MAR/APR 2015 Vol. 9 No. 2

MAR/APR 2015 Vol. 9 No. 2 SUPERHEROES an Association of Clinical Documentation Improvement Specialists publication www.acdis.org

Join the only association dedicated to support you and your facility s CDI efforts. Join ACDIS today for only $165! The Association of Clinical Documentation Improvement Specialists (ACDIS) is a community in which CDI professionals share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Its mission is to bring CDI specialists together for improvement. Full access to CDI Journal, our quarterly membership publication Sample forms, policies, and procedures in our popular Forms & Tools Library News briefs Tips and best practices Weekly poll Participation in CDI Talk, the mailing list where you can interact with other CDI professionals A one-year membership includes: ACDIS blog Quarterly conference calls, providing an open forum to discuss your pressing CDI questions CDI job board, updated daily with new opportunities Special reports and benchmarking surveys Discounted rate for the ACDIS National Conference and other ACDIS products To join, please call 800-650-6787 or visit www.acdis.org. Get certified! The CCDS certification program that sets the standard for recognizing clinical documentation improvement excellence. Earning the CCDS certification will help you: Demonstrate your specialized skills and experience Obtain credible leadership within the industry Stand apart from other roles within healthcare Achieve career growth and open doors for advancement Engage in career development with continuing education and learning opportunities For more information or to apply, visit www.hcpro.com/acdis/certification.cfm or call 800-650-6787. MO316673 25302

CONTENTS FEATURES 11 CC/MCC list: Query with confidence William E. Haik, MD, FCCP, CDIP, director for DRG Review, Inc., explores specific query opportunities from the CC/MCC list, as well as examples of where reporting an additional diagnosis may be appropriate. 17 Top concerns in pediatric record review Documentation for pediatric conditions differs from the adult care population. DEPARTMENTS 4 Associate director s note CDI specialists may well be the superheroes of the healthcare industry after all, they have the ability to adapt faster than changing government reimbursement initiatives, are stronger than the harshest physicians, and can leap through chart reviews like lightning. 5 Note from the advisory board Sylvia Hoffman talks to a group of physicians about their ICD-10 documentation improvement pain points, and shares the insights she found. 7 In the news Following a positive Congressional subcommittee meeting, ICD-10-CM/PCS implementation supporters express optimism regarding the 2015 implementation date. 15 Clinical corner Larry Faust, MD, discusses documentation requirements associated with mental and behavioral health disorders. 18 In the news Value-based purchasing hits headlines as the government speeds up implementation timelines. 20 Physician advisor s corner Trey La Charité outlines several areas where what the physician documents doesn t necessarily translate into the most appropriate code. MAR/APR 2015 Vol. 9 No. 2 27 Ask ACDIS CDI Boot Camp Instructor Laurie Prescott discusses ways to ensure CDI staff stay on track. 28 Coding Clinic CDI update CDI Boot Camp Instructor Sharme Brodie discusses the latest advice from Coding Clinic for ICD-10-CM/PCS. 30 Meet-a-member After finding true happiness in a career in CDI, Sheila Duhan discusses her professional growth and love of the industry. OPINION & INSIGHTS 9 Advocacy for the new code set continues Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, recounts the ICD-10-CM/PCS timeline and reiterates reasons for sticking to the 2015 implementation date. 23 Why the world should care about CDI ACDIS Editor Katherine Rushlau discusses the importance of CDI on healthcare and the community. 24 Using Lean tools to reboot your CDI program Michelle Wieczorek, RN, RHIT, CPHQ, offers insight into how CDI programs can employ the Lean technique to improve their efforts. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978-750-8400. CDI Journal (ISSN: 1098-0571) is published bimonthly by HCPro, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $165/ year for membership to the Association of Clinical Documentation Improvement Specialists. Copyright 2015 HCPro, a division of BLR. 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 or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email customerservice@hcpro.com. Visit our website at www.acdis.org. 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. 3 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

ASSOCIATE DIRECTOR S NOTE CDI superheroes provide benefits beyond improved reimbursement. Eight years ago, CMS implemented a new payment system: MS-DRGs. This new tiered system allowed for better capture of a patient s severity of illness. With it, documented principal and secondary diagnoses affected DRG assignment and adjusted the patient s expected length of stay, and reimbursement, for resources expended. Although CDI programs existed before October 2007, the MS-DRG system incentivized hospitals to implement them. If physician documentation improved, hospitals could capture additional diagnoses and increase reimbursement. CDI programs cut their teeth on CC/MCC capture rates and on increasing the case-mix index at their facilities. There is nothing wrong with this model; CMS specifically stated in the 2009 IPPS final rule that there is nothing wrong with hospitals maximizing Medicare payment as long as the coding is properly supported. For many, improved documentation for reimbursement remains their focus. But CMS is changing its reimbursement model has changed its reimbursement model from one which pays by episode to one which pays for the type and quality of the care provided. As discussed on p. 17 of this edition of the CDI Journal, pay-for-performance (P4P), value-based purchasing (VBP), and other programs are in place now and will play an ever larger role in hospital funding. Facilities with CDI programs in place are lucky (experienced, mature, well-functioning CDI programs luckier still) because CDI efforts may just be the magic elixir, the cure-all for a wide range of healthcare ailments. In some respects, a CDI team functions as a band of superheroes whose collection of powers help them capture CC/MCCs, improve the case-mix index, and identify patient safety indicators as well as present on admission and hospital-acquired conditions. Their tools include the electronic health record and the new ICD-10-CM/ PCS code set. (Read the latest code set news on p. 6.) Perhaps CDI won t save the world, but as our new ACDIS editor Katherine Rushlau writes in her debut column on p. 22, it has the potential to affect the communities hospitals serve. A saved dollar could mean a community hospital keeps its doors open. CDI can save lives, too. Capturing the most accurate depiction of patient care enables physicians to pick up the record and truly understand that patient s medical story. Of course CDI isn t saving the universe all by itself, but if we, as a profession, can advance our CDI efforts beyond the basic CC/ MCC capture rate, we just might be heroes after all. EDITORIAL Director Brian Murphy bmurphy@acdis.org Associate Director Melissa Varnavas mvarnavas@acdis.org Membership Services Specialist Penny Richards, CPC prichards@acdis.org Editor Katherine Rushlau KRushlau@hcpro.com Associate Director for Education Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer cericson@hcpro.com Director of Sales and Sponsorships Chris Driscoll cdriscoll@hcpro.com DESIGN Design Services Director Vincent Skyers vskyers@blr.com Senior Designer Vicki McMahan vmcmahan@blr.com Graphic Designer Tyson Davis tdavis@blr.com 4 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

NOTE FROM THE ADVISORY BOARD by Sylvia Hoffman, RN, CCDS, CCDI, CDIP I attended several medical conferences recently with my husband, a physician, and I was pleasantly surprised to discover that physicians were talking about things such as ICD-10, readmission rates, length of stay, and other topics familiar to all of us in the CDI profession. I am usually reluctant to join in the conversation, fearful they will ask me what I do for a living. In the past, my occupation as a CDI consultant was not met with a warm welcome; at worst, I was met with uncomfortable silence. Recently, however, I decided I would pull up my pantyhose and join in the discussion. Once physicians discovered I had knowledge of this mysterious world of coding and documentation improvement, they inundated me with questions. Evidently, folks, the tide has turned. The number one question they asked was how long ICD-10 would be delayed. They were terrified of the ICD-10 monster. Already overwhelmed with their different EMR systems, any additional stress on their workload was simply too much to consider. A few physicians stated their particular hospitals made them templates, but also noted that these templates did not include any specific wording or concepts to assist with increasing their severity of illness or risk of mortality. Only one physician knew about the significance of the GMLOS (geometric mean length of stay), and only one physician who worked for a colorful insurance provider knew about meaningful use and readmission rate tracking. He informed the group that his company was calculating the cost per patient admission according to providers. The physicians gasped and moaned. I decided to ask them what they wished their hospitals would teach them about ICD-10 and CDI in general, so I could then share it with other CDI specialists. And I m sharing it with you. Physicians want to know how we calculate the GMLOS: They stated they would not keep patients too long if they knew on admission how many days they were allotted. I asked how this could be done, and it was agreed that if hospitals analyzed their 20 most common admission diagnoses, and gave them the GMLOS for each (with CC/MCCs and without), this would be a great help. Many stated that the case managers and social workers should be educated as well, since they are responsible for setting up rehab, nursing home, ADVISORY BOARD Donald Butler, RN, BSN CDI Manager Vidant Medical Center Greenville, North Carolina dbutler@vidanthealth.com Wendy Clesi, RN, CCDS Director of CDI Services Huff DRG Review wendy.clesi@ huffdrgreview.com Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, IQCI, MBA Director Case Management University of California Irvine wdevreug@uci.edu Cheryl Ericson, MS, RN, CCDS, CDIP CDI Education Director HCPro Danvers, Massachusetts cericson@hcpro.com James P. Fee, MD, CCS, CCDS Vice President Huff DRG Review james.fee@drgreview.com Sylvia Hoffman, RN, CCDS, CCDI, CDIP President and CEO Sylvia Hoffman CDI Consulting Tampa, Florida sylvia@sylviahoffman.com Walter Houlihan, MBA, RHIA, CCS Baystate Health Springfield, Massachusetts walter.houlihan@ baystatehealth.org Thomas W. Huth, MD, MBA, FACP Vice President of Medical Affairs Reid Hospital & Health Care Services Thomas.Huth@ reidhospital.org Mark LeBlanc, RN, MBA, CCDS Clinical Documentation Manager HCMC Minneapolis, Minnesota mark.leblanc@hcmed.org Michelle McCormack, RN, BSN, CCDS, CRCR Director, CDI Stanford Hospital and Clinics Palo Alto, California mmccormack@ stanfordmed.org Karen Newhouser, RN, BSN, CCDS, CCS, CCM Director of CDI Education MedPartners karenmpu@ medpartnershim.com Judy Schade, RN, MSN, CCM, CCDS Clinical Documentation Specialist Mayo Clinic Hospital Schade.judy@mayo.edu Anny Pang Yuen, RHIA, CCS, CCDS, Corporate Director of CDI University of Pennsylvania Health System Anny.Yuen@uphs.upenn.edu 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 5

and long-term acute care (LTAC) placements. They also did not understand why admitting a patient for one day was unadvisable, since the goal is to reduce long length of stays. Physicians want to know more about CC/MCCs: Without a doubt, practitioners still do not understand this concept. One doctor said he thought the hospitals were the only ones who benefitted by this documentation. They found queries to be a big bother. This started a very hearty discussion. When we got home, I gave my husband a list of CC/ MCCs and told him to highlight the most common diagnoses seen in his practice. He began to hyperventilate when he saw all of the diagnoses. After I talked him off the ledge, he quickly marked off the most common diagnoses seen in his practice. I then made him a short list of common CC/MCCs he should know. I reassured him the CDI specialists would query for the rest. It totaled 30 CCs and 30 MCCs. This seems like a lot, but he was already documenting many of them and he could now concentrate on the diagnoses he was missing. We reduced the list again, and he was left with approximately 20 total CC/MCCs he needed to address. Across the board, physicians want to know how severity of illness (SOI) and risk of mortality (ROM) is calculated: They would like a brief explanation regarding this topic. The importance of CC/MCCs, in capturing appropriate SOI and ROM, again came to light. Physicians also want to see the numbers on how they are performing as individuals: They all agreed they would like to see statistics on their SOI, ROM, GMLOS, CC/MCC capture rate, query rates, readmission rates, and patient satisfaction scores. This particular group of physicians also wanted to know how to maximize their own billing: CDI specialists definitely need to be educated on outpatient and provider billing to increase buy-in. They all agreed they had taken a financial hit in the last few years, even though they were working longer hours. It might be beneficial for hospitals to hire an outpatient CDI to evaluate emergency room documentation and provide physician billing support. Physicians want templates on the EMR and warm bodies on the floor to help them with documentation and EMR concerns: They re looking for electronic help that prompts them to document the CCs and MCCs needed to capture true SOI/ROM. There was a general consensus (among the group that I talked to) that what remains of the time prior to ICD-10-CM/PCS implementation should be used for education and practice, so there isn t a dramatic effect on their documentation requirements when it finally gets implemented. They feel very isolated and overwhelmed, and would appreciate someone to be available if the need arises. One example given was the need for assistance answering queries in the EMR. Many complained it was complicated and time-consuming. It seemed to this group of individuals that no one ever asked physicians for their input, or asked them what they needed. Indeed, hospitals may be going about the CDI process in the wrong way. There needs to be physician involvement and feedback. Physicians are the providers of needed documentation, but they have no idea how or why it is needed. EMR systems have created a huge burden for them. One physician I spoke with had privileges at three hospitals, and had to learn three different systems (Epic, Meditech, and McKesson). He was not doing well at the two hospitals he visited the least. Many physicians stated they spent approximately two hours a day at home working on medical records (pre-clinic or pre-surgery). Many claimed they were tired, and one older gentleman said he would retire at the end of the year. We need to be advocates for our medical staff. To be successful, CDI specialists must work as a team with their physicians, coders, social workers, case managers, and other ancillary staff members. But we first need to consider the needs of our medical staff in order to better achieve our own goals. Editor s Note: Hoffman is president and CEO of Sylvia Hoffman CDI Consulting, in Tampa, Florida, and an ACDIS Advisory Board member. The views expressed are her own. Contact her at sylvia@sylviahoffman.com. 6 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

IN THE NEWS House committee hears ICD-10-CM/PCS supporters Query revision for ICD-10-CM/ PCS compliance is underway for at least 51% of those responding to a recent ACDIS poll. Of the 657 responses, 46% indicated that their facility has not embarked on a query update project, with 3% waiting until after the implementation date and 14% indicating they were holding off to see whether implementation would be delayed once again this year. Supporters of ICD-10-CM/PCS seem optimistic about implementation s fate following testimony before Congress House Energy and Commerce Committee subcommittee in late January. All the signs seem to be pointing to implementation, says ACDIS Advisory Board member Karen Newhouser, RN, BSN, CCDS, CCS, CCM, director of CDI education for MedPartners in Tampa, Florida. Nevertheless, by March 4, AHIMA sent its members an urgent message encouraging them to contact their elected officials in support of ICD-10-CM/PCS in the midst of rumors that Chairman of the House Rules Committee Pete Sessions, R-Texas, was looking to draft language to delay ICD-10. ACDIS Director Brian Murphy continues to support the current October 2015 implementation date and urges members to help spread the word about the importance of the additional documentation specificity the new code set contains. Ongoing rumors of delays, as the recent ACDIS poll illustrates, hurts facilities willingness and ability to prepare, Newhouser says. I was discouraged to hear that people halted their [education and training] efforts after the last delay, she says. Facilities should be moving forward, not stopping their training. At the very least, query language should be updated to include ICD- 10-CM/PCS language. The goal is October 1st. The goal should be to get so familiar with the documentation needs of the new code set that the implementation date, regardless of when it is, is seamless just another day for the physicians and coders who CDI serve. During the Congressional subcommittee, only one individual spoke against implementation, essentially reiterating old, erroneous arguments. Instead, the six supporters focused the discussion on ICD-10 s effect on quality of care, population Have you updated your query forms for ICD-10? Total Responses: 657 Yes- 51% No- 29% No, we are waiting to see if ICD-10 implentation will be delayed- 14% No, we are waiting until after the implementation date- 3% Don t know- 3% 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 7

health, and recent studies and testimonies regarding the expense of implementation. One such study, generated in cooperation with Professional Association of Health Care Office Management (PAHCOM), and published in the February edition of the Journal of AHIMA, garnered responses from 276 practices with six or fewer providers. These practices reported that average ICD-10-related expenditures for the entire practice cost $8,167 with average expenditures per provider of $3,430. A similar November 2014 report put transition costs at roughly $2,000 to $6,000 for small practices (three physicians). Hospitals have put so much time, money, and personnel resources into their ICD-10-CM/PCS preparedness that it would be a massive waste of productivity and monetary investment to the healthcare providers if the deadline does not stay intact, says Marion G. Kruse, RN, MBA, senior managing director of clinical services for Precyse in Alpharetta, Georgia. There is a general desire to end these delays and move on. Additional concerns regarding CMS own readiness to work within the code set have been alleviated with a recent report from the Government Accountability Office (GAO). The GAO says CMS has prepared for the transition by: Developing educational materials for HIPAA-covered entities (CE); i.e., facilities and physicians, and vendors Conducting outreach, including holding on-site training for some small physician practices Organizing stakeholder meetings, focus groups, group testing, and surveys to monitor CE and vendor readiness Changing Medicare fee-forservice (FFS) claims processing systems Providing technical assistance for Medicaid agencies Although the GAO raised concerns regarding the comprehensiveness of CMS testing and training, the agency has several additional testing rounds scheduled through to the implementation date. CMS declared its January 26 through February 3 test a success with 661 volunteers submitting 14,929 claims. CMS accepted 81% (12,149 claims) of them and identified zero issues. None of the claims were rejected because of front-end submission problems. CMS also has multiple avenues of training planned for a wide variety of CE types from small physician practices to hospitals to long-term care facilities and recently released a series of ICD-10-CM/PCS training videos on its YouTube channel. Although the mood of the day remains optimistic, January s hearing was just that a hearing. And rumors of secret drafts introducing further delays are just rumors at this point. No definitive stance was taken following the hearing, no rules made, no votes cast. Congress still needs to make a decision regarding the Sustainable Growth Rate (the bill that included last year s implementation delay), so those vested in postponing implementation may sneak language into that or some other bill. Nevertheless, facilities need to start that process of shadow coding and rollout of ICD-10 to determine how it s going to affect everyone, says ACDIS Advisory Board member James P. Fee, MD, CCS, CCDS, vice president of Huff DRG Review. Updating queries for ICD-10-CM/ PCS compliance is just one way to help, says Kruse. Facilities need to have that specificity built into their query forms to help get physicians used to the process and to obtain the necessary information for ICD- 10-CM/PCS coding, says Kruse. For facilities preparing by dual, or parallel, coding coding medical records in both ICD-9-CM and ICD- 10-CM/PCS for training and assessment purposes obtaining the additional detail through routine CDI query efforts helps close the loop in preparation efforts. If that documentation isn t in the record, how can the facility determine if the coders are effectively coding the record? Kruse asks. With delays and uncertainty, Newhouser understands the hesitancy, but when you think about it, we have only seven months before implementation and that s not a lot of time. We will blink and it will be here. We need to be ready. 8 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

ICD-10-CM/PCS Advocacy for the new code set continues by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS As part of the healthcare workforce, there is no doubt that CDI specialists are well aware of the implementation of ICD-10-CM. The CM part, the clinical modification of the ICD-10 code set, is specific to the United States and to diagnosis coding. And then there is the PCS portion, the hospital inpatient procedure coding system, also specifically created for the United States. Even though these systems were created and ready to use by 2011, implementation of the codes has been delayed time and time again. Nevertheless, CDI professionals today are well into the preparation for the current October 2015 implementation date. And yet we continue to hear that there has not been enough time to prepare for ICD-10, or that implementation is too costly. Let s do a quick review of the ICD-10-CM development timeline: In October 1996, 70 health information professionals were informally trained in the use of ICD-10- PCS. After the training, they coded a sample of records from their institutions using ICD-10-PCS and reported suggestions and problems to the ICD-10-PCS project staff. CMS conducted a formal test of ICD-10-PCS in order to determine if it would be a practical replacement for the current ICD-9-CM procedures. CMS used two contractors to evaluate ICD-10-PCS. In 1999, the United States began to use ICD- 10-CM for mortality reporting (death certificates). In 2003, there was formal testing of the code set by the AHA (American Hospital Association) and the AHIMA (American Health Information Management Association) for both hospital and physician settings. The medical specialty societies joined in as participants in the content development of ICD-10-CM. Ten years went by with dialogue and exchanges of the pros and cons of ICD-10. In 2006, the House Ways and Means Committee heard testimony supporting and opposing adoption. In August 2008, CMS proposed an adoption date of October 1, 2011. In January 2009, CMS final rule set the implementation date at October 1 2013, allowing five years of preparation. In 2012, the AMA petitioned the Department of Health and Human Services for a two-year extension. A one-year extension was granted, moving implementation to October 1, 2014. However, in March 2014, just under six months before implementation, opposition groups convinced some Congressional representatives to include yet another, one-year delay into a bill related to the Sustainable Growth Rate; the bill passed and the new implementation date became October 2015. So really now, you can t say there hasn t been enough time to prepare. This does, however, make me (and many other people in our industry, I m sure) wonder about the continuing requests for a delay. But I also wonder why some healthcare sectors struggle to use the tools, resources, and planning steps which CMS and others have provided tools which are easily and readily available. The timeline above demonstrates that there have in fact been many years to prepare for ICD-10, and for those few who continue to say that there has not, surely they must now recognize that their procrastination is a detriment to successful implementation. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 9

Why ICD-10 now? With continued debates about the implementation of ICD-10 being a necessity, one only needs to look at the short list of benefits of ICD-10 to know that it s the right step to take for our healthcare system. Although this should no longer need to be reiterated, let s nevertheless recount some of the benefits of the new code set: ICD-10-CM incorporates much greater clinical detail and specificity Terminology and disease classifications are consistent with current clinical practice The modern classification system provides much better data needed for: - Measuring the quality, safety, and efficacy of care - Reducing the need for attachments to explain the patient s condition - Designing payment systems and processing claims for reimbursement - Conducting research, epidemiological studies, and clinical trials - Improving global healthcare data comparison and initiatives - Setting health policy - Operational and strategic planning - Designing healthcare delivery systems - Monitoring resource use - Improving clinical, financial, and administrative performance - Preventing and detecting healthcare fraud and abuse - Tracking public health and risks - Advancing population health Although resistance to implementation remains, a strong positive advocacy effort for keeping implementation at its current go-live date has emerged. Individuals from across healthcare specialties, businesses, and professions came together to support ICD-10 implementation. The Coalition for ICD-10 includes a wide range of large healthcare entities and organizations (including payers). This coalition provides information and facts about ICD- 10 to assist the industry with the promotion of the code set and to clear up myths and erroneous information. The first week of February saw additional testimony related to the pros and cons of ICD-10 implementation and industry preparation in the House Energy and Commerce Committee. (Read the related recap on p. 7.) Although the speakers almost unanimously supported ICD-10 implementation, doubt and worry continues to cloud our preparation efforts. No one wants to see a repeat of last year s eleventh-hour sneak attack on implementation tucked into some other healthcare legislative bill. What can you do? I urge you to contact your legislative representatives. Contact those representatives who sit on the House Energy and Commerce Committee. Let them know how you and your facility have prepared for the transition. Urge them to keep the October 1, 2015 date in place. Our patients need this code set. Ongoing delays are costing our healthcare system dearly. It is estimated that the most recent delay of the code sets (to 2015) has already cost the healthcare industry approximately $6.8 billion dollars. When contacting your legislators, also share this recent information about the true cost of the implementation to small physician practices. Small physician practices are expected to spend between $1,900 and $6,000 to transition to the new code set, a far lesser total than many had anticipated. The study can be found on www.coalitionforicd10.org. In support of ICD-10 implementation, I now have a Twitter account and handle. Please follow me: @GloryannebICD10. Editor s Note: Bryant is a former ACDIS Advisory Board member and is a current and founding member of the CCDS Certification Board. She is a well-known HIM coding and documentation speaker and author. Contact her at Gloryanne.h.bryant@kp.org. 10 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

CC/MCC list: Query with confidence and compliance Additional diagnoses can cause confusion for physicians and CDI specialists. Whether the concern is when they should be reported, or what constitutes an additional diagnosis, William E. Haik, MD, FCCP, CDIP, director for DRG Review, Inc., in Fort Walton Beach, Florida, says the general rule is simple. Any condition that affects the patient s care would be considered a requirement for reporting a clinically significant additional diagnosis, says Haik, who spoke during a January ACDIS webinar on the topic. According to the UHDDS, in order for a condition to qualify as a reportable additional diagnosis for coding and reporting purposes, it needs to meet one of the following criteria: Clinical evaluation: This could include something as simple as a pulmonary consultation for atelectasis, says Haik. Therefore, one should not report isolated radiographic abnormality of atelectasis. Therapeutic treatment: For example, an oral treatment with medication such as Septra for a urinary tract infection. Diagnostic procedures: If a patient has hyponatremia, and the physician looks at the patient s serum cortisol level to work out the cause of the hyponatremia, hyponatremia would be reportable as a clinically significant additional diagnosis, says Haik. Extended length of hospital stay: A patient may have a gastrointestinal bleed, so the physician monitors and documents a drop in the hematocrit, Haik says. Then, if they ve done more than routine follow-up of a hematocrit drop (that is more than just daily), one could report drop in the hematocrit as an additional diagnosis. Increased nursing care or monitoring Has implications for future healthcare needs: As per the Official Guidelines for Coding and Reporting, this applies to newborn coding only for example, delaying the repair of a hernia for a few weeks in a newborn. Although these are the rules set by the UHDDS, Haik says the AHA s Coding Clinic for ICD-9-CM/ICD- 10-CM/PCS offers advice for when to report additional diagnoses. The best references for reporting 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 11

diagnoses, according to Haik, include: AHA s Coding Clinic for ICD- 9-CM, Second Quarter 1990, which features several examples for each rule to help individuals understand and apply the general rule for reporting additional diagnoses AHA s Coding Clinic for ICD- 9-CM, Third Quarter 2007 AHA s Coding Clinic for ICD- 9-CM, Third Quarter 2011 Here are some specific query opportunities from the CC/MCC list, as well as examples of where reporting an additional diagnosis may be appropriate. CC examples Angina (411.1): This type of angina, pre-infarction or unstable angina, is considered the most severe. The issue from a CDI perspective, according to Haik, is that the attending physician often prefers to use softer terms in the record, like accelerated, in situations when a myocardial infarction is not imminent (such as, in a patient who presents with atrial fibrillation with a rapid ventricular response and accelerated angina). Physicians may also use the term ACS, which, from a physician perspective, can mean any spectrum of acute ischemic heart disease (unstable angina, submyocardial, or transmural myocardial infarction). Unfortunately, the term ACS only codes to unstable angina. Haik suggests querying the physician in patients who have increased troponin as this could signal evidence of an acute myocardial infarction. Asthma (493.xx): Be aware of patients with pneumonia suffering from exacerbation of asthma, Haik says. Physicians may not document exacerbation of asthma or acute asthma. If an asthmatic patient is wheezing on admission to the hospital, has pneumonia, and is treated for asthma (with steroids etc.) in addition to receiving antibiotics for pneumonia, then the asthma can be considered an additional diagnosis, and a query may be needed. Cardiomyopathy (425.x): Physicians often document LV [left ventricular] dysfunction, especially in patients with reduced ejection fractions, according to Haik. If the patient is on cardiac medications, such as ace inhibitors or beta blockers, they don t just have LV dysfunction they have cardiomyopathy. Query the physician in this instance. In addition, cardiomyopathy is excluded as a CC when congestive heart failure, not otherwise specified, is the principal diagnosis. So to affect the DRG assignment, one must specify the type of CHF as being systolic and/ or diastolic. Deep vein thrombosis [DVT] (451.xx 453.xx): The main difference between the four classifications of DVT acute DVT, chronic DVT, post-thrombotic, and history of DVT is that acute and chronic are considered CCs, and post-thrombotic and history of are not. How can this be distinguished clinically? The only way is to see if the patient has a clot in the vein, says Haik. If symptoms persist longer than a week to 30 days, the diagnosis becomes chronic DVT. Dementia: In patients with senile or atherosclerotic dementia who are treated for acute confusion, delirium, delusions, depression, and Alzheimer s or Parkinson s disease Functional quadriplegia is different from quadriplegia that occurs from a central nervous system (CNS) lesions or spinal cord lesion. Patients with functional quadriplegia, do not have a CNS lesion, but are not able to move either because of dementia or severe contractures, or arthritis. with behavioral disturbances such as aggressive, combative, violent behavior, or wandering off, these conditions are clinically significant and should be captured to affect the DRG assignment, Haik says. Drug-induced delirium: Often a patient coming out of surgery, on medications, or coming off of anesthesia will be confused, and the physician will document confusion or sundowner s syndrome. As sundowner s syndrome does not have a specific code, query the physician if sundowner s syndrome is consistent with drug-induced delirium, says Haik. Heart failure (428.x2): Systolic heart failure relates to the failure of the ventricle to contract normally, 12 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

sometimes referred to by physicians by the new term reduced ejection fraction heart failure. Diastolic heart failure relates to the inability of the ventricle to relax and fill normally, referred to by physicians by the updated terminology of preserved ejection fraction heart failure. Unfortunately, current AHA Coding Clinic for ICD-9-CM/ICD-10-CM/PCS does not recognize these as synonymous terms, so you must query the physician to see if they mean systolic or diastolic heart failure. Hemiplegia (342.xx): This condition as a late effect of cerebrovascular accident (CVA) or acute effect of CVA is reportable as an additional diagnosis. The problem from a CDI standpoint, according to Haik, is that physicians will sometimes only document left-sided weakness. Weakness has its own ICD-9-CM code. In this case, query whether or not the physician s documentation of weakness is synonymous with hemiplegia. This is especially important because hemiplegia is a CC, and weakness is not. For quality reporting purposes, if you have hemiplegia as an additional diagnosis, it negates or severely adjusts patient safety indicators that assume poor quality, such as hospital-acquired decubitus ulcer. This, in turn, affects both CC capture and quality reporting perspectives. Respiratory failure, chronic (518.83): Physicians often document chronic obstructive pulmonary disease (COPD) oxygen dependent, or COPD with chronic hypoxemia. If a patient receives ongoing oxygen paid for by Medicare, Haik says his or her partial pressure of oxygen level must be less than 60, which is consistent with chronic respiratory failure. Query whether the patient s condition is consistent with chronic respiratory failure, and be sure the query provides reasonable options to remain compliant. Acute respiratory insufficiency (518.82): According to Haik, physicians frequently document acute respiratory insufficiency in patients with exacerbation of COPD. Don t report it in that instance, even though it may be documented, as it is considered integral to the disease process. It, however, is not integral in a patient who has pneumonia, Haik says, and therefore should be reported as an additional diagnosis. MCC examples Quadriplegia: Functional quadriplegia is defined as an inability to move. The patient cannot carry out daily activities and is considered bedridden. Functional quadriplegia is different from quadriplegia that occurs from a central nervous system (CNS) lesion or spinal cord lesion. Patients with functional quadriplegia, Haik says, do not have a CNS lesion, but are not able to move, either because of dementia or severe contractures, or arthritis. Query the physician to see if functional quadriplegia is present in bedbound patients who cannot perform basic activities such as feeding or dressing themselves. Renal failure: Physicians often document acute tubular necrosis (ATN). To determine ATN, the most important criteria is whether a urinalysis shows a tubular cast. ICD-10-CM updates ICD-10 will bring an abundance of changes, and many of them will have an impact on CC and MCC determinations, says Haik. Some conditions considered a principal diagnosis will serve as their own CC, for example. Combination codes will become a commonality. For example, a coronary artery disease diagnosis with unstable angina would then act as its own CC, and then go to the heavier-weighted DRG of that pair. This will also apply to MCCs. We can also expect a handful of CCs and MCCs to disappear entirely with ICD-10, as shown in the chart on p. 14. Didn t get to listen live to the CC/MCC: Clinical Conditions, Query Opportunities, and ICD-10 Update webinar? Listen to the on demand version and train your whole team. New coders and CDI specialists often struggle to identify the clinical indicators needed to qualify a diagnosis as a complication/comorbidity (CC) or a major CC (MCC). Even those who ve had multiple years of experience querying can get tangled up in new initiatives, letting their essential skills lapse. This program provides a detailed look at targeted CC/ MCC areas and highlights opportunities for improvement. http://hcmarketplace.com/ cc-mcc-clinical-conditions-query-opportunities-and-icd-10-update 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 13

ICD-9-CM CC/MCC DELETIONS AND REVISIONS IN ICD-10-CM (PARTIAL LIST) Condition ICD-9-CM Code ICD-10-CM Code Acute laryngitis with obstruction MCC, 464.01 Not an MCC or CC, J05.0 Angina, decubitus (nocturnal) CC, 413.0 Not a CC, I20.8 AV block, second degree or Mobitz (type) II CC, 426.12 Not a CC, I44.1 W Cellulitis of the larynx CC, 478.71 Not a CC, J38.7 Complete bilateral vocal cord paralysis CC, 478.34 Not a CC, J38.02 Confusion (acute) CC, 293.0 Not a CC, R41.0, unless specified as acute/ sub-acute confusional state, F05 Coronary AV fistula, acquired CC, 414.19 Not a CC, I25.41 Delirium, acute, due to other conditions/ sub-acute Depression, specify types such as acute Hypertension, malignant and accelerated CC, 293.0/293.1 Not a CC, R41.0 CC, 296.2x 296.3x CC, 401.0 Influenza due to avian virus with other respiratory manifestations and other manifestations Acute not a CC, unless specified as to its severity (mild, moderate, etc.), F32.0 F32.3, or specified as recurrent, F33.x, or in remission, F33.4x (not all types) Not a CC, I10 CC, 428.02 and 488.09, respectively Not a CC, J09.x2, J09.x3, and J09.x9 Papillary muscle dysfunction CC, 429.81 Not a CC, I51.89 Pleural effusion due to specified bacteria MCC, 511.1 CC, J90 Pulmonary insufficiency (acute) CC, 518.82 Not a CC, unless specified as postoperative and either acute or chronic, then an MCC, J95.2x Respiratory insufficiency (acute) CC, 518.82 Not a CC, R06.89 Schizophrenia CC, 295.xx, specify acuity even chronic Toxic nephropathy due to drugs (contrast media) MCC, 584.5 Specify as to its type, F20.0 F20.8, unspecified not a CC, F20.9 Not an MCC, N14.1, unless further specified as acute tubular necrosis (ATN), then may also report N17.0 as MCC, (N17.0 is an excluded MCC if N14.1 is PDx) 14 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

CLINICAL CORNER Capturing appropriate documentation for mental and behavioral health disorders by Larry M. Faust, MD, FAAP The American Psychiatric Association s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered by many clinicians as the authoritative guide to the diagnosis and classification of mental disorders. Following more than a decade of collaboration by leading authorities in the field of mental health, the Fifth Edition (DSM-5), released in May 2013, contains a consensus on current research in mental and behavioral disorders, and provides a common nomenclature for clinicians who diagnose and treat mental and behavioral problems. While providers may rely on DSM-5 criteria to base their diagnostic decisions, these diagnoses need to be translated into the required ICD-9-CM (and as of October 1, 2015, ICD-10-CM) code sets mandated for reimbursement and mortality/morbidity reporting. The APA developed DSM-5 to be compatible with ICD- 9-CM and ICD-10-CM codes. Before each disorder in the DSM-5 manual, a line was provided that contains an ICD-9-CM code, followed by an ICD-10-CM code in parentheses. A blank line indicated an ICD code was not applicable. The APA faced a challenge because the DSM-5 included many new disorders, nomenclature changes, and new combination codes. These were assigned the best available ICD codes, but the DSM-5 terminology sometimes did not match the names connected with the ICD codes. In addition, because diagnostic code selection was limited to those codes contained in ICD-9-CM and ICD-10-CM, it was sometimes necessary for different disorders to share the same diagnostic code. In some cases, a code could only be assigned based on a disorder s subtype or specificity. A detailed review of all of the changes in DSM-5 diagnoses and code selections is beyond the scope of this article, but let s review some of the major changes. Neurocognitive disorders Neurocognitive disorders are subtyped based on the known or presumed etiology. Because neurocognitive disorders exist on a spectrum of cognitive and functional impairment, a less severe form of cognitive impairment is included under a new classification of mild neurocognitive disorder that allows the diagnosis of less disabling symptoms. Criteria for the diagnosis of mild versus major neurocognitive disorder is provided, and the terms probable and possible have been added to the diagnosis of certain neurocognitive disorders. Substance abuse and dependency Substance abuse and substance dependency are no longer separately classified. The classification is now substance use disorder, and severity of substance use is defined as mild, moderate, or severe, based on the number of symptom criteria present. The term addiction is eliminated. When withdrawal, intoxication, substance-induced, or other substance-related mental disorder is present, the manual provides criteria and directs further specific code selection based on these co-occurrences. The multiaxial system used by some insurance companies and government agencies and stressed in the previous version of DSM (DSM-IV-TR) is no longer required. The Global Assessment of Functioning (GAF) score has been dropped, and providers are directed to use the V codes in ICD-9-CM and the Z codes in ICD-10-CM to record associated psychosocial and environmental problems. Schizophrenia Subtypes of schizophrenia (e.g. residual, paranoid, disorganized) are eliminated due to their limited reliability and validity. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 15

Autism, Asperger s, and developmental disorders Separate diagnoses for autism, Asperger s syndrome, and pervasive developmental disorder, not otherwise specified, have been eliminated and are now classified under the new term autism spectrum disorder. Eating disorders Non-physiologic feeding and eating disorders of early childhood are now classified as avoidance/restrictive food intake disorder. Somatiform disorders Somatiform disorders are now classified as somatic symptom and related disorders, and the terms somatization disorder, hypochondriasis, and pain disorder. Undifferentiated somatiform disorders have been removed. Some new disorders described in DSM-5 include: Premenstrual dysphoric disorder Disruptive mood dysregulation disorder of childhood (onset before age 10 years) Hoarding disorder Social (pragmatic) communication disorder Disinhibited social engagement disorder Rapid eye movement sleep behavior disorder Caffeine withdrawal Thus, it is uncertain when CDI specialists will see this effort fully realized, with modifications to ICD-10-CM codes that reflect the most up-to-date terminology and classifications for mental health disorders. In the interim, the new DMS-5 disorders, classifications, and nomenclature changes can create challenges for the coder. Certain terms used in DSM-5 may not be found in the ICD-9-CM or ICD-10-CM index, and the crosswalk in the DSM-5 manual may not always reflect an ICD code arrived at through existing coding guidelines. Coders could be faced with the conundrum of selecting a code specified in the DSM-5 crosswalk or selecting a code from ICD-9-CM that might not reflect the provider s intent or accurately represent the patient s diagnosis. A cooperative relationship between coders, CDI specialists, and providers is therefore essential for correct code assignment. Coders and CDI specialists must familiarize themselves with DSM-5 definitions and taxonomy in order to accurately translate into the language necessary for correct coding in ICD-9 and ICD-10. Editor s Note: Faust is a board certified pediatrician with more than 37 years of combined clinical and administrative experience, including working with special needs children. A co-presenter in the ACDIS The Physician Advisor s Role in CDI Boot Camp, Faust is presently associated with CDIMD, a physician-centric company whose primary mission is to assist and support providers, coders, and CDI personnel in all aspects of the clinical integrity of the medical record. Contact him at lfaust@cdimd.com. ICD-10-related concerns In anticipation of the implementation of ICD-10, and in an effort to ensure maximum consistency between DSM-5 and ICD code sets, the APA states that it is working with CMS and CDC-NCHS to include the new DSM-5 terms in ICD-10-CM. The APA states they will inform clinicians and insurance companies when ICD-10-CM modifications are made. However, the CMS and CDC Coordination and Maintenance Committee implemented a partial freeze on ICD-10-CM updates, with the proviso that there will only be limited updates to ICD-10 code sets afteroctober 1, 2015. Regular updates will not begin until October 1, 2016. 16 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

Top concerns in pediatric record review There are plenty of opportunities for new pediatric CDI programs to make a difference, but identifying those top query prospects can be difficult, says Karen Bridgeman, MSN, RN, CCDS, CDI educator, at the Medical University of South Carolina (MUSC) in Charleston. Prominent documentation opportunities include respiratory failure, asthma versus bronchiolitis, sepsis, shock, acute kidney injury, malnutrition, specificity of seizures, etiology of altered mental status, and complex pneumonia with failure to document suspected etiologies, says Larry Faust, MD, FAAP, a physician at CDIMD in Clarksville, Tennessee. Overall, CDI specialists should determine the most common conditions for the population at their facility and go from there, Bridgeman says. High-volume conditions at MUSC include asthma and seizures, while respiratory failure clarification offers the greatest impact, since pediatricians often prefer the less severe term respiratory distress. Very sick children may respond quickly to therapeutic interventions and, thus, pediatricians may be If you are new in reviewing pediatrics, start slowly, give yourself time to learn nuances in coding and the pediatric population. Karen Bridgeman reluctant to use terms that frighten anxious parents, says Faust. CDI can help physicians understand the terms needed for more specific code assignments. For example, in patients suffering breakthrough seizures, CDI specialists may need to query as to whether the seizures are intractable or medically refractory, or whether an increase in frequency is not due to medical noncompliance or patients on ketogenic diets, says Bridgeman. If you are new in reviewing pediatrics, start slowly, give yourself and your staff time to learn nuances in pediatric coding and the pediatric population, she says. Physicians receive reimbursement for their services based on their submitted CPT codes, not ICD-9-CM (ICD-10-CM/PCS) or MS-DRGs, so most pediatricians have not been educated on DRGs or the impact of diagnostic specificity. Pediatricians may use clinical language that is quite clear to colleagues, but is not congruent with codeable terms. Editor s Note: This article was adapted from a recent discussion on Pediatric CDI Talk, and originally published on the ACDIS Blog. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 17

IN THE NEWS HHS Ramps Up Value-Based Purchasing Plans Better, Smarter, Healthier was the headline which topped a January announcement shifting value-based purchasing (VBP) goals and shortening implementation deadlines. By 2016, 85% of all traditional Medicare payments will be tied to quality or value. By 2018, 90% of all payments will have some quality measures attached, according to Department of Health and Human Services (HHS) Secretary Sylvia Burwell. What is VBP? Essentially, it s an amalgamation of various government efforts tied together by a new payment methodology. Congress authorized use of VBP under the Affordable Care Act. Signed into law in 2010, the program uses the hospital quality data reporting infrastructure developed for the hospital inpatient quality reporting (IQR) system that was created under the 2003 Medicare Prescription Drug, Improvement, and Modernization Act. In fiscal year 2015, CMS funded the VBP by a 1.50% reduction from participating hospitals DRG payments. Hospitals have the potential to earn more than the 1.50% back, however, depending on their performance on VBP measures. Measures are divided into four categories or domains, including: 1. Efficiency: Medicare spending per beneficiary 2. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems): Includes patient perception of nurse/physician communication, hospital staff responsiveness, cleanliness, and other measures 3. Outcomes: Derived from mortality and patient safety indicators and currently focused on acute myocardial infarction (AMI), heart failure, pneumonia, central line associated bloodstream infections, and patient safety indicator 90 composite 4. Process: Includes 12 clinical process care measures such as AMI treatment with fibrinolytic therapy within 30 minutes of arrival at the hospital Each domain is weighted, and improvement (or negative progress) is measured against previously indicated benchmarks in time. For CDI specialists, obtaining documentation of these conditions which are often already top targets for CDI scrutiny can not only help ensure that current reporting of hospital activities remains as accurate as possible, but also help ensure that baseline data is also true. We all hear the news every day about new government programs such as accountable care, gainsharing, bundled payments, value-based payments, and other initiatives that are really moving us away from feefor-service models, says Glenn Krauss, RHIA, BBA, CCS, CCS- P, CPUR, CCDS, C-CDI, PCS, C-CDAN, executive director for the Foundation for Physician Documentation Integrity, who spoke on the February 18 ACDIS Radio program How CDI Must Adapt to Healthcare Reform. Although the idea of tying government healthcare reimbursement to efficiency and quality of care is nothing new, the aggressive plans outlined by Burwell and HHS are. They call for a three-year plan boosting the percentage of fee-forservice Medicare reimbursements based on alternative payment models (APM) and increasing the percentage of all reimbursements linked to quality and value, HealthLeaders Media reports. 18 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

To oversimplify, if hospitals do a good job, then they receive additional funding; if they don t do that well, then they lose funding. Although 55% earned higher payments for their VBP efforts, less than half of them actually received more money due to penalties associated with other related quality payment programs, according to a Kaiser Health News report. CMS penalized more than 700 hospitals for hospital-acquired conditions, for an estimated $373 million, Kaiser Health News reported in December 2014. In October 2014, Kaiser Health News reported that three-quarters of hospitals subject to the Hospital Readmissions Reduction Program were penalized, resulting in fines/payment reductions of about $428 million. Furthermore, preventive care, which aims to keep patients healthier and out of the hospital, reduces hospital volume. Coupled with the drop in payments, hospitals may really suffer, Greg Adams, MBA, FHFMA, senior vice president of Panacea Healthcare Solutions, said during a 2014 Talk Ten Tuesday broadcast. It s a volume to value issue. These cuts may not seem like a lot, but it s like having one foot on the deck and the other on the boat while hoping the boat doesn t move until you can jump on board. There are parts of the country where operating margins are so low it will be difficult for them to survive, he said. The ripples from VBP and the government s healthcare reform focus on payment for care quality touch all manner of healthcare providers including physician practices and outpatient services, ACDIS Advisory Board member James P. Fee, MD, CCS, CCDS, vice president of Huff DRG Review told ACDIS February Quarterly Conference Call participants. We are moving to clinical integration and partnerships; physicians and CDI staff are increasingly involved in capturing true severity and complexity of patients across the continuum of care, said Fee. Of course, all these payment changes nevertheless rely on one significant factor information and that information is what gets captured in the medical record, says Krauss. That s directly related to those of us who work in CDI, he says. It s just that we need to expand the scope of CDI beyond the capture of the principal diagnosis and the secondary diagnosis to a much more holistic approach, looking for any opportunity to improve the quality of the documentation and taking a focused look at some of the elements being targeted within the VBP program and healthcare reform. We need to maintain our awareness of these new concerns and look to obtain new levels of expertise and physician involvement if we (and our facilities) are going to be successful, Fee agrees. CDI programs may be wondering what steps they need to take to expand into these areas, says CDI Education Specialist Laurie L. Prescott, MSN, RN, CCDS, CDIP, with HCPro in Danvers, Massachusetts. Step one really is starting to educate yourself. Use CMS resources to identify target areas and look to see where your own facility s documentation needs are. Then, reach out to leaders in quality and other departments to determine what we can pull to help support those quality of care measures, says Prescott. Krauss suggests explaining to physicians that neither CDI nor healthcare reform is really asking them to change how they practice medicine. Instead, CDI specialists should focus on capturing: What the physician thinks Why the physician thinks diagnosis A or B Where the treatment or testing plan is headed What actions were taken and what actions are still needed How long it is going to take to plan for postacute care In a nutshell, this is what CDI specialists should be striving for in real CDI efforts. There s a much better chance of engaging the physician in CDI with this message, and a much better chance of adapting to the increased emphasis on VBP and other healthcare reform measures, Krauss says. This really is something we should embrace and be excited about, says Prescott. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 19

PHYSICIAN ADVISOR S CORNER Clinical versus coding definitions: Addressing challenges associated with difficult translations by Trey La Charité, MD When providers use different definitions for the same disease, confusion and chaos result. Inaccurate definitions allow Recovery Auditors (i.e., RACs) ample opportunities for denials, depriving your facility of valuable dollars/patient care resources. Unfortunately, providers learn disease definitions during medical training. When they begin practice, adopting new disease definitions or accepting terminology changes proves difficult. As CDI professionals, guiding your facility s providers toward more accurate disease definition usage is challenging, frustrating, and an ongoing process. And yet, maintaining accurate and consistent definitions of medical diagnoses is an important aspect of the CDI specialist s role. Definitions of medical diagnoses are rarely permanent; they change over time as our understanding of disease pathophysiology, recognition, and management evolves. This creates a significant challenge for CDI professionals and the providers with which they work. Since there is no uniform method for distributing medical information, adoption and implementation of changes vary tremendously between providers. For the CDI professional, this poses two problems: 1. Providers who fail to learn and apply new definitions (and continue to use outdated terminology) 2. Providers who adopt new terminology faster than the ICD system can create corresponding codes Outdated terminology may lead to unnecessary down-coding; using terminology with no corresponding ICD code may lead to a diagnosis not being reported. Both problems can lead to providers not receiving appropriate credit for the severity of illness of their patients. Changes in heart failure definitions Let s look at heart failure, for example. Starting in the late 1980s, the pathophysiology of congestive heart failure (CHF) shifted from the classic left-sided versus rightsided designations taught in basic physiology courses to the concept of systolic function versus diastolic function. Documenting CHF as either systolic or diastolic (in addition to being described as acute or chronic) allows coders to assign the most specific and highest weighted codes possible in our current ICD-9-CM coding system. However, if a clinician uses non-specific, outdated terminology such as CHF exacerbation or acute leftsided CHF, the corresponding ICD-9-CM code(s) are lower-weighted, the patient doesn t appear to be as ill, and the physician appears to not have done as much work to provide care to that individual. Additionally, the financial ramifications for a healthcare institution can be significant, as acute systolic CHF is an MCC, acute left-sided CHF is a CC, and CHF exacerbation is neither. On the other end of the spectrum, consider a clinician that has already adopted the new heart failure terminology proposed by both the American College of Cardiology and the American Heart Association in 2013. (Read the report, ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. ) In this new taxonomy, heart failure has been subdivided into heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. (These new phrases are invariably abbreviated in the medical record simply as HFrEF and HFpEF. ) Currently, there are no corresponding ICD-9 or ICD-10 codes for these 20 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

descriptors. Therefore, if these terms are used by providers, coders may only code congestive heart failure, unspecified (428.0), which does neither the clinician nor their host hospital any good. In fact, Coding Clinic for ICD-10-CM/PCS, First Quarter 2014, p. 25, stated that coders may not assume that HFrEF and HFpEF mean systolic or diastolic heart failure. For clinicians that practice in an academic institution, this can be a very difficult situation. Continuing with the heart failure example, what is the appropriate terminology that cardiologists and other providers should use when training medical students, residents, and fellows? Must a university-based healthcare system that emphasizes cutting-edge care use outof-date terminology to satisfy the coding needs of the hospital? This can be a bitter pill to providers who see themselves as guardians of the famed academic ivory tower. The cardiologists at my academic institution were unhappy when instructed to stop writing HFpEF and HFrEF in the medical record and return to systolic and diastolic descriptors they now consider archaic. As they are responsible for educating our future physicians, their frustration is justifiable. Changes in renal failure definitions As a second example, let s consider acute renal failure. For years, the definitions for this diagnosis varied widely. Finally, in 2004, the RIFLE criteria Risk, Injury, Failure, Loss, End-Stage Renal Disease was proposed by the Acute Dialysis Quality Initiative Group (ADQI), yielding one uniform definition for diagnostic accuracy. (Read the related literature online at www.ncbi.nlm.nih. gov/pubmed/15312219.) However, by 2012, the Kidney Disease Improving Global Outcomes (KDIGO) work group rewrote the definition and proposed the new terminology of acute kidney injury (AKI). (Visit www.kdigo.org for additional information.) While this change was instituted to facilitate provider recognition that even small changes in kidney function have significant clinical consequences, this taxonomy created a significant coding and reporting problem for our hospitals. Acute renal failure, as defined by the RIFLE criteria, referred to creatinine levels that were three times higher than a patient s baseline level, or to a 75% decrease in a patient s glomerular filtration rate (GFR). In contrast, the entire spectrum of acute renal dysfunction, including increases in creatinine levels of only 0.3 mg/dl up to the acute need for continuous renal replacement therapy (CRRT), is now covered by the single acute kidney injury term. (For the simplicity of my arguments, I have intentionally omitted the urine output components of these definitions.) In the current ICD system, however, when a provider writes AKI in the medical record, the corresponding code remains acute kidney failure (584.9). Therefore, for a relatively small rise in a patient s creatinine, the hospital submits a code designated as a CC. If a patient s creatinine only increased from 1.1 to 1.4 and was only treated with two bags of IV fluids, is this really an accurate portrayal of a patient s severity of illness? Should the hospital receive the associated increased reimbursement? As the RIFLE criteria are now clinically obsolete, AKI should have a corresponding ICD code. In fact, AKI as defined by the KDIGO includes three stages of severity based on increasing serum creatinine levels. Therefore, we should have an appropriately corresponding ICD code for each stage. My suggestion is to create three new codes labeled AKI Stage 1 (being neither a CC or an MCC), AKI Stage 2 (being a CC), and AKI Stage 3 (being an MCC). This would ensure an accurate description of a patient s clinical situation and appropriately compensate hospitals for the varying degrees of resource use required to treat each stage. Code changes such as these fall under the auspices of the ICD Coordination and Maintenance Committee; CDI professionals and clinicians must wait for them to take action on this subject. CDI leverage A CDI professional recognizes that his or her institution s providers attended different training programs. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 21

Therefore, they expect a certain degree of variability in how each provider establishes the presence of a certain diagnosis. However, the CDI professional also needs to be charged with standardizing (as much as possible) the definitional criteria used by their providers across the entire institution. When disease definition or nomenclature changes occur, the CDI team needs to quickly implement an efficient and effective communication plan. CDI programs can establish a regular cadence to review any standardized queries and update them according to clinical and coding definition changes. While a quarterly review may be too onerous (and potentially unnecessary), such examinations should be conducted at a minimum whenever clinical or coding definitions change. Additionally, many facilities work with their coders and physicians within a given specialty to regularly review definitions for common diagnoses such as those mentioned here. In such a collaborative forum, all sides are able to discuss the needs and problems associated with definition variances and establish mutually agreeable terms for the facility to use. Ideally, the ICD system would have the involvement and agility to modify or create code sets that correspond to these changes soon after they occur. However, until that happens, the CDI professional has to navigate a utilitarian, yet as compliant as possible, course within their facility. Editor s note: La Charité is a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville (UTMCK) and a former ACDIS advisory board member. He is also a clinical assistant professor with the Department of Internal Medicine and serves as the physician advisor for UTMCK s Clinical Documentation Integrity Program, Coding, and RAC response. His comments do not necessarily reflect those of UTMCK or ACDIS. Contact him at clachari@utmck.edu. The Clinical Documentation Improvement Specialist s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP. Your new CDI specialist starts in a few weeks. They need orientation, training, and help understanding the core skills every new CDI needs. We have a book that can help. Order now. $159 Order Now 22 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

ON TOPIC Why the world should care about CDI by Katherine Rushlau It s a question asked by many new to the CDI field: What is CDI? When I first interviewed for the CDI editor position at ACDIS, I quickly Googled the term, finding translations like customer data integration and capacitor discharge ignition. Clearly, I had no idea what I was getting into. While I soon learned the acronym CDI in the hospital setting meant clinical documentation improvement, I was still baffled by what exactly that meant. Finding out what specifically a CDI specialist does on a day-to-day basis, however, helped clear the fog. Laurie Prescott, MSN, RN, CCDS, CDIP, defines the role of the CDI professional as someone who makes sure the medical record thoroughly represents the patient s condition, so hospitals and providers can get reimbursed appropriately. They query physicians and review the medical record to make sure the language used in the record will directly translate to an appropriate code. Statistics for quality measures, she says, are pulled directly from the codes assigned based on the documentation. CDI reaches into many dimensions, says Prescott. The better the documentation, the better the organization will be represented and, therefore, the stronger they will be. Unfortunately, CDI programs are still so new that even nurses and hospital employees often don t know much about them. Often, Prescott says medical professionals especially physicians find the processes irritating because they don t understand why the CDI specialist reviewed the chart or asked questions about the records. Michelle McCormack, RN, BSN, CCDS, CRCR, director of CDI at Stanford Health Care in Palo Alto, California, and an ACDIS Advisory Board member, says the increased scrutiny of healthcare documentation from so many areas including the federal government for policy and reimbursement development, private insurers, and researchers means there is more pressure to justify treatment and payment. Documentation, she says, drives communication, and ultimately improves performance. I think it s really important to have that ongoing learning and knowledge sharing, says McCormack. When [everyone in a facility] works together to break down those walls and understand what each person is doing, there s much more than a financial or quality impact. It has a global impact. But why does this matter? CDI improves hospital reimbursement and quality measures that rank an establishment in the medical world. It seems like the only people who should be concerned about CDI and the role of CDI specialists are those who benefit from their work (hospital employees, patients, etc.), right? Wrong. Anyone who lives in a city or town with a hospital, Prescott says, knows how closely hospitals are woven into the fabric of the community. They are as important as the local businesses in both a financial and romantic sense. In fact, the general public needs to remember that hospitals are, at their core, businesses. They have to function in the same way as companies, they have to generate enough income to survive, and they often have very tight profit margins. Even a little bit of money, Prescott says, makes a big difference. Everyone thinks hospitals have tons of money, says Prescott. In reality, what they re putting out and getting back is so slim that, if you don t pay attention to every penny and make sure you re getting what you need, it can mean terrible things. I ve worked in hospitals that have no money and everything falls apart. For example, hospitals struggling with funding can t afford to purchase equipment they need to treat patients, which often means a potential patient will go to a different hospital. They also have fewer resources including the ability to pay the number of staff members they realistically need on hand. A hospital might need three nurses, but if money is tight and they can only afford two, that s a sacrifice they have to, and will, make a sacrifice that will 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 23

directly impact the quality of care provided to the patient population or community served. The increased precision of healthcare data is something everyone, including those not working in the medical field, can relate to, says Peggy Nail, BSN, CCM, CCDS, CDI specialist at University of Mississippi Medical Center in Jackson. The medical picture captured by the codes and documentation translates to rankings that we all use, including treatment success rates at individual hospitals and world health statistics that determine which regions are more susceptible to certain diseases. If you ve ever used a site like HealthGrades.com to find a doctor, or HospitalSafetyScore.org to choose a facility for a surgery or procedure, you ve used data determined by healthcare code assignment, and made more accurate by CDI programs and professionals. When we strive for detailed documentation, we provide the most accurate data for statistical and research purposes, which benefits us all, says Nail. CDI programs matter for all of us, not just those within a facility or organization. If the documentation isn t correct, the code assignment won t be correct, and neither the facility nor the physician will receive the reimbursement warranted for the care provided. Without accurate reimbursement, the hospital won t have the funding. A hospital is often considered the heart of the community; if it cannot remain financially viable due to the various pressures of today s healthcare environment, it may have to close its doors. And that can be very traumatic for the entire community, says Prescott. Employees lose their jobs. Those who rely on the proximity of the hospital have to travel longer distances for treatment and care. It may sound grandiose, but CDI efforts actually can help keep hospitals that struggle with their business from disappearing, she says. Accurate documentation is the heart of CDI, because it is used to communicate a patient s condition and give quality care to ensure proper reimbursement and accurate statistical representation, says Prescott. The documentation we put in a chart is making sure hospitals survive. Editor s Note: Katherine Katy Rushlau joined the ACDIS team in January as the CDI editor assisting on all ACDIS publications and social media efforts; she is located in our HCPro offices in Danvers, Massachusetts. Email her at krushlau@acdis.org. Using Lean tools to reboot your CDI program by Michelle Wieczorek, RN, RHIT, CPHQ Some estimates put CDI programs in more than half of healthcare organizations in the United States today. Most CDI programs have ambitious goals of improving documentation for clinical clarity of their health records, ensuring accurate and timely reimbursement, and accurately depicting patient acuity. Regardless of the actual number of CDI programs throughout the country, most industry experts assert that CDI efforts are now a mainstream, necessary practice in today s inpatient hospital setting. And while the emergence of CDI programs continues in nontraditional settings, such as in outpatient and ambulatory care, most CDI programs still focus primarily on reviewing inpatient Medicare or DRG-based payer records concurrently, querying physicians when there is a documentation deficiency or gap identified. As programs mature, however, the mechanics of daily record review and assessment have become just that: mechanical, leaving many programs stuck in a rut, in need of a reboot. Often, such programs focus on operational metrics simply to justify the money for the staff invested in it. Typically, such programs managers can show in intricate detail how many initial, subsequent, and reconciliation reviews each CDI specialist performs on a daily basis, in an effort to depict how busy their CDI specialists are. Such programs accept that some opportunities may get missed due to lack of weekend coverage and neglect to quantify the effect of seven-day-a-week coverage. 24 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

FIG 1. Programs needing a reboot frequently still submit the same queries as when the program was initiated, and either accept unanswered queries as common or do not measure and monitor the number of queries left unanswered prior to final coding. Often the vast majority of the CDI process for these programs is spent in chart review, with less than 50% of reviews resulting in a CDI query. Do these symptoms indicate that a CDI program is underperforming, or has gotten stale? Maybe. But until a CDI program is assessed in a systematic and unbiased way, an organization may never know the true potential of its investment. Herein lies the power of a Lean assessment. Lean methodology: Why it works Lean is a quality management methodology successfully used in manufacturing for decades. Lean has also become a contemporary practice embraced in healthcare because of its focus on eliminating waste in lieu of value. Lean is quick, collaborative, and examines the entire value stream (workflow) in order to pinpoint sources of waste using process visualization tools. Lean also relies on the voice of the customer to capture a customer s expectations, preferences, and aversions to produce a better product. Let s think about applying Lean in the context of CDI efforts. While there are many different tools available to be applied, we will focus on a few. Identify each step of the CDI process Using Lean methodology, the entire CDI process is assessed front to back (see Figure 1), starting with casefinding to define the current state of the CDI process and identify the future and/or ideal state of each step in the process. An inclusive approach to identifying the current state is used in order to allow all stakeholders in 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 25

the process to have input. So a typical Lean assessment will include HIM, coders, IT, finance or revenue cycle, and of course the CDI specialists themselves. The team then documents the current, future, and ideal processes needed to reduce inefficiency and improve customer relations (which in this case would be the CDI department s benefit to physicians, coders, and the overall facility revenue stream). This serves to document the desired states, gaps, and countermeasures needed, in addition to the actions, measures, and metrics to track progress. There are typically multiple tasks defined as outcomes of an assessment, as illustrated in Figure 1. Blueprint for improvement This program assessment serves as a foundational tool to monitor improvements, but CDI programs need to visualize their greater aspirations in the form of a program blueprint. The blueprint is an aggregate of the collective progress and goals of the program as it transforms into a future state. The blueprint keeps various team members, who may be working on improving different aspects of the program, tied to its greater mission. Consistently returning to this overarching blueprint allows the team to align program changes along a projected timeline. It also helps document the interrelationships between various improvement initiatives as they relate to core concepts. Typically the core stakeholders develop (and agree to) the blueprint. This team assigns priorities and timelines, and drafts a high-level timeline with sufficient detail so that anyone who views the blueprint can easily discern which activities are on track, in progress, or at risk of falling behind. In addition, it provides a composite of those current versus future characteristics, with each concentric pathway indicating a major milestone time frame between the two. Keys to Lean success in CDI If you wish to adopt the Lean methodology to improve your CDI department s functioning, I recommend the following steps/strategy: 1. Be inclusive. Ensure all stakeholders are at the table to provide input into the current and future of the CDI program. Include staff-level CDI LEAN DEFINITIONS FOR CDI GROWTH Editor s Note: Use the following definitions to get everyone on your CDI team on the same page. Casefinding: Identifying which cases must be reviewed by the CDI team Conducting the review: Reviewing a record for conflicting, ambiguous, missing, or unspecific documentation, including subsequent reviews Seeking clarification: Clarifying clinical documentation through a verbal or written query or clarification Reconciliation of the record: Ensuring that the clinical documentation reflects the required clinical clarity and specificity discussed with the provider as part of the clarification process Resolution of the review: Resolving a query or clarification or handing an open query or clarification off to a coder post-discharge Reporting and remediation: Transforming the data collected through the CDI process into information to improve performance and remediate process or structural issues specialists to get the best feedback on the CDI process as it truly works. 2. Address all aspects of the workflow, including the technology used and the all-important handoffs and transitions of information. 3. Think big. When envisioning the ideal state, remove any and all constraints such as time, money, and resources. 4. Aim to simplify the complex through visualization tools. 5. Celebrate the small successes along the road to the future state. Enjoy the journey. Editor s Note: Wieczorek is a senior consultant, coding and CDI practice lead, at e4 Services in West Chester, Pennsylvania. Contact her at mwieczorek@e4-services.com. 26 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

Reshaping a pre-existing CDI program Q: I recently took over a pre-existing, three-year-old program as its department manager and find myself in the unfavorable position of having to re-educate the CDI staff. It seems they were never trained on basic CDI principles such as querying for the etiology of the symptom(s) documented, or missing opportunities to link a symptom to a more definitive diagnosis. What should I do? How can I track missed query opportunities? What do you think would be the most effective way for me to rectify this situation? A: Your situation is not unique. There is so much variation among CDI program focus and expertise that one should expect a certain amount of re-orientation in taking on the management of a pre-existing program. Among the first steps is to review any existing CDI policies and procedures, process flow documents, job descriptions, and so forth to ensure that they meet accepted industry guidelines, such as the ACDIS/AHIMA physician query practice guidelines and ethics codes, as well as recommendations within the Official Guidelines for Coding and Reporting. You ll likely need to develop (or refresh) the query policy and address query construction, compliance, and opportunities (using the abovestated references). Try to include staff members in this process. Perhaps offer staff members particular guidelines to review and then gather the group to discuss their findings, letting them know that their investigations will help the team revamp its efforts. If done well, this process may help you earn support from the team, as they may see this as a gesture of respect, goodwill, and employee empowerment. If you do this, however, be sure to include as many of their recommendations as suitable and create a process for annual review and follow-through. One way to do this could be through developing a peer-auditing system that uses such policies as a baseline for ongoing reviews of query efforts. The July 2013 CDI Journal discussed such processes and included multiple examples of peer-to-peer auditing templates in the article Conduct peer audits to provide query practice insight. Work with the coding/him director to see if such policies and procedures are in place for his or her staff and mirror those efforts. See if the coding/him team would be willing to work with your staff through the audit process, as an external set of eyes with a different perspective may be helpful. Ideally, CDI department efforts would be reviewed in a random audit from an external team (either through the compliance or auditing staff or through an external consultant) to offer a fresh perspective and identify missed query opportunities. Keep peer-to-peer auditing efforts as nonpunitive as possible, focusing instead on individual CDI strengths, education, and additional query opportunities. As a CDI manager, of course, you ll want to conduct your own regular random audits of queries for compliance, effectiveness, and missed opportunities. Tracking this data can reveal educational opportunities and, in cases where education proves ineffective, the data can support additional remediation efforts. Of course it can be difficult inheriting someone else s team, but a little bit of kindness, tenacity, and diligence can make all the difference. I hope this helps! Editor s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, is a CDI education specialist with HCPro in Danvers, Massachusetts, and a lead instructor for its CDI-related Boot Camps. For more information regarding upcoming Boot Camp dates and locations, visit www.hcprobootcamps.com/courses/10040/location-dates. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 27

CODING CLINIC CDI UPDATE Fourth Quarter highlights include mechanical ventilation, principal procedure sequencing by Sharme Brodie, RN, CCDS The AHA wrapped up its Coding Clinic for ICD-10-CM/PCS advice for 2014 by answering a lot of questions regarding the coding of surgical procedures/ interventions a trend we ve seen over the last several issues of the publication. Let s take a look at some of the most interesting areas discussed. Counting the hours To start things off, Coding Clinic offered clarification regarding the duration of time a patient is on mechanical ventilation. ICD-10 gives us more options to describe the time frame than ICD-9, including: Less than 24 hours 24 96 hours Greater than 96 hours The counting of hours starts with one of the following; Endotracheal intubation (and subsequent initiation of mechanical ventilation) Initiation of mechanical ventilation through a tracheostomy Admission of a previously intubated patient or a patient with a tracheostomy who is on mechanical ventilation Ventilator support provided to a patient during a surgery is considered an integral part of the surgical procedure and is not coded separately, Coding Clinic states. If, however, the patient remains on mechanical ventilation for an extended period (several days) postsurgery, the mechanical ventilation should be reported. The removal and immediate replacement of an endotracheal tube (in situations such as mechanical problems, like leaking of the cuff) should be counted as part of the initial duration. When a patient is being weaned from the mechanical ventilation, the entire duration of the weaning process is counted. This process may take several attempts and includes the time a patient is on the ventilator, the actual weaning, and the ending, when the patient is extubated and the mechanical ventilation is turned off (after the weaning period). Not all patients require a weaning period and there are times, depending on the method used for weaning, that the mechanical ventilator will not be in use but is still considered part of the weaning process. For example, Coding Clinic explains that for a patient admitted to a long-term acute care facility on a T-piece or tracheostomy collar the day of transfer, and is placed on mechanical ventilation that evening, the clock would start at the time of admission, because all the time during the weaning period gets counted. Internal facility policies cannot be used to extend the weaning process, Coding Clinic states, and once mechanical ventilation is shut off, it would be inappropriate to continue to count ventilator hours, even if the patient is continuously being monitored per facility protocol. Coding Clinic also addressed the timing associated with the use of continuous positive airway pressure via a tracheostomy, which would be coded to respiratory ventilation and the exact code determined by the number of hours. The coding of bilevel positive airway pressure (BiPAP), per Coding Clinic, depends on the method of delivery i.e., whether it is invasive (tracheostomy) or noninvasive (a patient that is not intubated). If the patient receives treatment via a tracheostomy or T-tube, the coder can assign a code for mechanical ventilation and the number of hours in use. If noninvasive, then the coder would assign a code for ventilation support, assistance, and again the number of hours would determine the exact code. Should the patient require subsequent ventilation during the same hospital stay, then each episode of continuous 28 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

mechanical ventilation would be coded separately, and the clock restarted from the beginning of each period of intubation. Physicians should document whether an endotracheal tube is placed orally or nasally for coders to properly code the procedure, so tube placement could be an area where a CDI specialist reviewing the record concurrently could assist. Sequencing of procedures This issue of Coding Clinic describes new rules governing sequencing of the principal procedure per the ICD-10-PCS Official Guidelines for Coding and Reporting, which states: When there is a procedure performed for definitive treatment of both a principal and secondary diagnosis, sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure. When a diagnostic procedure is performed for the principal diagnosis and a procedure for definitive treatment of a secondary diagnosis, sequence the diagnostic procedure as the principal procedure because the procedure most related to the principal diagnosis takes precedence. When there are no procedures (definitive or non-definitive) performed related to the principal diagnosis, sequence the procedure performed for definitive treatment of a secondary diagnosis as the principal procedure. If more than one procedure is performed and documentation is unclear as to which one is more significant, query the provider. Most of this Coding Clinic explored the coding of specific procedures, and is less relevant, but it offered some general information helpful to understanding PCS code. This includes the following: Guideline B4.1 which states that when a body part is prefixed with peri, the procedure should be coded to the body part named i.e., perirenal is coded to kidney body part. This guideline only applies when a more specific body part value is unavailable. An accidental retention of a foreign body following surgery is classified as a complication even when there is no immediate problem resulting from the retained foreign body. When debridement is performed along with a surgical procedure, the physician should be queried to determine whether the debridement should be coded separately or if it is part of the original surgical procedure. Radical procedures can have different meanings depending on the procedure. In ICD-10-PCS, Guideline B3.2a states that if during the same operative session the same root operation is repeated at different body sites that are defined by distinct values of the body part character, multiple procedures should be coded. Guideline B3.1b clarifies that procedural steps necessary to close the operative site, including anastomosis of a tubular body part, are not coded separately. This guideline would apply regardless of whether the procedure is an end-to-end or a side-to-side anastomosis. The root operation control is only used when the intent of the procedure is to stop postprocedural bleeding. The root operation control is only available in the general anatomic regions. When a combination of drugs is administered during a single injection and the facility desires to collect this information, the introduction of both substances may be coded. Sepsis revisited Coding Clinic also revisited advice regarding non-candida albicans sepsis, stating that if Candida sepsis of any type is present, coders should assign code B37.7, Candidal sepsis. If the causal organism is not Candida at all, assign code B48.8, other specified mycoses. Editor s note: Brodie is a CDI education specialist for HCPro in Danvers, Massachusetts. Contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 29

MEET-A-MEMBER Sheila Duhon: Making a difference every day Sheila Duhon, MBA, RN, CCDS, A-CCRN, is the national director clinical documentation improvement educator, performance management and innovation division for Tenet Healthcare Corporation. She s been involved in CDI since 2006, and finding the position offered a career in which she could continue her love of learning. One thing I love to do is learn, says Duhon. The CDI specialist role offers something new to learn every day; a new physician to educate, a new coding guideline, a new case to review, a new disease to research, a new opportunity to make a difference. And making a difference, that s really what I love about the job. That s really why I do what I do. Married, with six grown children and three grandchildren, Duhon loves to travel and snuggle with her small, 10-pound dog, Romeo, who is good for nothing but love, which is just fine with us, she says. CDI Journal: What did you do before you entered the CDI field? Duhon: My clinical background is in intensive care. I worked in medical and surgical care units in the capacity of staff nurse, charge nurse, nursing preceptor and instructor, rapid response nurse, and nurse manager. I am passionate about the role nursing plays in the critical care setting, contributing to the overall restoration to wellness for the patient and family. CDI Journal: Why did you get into this line of work? Duhon: I was at a point in my career when I was searching for a challenge that would broaden my scope of practice and allow me to push myself to new levels, while building on my clinical foundation. A nurse colleague alerted me to the newly developed position of CDI specialist, and I applied that very day. The next day I was offered the position and I have never looked back. I love the challenge and the opportunity to help improve the quality across the care continuum in a meaningful way. CDI Journal: What has been your biggest challenge? Duhon: My biggest challenge in the CDI world has been to be patient with the process. Change takes time. Physicians require absolute evidence that the benefits for the desired outcomes are aligned with the efforts required to enact change. CDI Journal: What has been your biggest reward? Duhon: I love to teach and mentor. As such, my biggest reward is having a physician convert become a believer in the value of appropriate documentation and its effect on quality healthcare delivery. This serves to advance outcomes for the patient, the physician, and the healthcare organization, so it is a win-win in every aspect. CDI Journal: How has the field changed since you began working in CDI? Duhon: The CDI program at my facility started the day I began my position. From being a new program and concept to where we are now, nearly 9 years later, is much different than when it first began. The program began as a focus on concurrent medical record reviews and physician education in terms of compliant and complete documentation. The CDI program now serves as a touch-point with case management, quality improvement, medical staff services, core measures, publicly reported data, and HIM services for coding and compliance. CDI Journal: Can you mention a few of the gold nuggets of information you ve received from colleagues on CDI Talk or through ACDIS? Duhon: I am grateful to have ACDIS as a voice and leader in the CDI world. Sharing ideas, best practices, and challenges across the nation with fellow CDI specialists has been invaluable in improving my own CDI practice and knowledge base. An important gold nugget I learned is to always keep good lines of communication with your coding team. The coders are our friends in the 30 CDI Journal MAR/APR 2015 2015 HCPro, a division of BLR.

CDI world, and a collaborative team approach between [coders] results in best outcomes. CDI Journal: What piece of advice would you offer to a new CDI specialist? Duhon: Always be open to learning something new. We learn from coders, physicians, other CDS staff, ancillary healthcare staff, and our HIM leadership. Challenge yourself to explore, read, research, and relentlessly learn the intricacies of the documentation and compliance process. CDI Journal: If you could have any other job, what would it be? Duhon: I recently assumed the responsibilities of this position for Tenet Healthcare. I am driven to serve in this capacity at the level of excellence necessary to ensure the CDI program is superb. So, there is no other job I would want at this stage in my career. I am extremely blessed and honored to have this opportunity. CDI Journal: What was your first job (what you did while in high school)? Duhon: I worked as a horse trainer and English riding instructor in high school and continued through college. I competed in multi-state competitions for hunters and jumpers and was successful at the statewide level. I think a horse is a magnificent animal, and one of God s greatest creations. A few of Sheila s favorite things: Vacation spots: Any place tropical or exotic Hobby: Golf (a sport enjoyed year-round in Texas) and travel (she plans to take an Alaska cruise this summer) Non-alcoholic beverage: Iced tea Foods: Tex-Mex, Texas BBQ, Crawfish boils Activity: Biking, water sports, dancing, golf, college football Editor s Note: CDI Journal introduces an ACDIS member in each issue. If you would like to be featured or know someone who would, please email ACDIS Editor Katherine Rushlau at krushlau@acdis.org. 8 TH ANNUAL 2015 CONFERENCE MAY 19-21, 2015 HENRY B. GONZALEZ CONVENTION CENTER SAN ANTONIO, TX REGISTER BEFORE MARCH 17, 2015, AND SAVE $100! FEATURING FOUR EXCITING TRACKS! Management and Leadership Clinical and Coding Quality and Regulatory Initiatives Innovative CDI PRE-CONFERENCES May 17 18, 2015 The Physician Advisor s Role in CDI Boot Camp The ICD-10 for CDI Boot Camp CDI and Quality: Advancing CDI Boot Camp Special 2-Day Edition CCDS EXAM May 21, 2015 To register, please visit www.hcmarketplace.com or call us at 800-650-6787. 2015 HCPro, a division of BLR. CDI Journal MAR/APR 2015 31