by Richard D. Pinson, MD, FACP, CCS

The newly proposed Sepsis-3 definition has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association (JAMA) on February 23, 2016.  That controversial definition discarded the concept of SIRS as the basis for defining sepsis and eliminated the distinction between sepsis and severe sepsis.

Now JAMA has just published a letter in the July 26 issue submitted by three physician representatives of CMS announcing that CMS will not change the sepsis definitions used in its SEP-1 sepsis management inpatient quality measure implemented October 1, 2015.  The definitions used in the SEP-1 measure (NQF Sepsis #0500), which CMS described as "widespread and understood", rely on sepsis as SIRS due to an infection and severe sepsis as sepsis with acute organ dysfunction. 

CMS pointed out that clinical practice measures require "extensive real-world field testing to assess reliability, usability, and feasibility", and that "the SEP-1 measure underwent more than eight years of development and critical review" and is supported by a large body of clinical evidence.

While welcoming "new research and innovative thinking", the letter emphasized that "prior to changing the widespread and understood definitions used in SEP-1, rigorous clinical investigation will be required...".

Other reservations concerning the proposed Sepsis-3 definitions expressed by CMS in the letter included the potential for delayed diagnosis of sepsis, a disruption of a "15-year trend toward further reduction in sepsis mortality", and impeding ongoing quality improvement efforts.

The CMS letter expresses the same concerns voiced by the healthcare community at large since the new Sepsis-3 proposed definitions were first published.  Many other letters from across the country and the world were also published by JAMA together with the CMS response expressing concerns that focused on potential flaws in methods and statistical analysis and the need for prospective studies to substantiate the "real-world" clinical validity of the new Sepsis-3 definitions.  CMS will continue to track further research that the new "proposed definitions will inspire."

References: 

1. CMS JAMA editorial letter  (requires membership for purchase). 
2. Fact Sheet SEP-1: Early Management Bundle, Severe Sepsis/Septic Shock
3. NQF Sepsis #0500 - Severe Sepsis and Septic Shock Management Bundle, pages 20-21.  

Editor’s note: Richard Pinson, MD, FACP, CCS, principal of Pinson & Tang LLC, wrote this article. Contact him at info@pinsonandtang.com. Pinson has more than 12 years of experience improving coding and clinical documentation practices and educating thousands of coders, documentation specialists, and physicians. He is a recognized CDI authority who co-authored the CDI Pocket Guide published by ACDIS, co-developed ACDIS’ CDI for the Clinician eLearning program for hospitals, and has written the monthly Coding Corner of the ACP Hospitalist magazine for over four years.

CMS released the fiscal year (FY) 2017 IPPS final rule yesterday. CMS made changes to several quality initiatives and reversed the agency’s 0.2% payment reduction instituted along with the 2-midnight rule in the FY 2014 rule. 

Payment rates will increase by 0.95% in FY 2017 compared to FY 2016 for hospitals participating in the Inpatient Quality Reporting (IQR) Program and meaningful EHR use, according to the rule.

“This also reflects a 1.5 percentage point reduction for documentation and coding required by the American Taxpayer Relief Act of 2012 and an increase of approximately 0.8 percentage points to remove the adjustment to offset the estimated costs of the two-midnight policy and address its effects in FYs 2014, 2015, and 2016,” said CMS.

In the rule, CMS created two adjustments to reverse the effects of the 0.2% cut it instituted along with the 2-midnight rule, which has been the source of an ongoing legal challenge by the American Hospital Association and other parties.

CMS made a permanent adjustment of approximately 0.2% to remove the cut for FYs 2017 and onward, and a temporary adjustment of 0.6% to address the retroactive impacts of this cut for FYs 2014, 2015 and 2016, CMS states.

CMS finalized five changes to the Hospital-Acquired Conditions Reduction Program in this rule, as well as updates to the IQR program, changes to the Hospital Readmissions Reduction Program, and updates to the Hospital Value-Based Purchasing Program.

Listening to commenter feedback, CMS reduced requirements for reporting electronic clinical quality measures (eCQM) as part of the IQR program. Originally, CMS proposed requiring hospitals to submit data on all 15 eCQMs, but finalized a policy requiring hospitals to report four quarters of data on an annual basis for eight of the available eCQMs.

As part of the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, CMS created the Medicare Outpatient Observation Notice (MOON). 

The MOON is a CMS-developed standardized notice hospitals are required to give to Medicare patients receiving observation services as an outpatient for more than 24 hours no later than 36 hours after observation services are initiated. Hospitals must give a verbal explanation of the MOON to patients and obtain a signature to acknowledge receipt and understanding of the notice.

The entirety of the final rule is available in PDF format on the Federal Register, and is expected to be officially published by CMS on Monday, August 22. CMS says the rule applies to approximately 3,330 acute care hospitals and approximately 430 long-term care hospitals, and will affect discharges occurring on or after October 1, 2016.

Editor’s note: This article was originally published in JustCoding. 

CMS is proposing development of bundled payment models for cardiac care and hip surgeries, according to a July 25 announcement. These models would reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery. The proposed rule also would expand the existing Comprehensive Care for Joint (CJR) Replacement model to include other surgical treatments for hip and femur fractures beyond hip replacement.

The proposals qualify as Advanced Alternative Payment Models (APMs) and qualify for financial incentives in the proposed Quality Payment Program under the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), says CMS.

Under the new models, hospitals admitting Medicare patients for heart attack, bypass survey, and surgical hip/femur fracture would be accountable for the quality and costs of care provided from the time of the hospital stay through 90 days post-discharge.

The MS-DRGS included in the acute myocardial infarction (AMI) bundle include medical treatments and revascularization via percutaneous coronary intervention (PCI). However, CMS defines AMI episodes under the bundled payment models as medical treatment only. Including PCI would force hospital leaders to examine the efficiency of PCI treatment of AMI, reports The Advisory Board.

Once the models are in full effect, participating hospitals would be paid a fixed target price for each care episode, based on historical cost data. Hospitals that deliver higher-quality care would receive a higher target price.

Participation in the models will be mandatory for 98 randomly-selected hospitals, including 67 facilities already using the Comprehensive Care for Joint Replacement model. CMS would phase in implementation of the new payment models over five years.

For more information on the proposed bundled payments, click to view the CMS fact sheet.

Those of you lucky enough to attend a local chapter event know how much fun they can be. Earlier today, ACDIS Director Brian Murphy and ACDIS Editor Katherine (Katy) Rushlau buckled in for a two-hour drive across the great state of Massachusetts into the beautiful Berkshire hills to attend the Northeast CDI and Coding Symposium at Baystate Health Education Center in Holyoke.

The agenda was ambitious. It included panel discussion with both CDI specialists and coding staff, a session on provider engagement, one on hierarchical condition categories, data analytics, among other topics. Murphy offered insight into the state of the CDI industry pointing to expanding efforts in quality, outpatient, and other areas.

“It’s really a very exciting time to be in CDI,” said Murphy. “We’re seeing a number of trends and new areas of expansion from outpatient to quality that our folks can get involved in.”

After Murphy’s remarks, the day kicked off with an equally entertaining and informative session highlighting provider engagement through the lens of a physician, Mickey Leibowitz, MD, Clinical Quality Medical Director and Physician CDI Champion/Chair of the Health Information Management Council at Crouse Hospital in New York.  Leibowitz offered these “pearls” for how CDI can partner with physicians to improve documentation and quality metrics across the healthcare continuum:

1. Engage—help the providers care about and understand the importance of documentation.
2. Educate—teach providers why documentation matters and what documentation is needed.
3. Execute—meet with providers regularly and be a consistent presence and source of information.
4. Evaluate—discuss physician profiles one-on-one and celebrate successes.

“CDI need to understand physician characteristics,” says Leibowitz. “By getting to know the docs and being visible and available to them, we can bridge that gap and partner with them to build stronger CDI departments.”

Following Leibowitz’s session, a panel discussion featured CDI and coding experts from Massachusetts and New York facilities. The panel opened the floor to the nearly 200 attendees, who asked a number of questions from the CDI frontlines. Hot topics included expanding into outpatient CDI, working remotely, electronic health record nuances, quality reviews, and reviewing observation cases.

Matt Bohl, CDI Business Analyst at Baystate Health wrapped up the morning sessions with an overview of CDI and coding analytics and benchmarking resources. Bohl reviewed the basics of analytics, how to select performance metrics to review, and data visualization. “Data is becoming the language we all speak,” says Bohl. “Doctors like data because data establishes trustworthiness and can help prove return on investment.”

The afternoon was dedicated to networking and specialty presentations on outpatient CDI and communication of patient care. CDI specialists and coders from across Massachusetts, Connecticut, and New York had the opportunity to connect and discuss issues they are facing at their own facilities. The event was truly a success.

If you are interested in attending a local chapter event near you, check out the list of upcoming meetings below: 

August

• The North Carolina ACDIS Chapter meets Friday, August 5, at Wake Forest Baptist Medical Center, in Winston Salem. Registration is a two-step process: First, complete the conference registration form, then, enter your NC ACDIS registration fees, online, here. For information, email NCACDIS@gmail.com.
• The Georgia ACDIS Chapter meets Friday, August 12, 8 a.m. to 3 p.m., at Tift Regional Medical Center in Tifton. For information, contact Julie_bell@memorial.org.
• The Indiana and Kentucky ACDIS Chapters join for a regional event Friday, August 19, 8 a.m. to 4 p.m., at the Louisville (Kentucky) Marriott East. Click here to read the complete agenda. Click here to download the registration form. Deadline for registration is August 5. For information, contact Rita Fields at rita.fields@BHSI.COM.
• The Utah ACDIS Chapter meets Wednesday, August 17, at the University of Utah for a discussion with Russell Vinik, MD, Medical Director for CDI at the facility. For information, contact Molly Evans atMolly.Evans@hsc.utah.edu.
• The New Jersey networking group meets on Friday, August 19, 10 a.m. to 3 p.m., at Centrastate Medical Center in Freehold. Glenn Krauss, director of enterprise solutions at ZiRMED will present “CDI- Achieving the Potential.” To register, click here. For additional information, email Deborah Gardner-Brown at deborah@rra-inc.com.
• The California ACDIS Chapter meets August 24, 9 a.m., via webinar, to discuss “Leveraging the physician value based payment modifier,” with Richard Pinson, MD, and Cynthia Tang. For information, contact Shiloh Williams at Shiloh.Williams@ecrmc.org.

September

• The South Carolina ACDIS Chapter meets Friday, September 16, at Providence Hospital in Columbia. For information, contact Mary Hopkins at Mary.Hopkins@hcahealthcare.com.
• The Maryland ACDIS Chapter meets Friday, September 16, 9 a.m. to 3 p.m., at the Maryland Hospital Association. Registration is nearing capacity. For additional information, email Olga Firstbrook at ofirstbrook@cua.md.     
• The Tennessee ACDIS Chapter joins THIMA, and the Tennessee Hospital Association for a CDI summit on Thursday, September 22, at the THA offices in Nashville. For information, contact Sherri Clark SClark@mc.utmck.edu.
• The Maine ACDIS Chapter meets Friday, September 23, at Eastern Maine Medical Center, noon to 4 p.m. For information, email Cathy.Seluke@mainegeneral.org.
• The ACDIS NW Oregon Chapter meets bi-annually. The next meeting will take place on September 30 in Medford. For information, contact Karen Gray at Karen.Gray@salemhealth.org.

Save the date: October

• Three Missouri ACDIS chapters join together for their first state-wide full-day event on Saturday, October 15, at Boone Hospital Center in Columbia. For information, contact Karen Elmore atkelmore@bjc.org.

The new ACDIS Career Center allows you to upload your resume anonymously, browse open positions and sign up for alerts about new jobs specific to your criteria. If you’re looking to hire, we have job posting options (discounted for ACDIS members) as well as the ability to browse our resume database. Click here to learn more.

Here are the latest job postings:

• Lead Clinical Documentation Specialist CDI: SCL Health—Colorado
• Clinical Documentation Improvement Specialist (CDIS): Parkland Health & Hospital System—Dallas, TX, United States
• Clinical Documentation Specialist: Steward Heathcare System LLC—Westwood, MA, United States
• Ambulatory Clinical Documentation Specialist: Gundersen Health System – La Crosse, WI
• Clinical Documentation Improvement Specialist: Philadelphia, PA—The Children's Hospital of Philadelphia

by Brian Murphy

Tomorrow (Friday, August 12), we’ll open up speaking applications for the 2017 ACDIS conference.  Our 2017 program, which takes place May 9-12, at the MGM Grand in Las Vegas, marks the 10^th annual ACDIS conference. We hope you can join us, and we’d love to have you share your ideas, insight, and expertise on the podium!

Speaking at ACDIS has many benefits, including:

• Personal and hospital recognition. You’ll be visibly sharing your ideas and have a great addition to your resume and portfolio of accomplishments
• Additional CEU opportunities. Earn credits towards your CCDS (two CEUs for each half-hour of presentation time)
• Free admission to the conference for you and your co-presenters

Our 2017 ACDIS Conference Committee compiled a “must-have” list of recommended sessions to help you shape your submission. But if you don’t see your idea listed, that’s just fine: We also welcome creative, out-of-the-box applications as well.

The ACDIS conference offers basic sessions for profession newcomers, as well as sessions for those at an intermediate and advanced levels. This year the committee particularly wants enough advanced sessions on the podium to satisfy those with 8-10 years (or more) experience in the CDI profession. While we are accepting sessions at any level, advanced sessions will be given additional consideration by the committee. How are we defining “advanced,” you ask? It’s as follows:

Advanced CDI sessions are those that include information that benefit established CDI programs and the experienced CDI professional. This content includes statistics and data obtained after implementation and evaluation of new and advanced processes, second level review, collaboration with ancillary departments, identification of query opportunities beyond CC/MCC capture, and advanced management processes. Advanced coding/clinical sessions should include complex case examples.

The speaker application period opens tomorrow (Friday, August 12) and closes Monday, September 12. Speaker selection will be made by the Conference Committee and applicants will be notified of their decision in late October/early November.

In short, attend the conference and please apply to speak—sharing ideas and celebrating success are what ACDIS community and networking are all about.

Note: To get a better idea of the energy and information sharing that goes on at this one of a kind CDI event, please take a look at our 2017 promotional video here, shot onsite at the 2016 conference.

by Richard D. Pinson, MD, FACP, CCS

The new MCC/CC lists in 2017 IPPS Final Rule released by CMS on August 2, include several new codes and many new combination codes with greater specificity. Most, however, have little effect on CDI specialists’ daily work. One item, however, hypertension, should raise some interest.

Hypertensive crisis is a non-specific term intended to encompass both hypertensive urgency with marked elevation of blood pressure requiring prompt intervention and the more serious, potentially life-threatening hypertensive emergency requiring immediate aggressive intervention.

ICD-9-CM codes used archaic terms “malignant” and “accelerated” hypertension which were assigned CC status. ICD-10-CM had no codes to identify these serious conditions which were classified as benign essential hypertension and were assigned to code I10 (non-CC).

Thankfully, new codes have been created for these conditions:

• I16.0 (hypertensive urgency) – a non-CC
• I16.1 (hypertensive emergency) – a CC
• I16.9 (hypertensive crisis) – a CC

These additions put hypertension back on the documentation specialist’s agenda. CDI specialists will need to clarify whether a diagnosis of hypertensive urgency (non-CC) actually meets criteria for the more serious circumstances of hypertensive emergency (CC).

Physicians may have to unlearn the terminology for “malignant” and “accelerated” that we’ve been teaching them all these years. Ironically, documentation specialists may now find themselves asking physicians to clarify whether accelerated or malignant hypertensive (non-CC) actually represents a hypertensive crisis or emergency (CC).

There are a few other interesting points for 2017 in regard to capturing MCC/CCs.

• Stenosis of Vascular Stent. There are two new codes, both CCs, for an initial encounter for stenosis of a coronary stent or of a peripheral vascular stent to distinguish them from stenosis of a cardiac or vascular prosthetic device, implant, or graft.
• Acute Pancreatitis. All six of the acute pancreatitis codes have been expanded to specifically identify whether there is no necrosis or infection, necrosis with infection, or necrosis without infection. All of these codes remain MCCs.
• There are no changes to the encephalopathy codes for 2017, and all of them retain their current CC/MCC status. No codes were added to account for hepatic encephalopathy when the patient does not have coma.

Editor’s Note: Dr. Pinson principal of Pinson & Tang LLC, and author of the CDI Pocket Guide wrote this article. Contact him at info@pinsonandtang.com.

As the healthcare industry shifts from traditional fee-for-service to a value-based and quality-driven model, CDI specialists should be aware of the principles that drive risk adjustment payments. “I describe it as traveling down parallel to that which we travel to establish the DRG,” says Laurie Prescott,MSN, RN, CCDS, CDIP, CRC, CDI Educational Director for ACDIS and BLR Healthcare in Middleton, Massachusetts, during the August 10 ACDIS Radio program.

Patients bring their own medical complexity, and CDI specialists must make sure that the documentation captures those complexities. Each patient has their own level of risk, Prescott says, which includes the severity of illness and expected cost to manage their care needs. 

For example, take an 85-year-old woman who lives at home, participates in aerobic dance and yoga twice a week, is a non-smoker, and her only comorbidity is osteoporosis. This patient will have a very different rating in risk adjustment than an 87-year-old who lives in a skilled nursing facility, is diabetic, has a history of stage 4 chronic kidney disease, and chronic obstructive pulmonary disease with a history of smoking. This higher risk adjustment score reflects the higher cost of care we are expected to expend due to the higher severity of illness.

Many quality measures included in CMS’ hospital value-based purchasing program are risk-adjusted, including 30-day mortality and 30-day readmissions, says Prescott. “We want to make sure that we’re capturing [documentation] for risk adjustment, which is very different methodology.”

The most common methodology used in risk-adjustment is the CMS Hierarchical Condition Categories (HCCs), says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, CRC, director of HIM/Coding for BLR Healthcare. HCCs share many similarities to the DRG system CDI specialists are used to working with. Both are prospective systems, meaning there are pre-determined payments for different diagnoses, and both use diagnostic information to drive either the overall assigned DRG or HCC. However, HCCs are cumulative in nature—all you need is one heavily-weighted diagnosis to boost the DRG for a singular inpatient admission, but, with HCCs, diagnoses are extrapolated for many encounters for that beneficiary for a time period (e.g. year) that contribute to the total patient risk score. Procedures don’t affect HCCs like they can for DRGs, says McCall. HCCs are solely diagnosis-driven, an ideal fit for CDI specialists who typically focus on diagnoses for documentation improvement. 

Chronic conditions for risk-adjustment have a much bigger role in HCCs than DRGs, where most chronic conditions have little impact on reimbursement, says McCall. Take heart failure, for example. In the MS-DRG system, the CDI specialist may find an opportunity to query for added specificity for systolic or diastolic, as well as acuity to optimize the DRG. However, for risk adjustment, the documentation of heart failure in the record yields a HCC even without the additional specificity.

The common misconception is that HCCs apply to the outpatient setting only. This is not the case, according to McCall. Documentation to support a condition assigned to an HCC can come from outpatient, inpatient, and professional service documentation. Payers look at documentation from every setting for the reporting period for each beneficiary to determine whether a diagnosis should have been reported and is supported in the documentation.

“CDI specialists have to get used to looking at the record as a whole,” says McCall.

While conditions count toward a patient’s HCCs regardless of treatment setting, documentation and coding specialists need to follow the coding rules applicable to the setting in which the patient was treated and services were provided. Depending on the setting (outpatient or inpatient), documentation requirements for certain diagnoses in the HCC methodology will differ.

“From a rules standpoint, coding guidelines differ depending on setting and services,” says McCall. “CDI specialists need to be familiar with what diagnoses were documented, what setting they were provided in, and then apply the coding and documentation rules for that setting.”

For facilities looking to expand into risk-adjustment, Prescott says first identify which diagnoses “will map” to HCCs. Go to the CMS.gov website to find comprehensive HCC information, including lists of codes and how each maps to which HCC and its value. While self-study may seem intimidating, it is a great first step, Prescott said.

“Traditionally, the main focus of CDI is principal diagnoses and sequencing correctly,” says Prescott. “In HCCs, sequencing isn’t something we worry about.  We want to capture all of the appropriate diagnoses, and review records for missing or vague diagnoses. This is what CDI has been doing all along.”

The next ACDIS Quarterly Membership Conference Call will take place on August 18, at 1 p.m., eastern. Registration information has been e-mailed to all members. After registering, you will receive a confirmation email containing the dial-in information about joining the webinar.

This call features a special roundtable discussion with the ACDIS advisory board leaders. Pre-submitted questions for the board are welcome and encouraged, as these will help guide our discussion. Email ACDIS Associate Editorial Director Melissa Varnavas at mvarnavas@acdis.org, with your thoughts, questions, comments, and concerns. While we cannot guarantee your question or discussion point will be addressed on the call, we will try to work in as many as possible.

ACDIS members have access to this and all Quarterly Conference Calls Archives on our website www.acdis.org.

When CDI professionals from the state of Washington first started meeting, the half dozen or so participants headed to a nearby restaurant (the now closed Zoopa Organics) to share their stories and a meal. That was in 2009.

In 2014, the group of 20 or so, gathered in Capital Medical Center in Olympia for a collection of educational events including ICD-10-CM/PCS information and sessions on the theme of “add some spice to your CDI career.” Meeting host Susan Browne even supplied small herbal garden starter kits as the table centerpieces and also made “CDI Survival Kit” gift bags which included everything from Hershey kisses (to remind attendees that everyone needs a hug, kiss, or word of encouragement every day) and Lifesavers (to remind participants to think of their peers as “life savers”).

Browne, with assistance from Skagit Valley, Multicare, and other facilities helped keep the group going through 2015. “There were multiple hospitals who kept the momentum going,” Browne says. “It was certainly a team effort.”

This past month, she happily announced that nearly 50 participants joined her in Olympia on July 6 (during a holiday week no less). During the meeting, Browne asked for new volunteers to help provide leadership to the chapter and half a dozen individuals stepped forward. The group includes Barbara Anderson, Lillian Dickey, Nora Tiffany, as well as volunteers Andrea Dyson, Mo Brogoitti, Martha Khayyat, Lorri Sides, and Satyananda Vuddagiri.

The new team met in July to talk over various leadership expectations and ideas for keeping the chapter members invested in the organization. They also met earlier this week to review their plans for the overall chapter and for its upcoming meeting Thursday, October 6, 10 a.m., at Swedish Medical Center in Seattle.

A lot of behind-the-scenes effort and dedication to the profession goes into organizing meetings. So ACDIS is grateful to these new tremendous volunteers. We’re looking forward to hearing about all the exciting educational and networking efforts emerging from the “Evergreen.”

August

• The Georgia ACDIS Chapter meets Friday, August 12, 8 a.m. to 3 p.m., at Tift Regional Medical Center in Tifton. For information, contact julieltbell@gmail.com.
• The Indiana and Kentucky ACDIS Chapters join for a regional event Friday, August 19, 8 a.m. to 4 p.m., at the Louisville (Kentucky) Marriott East. Click here to read the complete agenda.  Deadline for registration was August 5. Participants may visit the local chapter pages of the ACDIS website to download the materials. For information, contact Rita Fields at rita.fields@BHSI.COM.
• The Utah ACDIS Chapter meets Wednesday, August 17, at the University of Utah for a discussion with Russell Vinik, MD, Medical Director for CDI at the facility. For information, contact Molly Evans atMolly.Evans@hsc.utah.edu.
• The New Jersey networking group meets on Friday, August 19, 10 a.m. to 3 p.m., at Centrastate Medical Center in Freehold. Glenn Krauss, director of enterprise solutions at ZiRMED will present “CDI- Achieving the Potential.” To register, click here. For additional information, email Deborah Gardner-Brown at deborah@rra-inc.com.
• The California ACDIS Chapter meets August 24, 9 a.m., via webinar, to discuss “Leveraging the physician value based payment modifier,” with Richard Pinson, MD, and Cynthia Tang. For information, contact Shiloh Williams at Shiloh.Williams@ecrmc.org.

September

• The Connecticut ACDIS Chapter meets Thursday, September 8, 1:30-3 p.m., at the Hospital of Central Connecticut in New Britain. For information, contact Janet Richardson at Janet.richardson@baystatehealth.org.
• The South Carolina ACDIS Chapter meets Friday, September 16, at Providence Hospital in Columbia. For information, contact Mary Hopkins at Mary.Hopkins@hcahealthcare.com.
• The Maryland ACDIS Chapter meets Friday, September 16, 9 a.m. to 3 p.m., at the Maryland Hospital Association. Registration is nearing capacity. For additional information, email Olga Firstbrook at ofirstbrook@cua.md.     
• The Tennessee ACDIS Chapter joins THIMA, and the Tennessee Hospital Association for a CDI summit on Thursday, September 22, at the THA offices in Nashville. For information, contact Sherri Clark SClark@mc.utmck.edu.
• The Pediatric ACDIS networking group meets via webinar on Thursday, September 22, at 3 p.m., eastern. To join, email Valerie Bica at vbica@nemours.org.
• The Maine ACDIS Chapter meets Friday, September 23, at Eastern Maine Medical Center, noon to 4 p.m. For information, email Cathy.Seluke@mainegeneral.org.
• The ACDIS NW Oregon Chapter meets bi-annually. The next meeting will take place on September 30 in Medford. For information, contact Karen Gray at Karen.Gray@salemhealth.org.

Save the date: October

• Three Missouri ACDIS chapters join together for their first state-wide full-day event on Saturday, October 15, at Boone Hospital Center in Columbia. For information, contact Karen Elmore atkelmore@bjc.org.

ACDIS hit a number of milestones in the last year—5,000 members, 3,400 CCDS holders, nearly 2,000 conference attendees. While we’re excited to see our numbers grow, every now and then, we’re contacted by a member unaware of the resources available to them. We want you to be able to make the most of your ACDIS membership. Here’s how you can take full advantage of your member benefits.

Read the CDI Journal: The bi-monthly, electronic CDI Journal offers members timely, in-depth news and regulatory information, clinical tips and analysis, case studies, and membership profiles. Whether you’re looking for advice on building a successful CDI program or expanding into outpatient or pediatrics, the journal offers a wide range of information to keep you abreast of industry trends and advances.

By reading the CDI Journal, CCDS holders may also obtain one continuing education credit. To obtain the credit, you must complete and pass the online quiz. Click here to access. Your certificate will be automatically emailed to you upon successful completion of the quiz.

Join the ACDIS Forum: Formerly known as CDI Talk, the new ACDIS Forum allows members to connect with and ask questions of their CDI colleagues from across the country. From expansion to management to pediatrics, the distinct categories make it easy to pose questions and peruse discussions.

New to the Forum? Many of our CDI Talkers loved that they could set up notification emails with new conversations and responses on the old website. The new Forum offers this feature too—click here for instructions.

Participate in quarterly networking calls: Members have the unique opportunity to participate in quarterly membership conference calls, an hour-long discussion and open Q&A with the ACDIS Advisory Board. These calls cover all things CDI, including top trends and current concerns in the industry. Members are e-mailed dial-in information the week prior to the event. Questions can be submitted ahead of time by e-mailing Melissa Varnavas at mvarnavas@acdis.org. The next quarterly call, sponsored by Optum360, is scheduled for today, Thursday, August 18 at 1 p.m., eastern. All quarterly calls are recorded and available to members on the ACDIS site. Click here to access.

Access helpful resources:

The electronic ACDIS Resource Library houses a myriad of sample queries, policies, and other tools, available exclusively to members. In addition to forms and tools, the library also houses peer-reviewed position papers, white papers, and surveys.

Post to our career center:

The new ACDIS Career Center allows you to upload your resume anonymously, browse open positions, and sign up for alerts about new jobs specific to your criteria. If you’re looking to hire, we have job posting options as well as the ability to browse our resume database. ACDIS members receive two free job postings a year as well as discounted additional posts. Click here to learn more.

And more…:

In addition to the numerus tools, resources, and opportunities, ACDIS members also receive discounts to the annual ACDIS conference, CCDS certification, and CDI Boot Camps. Members are also able to participate in an Official ACDIS Local Chapter, under the leadership of the Chapter Advisory Board.

Not a member?

Even if you aren’t currently an ACDIS member, we offer free content via our weekly e-newsletter, CDI Strategies, and the daily ACDIS Blog. Stay up-to-date with current news, trends, and tips without spending a dime. Remember, non-members must register to access free content—click here to set up your username and password.

The long-anticipated ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2017 were released earlier this month, and include a definition for Exclude 1 notes, guidance for meaning and application of the word “with,” and clarification for laterality, according to an article by founding ACDIS Advisory Board member Gloryanne Bryant, RHIA, CDIP, CCS, CCDS in a recent ICD-10 Monitor article.

However, one other change raised some specific concerns for CDI specialists, says Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director for ACDIS and HCPro in Middleton, Massachusetts. The 2017 Guidelines contain new language regarding clinical validation:

“The assignment of the diagnosis code is based upon the provider’s diagnostic statement that the condition exists. The provider’s statement that a condition exists is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

While some are concerned that the new guideline will make clinical validation queries obsolete, the statement is aligned with recommendations provided in ACDIS Boot Camps and publications, Prescott says. “The confusion lies in the practice of clinical validation and understanding that this is different from the practice of code assignment.”

As the new direction states, code assignment is not based on clinical criteria, but rather on the provider’s statement that a diagnosis is present, says Prescott. When Recovery Auditors (RAs) started clinical validation reviews, many organizations changed their practices to avoid denials, choosing not to code specific diagnoses, even when they are stated by the provider.

“This practice concerned me, because coders and CDI specialists are not caring for the patient—we are merely reviewing the record,” Prescott says. “Just as we can only add a diagnosis to a claim if documented by the provider, we should never remove one from a claim because we disagree with the provider.”

If the diagnosis is not clinically validated, both RAs and commercial insurance auditors are going to deny the claim, according to Allen Frady, RN-BSN, CCDS, CCS, a senior consultant for Optum360, in a recent ICD-10 Monitor article. On the other hand, if the coder or the facility decides not to report the diagnosis, then they are in violation of the coding guidelines, which is also a major problem.

The new Guidelines come shortly after the release of a new clinical validation query practice brief in the July 2016 Journal of the American Health Information Management Association, available to AHIMA members on their website. The brief emphasizes the coder’s responsibility to become more clinically astute, and refer cases to a nurse or physician advisor as necessary, stating “[i]t appears clinical validation may be most appropriate under the purview of the CDI professional with a clinical background.” 

James Kennedy, MD, CCS, CDIP, director of CDIMD Physician Champions in Tennessee, says a properly trained and certified coder who is well-versed in clinical terminology and definitions should be able to have the conversation with the provider and not have to delegate this to another individual that may not be as experienced. “That said, if the coder is insecure with the situation, they should have a lifeline for clinical support as to ensure the validity of the documented diagnosis or treatment,” Kennedy says, in a recent JustCoding.com article.

Additionally, CDI specialists should be involved in clinical validation auditing, per AHIMA’s recommendation to audit a small sample of coded records each year to ensure coding professionals receive some clinical validation education, says Kennedy. 

CDI specialists should work with physicians to ensure the diagnoses documented are clinically supported within the record, and query if the documentation does not support a diagnosis, Prescott says. When a diagnosis does not appear to be valid, or is vulnerable to denial, and the physician strongly believes it is relevant, they should be instructed to clearly outline the reason to include this diagnosis within their documentation. Our job as CDI specialists is not merely to capture every diagnosis, but to assure the documentation within the record supports their presence.

“The new Official Guidelines for Coding and Reporting simply confirm that we must assign the appropriate codes as documented by the physician,” Prescott says.

$14.2 million. That’s what Medicare paid New York-Presbyterian Hospital in overpayments for 123 claims because the hospital did not have “adequate controls to prevent the incorrect billing of Medicare claims,” according to the Office of the Inspector General (OIG).

For 46 of the selected inpatient claims, the hospital incorrectly billed Medicare Part A for beneficiary stays that it should have billed as outpatient or outpatient with observation services. Medicare payments may not be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury,” says the OIG. Documentation must reflect why inpatient care is medically necessary, and include conditions and procedures deemed appropriate for the level of care.

Additionally, for four of the selected outpatient claims, the hospital incorrectly billed Medicare for HCPCS procedure codes that were medically unnecessary. The medical record must contain why procedures and tests are necessary for the condition(s) patients present with.

The OIG recommended the facility strengthen their efforts to ensure compliance with Medicare documentation and billing requirements. 

For 27.3% of patients with depression and 27.7% of patients with bipolar disorder, providers did not integrate their diagnosis into their primary care electronic health record (EHR), according to a study published in the April 2016 Journal of the American Medical Informatics Association.

The study looked at insurance plan members ages 12 and over, assigned throughout 2009 to a large multispecialty medical practice in Massachusetts, with diagnoses of depression or bipolar disorder. The number of diagnoses was compared to data extracted from the primary care site’s EHR data. The EHR missed 89% of acute psychiatric services, the study says.

EHR implementation was intended to improve patient safety, research, and reimbursement. However, the majority of US health systems and electronic records are fragmented and do not share patient information. The study confirmed that EHRs inadequately captured mental health diagnoses, visits, specialty care, hospitalizations, and medications. Missing clinical information can result in medical errors and can affect research. CDI specialists can work with their IT department to ensure all aspects of a patient’s medical history and care—including mental health status—are incorporated into record templates.

Click here to download the full report. 

All those working in volunteer leadership capacity for current ACDIS local chapters are invited to join the Chapter Advisory Board (CAB) via webinar on August 25, at 1 p.m., eastern. The CAB, comprised of past and present leaders, will discuss its work on the leadership toolkit, answer questions from fellow leaders on important networking topics, and review highlights of local chapter networking activities from around the country. If you are a chapter leader, you should have received dial-in instructions via email. If you have not received the dial-in information, please email ACDIS Associate Editorial Director Melissa Varnavas at mvarnavas@acdis.org.

The following upcoming meetings will be taking place in the next few months:

August

• The New Jersey networking group meets on Friday, August 19, 10 a.m. to 3 p.m., at Centrastate Medical Center in Freehold. Glenn Krauss, director of enterprise solutions at ZiRMED will present “CDI- Achieving the Potential.” To register, click here. For additional information, email Deborah Gardner-Brown at deborah@rra-inc.com.
• The Minnesota ACDIS Chapter meets Wednesday, August 24, 1-2 p.m. (central). The presentation by Vicki Olson will discuss CMS pay-for-performance quality programs. For information, contact Fay Bakke at faye.bakke@essentiahealth.org.
• The California ACDIS Chapter meets Wednesday, August 24, 9 a.m., via webinar, to discuss “Leveraging the physician value based payment modifier,” with Richard Pinson, MD, and Cynthia Tang. For information, contact Shiloh Williams at Shiloh.Williams@ecrmc.org.
• The Puerto Rico ACDIS Chapter meets Thursday, August 25, to discuss developing a CDI program in the revenue cycle. For information, contact Carmen Y. Ibarrondo Malave at cibarrondo@picconsultantspr.com.
• Greater St. Louis (Missouri) ACDIS Chapter meeting will be held Wednesday, August 31, 6:30-8 p.m., at Barnes Jewish Saint Peters Hospital, featuring presentations regarding Type 2 MIs and new Coding Clinic for ICD-10-CM/PCS related to cardiology. For information, contact Michael McKelvey, mpm2239@bjc.org.

September

• The Connecticut ACDIS Chapter meets Thursday, September 8, 1:30-3 p.m., at the Hospital of Central Connecticut in New Britain. For information, contact Janet Richardson at Janet.richardson@baystatehealth.org.
• The South Carolina ACDIS Chapter meets Friday, September 16, at Providence Hospital in Columbia. For information, contact Mary Hopkins at Mary.Hopkins@hcahealthcare.com.
• The Maryland ACDIS Chapter meets Friday, September 16, 9 a.m. to 3 p.m., at the Maryland Hospital Association. Registration is nearing capacity. For additional information, email Olga Firstbrook at ofirstbrook@cua.md.     
• The Central Pennsylvania ACDIS Chapter meets Wednesday, September 21. For details, email Deanne Wilk at dwilk@hmc.psu.edu.
• The Tennessee ACDIS Chapter joins THIMA, and the Tennessee Hospital Association for a CDI summit on Thursday, September 22, at the THA offices in Nashville. For information, contact Sherri Clark SClark@mc.utmck.edu.
• The Pediatric ACDIS networking group meets via webinar on Thursday, September 22, at 3 p.m., eastern. To join, email Valerie Bica at vbica@nemours.org.
• The Maine ACDIS Chapter meets Friday, September 23, at Eastern Maine Medical Center, noon to 4 p.m. For information, email Cathy.Seluke@mainegeneral.org.
• The ACDIS NW Oregon Chapter meets bi-annually. The next meeting will take place on September 30 in Medford. For information, contact Karen Gray at Karen.Gray@salemhealth.org.

Save the date: October

• Three Missouri ACDIS chapters join together for their first state-wide full-day event on Saturday, October 15, at Boone Hospital Center in Columbia. For information, contact Karen Elmore atkelmore@bjc.org.

The new ACDIS Career Center allows you to upload your resume anonymously, browse open positions, and sign up for alerts about new jobs specific to your criteria. If you’re looking to hire, we have job posting options (discounted for ACDIS members) as well as the ability to browse our resume database. Click here to learn more.

Here are the latest job postings:

HIMS Manager, Coding Services

Shore Medical Center, Somers Point, NJ

CDI Specialist

Beth Israel Deaconess Medical Center, Boston, MA

RN Clinical Documentation Specialist

Providence Regional Medical Center Everett, Everett, WA

Clinical Documentation Specialist

Indian River Medical Center, Indian River Medical Center, FL

Want to present at the 10^th Annual ACDIS Conference, to be held May 9-12, 2017 at the MGM Grand in Las Vegas, NV? Applications are due Monday, September 12, and can be accessed by clicking here.

We seek speakers on all aspects of clinical documentation improvement (CDI). Advanced CDI sessions geared for mature programs are particularly welcome and will receive additional consideration. CDI, HIM, and coding professionals typically present at ACDIS, but we also welcome practicing physicians, case management, and quality personnel, healthcare auditors, lawyers, and other professionals with a tie to, or an interest in, CDI. Accepted speakers and co-presenters will have their admission fee waived.

We are seeking potential speakers and panel presentations for the 2017 ACDIS conference for the following tracks and sessions:

Track 1: Clinical and coding
Proposed breakout sessions:

• Physician/clinical  sessions on pathophysiology and diagnostic criteria (clinicians welcomed)
• Coding Clinic and Official Guidelinesfor Coding and Reportingupdates
• Surgical procedures (CDI/coder with surgeon co-presenters welcomed), emphasis on ICD-10-PCS and root operations, complications vs. conditions inherent to the procedure
• Coding and clinical criteria of complex and/or lesser reported diagnoses (i.e., functional quadriplegia, ATN vs. AKI, hypertensive heart disease, sepsis, types of respiratory failure, encephalopathy, traumas, malnutrition, HCAP/CAP, etc.)
• Advanced chart review techniques, including interpreting subtle clinical indicators, lab values, etc.
• Dealing with unsupported diagnoses in the medical record
• Presentation of specific documentation requirements to support code assignment by diagnosis
• Presentation of complex coding (ICD-10) case studies
• Impact of ICD-10 post-implementation
• Sepsis: Management of definitions

Track 2: Management and leadership
Proposed breakout sessions:

• Metrics: Selecting metrics to measure individual CDI staff and CDI departments, analysis and interpretation of data
• Proving/presenting CDI return on investment data
• Auditing CDI staff: How to audit, how often, and follow-up/training using audit findings
• Managing CDI staff: Setting productivity expectations, rewarding high performers, managing underperforming CDI specialists
• Training and orienting CDI staff, establishing career ladders, motivating senior CDI staff, providing continuing education
• Remote CDI: Management and operational issues
• Productivity: Setting standards, monitoring performance
• Electronic health records (EHR) management: Battling note bloat and copy/paste, managing problem lists, improving EHR CDI/physician documentation functionality through working with vendors, pros/cons of computer assisted coding and natural language processing, etc.
• Engaging physicians in CDI: Initial buy-in and education, ongoing training, tips for working confidently and effectively with providers
• Managing CDI in a regional/multi-hospital system
• Principles of effective leadership and department management

Track 3: Quality and regulatory
Proposed breakout sessions:

• IPPS and CMS regulations—critical updates and what they mean for CDI professionals
• APR-DRGs/severity of illness and risk of mortality, including diagnoses that affect SOI/ROM but not reimbursement
• Reviewing for Patient Safety Indicators (PSI), PSI 90 nuances and updates
• Reviewing for Hospital Acquired Conditions, Hospital Acquired Infections, Present on Admission indicators
• Partnering with quality
• Hospital Value Based Purchasing and the role of CDI professionals
• Hospital Readmission Reduction Program
• Utilization review and CDI (2-midnight rule, medical necessity reviews, etc.)
• Bundled payment initiatives and how CDI can make an impact
• MACRA and physician payment reforms—overview and leveraging to improve physician buy-in
• Mortality/retrospective reviews, CDI involvement in mortality conferences
• Compliance initiatives and ethics in CDI
• Accountable Care Organizations and the role of CDI

Track 4: CDI Expansion
Proposed breakout sessions:

• Outpatient CDI: All aspects including case studies of successful programs, starting/implementing/staffing an outpatient CDI program, defining payment models and metrics for success, sample outpatient queries and review strategies
• Medicare Advantage/HCCs and medical record review strategies
• Next steps/growth areas for advanced CDI departments
• Incorporating core measures (i.e., CMS quality measures) into CDI review
• Physician advisor specific sessions
• Recovery Auditor and up-front denials prevention
• CDI assisting with back-end denials management/appeals
• Query escalation policies and real-world examples
• Clinical validation: Examples and process, auditor denials, as well as appeals and prevention

Track 5: Innovative CDI
Proposed breakout sessions:

• Pediatric CDI, including advanced sessions on SOI/ROM impact, outpatient pediatric CDI, pathophysiology sessions unique to pediatric patients including heart failure, acute respiratory failure, sepsis definition, etc., ongoing measurement of pediatric CDI programs, pediatric research and quality improvement projects
• CDI in maternity, pregnancy, post-partum, NICU, OB/GYN
• Challenges of available NICU codes
• Educating residents and med students in documentation
• CDI in post-acute settings, including Long Term Acute Care (LTAC) and inpatient rehab
• Inpatient psychiatry
• CDI in critical access hospitals
• CDI in the physician office setting
• Development of specialized CDI roles
• CDI and concurrent coding
• Healthgrades, Leapfrog, Hospital Compare, etc.—a review of publically available rankings/scorecards and how CDI can use them to promote physician buy-in
• Next level of CDI metrics beyond CMI and CC/MCC capture
• Presentation of CDI research projects or findings

If you don't see your hot topic listed here, please write and let us know what expertise you can bring to the podium. Original ideas are welcome. Although we are looking for advanced level sessions, the ACDIS conference includes basic, intermediate, and advanced sessions to accommodate attendees at all levels. Please find your topic and level of choice and apply!

Click here to view and complete the speaker application. All final decisions will be made by the 2017 ACDIS conference committee and applicants will be notified of their decision in late October/early November.

by Laurie Prescott, RN- MSN, CCDS, CDIP

I recently celebrated my third anniversary working for ACDIS and HCPro. We are currently training a new instructor, and that has made me a bit reminiscent of my last few years and my career in CDI. I honestly think this is the best job in the world—I get to meet such interesting people and have found, on the whole, those who enter the profession are forward thinkers, smart, innovative, and up for a challenge. These qualities are necessary in this field because our world is forever changing.

When I started with HCPro, the focus of CDI was ICD-10 CM/PCS implementation. We were learning the new code set and trying to understand the procedural coding system. I remember cautioning Boot Camp attendees that the big changes would not necessarily occur with the transition to the new code set, but in the following years as CMS began to adjust the values of specific codes and mappings. We knew there would likely be changes to the Official Guidelines of Coding and Reporting, AHA’s Coding Clinic advice and DRG assignments. The effect of these changes are now being seen, and my bet is next year will provide even more challenges.

Many of the changes are significant, including the meaning of the word “with” within the tabular list and no longer needing linkage documentation by the provider—we can now differentiate the type of heart failure from the provider’s shorthand related to the ejection fraction. We have been introduced to new clinical definitions, such as Sepsis 3 and the National Pressure Ulcer Advisory Panel differentiation of pressure injury. Likely the biggest changes are related to how we are now reimbursed under Hospital Value Based Purchasing, bundled payments, and risk adjustment, to name a few.

It is easy to get overwhelmed by change. It is easy to put your head in the sand and not learn how these changes affect you and your organization. And yet, as I said, we, as CDI professionals, demonstrate the ability to take on change, move forward, and lead others. That is what we do best. We would not be doing our jobs, nor doing our providers and patients any favors, by ignoring change.

I have a sign by my desk that has been leading me for more than 15 years. It is a quote by Eric Hoffer that states, “In times of change learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists.”

Take charge and inherit the earth. Stay informed, educate others, and be a leader. That is the essence of CDI!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1. 

CMS doled out $1.5 billion to more than a third of U.S. hospitals as part of a longstanding Medicare billing dispute, according to data released by the agency. The top payouts include New York-Presbyterian Hospital ($16 million), North Shore University Hospital in Manhasset, New York ($14.5 million), and CHI Memorial Hospital in Chattanooga, Tennessee ($10.9 million).

In total, 2,022 hospitals shared in the government payout, which settled 346,000 claims for reimbursement for treating Medicare patients admitted on or before Oct. 1, 2013. The largest payments resolved thousands of claims at once—Memorial Hospital’s settlement covered nearly 3,000 claims, according to CMS.

The settlements were a compromise to reduce the backlog of Medicare appeals. In 2014, CMS offered to pay hospitals 68% of the value of inpatient claims that had been held up in Medicare’s hearings and appeals process, some of which were awaiting a decision by an administrative law judge for more than eight years, according to the Office of Medicare Hearings and Appeals.

Medicare pays private contractors known as recovery audit contractors (RACs) to review hospital claims for improper payments. If a hospital disagrees with RACs’ decisions, they can appeal. Most RAC reviews focus on medical necessity of inpatient status, questioning whether it was necessary to admit certain patients to hospitals if cheaper outpatient treatment would suffice, an issue CDI professionals are all too familiar with.

While many hospitals opted to settle quickly for a discounted amount, some declined and chose to continue their appeal. 18% of appealed claims were overturned in favor of hospitals between October 1, 2013 and September 30, 2014, says CMS.

Hospitals on average misidentify between 7% and 10% of incoming patients when registration staff search the electronic health record (EHR) database for patient records, according to Becker's Hospital CFO.

These errors pose a serious problem for patient safety during medical treatment, but it also has a quantifiable effect on hospital cash flow and can lead to reimbursement loss, administrative inefficiencies, resource drains, and liability concerns, says Becker's Hospital CFO.

Duplicate medical records occur when registration staff create multiple accounts for the same patient. This can happen when a patient changes their surname, address or insurance carrier, or uses a nickname at check-in. Between 8% and 12% of hospitals' medical records are duplicates, according to biometric identification provider RightPatient. 

The cost of repeated medical care due to duplicate records can average nearly $1,100 per patient and, since insurers typically reject duplicate medical procedures, hospitals have to cover these costs. Becker's Hospital CFO says rejected claims costs roughly $25 to rework. Once a duplicate medical record is discovered, merging and reconciling the records can incur another additional expense.

A study from Children’s Medical Center of Dallas found that it takes $1,000 to fix an inadvertently duplicated medical record. While some studies suggest EHRs lower costs and improve reimbursement, Becker's Hospital CFO says other studies—including one by the American Action Forum, a nonprofit think tank—make no direct connection between the use of an EHR and improved productivity.

Read the rest of the study on Becker's Hospital CFO’s website.