strong relationships with physicians and showing them the impact and progress they are making, as well as closing the gap between physicians and coders. Contact her at mlimo@svmh.com. Paul Evans, RHIA, CCS, CCS-P, CCDS, CCS-P, supervisor of clinical data integrity in the quality department at California Pacific Medical Center in San Francisco, will help the CA ACDIS chapter solicit speakers, organize its meetings, and coordinate communications among the group. Evans previously served as a project manager at Laguna Medical Systems, where he was responsible for a staff of 12 senior auditors performing compliance reviews at more than 30 hospitals. An ACDIS and AHIMA member, Evans has contributed to multiple articles regarding quality and data management and is a frequent contributor to the CDI Talk networking group on the ACDIS website. Contact him at evanspx@sutterhealth.org. 20 July HCPro, Inc.

21 Kentucky/Southern Indiana When Dee Schad stepped down from her role as chapter leader to become an ACDIS Advisory Board member, she vowed to maintain a connection to the chapter she started more than two years ago. Schad left the group in capable hands as its new leaders have also been with the group since its inception. The chapter boasts more than 80 members, with roughly people attending its quarterly face-to-face education sessions. The group will hold its first regional meeting in association with the Indiana ACDIS Chapter August 23. Rita Fields, RN, BSN, CDI specialist at Baptist Hospital East in Louisville, Ky., is the new co-chair of the Kentucky/Southern Indiana ACDIS chapter. She has 40 years experience in the healthcare profession, including labor and delivery, postpartum, medical-surgical, emergency department, ambulatory care, and cardiac rehab, and for the past three years has worked in CDI. She has extensive involvement in hospital/community bioterrorism preparedness. She also currently serves as a board member for the Kentucky Society for Healthcare Risk Management. Contact her at rita.fields@bhsi.com. Meloney Mantsch, RHIA, HIM/coding manager at the University of Louisville (Ky.) Hospital, will serve as chapter co-chair. She has 20 years experience in HIM and oversees the HIM, coding, and CDI teams at her facility, as well as providing leadership for the ICD-10 steering committee. She is actively involved in her regional AHIMA chapters serving as a delegate and on the education committee delegate and the co-chair of the KHIMA education committee. Contact her at melonema@ulh.org. Texas At present, the Texas (Dallas/Fort Worth) ACDIS chapter meets biannually and has seven team leaders. It welcomes participants from any geographic location, however, and hopes to expand its meeting frequency to quarterly sessions in the comming year. Its goal is to provide further education and exceptional networking opportunities for its members. Cindy Pritchett, RN, BSN, CCDS, CDI specialist at Medical City Dallas Hospital, is president of the Texas (Dallas/Fort Worth) ACDIS chapter. Her areas of responsibilities include critical care and telemetry and she has held a past certification in quality (CPHQ). She is a former critical care educator, presented at the ACDIS 2012 Conference in San Diego, and was instrumental in the development of many programs that enhance quality care. Contact her at cynthia.pritchett@hcahealthcare.com. Joanne Dukes, RN, BSN, MS, CCDS, CDI supervisor for Medical City Dallas Hospital, serves as vice president of the chapter. At Medical City, she is responsible for program oversight and development and CDI efforts for medical-surgical, oncology, and stem cell transplant. She has been a nurse educator and administrator in both the civilian and military sectors of nursing and is a retired lieutenant colonel in the Army Nurse Corp. Contact her at joanne.dukes@hcahealthcare.com. LaShan Davis, RN, BSN, MBA, ACM, CCDS, manager of care coordination at Baylor University Medical Center in Dallas, serves as the chapter s secretary. Since its inception in 2001, Davis has managed Baylor s CDI program and its three inpatient documentation specialists and currently serves as chair of the Baylor Healthcare System Inpatient Documentation Improvement Council. She has spoken at conferences locally, nationally, and internationally, and is a member of the American Case Management Association. She and her team from Baylor were also poster presenters at the 2012 ACDIS Conference in San Diego. Contact her at lashan.davis@baylorhealth.edu. Donna R. Sherrill, RN, BSN, CCDS, CDI specialist at North Hills Hospital in North Richland Hills, Texas, serves as the group s treasurer. Her nearly 30 years of experience includes CDI, revenue integrity, chargemaster, governmental regulatory 2012 HCPro, Inc. July

22 education, performance improvement, nursing management, travel nursing, and critical care. Contact her at hcahealthcare.com. Olivia Bussey, MSN, RN, CDI specialist at The Medical Center of Plano, serves as the chapter s membership coordinator. She has experience in acute care, public health, and healthcare auditing. Contact her at olivia.bussey@hcaheathcare.com. Kathy Choiniere, RN, BSN, CCDS, CDI specialist at Baylor Regional Medical Center Plano, serves as the chapter marketing/education coordinator. Her experience includes CDI, case management, and high-risk obstetrics. She has been a childbirth and American Red Cross educator in the past and is the owner and CEO of her own production company. Contact her at kathy.choiniere@baylorhealth.edu. Debbie Williams, CCS, CCDS, CDIP, CDI specialist at Southwest General Hospital in San Antonio, serves the group as its parliamentarian. Her experience includes more than 30 years in HIM as coding specialist, outpatient coding manager, tumor registry coordinator, coding compliance educator, among other roles. She is also a member of AHIMA and the Association for Integrity in Health Care Documentation. Contact her at debjac1974@gmail.com. Southeast Regional ACDIS (Georgia) When the Southeast (SE) Regional ACDIS chapter started, it was the only networking group in the region aside from Florida and North Carolina. So founder Bonnie Epps, CDI manager at Emory University Healthcare in Atlanta, decided the group should include not only CDI professionals from Georgia, but also adjoining states from South Carolina to Tennessee, and from Alabama to Mississippi. Since then, the group created bylaws, established a financial structure, and spurred the creation of chapters in Tennessee, Alabama, and South Carolina. The group meets quarterly at various locations and held its first inauguration of elected chapter leaders in June. Linda Franklin-Yildirim, RN, BSN, MBA/HCM, CCDS, CDI specialist at Emory University Healthcare, is the new president of the SE ACDIS chapter. A graduate of Florida A&M University School of Nursing, she holds a master s degree in business administration with a concentration in healthcare management. A nurse for 17 years, she was among the first group to take, and pass, the CCDS exam. A member of the SE ACDIS chapter since its inception, she also served as its vice president since 2010, and is excited to continue working with the group as its president. Contact her at linda.yildirim@yahoo.com. Maria Mann, RN, BSN, MSHL, CCDS, CDI supervisor at Gwinnett Medical Center in Duluth, Ga., serves as the chapter vice president. She graduated from City University of New York s Hunter-Bellevue School of Nursing in 1992 and holds a master s degree in healthcare law from Nova Southeastern University. Her 20-year nursing career includes experience in critical care and cardiology, among other disciplines. An active member of the SE ACDIS chapter since its inception, she says she has a true passion for CDI and the challenges we face on a daily basis. Contact her at mmann@gwinnettmedicalcenter.org. Jamie Doster, RN, CDI specialist at Emory UniversityHealthcare in Atlanta, will continue to serve as secretary of the SE ACDIS chapter. A nurse for the past 16 years, his experience includes emergency, cardiac cath, and EP labs. He helped start the local chapter of SE ACDIS in 2009, and has served as its secretary since Contact him at james.doster@emoryhealthcare.org. 22 July HCPro, Inc.

23 Julie Thomas Bell, RN, CCDS, CDI specialist at Hamilton Medical Center in Dalton, Ga., will serve as the SE ACDIS treasurer. A nurse for 15 years, she earned her degree from Armstrong Atlantic State University in Savannah, started her nursing career in a Level 1 trauma center emergency department, and has also worked in cardiac and intensive care units. She has been a CDI specialist for four years and says it is the best move she ever made. I am honored to be included with the other elected officers and I am excited about my new role as treasurer, Bell says. Contact her at jbell@hhcs.org. Renella Fruge, RN, BSN, MBA/HCM, CDI specialist at Emory University Healthcarein Atlanta, serves as the chapter parliamentarian. She has four years of CDI experience and more than 25 years of nursing experience, as well as leadership, quality customer service, cost containment, inventory control, and administrative and management skills. Contact her at renella.fruge@emoryhealthcare.org. West Virginia Sheila Harrison, RN, BSN, CDI specialist at Charleston (W.Va.) Area Medical Center, leads the newly formed West Virginia ACDIS chapter. She has nearly 25 years of nursing experience, including time spent as director of a home health agency. Harrison plans to take both the CCS and CCDS exams this fall. I am excited to establish a clinical documentation specialist group in West Virginia and am looking forward to connection to others from the area, she says. The group holds its first meeting Wednesday, August 15, from 1 to 3 p.m., at Thomas Memorial Hospital in South Charleston. Contact her at sheila.harrison@camc.org. Philadelphia/New Jersey Regional Recently, two energetic individuals teamed up to host a CDI networking group in the Philadelphia area, with its first successful regional event in Camden, N.J., in March, and its subsequent meeting at Albert Einstein Medical Center in Philadelphia in June. Judi Bates, RN, BSN, CCDS, CDI specialist at Our Lady of Lourdes Medical Center in Camden, N.J., serves as co-leader to the regional chapter. A nurse for nearly 30 years, her experience includes case management and home health, among other specialties. She helped initiate the program at her facility and enjoyed getting to know the physicians there. I really love being a CCDS, she says. There are so many people we are getting to know through the process of starting this chapter. I am looking forward to learning from everyone. Contact her at batesj@ lourdesnet.org. Deborah Dallen, RN, CCDS, CDI coordinator at Albert Einstein Medical Center in Philadelphia, serves as co-leader for the Philadelphia/New Jersey Regional ACDIS chapter. Contact her at dallend@einstein.edu. Heartland Regional (MO, IL, TN, KY, AR) Sara Baine, MSN-ED, BSN, CDI specialist at SoutheastHealth in Cape Girardeau, Mo., joined with her colleagues Vivian Bollinger, BSN, RN, and Dawn Witty, BSN, RN, to network with CDI specialists from several states where Missouri, Illinois, Kentucky, Tennessee, and Arkansas meet. The group will hold its first annual meeting Friday, June 22, from 5 to 7 p.m. Contact Baine at or sbaine@sehealth.org HCPro, Inc. July