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MAR/APR 2016 Vol. 10 No. 2

an Association of Clinical Documentation Improvement Specialists publication www.acdis.org

An Open Book: The Never-Ending CDI story

2 CDI Journal | MAR/APR 2016 © 2016 HCPro, a division of BLR.®

MAR/APR 2016 Vol. 10 No. 2CONTENTS

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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 © 2016 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 [email protected]. • 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.

FEATURES7 ICD-10-CM/PCS: Six months after implementation

CDI professionals weigh in on what’s working and what areas facilities continue to struggle with.

24 A behind-the-scenes preview of the 2016 ACDIS Conference

Hear the 2016 ACDIS Conference Committee share why participation in this year’s planning efforts has proven so rewarding.

DEPARTMENTS4 Associate director’s note

The growth of the CDI profession has given its members a wealth of stories to share.

5 Note from the Advisory BoardCheryl Ericson, MS, RN, CCDS, CDI-P, explores meaningful metrics beyond the case-mix index and financial ramifications of CDI.

10 Radio recapParticipants present tips for handling difficult ICD-10 target areas.

16 Ask ACDISMembers of the “Pediatric CDI Talk” networking group discuss encephalopathy.

19 Coding Clinic for CDICoding Boot Camp director Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, reviews some of the recent suggestions related to ICD-10-PCS.

22 Meet a memberHear how CDI efforts have expanded “down under” in Sydney, Australia.

OPINIONS & INSIGHTS13 Physician advisor’s corner

Trey La Charité, MD, examines the importance of compliance in CDI.

17 Laboratory speakVerona A. Lodholz, DC, MT(ASCP), CPC, CCDS, provides some tips to understand lab results related to complete blood counts.

19 Outpatient effortsACDIS Advisory Board member Anny Pang Yuen, RHIA, CCS, CCDS, CDIP, offers two areas of opportunity for CDI professionals to examine.

As payers expand the use of risk adjustment models across the care continuum, providers find their ability to accurately, completely and consistently capture a patient’s disease burden increasingly impacts provider reimbursement and patient premiums.

Accurate clinical documentation assures accurate health plan funding, providing more resources to effectively manage patients, address chronic illness, and direct population health initiatives.

Is your documentation strategy sufficient to ensure optimal care for your patients?

Nuance’s J.A. Thomas & Associates (JATA) has helped hospitals and health systems critically evaluate their clinical documentation practices so patient care, coding and billing are accurately reflected. We also help ensure quality compliance and revenue integrity. With more than 20 years of clinical documentation expertise, we can help you mitigate risk while maximizing your potential.

Let us show you how.

Learn how Nuance Clintegrity Risk Adjustment Solutions can help you, go to nuance.com/healthcare or email [email protected].

Is CDI part of your strategy to optimize patient care?

© 2016 Nuance Communications, Inc. All rights reserved. Nuance, the Nuance logo, Clintegrity, Clinic 360 and Dragon are trademarks and/or registered trademarks of Nuance Communications, Inc., and/or its subsidiaries in the United States and/or other countries. All other trademarks are properties of their respective owners. HC_4043 JAN 2016

Visit Nuance at Booth #609 during the 2016 ACDIS Conference in Atlanta.

ASSOCIATE DIRECTOR’S NOTE

EDITORIAL

Director Brian [email protected]

Associate Director, Membership and Product DevelopmentRebecca [email protected]

Associate Director Melissa [email protected]

Membership Services Specialist Penny Richards, [email protected]

EditorKatherine Rushlau [email protected]

Associate Director for Education Laurie L. Prescott, MSN, RN, CCDS, CDIP [email protected]

Director of Sales and SponsorshipsCarrie Dry [email protected]

CopyeditorAdam [email protected]

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Prior to joining HCPro, I’d been a reporter and editor for my home-town newspaper. It was a terrific job. I loved meeting new people, hearing their stories, and getting to share those prized moments with the rest of my community. I’ve been blessed to be able to play a similar role here at ACDIS.

I met Melissa Malabanan, RN, CDI specialist at Baylor University Medical Center in Dallas, during my first ACDIS Conference in Las Vegas in 2009. As a way to break the ice, I looked for other attendees named Melissa to befriend, and the first photograph I took was of the two of us. Every year since, Melissa and I have snapped a selfie together at the conference. A few times a year, we send each other an email just to say hello and check in. Now, she’s helping the leadership team of the Texas ACDIS chapter as well as fulfilling her other CDI duties at Baylor.

Leah Taylor, RN, CCDS, and I met as she and Jennifer Love formed the North Carolina ACDIS chapter. Now, eight years later, the chapter continues to grow. Over the years, I have formed bonds with other members of the chapter and leadership team: Abby Steelhammer, Cathy Dickey, Melissa Legere (yes, we took a selfie together one year too), Basanti Olsen, and Brenda Harris, among others. And in February, I

had the surreal pleasure of Sky-ping into their meeting for a dis-cussion of remote CDI opportu-nities, joining more than 50 other participants.

Over the years, through your involvement with the association, your attendance at the ACDIS Conference, your participation on “CDI Talk,” your CDI Week celebratory photographs, and your connection with local chap-ter events, we’ve come to know one another. Over the years, you’ve shared your stories with us and helped us tell the larger narrative of a growing profession called clinical documentation improvement.

But despite all we’ve experi-enced so far, there are so many more stories left to share. You’ll find a number of them inside this edition of CDI Journal, but you’ll also find them at your local chap-ter events and within your own facilities. Please reach out, join the ACDIS community, and share your stories with us.

© 2016 HCPro, a division of BLR.® CDI Journal | MAR/APR 2016 5

NOTE FROM THE ADVISORY BOARD

ADVISORY BOARD

Sam Antonios, MD, FACP, FHM, CCDSCDI/ICD-10 physician advisorVia Christi HealthWichita, KansasSamer.Antonios@ via-christi.org

Wendy Clesi, RN, CCDSDirector of CDI ServicesEnjoinwendy.clesi@ enjoincdi.com

Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, IQCI, MBADirector, Case ManagementUniversity of California [email protected]

Cheryl Ericson, MS, RN, CCDS, CDIPCDI Education [email protected]

Paul Evans, RHIA, CCDS, CCS, CCS-PClinical Documentation Integrity LeaderSutter West Bay [email protected]

James P. Fee, MD, CCS, CCDSVice [email protected]

Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM Manager, Care Coordination Wake Forest Baptist Health [email protected]

Robin Jones, RN, BSN, CCDS, MHA/EdSystem Director, Clinical Documentation ExcellenceMercy Health, Cincinnati [email protected]

Mark LeBlanc, RN, MBA, CCDSDirector, CDI ServicesThe Wilshire [email protected]

Michelle McCormack, RN, BSN, CCDS, CRCRDirector, CDI Stanford Hospital and ClinicsPalo Alto, [email protected]

Karen Newhouser, RN, BSN, CCDS, CCS, CCMDirector of CDI [email protected]

Judy Schade, RN, MSN, CCM, CCDSClinical Documentation SpecialistMayo Clinic [email protected]

Anny Pang Yuen, RHIA, CCS, CCDS,CDIP Director, Ambulatory [email protected]

Do your metrics really measure CDI impact? by Cheryl Ericson, MS, RN, CCDS, CDI-P

What keeps healthcare chief financial officers (CFO) up at night? A recent article published by Becker’s Hospital Report covering CFOs’ top 2016 concerns found that many were worried about remaining profitable.

How can this be? According to a variety of recent surveys, more than 80% of hospitals now have CDI programs. However, even with the efforts of their CDI teams, CFOs are concerned about continued losses associated with treating CMS beneficiaries.

It isn’t enough just to have a CDI program. Orga-nizations need a robust CDI program, one that can evolve to navigate the ever-changing reimburse-ment landscape.

Do organizations have what they need? Well, 44.5% of respondents to an American Hospital Association (AHA) survey reported a mature or high-functioning CDI program—yet The Advisory Board Company’s September 2014 report, “What sets the top 10% of documentation programs apart?” found only 10% of CDI programs operating at best practice.

Who is right?

We all know there is variation among CDI depart-ments and their role within their organization, but more often than not, success is measured by CDI’s financial impact. Let’s face it, CDI depart-ments are a supportive business function, and such functions are usually required to demon-strate a return on investment. Yet the question remains: Are we accurately measuring the effect of CDI efforts by using broad measures like case- mix index?

Most organizations have harvested the benefits from CDI efforts when it comes to common clini-cal conditions, considered the “low-hanging fruit,” so continued improvement in a facility’s case-mix index may be more difficult to achieve and sustain. Additionally, the difference between an average CDI program and CDI best practice can result in a $2 million gap, but it’s a gap that drops after one year, according to another 2014 report from the Advisory Board Company, “Get the most bang for your CDI buck.”

As expected, many organizations find it difficult to sustain the financial effects of their CDI efforts.


Does it need to be that difficult?

As financial pressures grow within the healthcare sec-tor, the need for a best-practice CDI department has never been greater. According to the AHA, one-third of hospitals lose money on operations. Beginning in 2012, hospital closures outnumbered openings for the first time in decades, with more closures expected in the years to come, according to the Medicare Payment Advisory Commission (MedPAC). Although payment rates from private payers have grown at an average of 5%–6% in recent years, CMS payments have been unable to keep pace. In fact, current figures place Medicare reimburse-ment at 88% of cost, leading to an industrywide Medi-care margin of -5.4%.

“We really do believe much harder times are coming from a reimbursement standpoint,” said one CFO in the Becker article.

One of the factors contributing to Medicare revenue reductions is the loss of lucrative short-stay admissions. In 2012, MedPAC reported a payment-to-cost ratio for one-day inpatient stays of 1.55, translating into payments that exceeded costs by 55%. No wonder CMS imple-mented the 2-midnight rule. The shift in patient services to the outpatient setting is also creating demand for out-patient CDI efforts to offset some of the potential losses.

Although many organizations are satisfied when CDI efforts increase the Medicare case-mix index, did you know it has risen 4.7% between 2011 and 2016? Yes, improved documentation contributed to the increasing case-mix index, but there are also several other factors.

In other words, your organization should be experi-encing an increasing case-mix index based on national trends, but the degree of that increase will likely vary depending on the sophistication of your CDI efforts.

So what does a rising case-mix index mean?

The fact is, the case-mix index is an arbitrary value. What is a realistic case-mix index goal for your organi-zation? What value is there is comparing your organiza-tion’s case-mix index to another’s?

The goal shouldn’t be an increasing case-mix index; rather, it should be to ensure the organization is prof-itable when treating Medicare patients. Profitability, or

the lack thereof, can be quantified. What value is a high case-mix index (i.e., higher reimbursement) if the cost of treating those patients exceeds the payment? This is why it’s so important to understand how CMS is incor-porating quality of care into its payments.

What is quality care? What is appropriate care?

It isn’t enough to add profitable diagnoses to a claim; they must also be supported by clinical evidence and appropriate documentation within the health record. One of the most common reasons for Medicare denials is insufficient documentation. In fact, coded diagnoses without appropriate clinical support have become such an issue that AHIMA joined with ACDIS in 2013 to revise its query practice recommendations (Guidelines for Achieving a Compliant Query Practice) to include clinical validation of documented diagnoses.

In order to be successful, an organization must be able to balance documentation improvement efforts address-ing both financial pressures as well as the quality per-spective, which often requires different skills.

MedPAC found that hospitals who perform well on both cost and quality metrics have an overall Medi-care median margin of 2% compared to the compar-ison group’s median of -6%. In other words, hospitals that appropriately meet the needs of their patients can be profitable, but achieving this requires a compre-hensive understanding of the factors influencing CMS reimbursement.

It is no longer enough to have CDI staff focus on iden-tifying missing diagnoses that are classified by CMS as a CC or MCC. Sometimes, CDI efforts are going to result in lower-paying MS-DRG assignments.

As organizations demand more from their CDI pro-grams, administrators must also provide clear guid-ance by understanding the interaction of provider doc-umentation, coded data, and profitability. It is time to move beyond equating a rising case-mix index with CDI success.

Editor’s note: Ericson is the CDI education director for ezDI and an ACDIS Advisory Board member; she previously served as CDI edu-cation director for ACDIS. Contact her at [email protected].


ICD-10 check-in: Six months after implementation

For the past few years, health-care professionals have focused on ICD-10 prepa-ration. That prep work paid

off—the transition has been largely successful. But facilities are experi-encing a few bumps as their focus shifts from preparation to improve-ment of clinical documentation and coding.

We spoke with a number of CDI experts, who identified five prom-inent post-implementation issues and gave their thoughts on how CDI specialists can work to tackle these challenges head-on.

Procedure mapping

Some inpatient procedure codes map to an incorrect DRG, says Anny Pang Yuen, RHIA, CCS, CCDS, CDIP, director of ambulatory

CDI at Enjoin. For example, nonsur-gical operating room procedures—such as arterial lines—map to surgi-cal procedure DRGs, which results in higher reimbursement and opens facilities to potential auditor scrutiny.

“This is a conundrum in the cod-ing world,” says Yuen. “Some facil-ities have decided not to pick up [and report the codes], while oth-ers follow the code book and are using its guidance for any denials appeals.”

This is perhaps the most apparent transition-related issue, and it likely will not be resolved without some direction from CMS, says Lau-rie Prescott, MSN, RN, CCDS, CDIP, CDI education director with HCPro in Danvers, Massachusetts. The placement of an arterial line or a paracentesis generally should

not boost payment by thousands of dollars by providing movement to a surgical DRG, she says, but correct use of the code set and the map-ping provided by CMS allows for this to occur.

“The decision to add these codes or not is something each organiza-tion should contemplate and ensure the decision is consistently applied throughout the organization,” says Prescott. (According to a February ACDIS poll, most facilities—62%—are coding them.)

“CDI specialists should work to make sure the documentation clearly supports the related diag-noses and the procedures per-formed so that, if challenged, the organization can support their deci-sion,” notes Prescott. Organizations should also investigate how private

http://www.hcpro.com/acdis/readerpoll_results.cfm

http://www.hcpro.com/acdis/readerpoll_results.cfm


payers will respond to these DRG mappings, she says.

Unspecified diagnoses

With the advent of ICD-10, there are many more unspecified diagno-ses—which indicate the documen-tation of a condition does not con-tain the characteristics and precise information needed to accurately code a diagnosis. There can be consequences if these unspecified diagnoses are overused.

Specific diagnoses impact sever-ity of illness, risk of mortality, risk adjustments, and other quality indicators. In addition, secondary diagnoses support medical neces-sity, resource use, level of care, and admission status, says Judy Schade, RN, MSN, CCM, CCDS, clinical documentation specialist at Mayo Clinic Hospital in Arizona.

“Even if it’s not going to change the DRG, it’s important to have spe-cific diagnoses,” she says. “In some cases, a link is needed between the condition and the cause in order to code the diagnosis accurately.”

There needs to be a balance between getting claims out the door and complete and accurate doc-umentation and coding, Schade

says. The goal for CDI specialists is to be proactive, not reactive, and to address high-volume unspecified diagnoses that occur within the facil-ity. When reviewing a record, spe-cialists should try to identify miss-ing information that could shift an unspecified diagnosis to a specific diagnosis.

By paying attention now, CDI can help avoid payment penalties or denials in the future, says Schade, because prior authorizations, ser-vices, and costly treatment plans need specific diagnoses.

Yet, clarifying six or seven unspec-ified diagnoses for one case can be overwhelming, Schade says. So use multiple educational venues, such as face-to-face interaction, docu-mentation tips, online training, case review presentations, and feed-back sessions, to raise physician awareness.

Involve coding colleagues in the educational efforts and create doc-umentation tip cards for unspec-ified diagnoses. Give providers the details, including the informa-tion required to code a diagnosis accurately, which can include acu-ity, laterality, location, relationship/cause, and organism(s) if there is an

infectious process. Through educa-tion, explain the value of document-ing a more specific diagnosis to achieve the complete clinical picture of the patient.

Excludes notes

There have been several ques-tions regarding interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another. By way of background, in ICD-9, an excludes note had two possible meanings. ICD-10-CM was set to resolve this confusion by insti-tuting two different excludes notes—Excludes1 and Excludes2—to differ-entiate the meanings:

■■ An Excludes1 note indicates that a coder should never use the excluded code with the code above the Excludes1 note. The two conditions can-not occur together.

■■ An Excludes2 note means a condition is not included in the code above the note. An Excludes2 note indicates that the excluded condition is not part of the condition the code represents, but a patient may have both conditions simulta-neously. When an Excludes2 note appears under a code, coders may report both the code above the note and the excluded code together, when appropriate.

According to an October statement released by the Centers for Disease Control and Prevention (CDC), there are circumstances where both con-ditions in the scope of an Excludes1 note should be allowed to be coded

ICD-10-PCS SURVEY

ACDIS has recently learned that some minor procedures coded in ICD-10-PCS lead to surgical DRG assignments and unexpectedly high pay-ments. As a result, some facilities have opted not to code these proce-dures, believing that coding them may result in future recoupments from CMS. Please take a moment to share your experiences by answering this anonymous six-question survey. ACDIS plans to alert regulatory coding authorities to these findings with the hope of attaining clarification.

https://www.surveymonkey.com/results/SM-ZGBY9CTW/

https://www.surveymonkey.com/r/HK2DCY8


together, thus making an Excludes2 note more appropriate. However, due to the partial code freeze, no changes to excludes notes or revi-sions to the Official Guidelines for Coding and Reporting can be made until October 1, 2016.

In the interim, the agency detailed temporary guidance, approved by the four Cooperating Parties, which says that if the two conditions are not

related to one another, it is permissi-ble to report both codes despite the presence of an Excludes1 note.

For example, the Excludes1 note at code range R40–R46 states that symptoms and signs constituting part of a pattern of mental disorder cannot be assigned with the R40–R46 codes. However, if dizziness is not a component of the mental health condition—such as dizziness unrelated to bipolar disorder—then separate codes may be assigned for both the dizziness and the mental health condition.

In another example, code range I60–I69, cerebrovascular diseases,

has an Excludes1 note for traumatic intracranial hemorrhage. Codes in this range should not be used for a diagnosis of traumatic intracranial hemorrhage. However, if the patient has both a current traumatic intra-cranial hemorrhage and a sequela from a previous stroke, then it would be appropriate to code for both conditions, according to the CDC’s October release.

CDI specialists need to ensure that the documentation clearly establishes the relationship between the two conditions, Yuen says. If the conditions are unrelated, the doc-umentation must reflect this, and a query should be placed if the rela-tionship is not clear. “It should not be a guessing game,” she says.

Electronic health records

Electronic health records frus-trate physicians because they focus on coding versus clinical needs, said Robert S. Gold, MD, CEO of DCBA, Inc., during a January 19, 2016, Talk Ten Tuesday broadcast. There are two major issues.

First, the digital field on which physicians are expected to play is designed by coders using coding rules. Instead of focusing on patient care, physicians are now mandated to focus on codes. “If you don’t get the right code,” said Gold, “you don’t get paid.”

Second, many physicians feel the support they once received from CDI specialists and ancillary staff is being replaced with computer-assisted cod-ing or clinical documentation software.

“We’re back to ICD-10 coding lan-guage and DRGs being the prime driving force, and docs are left out of the equation altogether,” said Gold. “What physicians need is support by humans who are clinically driven, and not digital programs that are coder driven.”

Capitalize on this CDI opportunity by helping physicians get acquainted with their electronic health records and processes, said Gold. Whether it’s done by a physician advisor or a clinically astute CDI specialist, take the opportunity to educate physi-cians and ensure they know what coding and clinical documentation support is available to them.

Include physicians when devel-oping query templates and policies, says Yuen. They should be allowed some say when it comes to the elec-tronic systems that they must use. CDI specialists can gather feedback and find out what works and doesn’t.

“ICD-10 and the meaningful use deadlines hit at the same time,” Yuen says. “Providers are greatly affected and upset that their EHR is taking time away from patient care. CDI staff members’ contribution to this conversation can be highly ben-eficial to resolve these issues.”

Finally, just because ICD-10 has been implemented does not mean coding- and documentation-related education should end. Physicians are looking for continued support, as well as education that is clinically based, not financially focused. Work to develop ongoing educational resources for physicians and pres-ent such education in a way that

Even if it’s not going to change the DRG, it’s important to have

specific diagnoses. In some cases, a link is needed between the condition and the cause in order to code the diagnosis accurately. — Judy Schade, RN, MSN, CCM,

CCDS


makes sense to physicians: in pure medical terms, said Gold.

Productivity

There’s been a slight decrease in productivity with the arrival of ICD-10, with the plurality (40%) of respon-dents to an ACDIS poll conducted prior to implementation reporting a

16%–20% reduction in productivity or less. At that time, 25% of respon-dents said they were not sure how ICD-10 would affect CDI productivity,

and 34% reported a greater than 20% reduction in productivity.

The effect of ICD-10 implemen-tation on CDI productivity has gen-erally been less drastic than some facilities feared, Yuen says, with most finding a 20%–30% decrease.

Most facilities took the opportunity afforded to them by the ICD-10-CM/PCS implementation delays to con-tinue their documentation education efforts. Those facilities that did not may be relying on outside contrac-tors. If a facility is using an outside resource that may not be operating at the appropriate skill level, it should conduct consistent audits from an internal perspective to ensure qual-ity, Yuen says.

In fact, she notes, facilities in gen-eral should evaluate their productiv-ity and success with ICD-10.

“If you can’t report accurate data from your facility, then public data

is going to be skewed,” Yuen says.

“Be proactive and understand the

case-mix index, specifically within

an institution. That’s where CDI

comes into play and can make an

impact in terms of getting the cor-

rect documentation that’s going

to be reported and available to the

public.”

CDI specialists need to stay on top

of education and not drop the ball

now that ICD-10 has been here for

a few months, she adds. Commu-

nication with coding is essential for

success.

“Open communication will offer

education opportunities among

two teams and reduce duplication

of efforts,” says Yuen. “Facilities can

create strategies and deliver the

same messages from coding and

CDI to providers, who will appreciate

a consistent message.”

RADIO RECAP

ICD-10 documentation: The devil is in the details No one thought ICD-10 imple-

mentation was going to be easy, but after a few months of working with the new code set, 19% called their implementation process just that—easy.

Another 73% said imple-mentation was only moderately

challenging, and just a handful called it “difficult,” according to an ACDIS Radio poll.

As facilities head into the sec-ond half of year one in ICD-10, CDI specialists and coding staff are noticing some anomalies within the code set. The smallest detail—or

lack thereof—in the documentation can affect reimbursement dramati-cally, says Judy Sturgeon, CCS, CCDS, clinical coding and com-pliance manager at Harris Health System in Houston, who spoke on the December 23, 2015, pro-gram. Because of this, she says,

What physicians need is support by humans who are

clinically driven, and not digital programs that are coder driven.—Robert S. Gold, MD


coders and CDI specialists need to understand which details matter.

Skin procedures

In ICD-9, if the physician admitted a patient with an abscess and per-formed an incision and drainage, the procedure—incision and drainage of skin and subcutaneous tissue for an abscess—mapped to the medical DRG group for cellulitis regardless of whether it was performed in the operating room, says Sturgeon.

In ICD-10, added documentation details can shift the code out of the DRG grouping for cellulitis and into the DRG for surgical procedures for infections.

If the physician documents “inci-sion and drainage of the foot,” the DRG does not change because the procedure is focused on the general anatomic section.

If the physician documents “inci-sion and drainage of the skin,” it still remains a medical DRG. But if the physician clearly documents an inci-sion into the subcutaneous tissue or fascia, the DRG could shift to surgi-cal DRG.

“This is definitely an opportunity for CDI to get surgical detail that didn’t matter in ICD-9,” says Sturgeon.

Newborns and obstetrics

Under ICD-9, physicians docu-mented common diagnoses such as hernias, hemangiomas, hydro-celes, and heart murmurs—which Sturgeon refers to as the “4 H’s”—and coders simply reported them (according to AHA Coding Clinic for

ICD-9-CM, First Quarter 1994, p. 13, and Second Quarter 1989, p. 14).

Now, physicians must be actively treating these conditions for the coders to report them, says Laurie Prescott, MSN, RN, CCDS, CDIP, CDI education director with HCPro in Danvers, Massachusetts.

Under ICD-10, “all conditions have to meet criteria for secondary diag-noses,” says Sturgeon. “You no longer get a freebie for things docu-mented at discharge.”

On the other hand, she says, “we’ve been given something in return.”

Take the case of a newborn who is in observation due to a mother’s suspected drug abuse. In ICD-10, whether the drug abuse is suspected or confirmed, it can be picked up and coded, says Sturgeon.

“If you have clear documentation showing extra lab tests or moving the baby up to a Level II nursery for monitoring,” she says, coders can pick that up.

For moms who have a perineal laceration at delivery, first- or sec-ond-degree lacerations do not shift the DRG out of the normal vaginal delivery DRGs, Sturgeon says.

If it’s a third- or fourth-degree lac-eration and documentation includes surgical detail on the repair, it could map to non-extensive, or extensive, procedures unrelated to the principal diagnosis, which affects the DRG.

The bottom line, she says, is that “CDI specialists need to be pay-ing attention to the moms, not just the babies.”

Hepatic coma

In addition, there have been a number of hepatic coma changes.

Persistent non-transient uncon-sciousness is now considered a coma and MCC, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Houston.

Hepatic coma is now classified as hepatic failure, with or without consciousness. Previously, cod-ers could report coma if the patient had symptoms of impending failure: now, however, hepatic encephalop-athy will not apply unless the patient is comatose.

“This is a huge hit in terms of MCCs,” says Pinson. “It’s a dilemma, and I wish they’d change it.”

CDI should also be aware that metabolic encephalopathy—due to fever, dehydration, hypoxia, and organ failure—is now an Excludes1, meaning the coder should never use the excluded code with the code above the Excludes1 note (the two conditions cannot occur together), according to Allen Frady, RN, BSN, CCS, CCDS, senior con-sultant at Optum360 CDI, during a December 9, 2015, webcast, “CDI in Transition: Breaking Bad Habits for ICD-10 Queries.”

The condition maps to an MCC for some subset of the patient pop-ulation, but only when the criteria for encephalopathy are met—mean-ing the patient must be comatose, says Frady.


Toxic liver has an Excludes2 note, meaning the excluded con-dition is not part of the condition the code represents, but a patient may have both conditions simul-taneously, and may be reported with alcoholic liver disease, which could result in an MCC. This also requires the patient to be in a coma, Frady says.

Sepsis

New coding guidance may ame-liorate some of the struggles facilities face regarding reporting a diagnosis for sepsis, says Pinson.

Furthermore, an international task force released updated definitions for sepsis and septic shock in the Journal of the American Medical Association in February. The new definitions state:

Sepsis should be defined as life-threatening organ dysfunc-tion caused by a dysregulated host response to infection. Septic shock should be defined as a sub-set of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are asso-ciated with a greater risk of mortal-ity than with sepsis alone.

Patients with septic shock can be clinically identified by a vaso-pressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lac-tate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

Updated clinical criteria and defini-tions were needed, the report said,

since the multiple definitions and terminologies led to discrepancies in reported incidences and observed mortalities.

Despite the new criteria, coders and CDI specialists must adhere to the existing coding and documenta-tion rules. Under these rules, there is no longer a default code for urosep-sis, and SIRS due to pneumonia no longer tracks to sepsis, says Pinson.

“I think the changes in ICD-10 are excellent,” he says. “They now put the coding classification in line, and it is comprehensible in terms of clin-ical practice and the standards of sepsis.”

Facilities have historically struggled with sepsis diagnoses, says Pinson. Systemic infections, like unspeci-fied sepsis, were actually classified as septicemia, whereas sepsis was classified with SIRS codes. Septic shock also had a separate code. “This created a lot of confusion,” he says.

In ICD-10, systemic infections are now classified as sepsis, which includes septicemia. “If we have a patient with unspecified sepsis, we have that systemic infection code,” says Pinson.

“Now, instead of SIRS codes, we have two simple codes that identify sepsis when it is severe and if there is sepsis shock associated with it. We add an additional code—either severe sepsis or severe sepsis with septic shock—and we eliminate the whole SIRS concept.”

Unfortunately, there’s not a code or indexing for infectious SIRS, Pin-son says. This means infectious

SIRS can no longer be coded when a patient has pneumonia—it would simply be coded as pneumonia.

There are still codes for non-infec-tious SIRS, Pinson says, including the cause of SIRS and codes for non-infectious SIRS with or without acute organ dysfunction.

Urosepsis is no longer codable unless it is qualified. For example, sepsis documented with urosepsis clarifies it.

Further, bacteremia is excluded from the diagnosis of sepsis, so there’s no need to query. “Over-all, thumbs up on the sep-sis changes,” says Pinson.

Moving forward

If there’s anything CDI specialists can take from ICD-10, it’s this: Pay attention. The smallest difference, whether a word or a sentence, can paint an entirely different clinical picture.

The industry has survived the hard part—implementation. Now, it’s time to move forward and identify ways to use documentation effectively to improve not just reimbursement, but also the quality of patient care. Doing so doesn’t have to take hours of additional work or training.

“From a practical standpoint, there are very few [changes] that require new or additional queries,” Pinson says. “The quantity of queries makes no difference.”

Editor’s note: ACDIS Radio is a free, bimonthly Web-based discussion with industry experts and stories from practicing CDI specialists. For information, visit www.acdis.org/radio.cfm.

http://www.acdis.org/radio.cfm

http://www.acdis.org/radio.cfm


PHYSICIAN ADVISOR’S CORNER

Keep on the straight and narrow path: Achieving (and maintaining) CDI compliance

by Trey La Charité, MD

Compliance represents one of the most important yet underappreciated goals of a CDI program. While my facil-ity’s eight-year-old CDI project did not start out with compliance as an initial

objective, we were able to identify and resolve its unin-tentional oversights.

Whether your program is in its infancy or is fully matured, you need to address compliance concerns to shield your facility from substantial, and completely avoidable, risk. Failure to follow certain tenets of CDI practice puts your facility at risk for financial penalties from those that audit its operations—penalties that ulti-mately can lead to a reduction in services offered to your patients.

Program origins

First, understand the probable origin of the CDI pro-gram. Most likely, a senior staff member (someone from the C-suite—chief financial officer, chief medical officer, CEO, etc.) was having lunch with another senior leader, lamenting reduced reimbursements resulting from healthcare reform, when that other leader mentioned how the new CDI program at his or her facility had gar-nered a substantial increase in the facility’s case-mix index. Your senior leader was dazzled by dollar signs, convinced that your hospital desperately needed a CDI program to accomplish the same results. Unfortunately, the most important reasons for starting a CDI program were likely ignored.

Understanding the probable origin and intent of your CDI program helps make your program’s structure make sense, too. Odds are that your CDI program started out only reviewing Medicare patients—it may still only review Medicare charts to this day. Why? Medicare patients represent the largest single proportion of MS-DRG pay-ers in your hospital. Some facilities are fortunate enough

to have adequate staff to review all MS-DRG payers, but most are not. My organization followed this initial path.

Eventually, though, I became aware that our govern-ment does not look favorably on organizations that only apply their CDI efforts to Medicare patients. Such limited scope of practice, in fact, looks suspicious to the enforc-ers of Medicare rules and regulations, such as the Office of Inspector General (OIG).

Expansion opportunities

You, as the leader of your CDI program, should explain to senior management that your program needs to expand its efforts to all MS-DRG payers, if not all patients. Setting the precedent that your organization is not solely targeting Medicare beneficiaries reduces the chance that the hospital will come under unwanted scrutiny.

The ideal scenario would be for your program to review every chart that comes through its doors—yes, even the totally uninsured. Why? There is a group of people within your facility whose sole job is to get uninsured patients health insurance, and they do a better-than-expected job of getting them some kind of coverage. When this occurs, your facility will eventually get some form of reim-bursement (albeit many months later). This reimburse-ment will probably be subject to some risk adjustment methodology like the MS-DRG system. Additionally, the coded ICD data from these newly reimbursed cases will be included in a publicly reported database.

My organization has about a 49% success rate in this endeavor. This means that there is about a 50/50 chance that my CDI program positively affects both the reim-bursement and the reported performance metrics for any given uninsured patient. I like those odds, and so does my hospital.

Continuing with the betting analogy, I would double down on a second probability: I bet your program only reviews records for those diagnoses considered to be


CCs/MCCs. Since money was the initial motivator, why would your CDI personnel review records for any diagno-sis that did not carry a financial implication?

Once again, it is up to you, the CDI professional, to gently guide your senior leadership to a more compli-ant and rewarding path. First, explain how querying for every diagnosis not documented in the medical record has substantial implications for your facility’s publicly reported performance data. While your senior leadership is aware of this on a conceptual level, they probably have not made the connection that your CDI program can positively affect these items.

Educate senior management about how metrics (out-side of the MS-DRG system) calculate how sick a patient is based on the documented diagnoses. Also explain how those methodologies take into consideration sub-stantially more diagnoses than the ones CMS has desig-nated as CCs/MCCs. The APR-DRG system is probably the most widely known of these and can serve as a per-fect example of how all diagnoses matter.

Once again, you will have to explain that reviewing for only CCs/MCCs looks suspicious to CMS and the OIG. Reviewing a record for all missed diagnoses sets the precedent that accurate portrayal of your patients’ sever-ity of illness is the goal of your program as opposed to financial gain. At my facility, the “I” in “CDI” stands for “integrity.”

Compliant queries and materials

A third mandate for CDI compliance is that no finan-cial or performance implications should be included on any CDI promotional materials. While this includes CDI pocket cards, flyers, posters, and preprinted documen-tation templates, the single most important item to dis-cuss here is queries.

Leading queries are highly frowned upon by CMS, the OIG, and our profession in general. Supplying provid-ers with the knowledge that the targeted diagnosis of your query is a CC/MCC, or listing the severity of illness, length of stay, or potential reimbursement outcomes of a positively answered query, can only be construed as leading.

Being accused of writing leading queries is unde-sirable—and expensive, if proven by governmental watchdogs. Not supplying this type of information to your providers at the point of service sets the prece-dent that diagnostic accuracy is the goal, not financial reimbursement.

It is perfectly permissible and necessary to teach your providers—through your educational efforts and presen-tations—which diagnoses are CCs and which are MCCs, and to communicate that proper documentation of these diagnoses improves severity of illness, length of stay, and reimbursement. But supplying those distinctions at the moment physicians are contemplating what to write in the medical record appears fraudulent and greed-driven.

Lastly, queries must be compliant with industry stan-dards (the 2013 ACDIS/AHIMA practice brief “Guidelines for Achieving a Compliant Query”)—queries constructed outside of these parameters may be considered leading. Following these guidelines helps show that your program follows accepted industry practice standards and that you are not leading your providers to answers they would not arrive at on their own.

Compliance is the unrecognized purview of the CDI professional. Keeping your CDI program on a straight and narrow path avoids potential ramifications that will harm your facility’s patient care efforts. While “selling” compliance can frequently be difficult since you are mar-keting prevention of things that might not happen, you do not want your program to be an unrecognized liability and an unanticipated risk factor.

Unfortunately, many solutions for increased compli-ance require adding more CDI personnel to your pro-gram. However, this should be an easier sell to your chief financial officer since reimbursement increases generally accrue from reviewing more records. I encourage involvement from your compliance depart-ment, as they too have a vested interest in flying under the radar and staying off the grid.

Editor’s note: La Charité is a hospitalist with the University of Ten-nessee Medical Center (UTMC) and a past ACDIS Advisory Board member; he serves as the physician advisor for UTMC’s clinical doc-umentation integrity program, coding, and RAC response. Dr. La Charité’s comments and opinions do not reflect necessarily those of UTMC. Contact him at [email protected].

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Look at complete blood count for CDI opportunitiesby Verona A. Lodholz, DC, MT(ASCP), CPC, CCDS

As you review all the numbers included in a complete blood count (CBC), are you gathering all the avail-able information? Do you just look at

the white blood count (WBC), hemoglobin (Hgb), hema-tocrit (Hct), H&H, and platelet count and move on? What are all those numbers, and furthermore, why should a CDI professional care?

As a medical technologist/clinical laboratory scien-tist turned CDI specialist, these are questions asked of me by my fellow CDI professionals. The lesser-reviewed numbers include the red blood cell count (RBC) and the indices. Let’s take a look at where they come from and why you should care.

RBC is the number of red cells present. This number is typically reflected by the Hgb/Hct, elevated count cor-responding with a higher H&H and vice versa, but there are conditions that can result in variation, often related to aberration in the indices.

The indices are calculated values that provide a picture of the red blood cell or platelet functionality and appear-ance, which is most often affected by abnormal cell cre-ation in the bone marrow. The most common clinical condition seen when this occurs is an anemia. The index value can point to the source of anemia.

The mean corpuscular volume (MCV) reflects the aver-age size of the red cells. Cell size abnormalities occur when one or more of the building blocks of the cells are deficient. High numbers correlate with macrocytes, while low numbers correlate with microcytes. Macrocytic cells are common in alcoholics and can also be due to other causes of vitamin B deficiency. Microcytes are typically seen in an iron-deficiency anemia.

The mean corpuscular hemoglobin (MCH) reflects the amount of hemoglobin within the cells. A low MCH is indicative of poor oxygen carrying capacity, even if the patient has an adequate number of red cells.

The mean corpuscular hemoglobin concentration (MCHC) reflects the amount of hemoglobin relative to the size of the cell. A low MCH and MCHC indicates pale red cells. Prior to a complete workup, a patient’s anemia may only be classified as microcytic hypochromic or macro-cytic hypochromic anemia.

Red cell distribution width (RDW) relates to variation in the size of the red cells. A large variation can occur following a recent transfusion if the donor cells are a different size than the recipient’s cells. A hemolytic anemia, including sickle cell, can also result in a large variation due to the small cell fragments left in circula-tion; this would be exacerbated in a person with a prior splenectomy.

The final index to mention is the mean platelet volume (MPV). This may be elevated in the presence of giant platelets. In certain conditions, giant platelets are not able to function normally.

The CDI professional that enjoys this cup of alphabet soup and numerical stew will have the information to bet-ter interpret the CBC results while gathering new clues to the clinical picture.

Editor’s note: Lodholz has more than 35 years of healthcare experience, encompassing nursing assistant, laboratory assistant, medical technologist, chiropractor, and clinical laboratory direc-tor, in addition to serving as a certified coder and CDI specialist. Her laboratory experience includes 20 years of laboratory testing as well as overseeing the day-to-day operations of both a high- and moderate-complexity laboratory in northern Wisconsin for more than seven years. Contact her at [email protected].

LABORATORY SPEAK



Pediatric encephalopathy query opportunitiesQ: We have a teenager with sys-

temic lupus erythematosus (SLE) and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilep-ticus and hypertensive urgency. The intensivists then documented hyper-tensive encephalopathy.

What should we choose as the principal diagnosis? Would it be the hypertensive encephalopa-thy and leave off the seizures (are seizures integral to hypertensive encephalopathy)?

The patient also definitely has chronic kidney disease but sees a nephrologist at another univer-sity hospital four hours away. The patient’s glomerular filtration rate (GFR) falls into Stage 3 CKD. We are considering querying for that to link it to the hypertension.

A: “Chronic kidney disease (CKD) in children is the highest cause of hypertension whereas in adults hypertension causes CKD,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. Hypertensive crisis takes two possible forms (and the blood pressure is usually in the less than 180 systolic to less than 100 diastolic range):

1. Hypertensive urgency: Patient exhibits extremely high blood

pressure without organ damage

2. Hypertensive emergency: Patient exhibits an extremely high blood pressure with organ damage

According to Gold, the target organs for hypertensive crises include:

■■ The central nervous system with hypertensive enceph-alopathy, hypertensive sei-zures, or hypertensive stroke

■■ The heart with acute pulmo-nary edema, unstable angina, or NSTEMI

■■ The kidneys with CKD

“The patient described in this sce-nario was admitted and treated for hypertensive seizure R56.9, a spe-cific manifestation of hypertensive encephalopathy I67.4, but code both. We will have ICD code I16.0 for hypertensive emergency in the near future. The patient has hypertension due to CKD I15.1 coming from lupus glomerulitis M32.14,” Gold says.

Hyper tensive encephalopa-thy refers to the transient migra-tory neurologic symptoms that are associated with the malignant hypertensive state in a hypertensive emergency, offers Kathy (Allen) Wilson, RN, CDI specialist at All

Children’s Hospital in St. Peters-burg, Florida.

The clinical symptoms are usually reversible with prompt initiation of therapy. Encephalopathy in general means any disorder of the brain, so the use of the word “hypertensive” provides the etiology.

For coding purposes, it is import-ant to distinguish that this is an “acute” encephalopathy.

In this scenario, there may be three different query opportunities, Wilson says:

1. Is this an acute metabolic encephalopathy due to hyper-tensive crisis?

2. Is the seizure activity due to the hypertensive encephalopathy?

3. Is the hypertension related to CKD, and what stage is the CKD?

“Once those questions are answered,” says Wilson, “you can better choose your principal diag-nosis between seizures, acute encephalopathy, or renal failure depending on the answers to your queries.”

Editor ’s note: This Q&A was adapted from the “Pediatric CDI Talk” networking group.


OUTPATIENT EFFORTS

Define outpatient CDI nuancesby Anny Pang Yuen, RHIA, CCS, CCDS, CDIP

As healthcare providers increas-ingly accept financial risk associated with patient management due to the transition from fee-for-service to risk-

based/value-based reimbursement, the traditional model of healthcare reimbursement has been flipped upside down.

Many of the value-based incentives and penalties rely on quality measures reported to programs like Physi-cian Quality Reporting System (PQRS), Hospital Inpatient Quality Reporting (IQR), and Hospital Outpatient Quality Reporting (OQR).

The intent is to have the providers show that they meet quality standards and provide quality care to the patient while managing costs. As a result, many organizations realize that success with risk-based/value-based reim-bursement actually relies, in large part, on complete and accurate documentation of diagnoses.

Therefore, many organizations also acknowledge that having a CDI program cover both inpatient and outpatient settings improves the accuracy of risk scores and reporting of diagnoses while mitigating risks associated with inaccurate coding (i.e. overcod-ing or undercoding).

With that said, the million-dollar question remains: How can an organization effectively strategize its existing CDI program and position the program for success while still trying to define what ambulatory (outpatient) CDI is?

Let’s start by examining how outpatient CDI differs from inpatient CDI. First, the volume of outpatient encounters will be significantly higher than in the inpa-tient setting. Secondly, timing is not on the outpatient reviewer’s side. Documentation in the outpatient set-ting occurs quickly; therefore, an outpatient CDI pro-gram must be nimble.

As a result, it is important to evaluate for any opportu-nity to improve process flow and to leverage technology

so that all necessary documentation can be captured to the highest level of specificity. Some areas for outpatient CDI may include the emergency department (ED) and physician practices/clinics.

Emergency department

The role of a CDI specialist is to ensure physicians’ documentation accurately reflects their clinical judgment and medical decision-making, as well as the acuity of patients; therefore, having a CDI presence in the ED will lead to fewer medical necessity denials. Other benefits of having a CDI team in the ED may include (but are not limited to) the following:

■■ Creating an accurate problem list starting in the ED

■■ Addressing and correcting any fragmentation/gaps in patient care from the time of admission into the ED to discharge

■■ Improving documentation of observation hours

■■ Improving documentation of infusions and injections

■■ Improving accuracy of present on admission indi-cators and reporting of codes

■■ Reducing audit risks

Outpatient CDI is like Pandora’s box, especially in the ED. So, the tasks of outpatient CDI specialists in the ED may be different from one organization to another. Some programs may have their CDI specialists review provider and nursing documentation for evidence of patient monitoring, along with compliance of physician orders and confirmation of diagnoses. Others may have the CDI team evaluate and monitor documenta-tion of observation hours from a compliance stand-point and/or review and educate physicians regarding the importance of accurate documentation of infusions and injections.

Since CDI specialists are documentation educators, it makes sense for the CDI team to expand its education to


the nursing team on the requirements for documentation of infusions/injections. By comparing provider and nurs-ing documentation to charges, organizations can ensure that charges for supplies and medications are appropri-ate for the services documented.

Physician practices/clinics

Similar to the ED, outpatient CDI specialists need to assist in obtaining documentation of confirmed diagno-ses in the physician practice/clinic.

It is essential for the highest level of specificity to be documented to support outpatient services and to max-imize ambulatory payment classification (APC) reim-bursement. Some other benefits of having a CDI team in a physician practice/clinic may include (but are not limited to) the following:

■■ Creating an accurate problem list starting in the physician’s office

■■ Improving documentation and ensuring that chronic conditions are continuously captured within the EMR/EHR

■■ Producing reliable medical records that can enhance the quality of patient care

■■ Reducing of audit risks and/or denials

■■ Improving accuracy of coding (i.e., outpatient, HCC) and Risk Adjustment Factor (RAF) score

As mentioned above, the scope of outpatient CDI is of course contingent on the objectives and mission of the organization, along with the resources that can be made available for the expansion of CDI into the ambulatory arena.

The key to success is to develop and nurture collabo-ration between providers, nursing, CDI, health informa-tion management/coding, and case management within the outpatient and inpatient setting.

As CDI continues to evolve, the sharing of knowledge will become essential. Since outpatient coding guide-lines are different than inpatient coding guidelines, one of the main tasks for outpatient CDI specialists will be working with providers on the confirmation of diagnoses and accurate documentation with appropriate specificity to support these diagnoses.

Furthermore, both outpatient and inpatient documenta-tion principles should be integrated into a CDI education program. Providers should understand the difference in documentation requirements since both outpatient and inpatient require strong foundations of documentation to support medical necessity and intensity of resource utilization.

Providers should have an understanding of how their documentation in both the outpatient and inpatient set-tings affects their ability to assign and bill evaluation and management levels and reduce claim denials.

A successful ambulatory CDI program will help demon-strate to the providers that CDI efforts will have an impact across the continuum of healthcare (i.e., ambulatory, inpatient, postacute).

Editor’s note: Yuen is an ACDIS Advisory Board member. She previously served as a corporate director of CDI at Penn Medicine, where she oversaw four hospitals and developed a unified and multi-disciplinary corporate CDI process focused on improving physician/provider documentation and accurate CDI financial reporting. Con-tact her at [email protected].


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CODING CLINIC FOR CDI

ICD-10 covers orthopedic, cardiovascular codingby Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS

Some interesting tidbits of information can be gleaned from the most recent release of AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.

I never thought I’d be so eager to read a release about coding instead of the newest James Patterson novel, but this newsletter highlights topics such as orthope-dic screw removals, revision of total knee replacements, heart failure with pleural effusions, leadless pacemakers, the Glasgow Coma Scale, and decompression of the spinal cord.

Orthopedics

Typically, when we see that a device is loose or break-ing, we automatically think, “That shouldn’t happen,” so we opt to code a complication of the device. Well, when this occurs in an orthopedic screw as an expected out-come (typically when the patient begins bearing weight during the recovery/healing process), it should not be coded as a complication.

The correct diagnosis codes would be assigned for the specified fracture site with a seventh character identi-fying a subsequent encounter with routine healing, along with the external cause code (if known), also as a subse-quent encounter.

(Remember that place of occurrence, activity, and sta-tus codes should only be used for the initial encounter, per the ICD-10-CM Official Guidelines for Coding and Reporting.)

The ICD-10-PCS root operation would be Removal (third character P) for the removal of the screw from the specified bone.

On the other hand, some orthopedic devices can present real complications necessitating removal and replacement. For example, a patient may be admitted for a painful total knee replacement, initial encounter

(T84.84xA). In order to remedy this situation, the previ-ously placed components (tibial and femoral) are removed and replaced with new components. This scenario leads coders to ponder whether this should be considered a Revision or Replacement, or perhaps something else.

ICD-10-PCS defines a Revision as “correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device.”

In this case, the prosthesis isn’t working exactly the way it should, but the ICD-10-PCS Reference Manual states that “putting in a whole new device or a complete redo is coded to the root operation(s) performed.”

Therefore, the correct root operations would be Removal (P) for taking out the old components, then a Replacement (third character R) for putting in/on a syn-thetic material that takes the place of the body part.

Cardiovascular

Although the codes for heart failure (category I50) are mostly identical to their ICD-9-CM counterparts, one thing that probably raised some eyebrows for coders was the Excludes2 note at category J91 (pleural effu-sion in conditions classified elsewhere), which seemed to state that a code from category J91 would be assigned as an additional code when seen “in heart failure.”

Of course, most coders will recall that in ICD-9-CM we normally could not assign a separate code for this situation, based off information in AHA Coding Clinic for ICD-9-CM, Third Quarter 1991. The new issue provides clarification that the same rules apply in ICD-10-CM for pleural effusions seen in heart failure patients.

The pleural effusions would only be reported sepa-rately if therapeutic/diagnostic interventions are required. Pleural effusion is commonly seen with congestive heart failure (CHF) with or without pulmonary edema. Usu-ally, the effusion is minimal and resolves with aggressive treatment of the underlying CHF.

The issue also addresses the correct coding of a newer procedure performed for heart blocks: the insertion of


leadless pacemakers. You may have asked, as I did, “How in the world does this device work if there are no leads to provide the electrical impulses?”

This technology has been explored for many years and is finally here. Current pacemaker devices are sus-ceptible to issues such as lead failure or malposition-ing, as well as pulse generator pocket complications, such as scar formation or even just the visible presence of the device.

In contrast, these new cylindrical devices fit directly into the right ventricle, accessed via a transcatheter approach and placed into the endocardial tissue of the right ventricular apex to provide pacing capabilities.

For coding purposes, the ICD-10-PCS table 02H (Insertion, heart and/or great vessels) does not pro-vide a specific device option for a leadless pacemaker. The correct device character should be D (intraluminal device).

The full ICD-10-PCS code to be assigned is 02HK3DZ (Insertion of intraluminal device into right ventricle, percutaneous) to identify a leadless pacemaker.

Neurology

Revisions in ICD-10-CM allow coders not only to report a coma (R40.20-, unspecified coma) but also to report codes that incorporate a common tool to assess the depth and duration of comas or impaired conscious-ness, known as the Glasgow Coma Scale.

Per the Centers for Disease Control and Prevention, this scale helps to gauge the impact of a variety of con-ditions, such as acute brain damage due to traumatic and vascular injuries or infections and metabolic disor-ders (e.g., hepatic or renal failure, hypoglycemia, diabetic ketosis).

ICD-10-CM contains subcategories to report the three elements that go into calculating the coma scale:

■■ R40.21-, coma scale, eyes open

■■ R40.22-, coma scale, best verbal response

■■ R40.23-, coma scale, best motor response

If coders opt to use this reporting option, three codes must be assigned to identify each of the three elements.

Codes for the individual Glasgow Coma Scale scores from these categories can be assigned if the provider documents the numeric values, as opposed to the physical descriptions associated with those numeric values.

The eye opening response is scored as follows:

■■ 4, spontaneous eye opening

■■ 3, eyes open to speech

■■ 2, eyes open to pain

■■ 1, no eye opening

The verbal response is divided into five categories:

■■ 5, alert and oriented

■■ 4, confused, yet coherent, speech

■■ 3, inappropriate words and jumbled phrases con-sisting of words

■■ 2, incomprehensible sounds

■■ 1, no sounds

The motor response is divided into six different levels:

■■ 6, obeys commands fully

■■ 5, localizes to noxious stimuli

■■ 4, withdraws from noxious stimuli

■■ 3, abnormal flexion, i.e., decorticate posturing, an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bent and held on the chest

■■ 2, extensor response, i.e., decerebrate pos-turing, an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, and head and neck arched backwards

■■ 1, no response


For example, the documentation states “Glasgow Coma Scale score was obtained upon arrival at the ED; eyes open = 2, best verbal = 3, and best motor = 5.” Coders may assign the following:

■■ R40.2122, coma scale, eyes open, to pain, at arrival to ED

■■ R40.2232, coma scale, best verbal response, inappropriate words, at arrival to ED

■■ R40.2352, coma scale, best motor response, localizes pain, at arrival to ED

Per the Official Guidelines for Coding and Reporting, the seventh characters must match for all three codes.

Subcategory R40.24- (Glasgow Coma Scale, total score) is an additional option provided that identifies the overall score as opposed to each of the three individual elements.

Those codes are:

■■ R40.241, Glasgow Coma Scale score 13–15



■■ R40.244, other coma, without documented Glasgow Coma Scale score, or with partial score reported

Codes from R40.24- would not be assigned if the indi-vidual scores are documented.

Laminectomies

Procedurally, Coding Clinic provided clarification regarding decompressive laminectomies and the assign-ment of the appropriate body part characters. When assigning an ICD-10-PCS code for a cervical decom-pressive laminectomy, the body part value states “cervi-cal spinal cord.”

The cervical spinal cord is considered a single body part value in ICD-10-PCS and would only be assigned one time regardless of the number of cervical levels decompressed to release the spinal cord.

The vertebral level designations of the cervical spinal cord do not constitute separate and distinct body parts anatomically; therefore, ICD-10-PCS Guideline B3.2 does not apply:

During the same operative episode, multiple proce-dures are coded if the same root operation is repeated at different body sites that are included in the same body part value.

Another note of caution: The ICD-10-PCS Index entry “Laminectomy” instructs coders to see Exci-sion (B), but the objective of a decompressive lami-nectomy is to release pressure and free up the spinal nerve root. Therefore, the appropriate root operation is Release (N).

Editor’s note: McCall is the director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts. She oversees all of the Certified Coder Boot Camp programs. For more information, see www.hcprobootcamps.com. This article was originally published in Briefings on Coding Compliance Strategies.

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MEET A MEMBER

Australian woman brings CDI ‘down under’ At ACDIS, it’s no surprise when we

hear about clinical documentation improvement efforts extending to hos-pitals and organizations throughout the United States. But when we heard about an Australian hospital launching a

CDI program—one of the first international programs of its kind—we were beyond excited.

Nicole Draper, RN, BN, MHA, is the woman spear-heading the efforts at her facility in Darlinghurst, Sydney, Australia. As the manager of length of stay, documen-tation, and revenue optimization, she works to address and alleviate documentation challenges. Using ACDIS resources and networking with CDI specialists in the United States, she was able to launch a pilot program for the first-ever CDI program down under.

Draper, married for five years to her husband Drew, an attorney, has two boys, James, 3, and Charlie, 2. In their free time, her family enjoys an outdoor lifestyle and takes advantage of living close to beautiful beaches. She also enjoys cooking and hosting barbecues and dinner par-ties, going to the park with her kids, and traveling.

CDI Journal: What did you do before entering CDI?

Draper: I completed my bachelor degree in nursing in 1994 and my master’s degree in health administration in 2004. I am currently pursuing a doctorate in health with a research focus on clinical documentation. Prior to get-ting into CDI, I was a nurse manager in the perioperative environment for 16 years.

CDI Journal: How long have you been in the CDI field?

Draper: I have been in the CDI field for 18 months. Currently, I work at St. Vincent’s Private Hospital Syd-ney, which is the oldest private hospital in Australia. It is located in Darlinghurst, quite near the city and the iconic Sydney Harbor Bridge and Opera House. My title, manager of length of stay, documentation, and revenue optimization, is a newly established role with one of the focuses being documentation.

In my new role, I was seeking ways to address the challenges around documentation, particularly medical staff documentation. In our facility, we are paid in one of two main funding models: case payments based on Australian Refined Diagnosis Related Groups (AR-DRGs) or a per diem method.

In a case payment environment, documented patient complexity results in a higher reimbursement from the health funds. A large portion of our work is funded in this way. We knew because of our high patient complexity and a longer length of stay in some specialty areas com-pared to our peers that documentation was sometimes insufficient, and thus we were not being reimbursed appropriately.

CDI Journal: Tell us about your experiences building a CDI program in Australia.

Draper: I began researching to look for ways to improve our documentation and found ACDIS. I immediately joined and attended the 2015 conference in San Anto-nio. I returned bursting with ideas and post-conference energy. On returning, I met with our HIM manager and director of nursing and clinical services to discuss the benefits of a CDI program.

From there, we developed a proposal to undertake a nine-month pilot CDI program. We identified two spe-cialty areas based on length of stay and patient com-plexity, and went to the hospital executive and the nurs-ing executive to seek approval, which I was given. The two areas we are concentrating on are neurosurgery and general surgery, which includes colorectal, upper gastro-intestinal series, and vascular.

We established a steering committee and [recruited] two experienced clinical nurses to undertake the CDI specialist role, who began training on January 11, 2016. We are working closely with 3M to provide the training, modifying the CDI modules for the Australian market.

CDI Journal: What are some of the differences between CDI in Australia and CDI in the United States?


Draper: The DRGs in Australia look different than those

in the United States. For example, a knee replacement

without complications is an I04B, and with complications

is an I04A. A hip replacement is an I03B, spinal fusions

I09B, and craniotomy B03B. Incidentally, Australia has

been on ICD-10 for about 10 years.

CDI Journal: What has been your biggest challenge?

Draper: We’re very lucky, because the hospital execu-

tive and medical staff support the program and its aims.

I imagine once the program is up and running, we may

face some challenges. We’re trying to be prepared and

have been engaging our medical officers early to ensure

the program is successful.

CDI Journal: What has been your biggest reward?

Draper: Meeting individuals who are so generous with

their time and support in helping us start a CDI program

from scratch.

CDI Journal: Can you mention a few of the “gold nug-

gets” of information you’ve received from colleagues on

“CDI Talk” or through ACDIS?

Draper: The CDI Roadmap for establishing a CDI program has been invaluable, along with the policies in the Forms & Tools Library.

CDI Journal: What piece of advice would you offer to a new CDI specialist?

Draper: The ACDIS groups are warm, welcoming, and will-ing to share their experiences. So, join and become part of it.

CDI Journal: If you could have any other job, what would it be?

Draper: This job is exactly where I want to be. I have the flexibility to be with my family, drive a program like this, look for innovative ways to improve

and contribute to patient-centered care, and be at the forefront of something that is quite new in Australia.

CDI Journal: What was your first job (what you did while in high school)?

Draper: I worked in a kiosk at Caves Beach, where I grew up. I think I was paid $20 a day—and that was on top of ice blocks and hot chips!

CDI Journal: Tell us about a few of your favorite things.

■■ Vacation spots: My brother and his family live in Columbus, Ohio, and I have visited at least eight times. When you live so far away, you have to make the most of your holidays by seeing as much as you can. Door to door, Sydney to Columbus is 24 hours! Last Christmas, we trav-eled through Europe, which was wonderful. The Greek islands are also a favorite.

■■ Hobby: Going to the beach, reading, and making and decorating cakes.

■■ Non-alcoholic beverage: Sparkling water with a dash of lime.

■■ Foods: Thai, Indian, and Italian.


2016 ACDIS Conference: A behind-the-scenes previewAnyone who has participated in the ACDIS Conference

knows that there’s a lot going on—and trust us, it’s a lot of work. But what you might not know is that the entire agenda of speakers and sessions isn’t selected by the ACDIS administration alone—we recruit a team of 12 vol-unteers to serve on our Conference Committee.

The committee reviews all speaker applications, sets the conference agenda, reviews submitted materi-als, and chooses recipients of the ACDIS Achievement Awards. Its work is invaluable to the success of the annual conference.

Now that the speakers have been selected and the agenda has been finalized, we caught up with a few of the committee members to talk about their experiences and what you can expect at this year’s conference.

The tracks

The conference committee had its first meeting last June. Members evaluated the 2015 event and started brainstorming new ideas for tracks and sessions. The first step was to develop the speaker application, which required the group to identify the focus for each educa-tional track and determine a list of must-have session topics. The call for speakers, which went out in July, gar-nered more than 100 applications.

When the application period closed in September, the committee quickly realized that the number of top-notch sessions and speakers could not be crammed into just four tracks, so the group decided that a fifth track was warranted for this year’s lineup. Tracks include:

■■ Clinical and coding

■■ Management and leadership

■■ Quality and regulatory

■■ CDI expansion

■■ Innovative CDI

“Each year, [the ACDIS Conference] keeps growing and the competition [for speaker spots] is really difficult,” says Peggy Reap, RN, who is serving on the committee for the second time. “There’s more people coming out

and wanting to present, and we tried our best to include as many of the terrific speakers as we could.”

The speakers

With the applications in hand, the committee, led by ACDIS Director Brian Murphy, began the review pro-cess. The speakers were categorized by session topic and divided into groups for review at weekly committee meetings.

Each member had the opportunity to review the applications ahead of time and bring his or her feed-back to the meetings, says Shiloh A. Williams, MSN, RN, CCDS, CDI specialist at El Centro Regional Medi-cal Center in Holtville, California. Williams reviewed each speaker’s topic and presentation outline, and looked at the applicant’s skill level and presentation experience.

“We wanted the presentations to appeal to various skill levels and ensure that everyone, whether they were new to CDI or a veteran, had something that would interest them at conference,” she says.

During the weekly meetings, the committee went through each presentation individually, sorting them by yes, no, and tentative.

“As a committee, we were able to quickly focus on those presentations that interested the group as a whole and start placing them in potential tracks,” says Williams.

Of course, rejecting an application was the biggest challenge, especially in a pool of such qualified candi-dates, but Williams says the committee felt confident in its decisions.

“There were several really good presentations on the same topic, and it was difficult to start weighing the minute details of each presentation against each other,” she says. “There were a couple of presentations that we could not quite let go of as a committee, so thankfully we were able to expand to five tracks.”

Between September and October, the group met seven times to finalize the speaker lineup. This year’s


speakers include outpatient CDI specialists, CDI manag-ers, pediatric CDI specialists, an attorney, and more than two dozen physicians.

The sessions

The ACDIS Conference always aims to include a diverse range of sessions, and this year will be no differ-ent. Attendees will enjoy dedicated tracks on expansion and innovation, highlighting such topics as outpatient CDI and risk-adjusted payments, postacute CDI, read-missions, and medical necessity.

CDI managers will have sessions tailored to their needs and interests. The conference will also offer three special panel discussions: two with the ACDIS Advisory Board, and one focused on physicians’ per-spectives on ICD-10.

When asked what session they’re most looking for-ward to, most of the committee members couldn’t choose just one. Williams will be checking out the tracks dedicated to program management and leadership and CDI program innovation.

“There are CDI professionals presenting that have already blazed the trail and would love to share their experiences and lessons learned,” she says.

The large number of physician-led sessions will offer an opportunity to learn from providers’ clinical expertise, says Tracy Boldt, RN, BSN, CCDS, CDIP, CDI consul-tant at Enjoin.

“I find it a blessing to learn and grow from the multitude of knowledge from others in the CDI arena,” she says.

This year’s conference will also offer sessions on remote CDI, which Michele E. Thornton, RN, BSN, CCDS, clinical documentation specialist at Novant Health Presbyterian Medical Center in Charlotte, North

Carolina, is eager to check out. She also plans to attend

the pathophysiological/disease process sessions.

“Aside from the incredible educational opportunities,

what I’m most looking forward to is networking with

other CDI team members,” says Thornton.

The awards

As we head into the final months before this year’s

conference, the committee still has one more task to

complete: selecting the recipients of the ACDIS Achieve-

ment Awards. This year, the ACDIS Advisory Board

made some significant changes to the awards, and so

the committee will review nominations in the following

categories:

■■ CDI Professional of the Year

■■ Recognition of CDI Professional Achievement

■■ Excellence in Provider Engagement

■■ Rookie of the Year

The committee will be responsible for reviewing the

nominations and, along with ACDIS administration, vot-

ing on four recipients, who will be honored at the confer-

ence during a general session.

“I think the committee did a great job of giving our

attendees options and variety to make their conference

experience unique and rewarding, and I’m excited to

head into our next task of reviewing and selecting our

award recipients,” says Williams. “It will be awesome to

get to acknowledge and honor our hardworking col-

leagues.

Editor’s note: The 2016 ACDIS Conference wil l be held May 23–26 in Atlanta. For more information, visit http://hcmarketplace.com/9th-annual-acdis-conference.

http://hcmarketplace.com/9th-annual-acdis-conference

http://hcmarketplace.com/9th-annual-acdis-conference?SID=0f4g60hp26r8q7pg6nksqgj177

An Open Book: The Never-Ending CDI story · Copyeditor Adam Carroll acarrollhcpro.com DESIN Design...

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