BS, RHIA, RHIT, CCS, CDIP, CCDS,

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1 cdijournal January 2014 Vol. 8 No. 1 Director s Note 5 ICD-10 will take center stage at May conference. Dual coding 6 Coding for ICD-10 now highlights areas for physician education and concurrent CDI opportunities. Staff retention 8 Programs put bonus models in place to keep staff engaged through ICD-10 implementation. Homegrown training 10 Comprehensive efforts lead to new team member success. Staff goals 12 Sample goals for new CDI staff outline expectations from three months to two years. EHR efforts 14 Three specialists share their EHR implementation experiences. Meet a member 16 Christina Raad, RN, CCDS, receives her certification. Physician corner 17 Trey La Charité, MD, discusses how CDI helps prevent auditor denials. Clinical corner 20 Richard Pinson, MD, FACP, CCS, revisits respiratory failure documentation. Survey results 24 Get the breakdown on how programs are preparing for the ICD-10 transition. Review queries for ICD-10 focus, compliance The results of a December ACDIS survey show the CDI profession toddling toward the ICD-10-CM/PCS transition, says founding ACDIS advisory board member Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and HIM professional in Fremont, Calif. (See p. 24 for the complete survey results.) People seem to be getting there, but they re taking baby steps. That s good, but now we really need to be getting ready to jog and run, she says. Twelve percent of survey respondents indicated they received no information to raise their awareness of ICD-10-CM/PCS documentation improvement needs. Only 68% said they received training on the code set, and 32% indicated their CDI staff assists with ICD-10-related education for physicians. Those who haven t had any training whatsoever need to move ahead, start with an orientation or awareness of ICD-10 code set, Bryant says. One of the simplest ways to do that is to evaluate your queries and audit them for ICD- 10-CM/PCS opportunities. And the good news, according to the survey results, is that many programs have already started doing so. First steps Fifty-eight percent of survey respondents indicated they had reviewed their queries for type and frequency as of December This is a great first step, Bryant says. According to the survey, facilities typically use templates for the following queries (read the complete list of query templates on p. 25): Heart failure: 96% Sepsis: 91% Anemia: 90% Malnutrition: 88% Renal failure: 84%»» Respiratory failure: 82% Although only 37% of respondents indicated that they have begun reviewing their forms for ICD-10-CM/PCS documentation specificity, another 29% indicated that they will begin doing

2 so during the first quarter of I would like to have seen the percentage of programs revising their queries for ICD-10 to be a bit higher, says Bryant. The more we focus now, the more we will learn about where potential documentation gaps may be. The sooner we incorporate those areas into our query efforts, the better off we ll be in terms of ensuring a smooth transition to the new code set. People [need to be] looking at what their documentation is today and how that should influence their actions in relation to the ICD-10-CM/PCS implementation, says former ACDIS advisory board member Shelia Bullock, RN, BSN, MBA, CCM, CCDS, CDI director at the University of Mississippi Medical Center (UMMC) in Jackson. Once you take a good hard look at it, you ll see which items are really worth worrying about. While many facilities have contracted with consultants or outside auditing companies to conduct a documentation gap analysis, this isn t strictly necessary, and individual CDI specialists can make progress, says Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, vice president of HIM consulting services for United Audit Systems, Inc., in Cincinnati, an AHIMA-approved ICD-10-CM/PCS trainer. Even a lone CDI specialist with the most limited of training budgets can, at the very simplest level, order an ICD-10- CM coding manual and look up codes while dropping a query to see what the definitions say, to identify areas where additional documentation will be needed, Stanfill suggests. Alternatively, set aside time to pick a manageable percentage of records and review them Fridays for ICD-10 opportunities, she says. Have the entire team participate and review all the different types of records, says Stanfill, not just the top DRGs. You want to be sure that everyone gains hands-on experience with documentation needed for the new code set across various topic areas not just the codes that result in a CC/ MCC, but all the floors and all the specialties, so you re not blind-sided during implementation, she says. Walk through policies to ensure compliance ICD-10-CM/PCS hasn t been the only new CDI program focus in recent years. Everything from electronic health Advisory Board ACDIS Director: Brian Murphy bmurphy@cdiassociation.com Associate Director: Melissa Varnavas mvarnavas@cdiassociation.com Membership Services Specialist: Penny Richards, CPC prichards@cdiassociation.com Dee Banet, RN, BSN, CCDS Director of CDI Norton Healthcare Louisville, Ky. dee.banet@nortonhealthcare.org Susan Belley, MEd, RHIA, CPHQ Project Manager 3M HIS Consulting Services Atlanta, Ga. sebelley@mmm.com Timothy N. Brundage, MD, CCDS Physician Champion Kindred Hospital North Florida District St. Petersburg, Fla. DrBrundage@gmail.com Donald Butler, RN, BSN CDI Manager Vidant Medical Center Greenville, N.C. dbutler@vidanthealth.com Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/ PCS Trainer CDI Education Director HCPro Danvers, Mass. cericson@hcpro.com Robert S. Gold, MD CEO DCBA, Inc. Atlanta, Ga. DCBAInc@cs.com Sylvia Hoffman, RN, CCDS, CCDI, CDIP President, CEO Sylvia Hoffman CDI Consulting Tampa, Fla. sylvia@sylviahossman.com Walter Houlihan, MBA, RHIA, CCS Baystate Health Springfield, Mass. walter.houlihan@baystatehealth.org Fran Jurcak, RN, MSN, CCDS Director, CDI Practice Huron Healthcare Chicago, Ill. fjurcak@huronconsultinggroup.com Trey La Charité, MD Physician Advisor University of Tennessee at Knoxville Knoxville, Tenn. Clachari@UTMCK.edu James E. Vance, MD, MBA CEO Physician Executive Management Services, LLC Highlands, N.C. jevancemd@physicianexecutiveservices.com Donna D. Wilson, RHIA, CCS, CCDS Senior Director Compliance Concepts, Inc. dwilson@ccius.com Previous ACDIS board members: Cindy Basham, MHA, MSCCS, BSN, CPC, CCS ( ) Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS ( ) Shelia Bullock, RN, BSN, MBA, CCM, CCDS ( ) Jean S. Clark, RHIA ( ) Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS ( ) Garri Garrison, RN, CPUR, CPC, CMC ( ) Colleen Garry, RN, BS ( ) Robert S. Gold, MD ( ) William E. Haik, MD, FCCP ( ) Tamara Hicks, RN, BSN, CCS, CCDS ( ) Robin R. Holmes, RN, MSN ( ) James S. Kennedy, MD, CCS ( ) Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS ( ) Pam Lovell, MBA, RN ( ) Gail B. Marini, RN, MM, CCS, LNC ( ) Shannon E. McCall, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS ( ) Lynne Spryszak, RN, CPC, CCDS (founding member) Colleen Stukenberg, MSN, RN, CMSRN, CCDS ( ) Heather Taillon, RHIA ( ) Lena N. Wilson, MHI, RHIA, CCS, CCDS ( ) CDI Journal (ISSN: ) is published quarterly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $165/year for membership to the Association of Clinical Documentation Improvement Specialists. Postmaster: Send address changes to CDI Journal, P.O. Box 3049, Peabody, MA Copyright 2014 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, a division of BLR, or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/ vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CDI Journal. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. 2 January HCPro, a division of BLR.

3 record implementation, Medicare reimbursement changes such as hospital value-based purchasing, and quality reporting metrics have become front-burner topics and led to a shift in some traditionally held CDI conceptions. CDI programs that are solely financially focused may need to make some adjustments, Bryant says. The change to ICD-10 is about expanding our ability to capture clinical data, to improve the data quality we have in this country, she says. There is going to be a host of reasons to expand the purpose of CDI query efforts, such as severity of illness, risk of mortality, and for research purposes; programs need to be ready for that. CDI programs should already be reviewing their query forms/templates on a regular basis, as recommended in AHIMA s 2008 practice brief Managing an Effective Query Process, says Laurie L. Prescott, MSN, RN, CCDS, CDIP, CDI education specialist for HCPro in Danvers, Mass. Those facilities which already had such practices in place most likely responded positively to December s survey. Although the practice brief does not specify the frequency of such reviews or the composition of the committee(s) who should review them, annual or biannual auditing helps for two reasons, according to Prescott: compliance with industry recommendations and incorporation of the most up-to-date clinical indicators. Ensuring query forms comply with the latest CDIrelated industry recommendations is important. For example, the 2013 ACDIS/AHIMA practice brief Guidelines for Achieving a Compliant Query Practice updates previous AHIMA releases in light of the forthcoming shift to the new ICD-10-CM/PCS code set. The brief outlines ways in which so-called yes/no queries can be compliantly drafted and describes use of multiplechoice queries. Yes/no queries can be useful in ICD-10-CM coding by establishing a cause-and-effect relationship necessary to assign combination codes, writes Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA approved ICD-10-CM/PCS trainer and CDI education director at HCPro, in the book The Clinical Documentation Improvement Specialist s Guide to ICD-10. At Swedish Medical Center in Seattle, Jennifer Woodworth, RN, BSN, CCDS, director of CDI, and her team reviewed their standard query formats reducing their templates to just four or five ways in which we can ask the physician a question in order to ensure compliance, she says. They also created easy step-by-step formats for queries related to linking diagnoses, such as complications due to diabetes, and contemplated the problem of unlinking diagnoses as well. We know that linking one causal diagnosis to another will be a concern withthe new code set, says Woodworth, and we want to be sure to capture that information. Yet we have to be aware of situations where the two diagnoses really do not go together, and we need to know how to ask that question without second-guessing the physician s clinical judgment. Reassessing query forms for ICD-10-CM/PCS isn t just about adding the right verbiage to the forms, she says; it s also about rethinking the query process. The word template means different things to different people. For us, it really meant taking a look at what the most recent query practice brief indicates and incorporating the additional underlying elements of the new code set. Really, this isn t just a matter of adding some language here and there but updating our process, retooling our efforts, says Woodworth. Having a multidisciplinary team vet query forms helps to ensure compliance related to a broad range of concerns clinical validity, regulatory compliance, and coding accuracy. Regular query template reviews should be done by the CDI and the coding staff with input from the compliance officer or the compliance committee, says Prescott. Although 54% of survey respondents indicated that their compliance department does not review new/updated query forms, Bryant says such input is warranted. That [survey] result is sort of surprising considering the emphasis of the various [ACDIS and AHIMA] query practice briefs on compliance concerns. So this is an area for CDI programs to improve, particularly in light of the work required in revising query forms for ICD-10-CM/PCS, Bryant says. Additionally, regular reviews of templates with input from the CDI program s physician advisor and/or facility medical staff can help to ensure forms reflect the most recent clinical indicators, such as updates from the Surviving Sepsis campaign, and recommendations published in the May 2012 Journal of the Academy of Nutrition and 2014 HCPro, a division of BLR. January

4 Dietetics regarding diagnosing malnutrition. The CDI team needs to ensure that queries are accurate and up to date with latest standards of practice, Prescott says, and this is where a multidisciplinary team including a physician advisor s involvement would be useful. Nevertheless, 61% of survey respondents indicated that their physicians did not review any new or updated queries. In a related poll on the ACDIS website ( msgy854), only 13% indicated that a multidisciplinary team defines which clinical standards should be used as general query definitions for a given diagnosis. We really need to get back to the physician connection to CDI efforts, says Bryant, not only because that connection is highly recommended in the industry, but because we know that when physicians are involved in the process, involved in helping to create the query forms, they tend to support it. Expectations for productivity Numerous speakers at the AHIMA conference in Atlanta in October addressed projected coder productivity losses, with estimates ranging from 20% to 60%. In Canada, coder productivity dropped by 50% after the country s initial 2001 transition to ICD-10, said Elaine O Bleness, MBA, RHIA, CHP, AHIMA-approved ICD-10-CM/PCS trainer and revenue cycle executive for Cerner Corporation in North Kansas City, Mo. Coder productivity has since only rebounded to approximately 80% of pre-icd-10 levels. Consider, also, that Canada did not have to deal with the procedure portion of the code set so the U.S. may be in for an even bigger productivity decline. Why the slowdown? In part, since ICD-10 codes use both numbers and letters, coders can no longer just use the keypad to type in codes, said O Bleness. But coding also takes longer due to the greater analytical skills required from the coder and the additional documentation needed from the physician. According to the new coding guidelines for PCS, the hospital cannot submit a bill unless all the characters within that code are complete. With that came an expectation that coders would spend 50% more time on these cases alone, says Paul Weygandt, MD, JD, MPH, MBA, CPE, vice president of physician services at J.A. Thomas and Associates, Inc., a Nuance company. That s one reason many believe that procedure documentation could be an area ripe for regulatory review and intervention (denials). We were scared to death about the procedure coding system until we started looking at the codes and the documentation requirements, says Bullock. After careful review, Bullock s team found that many of the documentation needs associated with ICD-10-PCS could be resolved with simple amendments to either surgical templates or physician order forms. For example, UMMC updated its cardiology templates to include the type of contrast and number and location of vessels used, all of which will reduce the number of queries needed later in the process. At Swedish Medical Center, Woodworth and her team developed a template that identifies which type of stent the physician used during an angioplasty. They also amended documentation templates to identify cemented versus noncemented hip replacement procedures to avoid the need for queries. We are taking a look at what procedures our different specialty lines are doing day in and day out, says Woodworth. We re looking to see what additional documentation is going to be needed, and then seeing what solutions we can come up with to capture that information in a relatively easy, noninvasive way, using the tools the physicians currently use, she says. It s a different solution set but one we think will actually solve the problem and keep us from having to query for every little thing. Despite the anticipated increase in coder workload associated with ICD-10-PCS, Weygandt says much of the documentation may already be in the record or could be obtained through simple template adjustments. Part of the challenge of ICD-10 reviews is identifying which items represent actual CDI focus areas and which require a focus on coder theory and education, Weygandt says. There s been a panic mentality, particularly in regards to PCS, he says, but I don t think we really need to panic. We simply need to get on with the process, apply ICD- 10-PCS to the types of cases relevant to each hospital, and identify the opportunities to improve documentation and coding. 4 January HCPro, a division of BLR.

5 December ACDIS ICD-10-CM/PCS query preparation survey results 1. To date, have your CDI staff received information to raise their awareness of ICD-10 implementation and documentation improvement needs? Yes 87.7% 100 No 12.3% 14 Other (please specify) 0 answered question 114 skipped question 0 2. To date, have your CDI staff received ICD-10 training on the code set? Yes 67.5% 77 No 32.5% 37 Other (please specify) 0 answered question 114 skipped question 0 3. To date, have your CDI staff assisted with the ICD-10 education of physicians? Yes 31.5% 35 No 68.5% 76 Other (please specify) 3 answered question 111 skipped question 3 4. Have you to date, or do you plan to, train CDI staff on the actual ICD-10 code set? Yes 90.8% 99 No 9.2% 10 Other (please specify) 7 answered question 109 skipped question 5 24 January HCPro, a division of BLR.

6 5. Which of the following query templates do you use in your organization today? Anemia 89.5% 85 Angina 36.8% 35 CAD 32.6% 31 Cause and effect 54.7% 52 Coma 21.1% 20 Complication 47.4% 45 Diabetes 50.5% 48 Diabetes, controlled or uncontrolled 41.1% 39 Fracture 31.6% 30 Heart failure 95.8% 91 Liver failure 14.7% 14 Malnutrition 88.4% 84 Renal failure 84.2% 80 Respiratory failure 82.1% 78 Sepsis 90.5% 86 Other (please specify) 26 answered question 95 skipped question Have you conducted an inventory of your physician queries by type and frequency? Yes 37.5% 42 Yes, by type 11.6% 13 Yes, by frequency 8.9% 10 No 34.8% 39 Don t know 7.1% 8 Other (please specify) 1 answered question 112 skipped question HCPro, a division of BLR. January

7 December ACDIS ICD-10-CM/PCS query preparation survey results (cont.) 7. Have you started to audit (review) and update queries for ICD-10 language changes? Yes 18.2% 20 Yes, we have audited our queries 8.2% 9 Yes, we have audited our queries and updated them for ICD % 12 No 30.9% 34 No, but we plan do this in the first quarter of % 32 Don t know 2.7% 3 Other (please specify) 7 answered question 110 skipped question 4 8. Does your compliance department review new/updated physician queries to ensure they are compliant? Yes 29.5% 33 No 53.6% 60 Don t know 17% 19 Other (please specify) 5 answered question 112 skipped question 2 9. Do your physicians review new/updated queries? Yes 5.5% 6 Yes, our physician advisor reviews all new/updated queries 20% 22 Yes, our physicians review any new/updated queries by specialty 5.5% 6 No 61.8% 68 Don t know 7.3% 8 Other (please specify) 7 answered question 110 skipped question 4 26 January HCPro, a division of BLR.

8 10. Does your CDI program staff meet regularly with your HIM/coding staff? Yes 19.1% 21 Yes, weekly 10% 11 Yes, monthly 30% 33 Yes, quarterly 15.5% 17 No 24.5% 27 Don t know 0.9% 1 Other (please specify) 5 answered question 110 skipped question HCPro, a division of BLR. January