cdijournal Tips to pick an e-query system Vendors outline top concerns to address in an e-query system

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1 cdijournal October 2010 Vol. 4 No. 4 E-query advice from system vendor 4 n Jonathan L. Elion, MD, FACC, explores how new technology leads to better data. Director s note 6 n Nearly 90 speakers apply to present at the 2011 ACDIS conference in Orlando. HCC presents additional opportunity for CDI 7 n Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, discusses Medicare Advantage Hierarchical Condition Categories. Review definitions for acute kidney injury 9 n Jon Arnott, MD, CMQ, offers clinical indicators from the National Kidney Foundation. Surviving the CCDS 11 n Get advice on how to master the exam from those who ve taken it. Maxim moment 18 n Incorporate government initiatives into CDI program initiatives. Benchmark report 22 n More than 300 ACDIS members answer questions about their facility s ICD-10 preparations. Tips to pick an e-query system Vendors outline top concerns to address in an e-query system Only 1.5% of the nearly 3,000 nonfederal hospitals in the United States reported the use of a comprehensive electronic medical record (EMR) system, according to a March report published in the New England Journal of Medicine. With so few facilities employing EMRs, why should CDI program managers consider implementing an electronic query system (EQS)? Simple, says Jonathan L. Elion, MD, FACC, founder of ChartWise Medical Systems, Inc., in Wakefield, RI. We are going electronic. Maybe kicking and screaming, but the healthcare system will eventually use an electronic health record. When that happens, where will [your CDI staff] stick their sticky notes? Where will they put their paper queries? Even if your facility has not made the EMR shift or has no plans to employ an EMR in the coming year, it still makes sense to start planning for EQS implementation now, says Elion. Define EQS expectations Traditionally, CDI programs use some form of paper queries. These are either a formal query template (developed in-house or provided by a consultant) or a form of sticky note placed in the patient s medical record. Some facilities develop special colored forms and dub their queries the pink or blue or purple sheet to capture the physician s attention. Many programs also manually track their query data physician query response rates, CDI/HIM agreement rates, DRG improvement statistics, etc. using Excel spreadsheets. Spreadsheets are fine, but electronic systems can help analyze and track data in new ways ways that can help prove the value of the CDI program as well as outline educational opportunities for CDI staff, says Terry Demers, vice president and chief software developer for Milford, NH based Demers, Negrete & Associates, Inc., creator of the software package CDIP.web. Prior to pursuing an electronic query vendor, CDI program managers need to determine their own definition of an electronic query and what they hope to gain from their new query system, says Barbara Hinkle-Azzara, chief product strategist for Meta Health Technology, an HIM software developer based in New York. What is an electronic query? asks Elion. Is it a program that simply performs electronically what you already do in paper form? Or is it something else? If the facility is implementing a new CDI program, for example, it may want an EQS that includes a library of sample query templates. continued on p. 2

2 E-query system continued from p. 1 Some vendors provide this feature but others do not, says Hinkle-Azzara, adding that both parties need to establish a firm understanding of their definition of standard query templates. Is the system you want one where you pick your query from a database, print it, and put it in the paper chart? Is that the level of electronic query you re looking for? Does it provide you with some sort of additional benefit? asks Elion. (Read his related column on p. 4.) Even though The Miriam Hospital in Providence, RI (where Elion serves as a practicing cardiologist) boasts of its fully integrated EMR, Elion says staff members continue to print the progress note and place it in the patient medical record. Why? To ease the transition to EMR, he says. Everyone has some sort of hybrid medical record, says Todd Johnson, president of Salar, Inc., in Baltimore. The trick is in determining how the EMR bridges traditional modes of communication. Analyze current query process Begin your search for an EQS vendor not externally, but internally within your own CDI department. First, assess your CDI program s work flow, says Hinkle-Azzara. Consider the following: Do you keep queries as a permanent part of the medical record? Have you developed a documented set of query policies and procedures? Do you have a compliance policy in place? Does the CDI team review only concurrent records? What role, if any, does the CDI staff have in handling retrospective queries? How does the facility manage CDI/HIM reconciliation? The process and goals you outline will help define your requirements for the software vendor and help them better address your needs, says Hinkle-Azzara. Information systems are great tools, but you need to know your own systems first for the electronic component to aid your process, says Robert S. Hodges, BSN, MSN, RN, Editorial Board ACDIS Director: Brian Murphy, CPC bmurphy@cdiassociation.com Associate Director: Melissa Varnavas, CPC mvarnavas@cdiassociation.com Publisher: Lauren McLeod Cindy Basham, MHA, BSN, CPC, CCS CEO/Key Consulting, Inc. Senior Quality Documentation Improvement Consultant VHA Maryville, TN cindy.basham@gmail.com Gloryanne Bryant, RHIA, RHIT, CCS, CCDS Regional Managing HIM Director Kaiser Permanente Oakland, CA gloryanne.h.bryant@kp.org Shelia Bullock, RN, MBA, CCM, CCDS Manager, Clinical Documentation Services University of Mississippi Medical Center Jackson, MS sabullock@patacct.umsmed.edu Jean S. Clark, RHIA Service Line Director for HIM Roper St. Francis Hospital Charleston, SC Jean.Clark@RoperSaintFrancis.com Wendy De Vreugd, RN, FNP Senior Director of Case Management Kindred Healthcare, Hospital Division Orange County, CA wdevreugd@ca.rr.com Garri Garrison, RN, CPUR, CPC, CMC Director, Consulting Services 3M Health Information Services Atlanta, GA glgarrison@mmm.com Colleen Garry, RN, BS Clinical Documentation Manager NYU Medical Center New York, NY Colleen.Garry@nyumc.org Robert S. Gold, MD CEO DCBA, Inc. Atlanta, GA DCBAInc@cs.com William E. Haik, MD, FCCP Director DRG Review, Inc. Fort Walton Beach, FL Behaik@aol.com DRGreview@aol.com Tamara Hicks, RN, CCS, CCDS Manager, Care Coordination North Carolina Baptist Hospital Winston-Salem, NC thicks@wfubmc.edu Robin R. Holmes, RN, MSN Manager, Clinical Documentation Improvement DCH Health System Tuscaloosa, AL rholmes@dchsystem.com James S. Kennedy, MD, CCS Managing Director FTI Healthcare Brentwood, TN James.kennedy@ftihealthcare.com Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI Manager of Clinical Documentation Services at YPRO Corp. glennkrauss@earthlink.net Pam Lovell, MBA, RN Regional Director, Clinical Intake Team Humana, Inc. Louisville, KY plovell@humana.com Gail B. Marini, RN, MM, CCS, LNC Manager, Clinical Documentation South Shore Hospital Weymouth, MA Gail_Marini@sshosp.org Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS Director of HIM/Coding HCPro, Inc. Marblehead, MA smccall@hcpro.com Lynne Spryszak, RN, CPC-A, CCDS CDI Education Director HCPro, Inc. Marblehead MA lspryszak@hcpro.com Colleen Stukenberg, MSN, RN, CMSRN, CCDS Clinical Documentation Management Professional FHN Memorial Hospital Freeport, IL cstukenberg@fhn.org Heather Taillon, RHIA Manager of Coding Compliance St. Francis Hospital Beech Grove, IN Heather.Taillon@ssfhs.org Lena N. Wilson, MHI, RHIA, CCS, CCDS HIM Operations Manager Clarian Health Indianapolis, IN lwilson9@clarian.org CDI Journal (ISSN: ) is published quarterly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA Subscription rate: $129/year for membership to the Association of Clinical Documentation Improvement Specialists. Postmaster: Send address changes to CDI Journal, P.O. Box 1168, Marblehead, MA Copyright 2010 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. 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3 clinical documentation specialist at Aleda E. Lutz, VAMC in Saginaw, MI (Hodges views do not necessairly represent those of the VAMC). Hodges has the benefit of a 100% fully integrated EMR that allows him to review all documentation from his desktop. But a full EMR has its own difficulties that CDI specialists may not consider. For example, Hodges and Elion point to capability as an example of the pitfalls associated with perceived benefits. There s the problem of sending protected health information (PHI) over unprotected systems, Elion says. The vendor you choose will need to either encrypt the data or work within the system already established. Although Hodges EMR includes an integrated system which is secure, his facility s physicians don t routinely use it. So you need to know that up front about your physician s work flow process, he says. What good would an electronic query system with an aspect be if the physicians aren t using the system they currently have? Elion has three different accounts one for each of his professional hats. Only his hospital account can be used to transmit PHI, he says, and most of his colleagues don t use at all. If the physicians at your facility are currently overloaded with messages in their inbox, then using [queries] won t help you, Elion says. You need to determine the best way to get your message through in this new venue. The biggest blunder when implementing an EQS, or any EMR for that matter, is trying to get physicians to document online, says Johnson. In many cases, the physician s note already serves so many purposes that the physician can easily become distracted by the number of requests it contains. This problem arises when physicians are not involved in deciding how to implement the systems from the get-go, he says. Effective EQS implementation needs input from physicians and other area of the hospital as well, says Hinkle- Azzara. Determine how your CDI program impacts other departments and how the implementation of the EQS will affect those relationships, she says. If your CDI program conducts both concurrent and retrospective reviews, for example, you ll need to consider how those two processes work currently, determine how to integrate the EQS into the existing process, and ensure that all affected staff are educated about any changes to the work flow. It is easy to get into conflicts because all the parties don t always know what each other needs to succeed, Johnson says. Review data analysis needs The primary reason to move to an EQS is data analysis, Elion says. For example, the ChartWise Medical Systems asks CDI specialists to check off one of five options to determine the reason for the query. The choices legibility, completeness, clarity, consistency, and precision are based continued on p. 4 Take time to interview electronic query vendors Informal vendor research can begin at any time, says Barbara Hinkle-Azzara, chief product strategist for Meta Health Technology, an HIM software developer based in New York. It can come in the form of casual conversations with colleagues during local CDI networking meetings, existing vendor relationships, inquiries, or research at exhibit halls during annual industry conferences such as AHIMA and ACDIS. Some facilities have more formal purchasing processes, including a formal request for proposals made through a hospital s purchasing agent. These generally include an outline of the project scope, details of specific needs, and possibly a checklist of items the facility wants the vendor to provide, Hinkle-Azzara says. Once you ve whittled your prospective electronic query system vendors down to a collection of top possibilities, invite representatives from each firm to present their product. At this point you ve already done all your research, says Hinkle-Azzara. You ve held all your internal meetings and delineated what your requirements are, so you can outline the points of your program and present targeted questions and answers. Providing the vendor with a detailed set of priorities will help you to ensure that you select the right product to best meet your facility s specific needs HCPro, Inc. October

4 E-query system continued from p. 3 on the October 2008 AHIMA guidance Managing an Effective Query Process. Including this seemingly simple step in the electronic query process allows for easy interpretation of data later, Elion says. Once that data is captured in an electronic format, you can easily go back at the end of the month and see that 80% of all the queries submitted to Dr. Elion, for example, were for issues related to legibility. That s data you can do something with, he says. Armed with that information, a CDI manager or physician advisor can approach a physician or medical staff leader and effectively communicate the problem and its effect on the facility. It also generates similar opportunities to capture CDI staff productivity elements, Elion says. This type of electronic data collection and analysis allows you to drill down into the information easily, down to the level of the specific physician, the CDI specialist, even the patient, says Demers. Create an EQS task force Although all this preparation and fact-finding may sound daunting, it can be as simple as taking a second look at your CDI program s day-to-day processes and documenting them. If your program has not developed policies and procedures, the task may indeed involve additional efforts. At a minimum, establish a task force to determine your facility s specific needs. The group should involve not only department heads but those whose daily work may be affected by the EQS implementation, such as coders, nurses, physicians, and CDI specialists. Establish a timeline and agenda for the group that includes: CDI program process mapping Policy and procedure analysis Information technology review Review of data analysis needs Examination of potential vendors Creation of a comprehensive list of EQS wants versus needs You really need to know what s important to you and to your facility, Hinkle-Azzara says. What are the things that are crucial to your program and what are the things that you think would be nice to have? Revise EQS expectations The range of vendors offering EQS is wide and varied. Large companies like 3M and Navigant offer CDI consulting packaged with query templates, software products, and automatic data reporting. Some smaller companies provide customizable products capable of meeting the specific query needs of a given facility. And then there s everything in between. Each hospital and each CDI program is different, says Hinkle-Azzara. They each have individual needs. There isn t one solution that works for everyone, so it s important to communicate your requirements. With the appropriate amount of research and self- analysis, however, your CDI program can determine the EQS that will work best for it. By bringing the query into the electronic query system, you bring all things together, Johnson says. There s a huge opportunity here to improve physician documentation. Technology provides additional opportunity for CDI analysis by Jonathan L. Elion, MD, FACC The value of a new technology is often not understood for many years after its invention. For example, the first film cameras were initially used to capture photographic paintings of landscapes, still life studies, and portraits, the standard subject matter for artists using more traditional media. It wasn t until much later that the technology began to realize its full potential in fields as diverse as astronomy, microscopy, high-speed photography, and movies. Computer applications in the CDI field are poised to make a similar transformative leap. Rather than simply re-creating what we already do today with notes and 4 October HCPro, Inc.

5 spreadsheets, emerging and converging advances will allow for completely new work flows, efficiencies, integration, reporting, and analysis. Some of these recent trends will have a tremendous impact on the CDI profession. Rules-based expert systems What we call an expert system is a specialized type of software that provides answers to problems, eliminating the need to consult a human expert. For a CDI program, an expert system would collect clinical information, examine its own knowledge base, and apply the rules of its programming to make documentation expertise widely available throughout a facility. Although such technology has been around since the early 1970s, it has not found a significant place in commercial medical products due to the difficulties in developing and maintaining the medical content databases. Traditionally, a human expert needed to work side by side with a computer engineer to program the rules. Today, expert systems have provided a number of enhancements to CDI. For instance, by examining the list of a patient s medications and laboratory results, a computer program can suggest additional diagnoses. This can be as simple as a reminder to add the diagnosis of anemia when hemoglobin or hematocrit are low, or it could include more complex inferences and interactions. In identifying simple relationships among diagnoses, the system can make suggestions, such as volume overload when there is acute systolic heart failure. As another example, by putting together more abstract diagnoses such as gastrointestinal bleeding and a low hemoglobin and hematocrit, a computer system could suggest the user consider anemia and query the physician for acute post-hemorrhagic anemia. Although a computer system or electronic query product cannot be expected to be better than a human expert, the system provides the ability to automate and clone the expertise. This becomes extremely helpful in improving efficiencies and in training new staff in the subtleties of CDI. Business intelligence An electronic CDI program enables its user to group, analyze, and present data in a way that isn t possible with paper-based systems. More than providing the user with a list of work to be done that day, an electronic system can provide reporting layers that start with a summary snapshot and drill down to details and metrics. This can include query response rates, case-mix index changes, and revenue impact and compliance, both within the individual hospital and across a peer group. Most importantly, it not only monitors the efficiency of the current CDI program but can provide insight into improvement efforts still left to be achieved. The end result of CDI programs is better documentation. An electronic CDI program that uses advanced computing technology will help: Ensure information has been captured to support an audit Capture more complete documentation from the beginning of the documentation process Standardize queries in an AHIMA-compliant format Capture and retain query results Provide audit-ready records to show compliance between CDI and coders Provide documentation that can be read on demand The combination of knowledge-based expert systems and electronic delivery methods will transform CDI efforts from paper-intensive programs into powerful and easy-to-use documentation systems. These can ultimately be integrated into a hospital s information system, making the expert system even smarter as it captures medication, procedure, and lab data and gathers diagnostic suggestions and query proposals before the user logs on. Just as the original film camera found a purpose far beyond landscape photography, emerging and converging technologies will revolutionize healthcare documentation. Editor s note: Elion is an associate professor of medicine at Brown University and a practicing cardiologist at The Miriam Hospital in Providence, RI. He is the founder of ChartWise Medical Systems, Inc., in Wakefield, RI, a medical software firm whose products assist physicians and CDI specialists. Contact him at 401/ or by at jelion@chartwisemed.com HCPro, Inc. October

6 Director s note Our best conference yet? You decide When I first met with the ACDIS 2011 conference committee in July, I knew right away this was a great group. Why? Because they took their job seriously. A couple of members told me flat out that serving on the committee was intimidating because they enjoyed the other ACDIS conferences so much and felt obligated to try and build on our past successes and deliver an even better experience in That s exactly what I and the committee have been working on for the past three months or so. When we put out a call for speakers in August, we received almost 90 applications for approximately 23 speaking slots. The amount of expertise and willingness to present was overwhelming. Our committee had a lot of hard work to do. We began a painstaking review of the applications, discussing the candidates and selecting which speakers fit our must-have sessions, as well as those who offered intriguing new ideas that we couldn t miss. Whittling down so many great applications proved to be a very, very difficult task. Although the conference lineup is still being finalized at the time of this writing, I can tell you with certainty that we ll have a couple practicing surgeons to talk about surgical complications, a lawyer intimately involved with healthcare documentation and coding issues, a hospital consortium willing to share its CDI data and benchmarks, and the return of a few of our most popular presenters from I feel lucky to be blessed with such an invested group of volunteers. I wouldn t expect any less from our ACDIS membership. Below are their names: If you know one of them, give them your thanks. I did. I hope to see you in Orlando April 7 8. I think it will be our best conference yet. ACDIS director Brian Murphy supervises one of the general session meetings during the 2009 conference in Las Vegas. Nearly 90 speakers applied to participate in the ACDIS 2011 conference in Orlando. ACDIS 2011 conference committee Virginia Bailey Shelia Bullock Christine Cox Mary Ann DeSilveria-Davidson Bill Freeman Kristen Geissler Natalie Howell Jennifer Love Melissa Moog Judith Rochelle Christi Sarasin Dee Schad Linnea Thennes Take care, Brian J. Murphy, CPC ACDIS Director bmurphy@cdiassociation.com 781/ , Ext October HCPro, Inc.

7 Extend your CDI efforts to Medicare HCCs by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS Approximately 11% of Medicare beneficiaries are now enrolled in private managed care health plans, with the rest in the traditional fee-for-service (FFS) programs. Did you know that Medicare Advantage (MA) payment methodology is driven by documentation and ICD-9-CM diagnosis codes? Like most aspects of our healthcare system, there are great complexities. In this article, I want to share with you some basics about MA Hierarchical Condition Categories (HCC) and the ICD- 9-CM codes behind them. Risk score determines payment MA, Medicare Risk, and Medicare Part C are all names for the same program. MA allows Medicare beneficiaries to receive their Medicare benefits from private insurance plans (health plans) rather than from the traditional FFS program. Under the MA program, which can be chosen by the Medicare beneficiary, certain clinical data elements are vital to accurate payment/reimbursement. These data elements provide insight into overall patient severity and quality of care. When a beneficiary enrolls in MA, it is with a managed care organization or a health plan. In addition, providers (physicians and hospitals) contract with the MA program to provide care. MA collects data about each beneficiary or patient. These data are used to determine reimbursement. The process includes the collection of demographic and clinical data (health risk characteristics) that help establish a risk score for a patient. Medicare uses these beneficiaries characteristics (e.g., age, prior health conditions) and a risk-adjustment model the CMS-HCC to develop a measure of the patient s expected relative risk for covered Medicare spending. A patient s risk score helps determine the reimbursement the provider and managed care organizations receive. The risk score is similar to the relative weight seen with MS-DRGs. The base payment for an enrollee is the base rate for the enrollee s county of residence, multiplied by the enrollee s risk measure, also known as the CMS-HCC weight. Understand the HCC/coding connection This payment structure, which is on an annual basis, was summed up best in a 2005 article in Medical Care Journal: CMS-HCC model uses demographics and a diagnosis-based medical profile captured during all clinician encounters both inpatient and outpatient to produce a health-based measure of future medical need. Following are some of the HCCs. Keep in mind there are some 3,400 ICD-9-CM diagnosis codes behind them: HCC 2: Septicemia, shock HCC 5: Opportunistic infections HCC 17: Acute complications of diabetes, such as Diabetic ketoacidosis (DKA) HCC 21: Protein-calorie malnutrition (could be long term) HCC 31: Intestinal obstruction HCC 37: Bone/joint/muscle infections HCC 51: Drug/alcohol psychosis HCC 78: Respiratory arrest HCC 79: Cardiorespiratory failure and shock HCC 81: Acute myocardial infarction (AMI) Most of the diseases that have been mapped to the HCCs represent chronic conditions that persist from one data period to the next or from one year to another. However, as you see above, there are also acute or subacute conditions included in the HCC methodology. The HCC methodology emphasizes diagnoses, not procedures or surgeries. Disease categories are accumulated that is, reimbursements are based on the sum of all chronic conditions diagnosed in different hierarchical categories. Next, the demographics are added to determine the total payment. MA managed care reimbursement depends on accurate and complete diagnostic documentation from the physician(s), hospital inpatient and outpatient settings, and physician office/clinic visits/encounters. ICD-9-CM coding must be accurate and complete in order to capture an accurate HCC. Some providers don t take the time to document accurately or specifically, and if the coding staff doesn t code completely, a hospital will lose out on justified HCC reimbursement. If this scenario sounds familiar, yes, this continued on p HCPro, Inc. October

8 Medicare HCCs continued from p. 7 is a similar challenge faced each and every day under the MS-DRG system and in other healthcare settings, too. The hierarchies are established so that hospitals are only paid for patients with the most severe manifestation among related diseases. For instance, ischemic heart disease diagnoses are organized in the coronary artery disease (CAD) hierarchal category. The CAD hierarchy consists of three HCCs arranged in descending order by clinical severity and cost HCC 81 for AMI through HCC 83 for coronary atherosclerosis/other chronic ischemic heart disease. For example, a patient with a diagnosis code in HCC 81 is excluded from the payment grouping in HCCs 82 and 83, even if these ICD-9-CM codes are present, as the hierarchy structure is applied. (See the related chart on p. 7.) Add HCC to audits and CDI efforts Hospitals should perform HCC audits, similar to other inpatient and outpatient coding audits, to identify opportunities and gaps. Providers have also found that having a hospital- or ambulatory-based concurrent CDI program in place can capture and improve documentation as well as the coding that influences the HCCs. Even expanding the physician query (clarification) process to include the ICD-9-CM diagnoses for HCCs can yield additional clinical data, resulting in a positive financial impact. Providers and MA health plans should be proactive and conduct audits and data mining to identify opportunities. CMS performs audits to validate the HCCs reported by the MA providers and health plans.as a good first step, request a data report of the volume of patient encounters or discharges by payer and ask for MA patients to be separated out. Determine whether you need to include MA in your documentation improvement and/or coding audits. Editor s note: Bryant is Regional managing director of HIM at Kaiser Permanente in Oakland, CA. She is also a founding member of the ACDIS advisory board. Contact her at 510/ or by at gloryanne.h.bryant@kp.org. Resources Lewis, A. (2007). Medicare HCC Coding Is Mission Critical for HMOs. Medical Care 43(1): 34. Risk Adjustment of Medicare Capitation Payments Using the CMS-HCC Model. Healthcare Financing Review, September PartCRecon.asp Mapping ICD-9-CM to CMS-HCC ICD-9-CM code ICD-9 description Diagnosis code effective date CMS-HCC model category CMS-HCC model calendar year 2009 payment CMS-HCC model calendar year 2010 payment Subendo Infarct, Subseq 1/1/ Yes Yes Ami Nec, Unspecified 1/1/ Yes Yes Ami Nec, Initial 1/1/ Yes Yes Ami Nec, Subsequent 1/1/ Yes Yes Ami Nos, Unspecified 1/1/ Yes Yes Ami Nos, Initial 1/1/ Yes Yes Ami Nos, Subsequent 1/1/ Yes Yes 4110 Post Mi Syndrome 1/1/ Yes Yes 4111 Intermed Coronary Synd 1/1/ Yes Yes 4118 Ac Ischemic Hrt Dis Nec* 1/1/ No No Acute Cor Occisn W/O Mi 1/1/ Yes Yes AC Ischemic NRT Dis Nec 1/1/ Yes Yes 412 Old Myocardial Infarct 1/1/ Yes Yes 4130 Angina Decubitis 1/1/ Yes Yes Source: CMS. 8 October HCPro, Inc.

9 Consider NKF definitions when documenting renal disease by Jon W. Arnott, MD, CMQ Acute kidney injury (AKI) serves as warning that acute renal failure (ARF) and end-stage renal disease (ESRD) are possible if a patient s clinical status does not improve. The National Kidney Foundation (NKF) has endeavored to detect and protect patients from kidney failure and dialysis. The NKF s model started with chronic kidney disease (CKD) and was a reminder to all physicians that kidney failure and dialysis are avoidable progressions if physicians follow several best practices. The concept spurred development of the AKI model. This model depends on a core concept known as RIFLE, which stands for: Risk Injury (48-hour abrupt event) Failure Loss (four weeks without recovery) ESRD The first step in identifying patients with AKI is to recognize those at risk. The model allows for use of two ways to identify these patients. The first is urine output, which may be the easiest to recognize as long as the intake and output measurements are reliable. (See Figure 1 below.) A six-hour urine output of < 0.5 ml/kg body weight would qualify as risk. A man weighing 70 kg would be expected to produce less than 35 ml of urine in this time period to be at risk. Glomerular filtration rate (GFR) and serum creatinine are the second way to detect risk. The RIFLE concept overlaps risk and stage 1 injury on the AKI model. Diagnostic criteria for AKI include an abrupt (within 48 hours) reduction in kidney function, currently defined as any one of the following three conditions: 1. An absolute increase in serum creatinine of > 0.3 mg/dl ( > 25 micromole/l) 2. A of 50% increase of serum creatinine 3. A reduction in urine output (documented oliguria of < 0.5 ml/kg/hr for > 6 hours) Watch for documentation tips that include the following indications when considering a diagnosis of AKI stage 1: Elderly dehydrated patients Orthostatic patients Diabetic, hypertensive patients receiving dye from CT scans or heart catheterizations Acute heart failure patients aggressively treated with furosemide or other medications D5W with 1 ampule sodium bicarbonate after a heart catheterization or contrast CT scan Reduction of certain blood pressure medicines in light of changes in creatinine Stopping nephrotoxic meds written in consult or notes Stage 1 AKI is often treated but infrequently captured as a CC. A motivated CDI specialist will find many hospitalized patients meet the criteria for AKI and are being treated for it. Remember, a serum creatinine of 0.5 mg/dl prior to admission that rises to 0.8 mg/dl is stage 1 AKI. continued on p. 10 Figure 1: Classification/staging system for AKI Stage Creatinine criteria Urine output criteria 1 Increased serum creatinine of > 0.3 mg/dl or increase to 150% 200% from baseline < 0.5ml/kg/hr for > 6 hrs 2 Increase serum creatinine to > 200% 300% from baseline < 0.5ml/kg/hr for > 12 hrs 3 Increase serum creatinine to > 300% from baseline (or serum creatinine 4.0 mg/dl with an acute rise of at least 0.5 mg/dl) Source: National Kidney Foundation. < 0.3ml/kg/hr x 24 hrs or anuria x 12 hrs 2010 HCPro, Inc. October

10 NKF definitions continued from p. 9 Pitfalls to avoid The AKI model is in place to detect abrupt 48-hour changes in serum creatinine, GFR, or urine output. This 48-hour worsening may have already taken place prior to admission. Patients with CKD may have acute worsening of their CKD but already have existing disease. Don t hurt yourself trying to fit their creatinine levels into this model. The criteria state that an acute rise of 0.5 mg/dl is consistent with stage 3. (See Figures 2 and 3.) Also remember that malnourished patients may not have enough muscle mass for creatinine criteria. That s where urine output becomes the best predictor of AKI. Finally, there is little difference between AKI stage 3 and ARF. An ARF patient s urine output and creatinine levels remain abnormal beyond the 48-hour mark. If this is the case, CDI specialists should query for ARF. The urine output values in stage 3 AKI also meet the renal failure criteria from the RIFLE model. If the derangements persist beyond the initial 48 hours despite intervention, then ARF is the likely entity. Despite changes in the recent 2011 CMS IPPS final rule regarding the reclassification of ICD-9-CM code (ARF, unspecified) from an MCC to a CC, stage I AKI is prevalent in most medical admissions. The fact is, CMS hit a home run. More hospitals will start to focus on AKI stage I and reduce injury and harm to the patients they serve. Figure 2: Creatinine levels and AKI stages Baseline creatinine mg/dl Stage 1 AKI creatinine mg/dl above Stage 2 AKI creatinine mg/dl Stage 3 AKI creatinine mg/dl above Source: Jon Arnott, MD, CMQ. Criteria is king. Base all your queries on the NKF criteria and watch your DRGs without a CC/MCC shrink. Good luck. Editor s note: Arnott is a senior physician consultant for Physician Motivators ( in Canfield, OH; senior vice president of quality and utilization management, academic affairs, and graduate medical education at Northside Medical Center in Youngstown, OH; and somehow still sees patients in his office in Canfield. You can contact him by at jarnott@ physicianmotivators.com. Figure 3: Body weight/urine output AKI stage indicators Body wt in kg Body wt in pounds Stage 1 AKI urine output in ml/6 hours Stage 2 AKI urine output in ml/12 hours Stage 3 AKI urine output in ml/24 hours < 150 < 150 < < 180 < 180 < < 210 < 210 < < 240 < 240 < < 270 < 270 < < 300 < 300 < 720 Source: Jon Arnott, MD, CMQ 10 October HCPro, Inc.

11 CCDS preparation Test takers offer their perspective on the credentialing exam Shortly after the association s inception, ACDIS members began to ask about the creation of a credential. Something special. Something that represented the unique skill sets they possessed, which no other existing credential (RN, RHIA, CCS, etc.) truly represented. Something just for the CDI profession. Before the end of the first annual ACDIS conference in 2008, a 12-member committee formed to establish the Certified Clinical Documentation Specialist (CCDS) credential. The group joined with a national testing administration company, Applied Measurement Professionals (AMP), Inc., to develop a comprehensive test designed to capture the skill sets and knowledge base of this unique profession. On Saturday, May 16, 2009, 123 individuals took their seats in a Las Vegas conference room, prepared to take the first administration of the CCDS exam. Mark LeBlanc, RN, MBA, CCDS, CDMP specialist at Park Nicollet Health Services in Minneapolis, was among them. It was my first professional conference and it was the first administration of the exam. I figured it was as good a time as any to take the test, LeBlanc says. A certified credential Those first test takers had no exam study guide except for the CCDS Certification Handbook (available as a free download on the ACDIS website), suggestions from the CCDS committee, and requirements posted on the website. (The CCDS Exam Study Guide, designed as a review of basic CDI core principles, was published in April.) Few outside the ACDIS membership knew of the credential at all, and fewer accepted it or looked for it when hiring new candidates. There was a lot of hesitancy among those I was speaking with [regarding whether to register to take the exam] because there wasn t a lot of information out there about how the test is, who took it, or what it was like. So it was stressful. You sort of felt alone in being one of the few who had taken the exam, says Jennifer Woodworth, RN, BSN, CCDS, manager of CDI at MultiCare Health System in Tacoma, WA. Vickie Bell and Mary Beth Bednarz were among the brave and lucky souls who took the CCDS exam paper and pencil administration in Chicago earlier this year. Woodworth sat for the second paper administration of the exam following the Chicago conference this past June. At that time, less than 300 people had taken the exam and passed. As of September 1, nearly 600 people had taken the test. (See a complete list of recently credentialed professionals on p. 15.) As more people take the exam, newcomers can go to those who are more experienced and ask them about it, she says. Talking with others about their firsthand experiences with preparing for and taking the exam provides a measure of comfort not easily found in the pages of test preparation materials, says Woodworth. (Read an account of the exam experience on p. 14.) Furthermore, ACDIS is in the process of applying for approval from the National Commission for Certifying Agencies (NCCA). The NCCA requires that an association s certification process be in place for at least one year or that at least 500 individuals pass the exam. The NCCA will conduct a comprehensive review of the CCDS exam process, which may take up to five months to complete, according to the NCCA website. As part of the process, the CCDS committee conducts regular reviews of the exam questions, ensuring that the content remains up to date and reflects the changing nature of the CDI profession. continued on p HCPro, Inc. October

12 CCDS preparation continued from p. 11 Exam trouble spots The exam consists of 120 multiple-choice questions designed to test candidates multidisciplinary knowledge of clinical, coding, and healthcare regulations, as well as the roles and responsibilities of a CDI specialist. Questions test candidates ability to recall and analyze information as well as apply particular rules to specific examples. The test covers seven basic proficiency levels: 1. Regulations, reimbursement, and documentation requirements related to the inpatient prospective payment system 2. Anatomy and physiology, pathophysiology, pharmacology, and medical terminology 3. Medical record documentation 4. CDI program analysis 5. Communication skills 6. ICD-9-CM Official Guidelines for Coding and Reporting 7. Professionalism, ethics, and compliance At first, LeBlanc was a little surprised by the limited number of questions regarding clinical/coding translations compared to questions regarding coding guidelines and statistical analysis of CDI programs. Many CDI specialists do not get involved in that aspect of the program, he says. That s where Janine Daniel, RN, BSN, CCDS, DRG resource reviewer at Community Memorial Healthcenter in South Hill, VA, had difficulty too. I had trouble with situations that we do not perform in our facility, she says. For example, Daniel doesn t regularly provide physician education, and data analysis comes directly from 3M reports. Further, there were ethical questions that I thought really could have gone either way, so that was difficult, too, she says. There were more regulatory questions on the exam than Woodworth anticipated, as well. Two days of intensive educational sessions in Chicago, however, gave her more insight into the compliance and regulatory aspects of CDI than she might have otherwise been aware of, she says. This awareness could either work for or against the examinee, Woodworth notes. An overabundance of information could be confusing; on the other hand, conference sessions can serve as a refresher prior to the exam. Either way, I d say to go with what you know, not what you think the creators of the test may have wanted you to answer, and not what you think the politically correct answer might be, Woodworth says. I tried to remember that this isn t a trick test and went with my gut instinct on those questions I wasn t 100% sure about. The test has since been revised, and slightly more emphasis has been placed on clinical scenarios and appropriate diagnoses for which a CDI specialist may query. But test takers are still expected to know how to benchmark the performance of a CDI program and the basics of data mining and reporting, says ACDIS director Brian Murphy. A mark of distinction Daniel has worked as a CDI specialist at a 90-bed facility in the care management department for five years, having started at her facility in October She previously worked in dialysis and was ready for something different, she says. So when she saw an advertisement for the CDI staff spot, she took a chance, got the job, and fell in love with her new career. Each patient encounter is like a puzzle, Daniel says. As a CDI specialist, you get to help to put the pieces together in terms of their clinical record and the resolution of their healthcare difficulties and that s really rewarding. LeBlanc and Woodworth have also been in CDI roles for more than five years. A measure of professional experience is one of the prerequisites of the CCDS test. I know [some level of experience as a CDI specialist] is a requirement for taking the test, says LeBlanc, but you really do need to have been doing the work for at least two or three years to be a CCDS. There are four routes or potential qualifications needed before a prospective examinee may sit for the test. Under the first route, test takers must show that they have at least two years full-time experience as a documentation specialist, as well as formal training in human anatomy and/ or physiology, medical terminology, and disease processes. The second route requires a minimum of one year s fulltime experience as a documentation specialist and successful completion of at least an associate s degree in an approved college-level curriculum in a recognized allied health field. 12 October HCPro, Inc.

13 The third route requires a minimum of one year s full-time experience, successful completion of an associate s degree, and a license or certification in a recognized allied health field. The fourth route is a minimum of one year s full-time experience, successful completion of a baccalaureate degree or higher college-level curriculum, and formal training (accredited, college-level course work) in human anatomy and/or physiology, medical terminology, and disease processes. Achieving this credential recognizes that a clinical documentation specialist possesses prerequisite educational requirements as well as proven, hands-on experience performing the function of a clinical documentation specialist, according to the program requirements page of the certification website ( The credential is a mark of distinction, says Woodworth. RNs, she explains, take their exam upon completion of their school coursework and either pass or fail the exam. Conversely, the CCDS credential gauges your experiential understanding of the CDI specialist s job as well as your institutional understanding of the role, she says. Location, location, location Whether it s a high school geography exam or the CCDS, any test-taking experience can be stressful. Some people are simply better at test-taking than others. Some do well in the relative silence of a classroom setting with a paper-andpencil exam, whereas others prefer the solitary experience of remote testing. The CCDS provides both. ACDIS staff administer a paper-and-pencil version of the test on the Saturday following its annual conference. In addition, there are more than 170 remote testing centers located all over the country. Each option offers benefits and drawbacks. The paper test was the worst. Why did I do that? All the drama? jokes Woodworth, referring to the stress of taking the exam after the intense Chicago program. But was it worth it? For me, sure; I have my CCDS now. Another drawback of the paper exam is the lag time in receiving test results. Generally, paper tallies take four to six weeks due to the additional analysis and revision of the questions. These changes to the exam are rolled out first in the paper administration of the test. AMP then provides an analysis of the exam s efficacy and advises the board on further adjustments. The wait time for results is probably the most difficult thing about the paper test, says Woodworth. Those who take the exam electronically can schedule the test at their convenience and receive the results immediately. Daniel opted to take the exam at an H&R Block testing site in Richmond, VA. The site was a room in an outlet mall with three computers in it. The best part about taking the test remotely was that I knew right away whether I d passed or not, Daniel says. If they had it to do over again, LeBlanc and Woodworth both say they d take the electronic version of the test. I prefer the computer, LeBlanc says. But when I took it, it was the first administration of the exam, so it was really something to be a part of that whole experience. The whole experience Once a CDI specialist meets the basic requirements to sit for the exam and sets his or her testing date, the time for preparation comes. Review all the materials on the website, advises LeBlanc, whose only review option came from the initial material packages. Because there was no formal book available, Leah Taylor, RN, CCDS, clinical documentation specialist at Iredell Memorial Hospital in Statesville, NC, created her own study packet based on the ACDIS website. Taylor, who serves as president of the North Carolina ACDIS chapter, later formed a study group to help those in her chapter prepare for the test. It is a hard exam, but fair, I think, Taylor says. On the whole, it was very professionally done, says LeBlanc. The CCDS credential adds another level to being a careeroriented CDI specialist, Woodworth says. This new level includes follow-through on data analysis, educational work with coders and physicians, and maintaining an understanding of the latest information regarding regulatory news and coding legislation, says Woodworth. The CCDS credential and exam makes sure people know these things, she says. It is a test to make truly sure that you take what you do seriously and that you re going to continue to take your profession seriously. The credential gives you that backing that yes, I do have the knowledge and the experience to do this profession. I have my CCDS now, and it feels good, says Daniel HCPro, Inc. October

14 If at first CCDS shares story of exam failure and ultimate triumph by Leah Taylor, RN, CCDS Have you ever failed at anything? I am pretty sure all of you would answer that with a resounding yes. But I ll go one more I failed the CCDS exam. I took the test for the first time in Las Vegas in May 2009 at the second annual ACDIS conference. It was the first time the test was given. Although I didn t know what to expect, I felt confident that my knowledge base as a CDI specialist would carry me through. I even felt fairly sure I d passed when I came out of the test. Sure, there were questions I didn t know, but I felt like I must have gotten enough correct to pull me through. Waiting game So, feeling fairly positive, all I had to do was wait the projected six weeks for results. I was on pins and needles. I got an from a friend who had taken the test with me. It read: Did you get your test results? She had. She passed. I hadn t heard any news yet. When I checked online, I found a list of those who had passed. I scanned the names mine wasn t there. I thought, Okay, it s a glitch. Surely I passed. But there was a knot in my stomach. How could I face my coworkers if I didn t pass the test? How could I face my fellow chapter members if I failed? Why did I tell anyone that I was going to take the test? A failure of a few points I contacted ACDIS director Brian Murphy, who told me that I had missed the cutoff passing rate by a few points. I was so upset, but I held it together until I saw my coworker. And, at that moment, despite my immense embarrassment (or perhaps because of it), I broke down and cried. It s that moment when, even though you re embarrassed, you know your friend will understand. What was I thinking? Why did I put myself out there? Why did I waste all that money and not even pass? All these thoughts continued spinning in my head. I really wanted to earn this certification as a sign of my expertise and experience in the field of clinical documentation. And I had let myself down. There s always next time Those who knew I took the exam continued to encourage me. They said, You re a great CDS, and Don t worry, you ll pass next time. My brain shouted: Next time! What? Are you kidding me? It will be a while before there is a next time. But I knew in my heart that I would take the test again and I would pass. I am the North Carolina ACDIS chapter president. Later that fall, our chapter membership decided to issue a challenge to the other chapters throughout the country a contest of sorts. We challenged them to see who could tout the highest number of CCDS holders by the time the Chicago 2010 conference came around. With the challenge issued, I knew I would have to retake the test. I started compiling my own study guide. I looked to ACDIS and what others had said about taking the test. I put together a binder. Our chapter held a study group to encourage members to take the test. I knew that there were those who would never take the test without my voice. I signed up to retake the exam in April, 10 months after the last time I took it. At the time, I didn t have The CCDS Exam Study Guide that s offered now. It had only just been published. But I studied my homemade materials and read and reread the information available on the ACDIS website. I felt like I was more prepared. I woke up extremely nervous on the morning of the test. I had my husband drive me so I could spend time looking over material on the way. My appointment was at 9 a.m. at the H&R Block in Charlotte. We arrived at about 8:15 a.m. because, well, you can never tell with Charlotte traffic. This left me time to sit in the parking lot and pray. The office didn t open until 9 a.m., but next door was a restaurant open for breakfast. I had a light meal and the allimportant coffee. I didn t study any more. I took some deep breaths and told myself, I can do this! 14 October HCPro, Inc.

15 CCDS success I was in the testing area for two of the three allotted hours. As I left the testing area and waited for my results to print, I thought, It all comes down to this. My eyes quickly scanned to the bottom of the page, and I read: You may begin using the CCDS credential! I was elated and so was my husband. I called everyone who had stood behind me, and they celebrated with me. Those who had not yet taken the test in my department now felt they could. I share my story now so that any of you who have taken the test and failed will know you can pass this test too. My best advice is to study. The test is not easy, but it is fair. I am extremely proud of my certification. I have worked hard to obtain the title CCDS. Editor s note: Taylor is the president of the North Carolina ACDIS chapter and clinical documentation specialist at Iredell Memorial Hospital in Statesville, NC. Contact her at leah.taylor@att.net. CCDS list ACDIS is proud to recognize and congratulate our most recent group of professionals to pass the Certified Clinical Documentation Specialist (CCDS) exam. They are free to use the CCDS credential after their name. Members of this group took the test between December 1, 2009, and September 1, Exams were taken at one of our 170 assessment centers nationwide or during the third annual ACDIS conference in Chicago in June ACDIS will publish the list of credentialed individuals annually in the October edition of CDI Journal. Visit for details or to apply. Visit our website for updates as ACDIS continues to build industry recognition of this important new certification. Alabama Joy J. King, CCDS Arizona Linda Renee Brown, CCDS Michelle Custodio, CCDS Carol Jackson, CCDS Stephanie Woody, CCDS Arkansas Angela W. Maxfield, CCDS Diane Mayfield, CCDS Tina Simpson, CCDS California June Alberti, CCDS Hassan Alkhouli, CCDS Jill Marie Benjamin, CCDS Maria Nelia Castillo, CCDS Roberta Hyatt, CCDS Carolyn Kay Lane, CCDS Aimee Macarewa, CCDS Karen MacArthur, CCDS Joanne Pridgen, CCDS Melinda Scharf, CCDS Liana Vysotskaya, CCDS Connecticut Mary Beth Bednarz, CCDS Erinne Hall Houton, CCDS Florida Virginia Bailey, CCDS Norma T. Brunson, CCDS Victoria Corley, CCDS Clare Garrard, CCDS Sylvia Hoffman, CCDS Juliann Jamison, CCDS Letitia Klopp, CCDS Nancy Lero, CCDS Dianne Martinez, CCDS Donna Lou McCormack, CCDS Vilmarie McIvor, CCDS Teena Meacham, CCDS Charrington Morell, CCDS John Noble, RN, CCDS Kimberly Richert, CCDS Carole J. Pakula, CCDS Jodi Park, CCDS Mary Catherine Shebeck, CCDS Seher Swenson, CCDS Kathleen Shamblen Wallace, CCDS Kelley Walrath, CCDS Jacqueline Weller, CCDS April Wojcik, CCDS Georgia Fran Andrews, CCDS Henry Asemota, CCDS Gerri Birg, CCDS Selina J. Brown, CCDS continued on p HCPro, Inc. October

16 CCDS list (cont.) Linda Taylor Cooper, CCDS Margaret Cousart, CCDS Brandy Kline, CCDS Maria Mann, CCDS Angela McKee, CCDS Vicki Scott, CCDS Jane Harte Sipple, CCDS Fred Wulf, CCDS Idaho Robin O Leary, CCDS Cynthia Ziblis, CCDS Illinois Geri Boyle, CCDS Ellen Chang, CCDS Christina Demke, CCDS Sandra Domagala, CCDS Halina Head, CCDS Nancy Rae Ignatowicz, CCDS Mary Karlberg, CCDS Nancy Sikorski, CCDS RoseMarie Thomas, CCDS Indiana Katrina Casteel Frailley, CCDS Linda J. Richardson, CCDS Mary Kathleen Silvey, CCDS Lisa A. Statzer, CCDS Lena N. Wilson, CCDS Iowa Jean M. Allen, CCDS Christina Gray, CCDS Kansas Jolene A. File, CCDS Michelle L. Thimmesch, CCDS Charlene Thiry, CCDS Kentucky Kim E. Eakins, CCDS Jeanette Goodwin, CCDS Melissa L. Horn, CCDS Ada Howard, CCDS Kelly McDaniel, CCDS Dawn E. Shende, CCDS Vicki Wright, CCDS Louisiana Christine Kasner, CCDS Patricia R. Perez, CCDS Teresa L. Savoie, CCDS Maine Michelle Bechard, CCDS Susan Brennan, CCDS Jolene St. Jean, CCDS Mary Orloski, CCDS Cathy L. Seluke, CCDS Maryland Margaret Naawu, CCDS Massachusetts Bernadine Darienzzo, CCDS Judy Jansen, CCDS Michigan Julie C. Dagen, CCDS Dianne Elkins, CCDS Brenda Etefia, CCDS Susan Haley, CCDS Denyatta Henry, CCDS Minnesota Karolyn Skudlarek, CCDS Sherri Wacha, CCDS Shelli Wolenetz, CCDS Mississippi Stephanie K. Cobarrubia, CCDS Debbie Hoaglin, CCDS Jennifer Jones, CCDS Montana Donald L. Collins, CCDS Nevada Maria Demarco, CCDS Terri Thomas, CCDS New Jersey Katherine Arton, CCDS Karen E. Bachmann, CCDS Judith Bates, CCDS Eileen Hickey, CCDS Renee Krul, CCDS Jane Krumm, CCDS Marie G. Mathieu, CCDS Tricia Norton, CCDS New Mexico Sandra Nettles, CCDS Cherylene Straus, CCDS New York Patricia Akinyombo, CCDS Laura Bakaleynik, CCDS Sylvia Bartholomew, CCDS Christine Cox, CCDS Evelyn Delaney, CCDS Barbara S. Fontana, CCDS Maureen Henry, CCDS Shamsul Islam, CCDS Adelaide M. La Rosa, CCDS Ma Elvira D. Lasam, CCDS Ruth MacLarion, CCDS Ellen R. Mitchell, CCDS 16 October HCPro, Inc.

17 Ruth Pfrengle, CCDS Michael J. Roddy, CCDS Miriam Sereno, CCDS Ann Sweeney, CCDS Susan Tiffany, CCDS North Carolina Rhonda K. Bass, CCDS Steven Brush, CCDS Carolyn Byrd, CCDS Nita B. Campbell, CCDS Carol Canipe, CCDS Glenda B. Crowell, CCDS Janice Davis, CCDS Deborah DeSantis, CCDS Allyson Grass, CCDS Brenda A. Harris, CCDS Sue Herring, RN, CCDS Natalie Howell, CCDS Melissa Legere, CCDS Jennifer Love, CCDS Maureen Mbamalu, CCDS Alycia Minter-Caldwell, CCDS Tiffany Murriel, CCDS Jean O Hare, CCDS Dana Painter, CCDS Elinore Poindexter, CCDS Linda Price, CCDS Lisa Reed, CCDS Beth Robertson, CCDS Wendy Shedd, CCDS Susan Suggs, CCDS Leah Taylor, CCDS Judith C. Thomas, CCDS Patricia A. Umanah, RN, CCDS Joyce Vaughn, CCDS Ann Marie Wells, CCDS Ohio Peggy Callan, CCDS Susan Moore, CCDS Chris Polomsky, CCDS Jean Sands, CCDS Kathleen Schopper, CCDS Oklahoma Kati Cook Beisel, CCDS Jerry Davidson, CCDS Deborah Hale, CCDS Stacy Huddleston, CCDS Dyan Post, CCDS Oregon Lisa Baxter, CCDS Virginia Berggren, CCDS Tami Robinson, CCDS James Suiter, CCDS Regina Wright, CCDS Pennsylvania Josephine Pearson, CCDS John P. Pettine, CCDS Sharon Pipilo, CCDS Anne Seneca, CCDS South Carolina Patsy Fowler, CCDS Elaine M. Shimkus, CCDS Harminder Singh, CCDS Tennessee Elizabeth Anne Dickerson, CCDS Kathleen Green, CCDS Texas Ameena Abdul-Malik, CCDS Vickie Bell, CCDS Robbin Borg, CCDS Melissa Broussard, CCDS Glenda Hebert, CCDS Christine Killen, CCDS Christy McDole, CCDS Suzan Morrison, CCDS Lea Rice, CCDS Kathryn Schulze, CCDS Shelly Smith, CCDS Nancy Temple, CCDS Patricia Thomas-Clark, CCDS Deborah J. Williams, CCDS Utah Katherine Bond, CCDS Eileen Guenther, CCDS Virginia Janine W. Daniel, CCDS Vivian E. Gannon, CCDS Catherine Iveson, CCDS Dawn LaRoque, CCDS Linda M. Triolet, CCDS Gail Wallace, CCDS Washington Jennifer Woodworth, CCDS West Virginia Amy E. Pinson, CCDS Wisconsin Diane Draize, CCDS Heidi M. Hillstrom, CCDS Lynn M. Sisler, CCDS 2010 HCPro, Inc. October

18 Sponsored Content Incorporate quality mandates into the CDI function POA, RAC, and quality measures ripe for review by Steven Robinson, MS, PA-O, RN, CPUR The DRG system, implemented nationally in 1983, was the first major healthcare mandate in the United States imposed on acute healthcare facilities. The purpose of the inpatient prospective payment system (IPPS) was to not only systemize reimbursement for inpatient hospitalizations, but also to better measure quality of care. Since 1983, there have been many revisions to the DRG system, most of which focus on the same topic improvements to quality of care. This article will address complying with recently expanded CMS quality mandates by proactively incorporating them into the CDI concurrent review process. The traditional concurrent review role of the CDI specialist is expanding. Due to increasing demands to demonstrate quality initiatives in real time, the role will become even more important in the future. As CDI programs have matured, the foundation of any results-driven concurrent documentation review process includes knowledge of: CMS/AHA coding guidelines Medicare Severity (MS) APR DRG systems Severity and mortality profiling accuracy DRG assignment is related to the patient s length of stay in the facility as well as the venue of care. We know that these core CDI principles support the quality and accuracy of MS-DRG and SOI/ROM profiles. With this in mind, it is possible to expand the concurrent review process to include three additional quality initiatives: 1. Designating the correct present-on-admission (POA) code for each diagnosis 2. Proactively addressing each MS-DRG that is at risk for retrospective RAC reviews/denials 3. Proactively recognizing all MS-DRGs that are under core measure review In the 2010 CDI Program Benchmarking Survey, which was conducted by ACDIS and published in July 2010 (www. hcpro.com/ content/ pdf), it was reported that of the 401 acute care healthcare respondents, 42% stated that they provided some type of quality review in addition to the assignment of MS-DRGs (see p. 38 of the report). Of that 42% (or approximately 168 facilities), 25% (42 facilities) reviewed core measures, 34% (57 facilities) Clinical scenario 1: POA review The following scenario demonstrates the value of concurrently reviewing for accurate present-on-admission (POA) codes: A patient presents in the emergency department who had been discharged two days prior after a colon resection. Currently, the patient has clinical indicators consistent with shortness of breath, nausea and vomiting, dehydration, oxygen saturation of 87%, and hematocrit and hemoglobin of 26/9. The patient is taken to surgery with an acute abdomen and a bleeder is cauterized at the original site of surgery. A CDI specialist leaves a query for the physician of record to determine, if possible, when the pulmonary embolus actually occurred. The physician indicates in the patient s progress notes DVT and pulmonary emboli were present on admission. Without this query exchange, it would have been unclear when the DVT and resulting pulmonary emboli occurred. With this additional information in the medical record, the POA can be coded as the pulmonary embolus present at the time of admission. As such, the MS-DRG relative weight is It would have been if the pulmonary embolus had occurred during this admission and been considered a hospitalacquired condition. 18 October HCPro, Inc.

19 Sponsored Content reviewed RAC risk, and 72% (121 facilities) reviewed POA information. These findings lead us to believe that incorporating all three CMS quality measures can support CDI methodology effectiveness. Since all of the HACs are CCs or MCCs, an incorrect code application can be costly and affect SOI, ROM, and reimbursement accuracy. POA integration POA codes are assigned to every diagnosis coded on the UB-04 at the time of discharge. They were created to designate all billed inpatient conditions as POA or not. Those conditions not POA are considered hospitalacquired conditions (HAC). CMS will not pay for the care associated with a HAC if the condition could reasonably have been prevented through the application of evidencebased guidelines. CMS, through a congressional mandate within the 2006 Tax Relief Act, requires that diagnoses occurring at the time of the acute care stay be evaluated alongside the HAC list. If that condition is on the HAC list, CMS will not pay for the care associated with that condition. CMS uses the following criteria to select HAC conditions: High cost High volume Results in a DRG that have a higher payment when present as a secondary diagnosis Could reasonably have been prevented through the application of evidence-based guidelines The adoption of this mandate generated many questions regarding HAC costs/charge allocations. CMS ruled that each condition associated with a HAC occurring during the hospital stay cannot be recognized as a CC or MCC if it occurs during the hospitalization. It was also ruled that the coding professional could make that decision (querying the physician if the condition s status is unclear). There are no known national studies qualifying retrospective POA queries generated by coders. However, it is rare for a coding professional to generate a POA retrospective query. If a condition is documented as occurring during the hospital stay, it may be able to be determined that the condition was indeed present on admission. Since all of the HACs are CCs or MCCs, an incorrect code application can be costly and affect SOI, ROM, and reimbursement accuracy. Including a review and POA code designation during a CDI concurrent review primarily ensures that the diagnoses presented at the time of admission are clear and that all contributing information during an ED visit is considered for MS-DRG support as well as POA code accuracy (see Clinical scenario 1 on p. 18 for an example). Certain HACs do not influence MS-DRG assignment if they occur during the hospital stay. The only POA or HAC rule change Clinical scenario 2: RAC review continued on p. 20 The RAC has requested a medical record with the following scenario: A patient is admitted to the acute care setting in the hospital. The principal diagnosis is established as an acute myocardial infarction. The physician also documented that the patient has congestive heart failure (CHF). Clinical indicators include chest pain with left arm radiation, troponin levels elevated with shortness of breath, diaphoresis, O2 saturation of 88%, and rales and rhonchi upon auscultation. The treatment plan is IV morphine, non-rebreather O2 mask with Lasix 40 mg IV. A CDI specialist queries the physician for CHF specificity. The physician responds that the patient s heart failure is acute and probably systolic in origin. The CHF specificity allows the coder to provide accurate coding assignment and billing. This record is no longer at RAC risk due to the collaboration between the CDI specialist, physician, and coder. Because the physician was queried, as suggested, the coder was able to code the record with the specificity of acute systolic heart failure rather than unspecified CHF, putting the facility at risk for RAC audit HCPro, Inc. October

20 Sponsored Content Quality mandates continued from p. 19 CMS implemented in the 2011 IPPS final rule is the designation of five specific codes for blood incompatibility specification. For 2011, CMS will add 12 items to the measures set only for CMS 2010 listing of HACs has had no additions for 2011 except that blood incompatibility has been further specified into five categories. Items include the following: Foreign object retained after surgery Catheter-associated urinary tract infection Air embolism Vascular catheter associated infection Blood incompatibility Surgical site infection following coronary artery bypass graft, bariatric surgery, and/or orthopedic procedures Stage III and IV pressure ulcers Deep vein thrombosis pulmonary embolism post total knee or hip replacement Falls and trauma (fractures, dislocations, intracranial injuries, crushing injuries, burns, electric shock) Manifestations of poor glycemic control (diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma) A complete list of HACs are available on the CMS website: Conditions.asp#TopOfPage. Decreasing the RAC risk Each of the four RAC contractors has released lists of inpatient MS-DRGs that they will review. The lists exceed approximately 75% of all MS-DRGs. The RACs indicate that all MS-DRGs will be open for review eventually. Following the RAC demonstration project, a review of 837 RAC denials was conducted at a 580-bed health system. The review found that 60% of all denials were documentation-driven and 40% were medical necessity driven. The study demonstrated that documentation denials were primarily in the areas of: Excisional debridement Acute respiratory failure Sepsis Procedures unrelated to the principal diagnosis Dehydration Renal failure Syncope Diabetes During the CDI concurrent review process, all MS-DRG documentation should be considered as a potential RAC risk. The compliant approach is to clarify all open documentation by querying the physician, eliminating RAC review Clinical scenario 3: Assisting in core measure review When a CDI specialist is querying the physician for one of the six core measure diagnoses or procedures, he or she should notify the department responsible for core measures indicator validation (quality, care management, or utilization team). The following scenario provides an example of the value of participating in the core measures process: A patient presents with signs/symptoms of Cerebrovascular accident (CVA): confusion, left facial droop, and left-sided paresis of limbs. A CDI specialist queries the physician for a diagnosis that would correspond with the clinical indicators above. Since CVA is a core measure condition, the CDI specialist notifies the quality department (responsible for core measure indicators) upon leaving his or her query. Without a review of the CVA core measure indicators, some or all of the indicators could go without intervention. If that were to occur, the core measure would be reported as incomplete and reimbursement could be affected.core measure indicators for CVA include venous thromboembolism prophylaxis, discharged on antithrombotic therapy, anticoagulation therapy for atrial fibrillation/flutter, discharged on statin medication, antithrombotic therapy by end of hospital day two, stroke education, and assessment for rehabilitation. 20 October HCPro, Inc.

21 Sponsored Content concerns. (For an example of how a CDI specialist can proactively reduce RAC risk, see Clinical scenario 2 on p. 19.) Joint Commission core measure sets Core measure sets or quality measures are mandated as an initiative to aid in the compliance of monitoring documentation and completion of standardized care indicators for specified diagnoses. The most common core measure concerns associated with the CDI process are heart failure, acute myocardial infarction, surgery (total hip), venous thrombus, pneumonia, and stroke. During the CDI concurrent review process, all MS-DRG documentation should be considered as a potential of RAC risk. The 2010 CDI Program Benchmarking Survey reported that approximately 10% of acute care facilities have incorporated core measure concurrent reviews into the role of the CDI specialists. Many healthcare leaders believe this is a quality-of-care function and should be incorporated into the quality/care management/utilization review function. Even if the CDI specialist is not responsible for core measures, he or she should nevertheless be familiar with core measure types. CDI specialists querying a physician for one of these six core measure diagnoses will want to make the responsible department aware of any applicable query. (For an example of how a CDI specialist can add core measure reviews to his or her typical chart review duties, see Clinical scenario 3 on p. 20.) About the author Steven Robinson, MS, PA-O, RN, CPUR, has successfully managed CDI services for more than 200 acute healthcare hospitals, medical centers, and health systems over the past 19 years. An RN and physician assistant with a master s degree in health management, Robinson currently serves as the senior director of CDI at Maxim Health Information Services (MHIS) in Cleveland. Prior to working at MHIS, Robinson served as vice president of clinical consulting services at a CPA healthcare firm acquired by 3M, senior vice president of clinical consulting at HP3, and director of forensic healthcare consulting at KPMG, LLP. He is committed to providing clients across the country with quality CDI services. About Maxim Health Information Services (MHIS) MHIS provides CDI services nationwide. MHIS offers CDI services that are tailored to your facility s unique needs and allow you to proactively support your medical record staff to minimize incomplete documentation, increase medical record quality, enhance care communication, and receive more accurate reimbursement. MHIS delivers CDI services in a series of four comprehensive phases: a client interface phase, evaluation phase, education phase, and metrics and process follow-up phase. By choosing MHIS for your CDI needs, you can expect quality customer service, customized results reporting, and a commitment that MHIS will support your long-term CDI success. To learn more about MHIS CDI services, visit or call 866/ (East) or 866/ (West). Summary The traditional concurrent review role of the CDI specialist is expanding. Due to increasing demands to demonstrate quality initiatives in real time, the role will become even more important in the future. Proactive review of the three mandates (POA coding, RAC risk prevention, and core measures) will continue to be important aspects of qualityof-care initiatives. n 2010 HCPro, Inc. October