by Melissa Varnavas

Healthcare has often been referred to a both a science and an art. Nevertheless, the healthcare industry continues its hunt for proof of quality healthcare services to, as much as possible, remove the art portion of the art-versus-science debate. That’s why the March/April edition of the CDI Journal pulls from a range of experiences and expertise to examine the many ways CDI efforts touch quality measures.

As Congress continues working to dismantle the Affordable Care Act (ACA), a wide range of vested entities contemplate the future of government payment methods. Hospital value-based purchasing (VBP), part of the ACA, offers a number of incentives—both positive and negative—to more closely tie patient outcomes to reimbursement on a host of measures. VBP represents the most comprehensive government pay-for-performance program, but it’s easy to feel overwhelmed by its various components when also considering the myriad collections of quality-focused programs hospitals and physicians need to navigate.

Quality-tied payments and public reporting measures can seem like the multi-headed Hydra of Greek lore—no sooner has a CDI program focused on, and defeated, one serpent than two other initiatives pop into existence. CDI programs understand the need to expand record review efforts, now that CC/MCC capture isn’t their only documentation goal.

Cheryl Ericson, MS, RN, CCDS, CDIP, does a nice job of summarizing the shift in her “Note from the Advisory Board” on p. 6, and on p. 10, ACDIS Editor Linnea Archibald looks at the various components of CMS’ VBP efforts, including a review of hospital-acquired conditions and present on admissions indicators. These articles help illustrate the complexity of quality concerns.

These aren’t the only measures considered in this issue, either. Advisory Board member Sam Antonios, MD, FACP, SFHM, CCDS, offers three tips for programs to help improve outcomes in regard to readmission reductions on p. 8, and ACDIS member Bonnet Tyndall, RN, CCDS, provides readers with a case study of how her team implemented record reviews for mortalities on p. 19.

All these potential review targets can be daunting, but don’t be intimidated. Take a look through this edition of CDI Journal and note how many of these programs aim to capture some of the diagnoses already found on most CDI programs’ top 10 lists.

As ACDIS CDI Boot Camp instructor Allen Frady, RN, CCDS, CCS, says on p. 22, “times like these are exciting for us CDI nerds.”

Editor’s Note: Varnavas is the Associate Editorial Director for ACDIS, overseeing its various publications and website content. Contact her at mvarnavas@acdis.org.

CMS recently made the July 2017 Hospital Compare preview reports available on QualityNet for participating Inpatient Quality Reporting (IQR), Outpatient Quality Reporting (OQR), and PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) hospitals and facilities.

The reports will be accessible from April 6 through May 5 by logging into QualityNet.

Reports include discharge-level data, hospital-specific results, and state and national results for the IQR claims-based measures.

Due to problems with the patient safety indicator (PSI) software, the IQR PSI results are not included on the preview reports. CMS anticipates the fiscal year (FY) 2018 PSI results will be available by October 2017, at which point they will be added to the preview report.

The Hospital Compare Overall Hospital Quality Star Rating will be updated in July 2017 using the FY 2017 PSI results and hospital-specific reports.

HIM Briefings, a sister publication of ACDIS, published the findings from their 2017 EHR Benchmarking Survey this week. Overall, the survey found an increased use of EHR systems over the previous survey conducted in 2015. In fact, no respondents reported using only paper health record systems and 47% reported using a hybrid system, down from 58% in 2015.

Not including scanned documents in the medical record, 32% of the survey respondents said they create 81-99% of the medical record electronically and only 21% said they create 61-80% electronically. These numbers also show a swing in the EHR direction over the 2015 survey.

In some cases, facilities still need to print out a document, complete it, and scan it back into the record. In these cases, the survey found that only 41% of respondents use an electronic document management system (EDMS) to capture 100% of the medical record, including any scanned documents.

There were 44% of survey respondents who reported being “somewhat satisfied” with their EHR’s ability to enhance patient care. This number remains consistent with previous survey finding. Additionally, 42% of respondents said the physicians at their facility fully use the EHR, including for dictation. This was the first year the survey explored such a question.

Perhaps one reason more than half of physicians resist using the EHR fully, according to EHRIntelligence, could be the time needed to use the system. According to another study conducted by Health Affairs this month, physicians spend more time in the EHR than they do on face-to-face patient care.

In terms of correct reimbursement for the physicians, the researchers conducting the Health Affairs survey believe the value-based payment systems move in the correct direction. Any new federal incentives will need to address the demands of new EHR technology on physicians’ time, according to EHRIntelligence.

A recent study from the University of Michigan concluded that the Leapfrog Group’s Safe Practice Score (SPS) produces different result than those used by CMS’ Hospital Compare to track common complications and readmissions, HeathLeaders Media reported.

The study found that Leapfrog’s findings “skew toward positive self-reporting,” according to the study published in the journal Medical Care. Part of the issue, the researchers suggest, comes from facilities self-reporting data more likely to earn higher scores.

The Leapfrog Group responded to the findings saying that they go to extreme lengths to prevent facilities playing the system. Additionally, Leapfrog conceded that there are different ways to measure quality and that they did not expect the findings to “correlate 100%” with other methods, according to HealthLeaders Media.

According to a survey conducted by Public Agenda, one in five patients comparison-shop for their healthcare, FierceHealthcare reported. With these numbers, the need for complete and accurate publicly reported data becomes more pressing.

As it stands right now, however, the accessible data can be inconsistent and carry the risk of incorrectness.

While the main conference doesn’t start until May 9, there are three pre-conference events taking place in Las Vegas, May 8-9. Each pre-con session offers attendees a way to extend their ACDIS experience a couple more days, gain valuable CDI knowledge, and interact with the best instructors around. Even better, there’s really an option for everyone.

Join Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, the authors of the best-selling CDI Pocket Guide, for the “Building a Best Practice CDI Team” pre-con. This session focuses on communication and collaboration between CDI specialists, coders, physicians, physician advisors, and other professionals, to create a holistic and successful CDI team.

Pinson offers a valuable perspective on physician engagement throughout the session, spotlighting on evidence-based education.

The “Risk Adjustment Documentation and Coding” pre-con, taught by beloved Boot Camp instructors Shannon McCall, RHIA, CPC, CCS, CCS-P, CPC-I, CCDS, CEMC, CRC, and Laurie Prescott, MSN, RN, CCDS, CDIP, CRC, reviews both inpatient and outpatient coding guidelines and documentation requirements for CMS’ Hierarchical Condition Categories (HCCs).

“What could possibly be more fun than a coding and CDI class all wrapped up in one information-filled risk adjusted package? We are looking forward to working together and learning from each other,” McCall and Prescott say.

Finally, the popular “Physician Advisor’s Role in CDI” pre-con is back this year. Day one will be taught by James Kennedy, MD, CCS, CCDS, CDIP, president of CDIMD-Physician Champions near Nashville. Kennedy is known for his CDI quips, saying last year, “If the physicians says it quacks, waddles, and flies south for the winter, the coder cannot say it’s a duck. It might be a goose.”

Day two of this pre-con includes two tracks. The first led by Trey La Charité, MD, medical director for clinical integration and physician advisor for clinical integrity at the University of Tennessee Medical Center in Knoxville, shows how physician advisors can support their CDI teams in engaging with providers, providing meaningful educational outreach, and working across departments to prevent denials. The second track features a case study highlighting the physician advisor program University Hospitals Health System with Erica Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., and Kelly Skorepa, BSN, RN, CCDS, corporate manager of CDI at University.

In 2016, salaries of those in the $70,000–$79,999 range rose by just 2%, as did those earning $80,000–$89,999 (which grew from 15% to 17%). Those earning less than $69,999 remained the same at about 26%, and the number of those earning $59,999 or less increased by a little over 2%. But as professionals gain experience in the CDI role, earn related credentials such as the Certified Clinical Documentation Specialist (CCDS), and obtain degrees in focused, higher-level education such as masters and doctorate degrees salary ranges tend to rise, according to the 2016 CDI Salary Survey.

“Being at the top of your career and obtaining relevant credentials definitely helps make professionals more marketable and can help put an individual at the top of the list as someone capable of adapting to specialized roles within the department,” says Wendy Frushon Tsaninos, RN, CCDS, CCS, CMSRN, MSTD, an independent CDI specialist in Phoenix, Arizona, in the report.

CDI program managers can help both their staff and their programs grow by identifying program targets and nurturing career paths for mature team members that play to the needs and strengths of the team.

In 2016, more CDI specialists indicated they have options for diversified roles, including:

• CDI preceptor/mentor (29%, up from 27% in 2015)
• CDI education lead (28%, up from 26%)
• Quality reviewer (27%, up from 22%)
• Denials manager/reviewer (9%, up from 6%)

The 5% increase in those who have an opportunity to conduct quality reviews illustrates an area of significant potential growth for CDI professionals and programs, as does the 3% increase in denials documentation review opportunities.

In its November 2016 white paper, “Keep your staff growing and engaged with a CDI career ladder,” the ACDIS Advisory Board says “strategic initiatives demand additional skill sets for CDI specialists, as well as strong CDI leadership and management. Mortality reviews, auditing, EHR nomenclature standards, policy and procedure development, appeals/denials, coding expertise, education, and informatics are but a few of the initiatives and roles that are enhanced by the knowledge and critical thinking CDI specialists bring to the table.”

In the white paper, the board pulls information from previous salary survey results to demonstrate the growing need for career stratification within the CDI profession and offers several examples for roles and responsibilities.

And if true career ladders aren’t possible for your program, the white paper encourages incentive or recognition programs which require and reward staff for efforts above and beyond typical record review duties. Such efforts might include creating a study group for teammates looking to earn a CDI credential, creating a poster presentation for the ACDIS national conference, or volunteering to speak at a local educational event.

No matter what career or professional advancement goals an individual holds, self-education, communication, and networking often offer the best tools for growth, Tsaninos says in the 2016 Salary Survey.

“It’s a word to the wise,” she says. “Your salary can increase by being a more active participant in the CDI community at large. More opportunities are bound to come one’s way by making oneself visible and showing passion for the profession.”

There’s no doubt that focus in healthcare reimbursement shifted in the past decade—from payment for services rendered to payment methods which take the quality of those services into consideration.

About 41% of CDI programs currently review medical records for quality improvement items, according to an online ACDIS membership poll.

But buzzwords related to “healthcare quality” represent a wide-range of initiatives from an equally wide-range of agencies—from government and private insurers to private companies crunching data for public reporting.

Looking to expand program efforts into quality therefore, can prove daunting. It’s often helpful to hear from those who’ve delved into the process and have proved not only that it can work, but who can demonstrate how to adapt those focus areas to your own CDI programs.

That’s why ACDIS Advisory Board member Deanne Wilk, BSN, RN, CCDS, CCS, CDI manager at Penn State Hershey Medical Center brings along her team Marcy Miles, MT, (ASCP), MBA, manager of quality and process excellence, Melissa Macguire, RN, CDI educator, and Carol Houlihan, MHA, RHIA, quality informatics manager for a special ACDIS Live! webinar on Thursday, April 27.

In the program, Wilk will show how she and her CDI team moved from traditional CC/MCC capture to clinical support for severity of illness, to mortality reviews, to patient safety indicators, to readmission reduction and length of stay measures, to hospital acquired conditions and present on admission conditions, all the way to value-based purchasing items, core measures, and even bundled payments.

Before joining Wilk and her team on the extended webinar, do a little background research by reading through the March/April edition of the CDI Journal which includes a number of articles from a variety of industry experts on ways CDI record reviews for quality-focused initiatives can yield a host of positive results.

Even with the addition of quality measures, CDI should still concentrate on documenting an accurate picture of the patient’s episode of care. As Tamara Hicks, RN, BSN, MHA, CCS, CDS, ACM, director of clinical documentation excellence at Wake Forest Baptist Health in Winston-Salem, North Carolina, says in the article “Foray into CDI for value-based purchasing,” “It’s not all about the money; it’s about getting it right.”

The Local Chapter Advisory Board (CAB) welcomed its newest voluntary member, Michael McKelvey, RN, MBA, CCDS, Clinical Documentation Quality Coordinator at BJC Healthcare in St. Louis, Missouri, during its roundtable teleconference last Friday. The CAB includes past and present local chapter leaders who help guide and inform the ACDIS administration about networking, education, and event strategies on the local level. The rest of the committee includes:

• Judi Bates from eastern Pennsylvania
• Katherina Burleson from North Carolina
• Sherri Clark from Tennessee
• Emily Emmons from California
• Bonnie Epps past Georgia leader
• Rita Fields past Kentucky leader
• Susan Haley from Michigan
• Aimee Van Balen from Massachusetts
• Julie Bell from Georgia

During Friday’s meeting, CAB discussion focused on the ways local chapters’ seem to have expanded event offerings with many now planning full-day, multi-speaker events, inviting vendor participation and even joining with regional component organizations of AHA and AHIMA.

The group also discussed plans for leadership networking during the national conference. Events include:

• Day 1: Leadership panel discussion: This event takes place at the end of regular conference sessions and features insight from the CAB as well as from fellow local chapter leaders across the country. It’s an opportunity for local leaders to meet face-to-face and identify best practices for success event organization. (Contact Melissa Varnavas for more information.)
• Day 2: Local chapter theme day: Attendees are encouraged to dress in sports gear related to their state or in clothing best representing their region. (One year, an attendee from Maine wore a lobster claw headband.) This makes it easier to pick out those from your home state amongst the crowd.
• Day 2: Local chapter lunch: Local chapter leaders are encouraged to pick a few tables in the lunch area to decorate with a theme of their choosing to help foster networking within your geographic region. (Last year, Florida leaders brought an inflatable palm tree!)

Please feel free to reach out to any of the members of the CAB or to Associate Editorial Director Melissa Varnavas at mvarnavas@acdis.org, or ACDIS editor Linnea Archibald at larchibald@acdis.org for more information.

April

• The Westchester New York CDI networking group meets Thursday, April 20, 2:30-4:30 p.m. For information email kseekircher@nwhc.net.
• The central New York CDI networking group meets Friday, April 21, 2-4 p.m., at the Pomeroy School of Nursing in Syracuse, featuring a presentation by Bobbie Massena, RN, assistant director of UM/CDI. RSVP by April 17, by email to Dawn Burr at dawnburr@crouse.org.
• The Washington Evergreen ACDIS Chapter meets Friday, April 21, 10 a.m. to 2 p.m. For information, contact Lillian.Dickey@providence.org. To see the meeting flyer, click here.
• The St. Louis Missouri ACDIS Chapter meets April 26, 6:30-8 p.m., at St. Luke’s. Outside food/drink is against hospital policy, so no potluck this time. For information, contact Michael McKelvey, michael.mckelvey@bjc.org.
• The New Jersey ACDIS Chapter meets April 27. For information, contact Gina Stewart at gstewart@e4-services.com.

May:

• The Arizona ACDIS Chapter plans on holding a get-together at the national ACDIS conference in Las Vegas, in the MGM Grand lobby. More details will be emailed to chapter members by the end of April.
• The California ACDIS Chapter set a tentative date of May 24 for their education conference call. For more information, visit their local chapter page and read Vol. 3 of their newsletter.

Save-the-date

• The Arizona ACDIS Chapter is planning its next big event tentatively for June 2017. Chapter members should send all suggestions to Chapter President Alma Yap at rnalmay@gmail.com.
• The California ACDIS Chapter holds its third-annual conference Friday, September 15, 8 a.m. to 4 p.m., at Torrance Memorial Medical Center. For information, contact Rani V. Stoddard at stoddardrv@henrymayo.com.
• Missouri’s three ACDIS local chapters join for a full-day conference event on October 14, at the University of Kansas Hospital. For information, contact michael.mckelvey@bjc.org.

CMS released the fiscal year (FY) 2018 IPPS proposed rule on Friday, April 14. The rule includes updates to quality initiatives and changes to the 2018 ICD-10-CM/PCS codes.

In addition, the proposal seeks to modify the electronic health record (EHR) reporting periods from the full year to a minimum of any continuous 90-day period during the 2017 calendar year for new and returning participants attesting to CMS or their state Medicaid agency, Revenue Cycle Advisor reported.

CMS also requested comments and proposals related to existing hospital-acquired conditions (HAC) reduction program policies such as:

• Greater specification of the dates used to calculate hospital performance for the FY 2020 HAC reduction program
• Additional measures for potential future adoption
• Accounting for social risk factors
• Accounting for disability and medical complexity in the Centers for Disease Control and Prevention’s National Healthcare Safety Network measures in Domain 2
• Updates to the Extraordinary Circumstance Exception policy

The proposal would also change the requirement for updating diagnosis and procedure codes from a single update on October 1 to a biannual update. Through this update, CMS believes new technologies will be better recognized under the IPPS system at earlier dates. CMS did note in the rule, however, that the addition of new codes will not affect payments or DRG classification changes until the following FY, according to Revenue Cycle Advisor.

CMS also released the proposed list of ICD-10-CM/PCS code updates, revisions, and deletions, which can be reviewed on their website.

The proposed rule would increase the operating rates slightly for general acute-care hospitals paid under the IPPS. Those facilities, however, also need to successfully participate in the Hospital Inpatient Quality Reporting Program and use an EHR system.

While CMS also opened the door for comments and suggestions on the proposed rule, they stipulated that the comments would not necessarily prompt a response in the final rule. CMS will, however, consider the comments for future guidance and rulemaking. The comment period remains open through June 13.

For more information, review the CMS fact sheet on the FY 2018 proposed rule. CMS expects to issue the final rule by August 1. Once the rule is finalized, the changes become effective on October 1.  

According to a recent study by the University of Michigan, participation in voluntary federal quality reporting programs has a greater effect on reducing readmissions than financial penalties levied against facilities for high rates alone, FierceHealthcare reported.

The researchers studied heart attack, heart failure, and pneumonia patient records from more than 2,800 U.S. hospitals from 2005 to 2015. Those hospitals that participated in one of three federal quality programs (accountable care organizations, meaningful use, and bundled payments) saw a decrease in 30-day readmissions rates by a wider margin than those that did not participate, according to the study published in JAMA Internal Medicine.

Before the Affordable Care Act’s (ACA) implementation, none of the examined facilities participated in the quality reporting programs. After the ACA implementation, however, only 56 facilities remained unenrolled in quality reporting programs. Of those 56 facilities, their readmission rates decreased by 1.3% annually. The researchers attributed the decrease to the fines levied by CMS’ Readmission Reduction Program, according to FierceHealthcare.

Facilities participating in an accountable care organization, on the other hand, reduced readmissions by 2.1% annually. Those participating in only the meaningful use program saw a 2.3% reduction annually. Finally, those facilities participating in all three programs saw a readmission reduction of 2.9% annually, according to the study.

For CDI programs, the growing focus on quality remains a looming question and concern. With the rise of quality programs and their positive affect, documentation opportunities present themselves readily for the enterprising CDI specialist. To read more about quality programs and CDI’s role, read the March/April edition of the CDI Journal.

The use of electronic health records (EHR) should be guided by ethical principles that put patient care at the forefront, according to a position paper published by the American College of Physicians (ACP). EHRs can be an asset in the delivery of quality care, but may have unintended ethical consequences, the ACP said in a March 21 statement, Revenue Cycle Advisor reported.

The position paper, “Ethical Implication of the Electronic Health Record: In the Service of the Patient,” published in the March issue of the Journal of General Internal Medicine, outlines three principles that should be applied to EHR use, including:

• Facilitate patient care, support the patient-physician relationship, and support the physician’s ethical duties
• Assist and improve clinical reasoning and diagnostic skills
• Maintain the privacy of protected health information

EHR use should not minimize or interfere with direct patient care, the ACP said, and features such as copy and paste should be used judiciously, according to Revenue Cycle Advisor.

Editor’s note: To read an ACDIS White Paper about EHR use and the role of CDI specialists, click here. To read about how electronic records change CDI processes and interactions, click here.

ACDIS is pleased to welcome a new association into the fold under our parent company, HCPro: The National Association of Healthcare Revenue Integrity (NAHRI).

The new association is dedicated to providing the hospital revenue integrity community with the resources, networking, and education needed to foster this growing profession.

Membership benefits include a quarterly networking call, a resource library, dedicated forms, and a quarterly journal that includes articles and columns from board members, regulatory experts, and peers. Members also receive a special discount on products and events such as the Revenue Integrity Symposium and Boot Camps.

Revenue integrity professionals of all kinds are making positive changes for their hospitals and health systems, and now they can connect with each other as they forge the way. NAHRI is the place to ask questions, discuss strategies and standards, trade ideas, and access valuable resources.

We haven’t officially launched yet, so in the meantime, you can stay up to date on the progress of NAHRI—including the development of a credential for revenue integrity professionals—through the free e-newsletter, Revenue Integrity Insider.

Are you a local chapter leader and planning to be at the ACDIS conference?

The chapter advisory board (CAB) met last week to discuss plans for local chapter-related events at the 10th anniversary ACDIS conference. If you’ve had the pleasure of attending the conference in years past, then you’re familiar with the various ways ACDIS attempts to help local chapters engage with fellow attendees from their state. This year, events include:

• Day 1:Leadership panel discussion: This event takes place at the end of regular conference sessions (from 5-6 p.m.) and features insight from the CAB as well as from fellow local chapter leaders across the country. It’s an opportunity for local leaders to meet face-to-face and identify best practices for successful event organization. Please email Melissa Varnavas at mvarnavas@acdis.org, if you would like to attend.
• Day 2: Local chapter theme day: Attendees are encouraged to dress in sports gear related to their state or in clothing best representing their region. (One year, the Maine chapter leader wore a lobster claw headband.) This makes it easier to pick out those from your home state amongst the crowd.
• Day 2: Local chapter lunch: Local chapter leaders are encouraged to pick a few tables in the lunch area to decorate with a theme of their choosing to help foster networking within their geographic region. (Last year, Florida leaders brought an inflatable palm tree and Ohio leaders brought battery powered marquee letters that spelled OHIO!)

About a week or so prior to the conference, Melissa Varnavas will inform all attendees regarding local chapter events

Please let Melissa Varnavas or Linnea Archibald know about your conference plans so we can update those attending from your state/region. If you have a photo from an early conference you attended or an early local chapter event feel free to email it Melissa at mvarnavas@acdis.org, or ACDIS editor Linnea Archibald at larchibald@acdis.org.

Events this week

• The Westchester New York CDI networking group meets Thursday, April 20, 2:30-4:30 p.m. For information, email kseekircher@nwhc.net.
• The CentralNew York CDI networking group meets Friday, April 21, 2-4 p.m., at the Pomeroy School of Nursing in Syracuse, featuring a presentation by Bobbie Massena, RN, assistant director of UM/CDI. For information, email Dawn Burr at dawnburr@crouse.org. To download the flier, click here.
• The Washington Evergreen ACDIS Chapter meets Friday, April 21, 10 a.m. to 2 p.m. For information, contact Lillian.Dickey@providence.org. To see the meeting flyer, click here.

April

• The St. Louis Missouri ACDIS Chapter meets Wednesday, April 26, 6:30-8 p.m., at St. Luke’s. Outside food/drink is against hospital policy, so no potluck this time. For information, contact Michael McKelvey, michael.mckelvey@bjc.org.
• The Minnesota ACDIS Chapter meets Wednesday, April 26. M. Fareed Suri, MBBS, will present  on ”Interventional Neurology Procedures." . For information, contact Teresa Krueger, Kruegert@centracare.com.
• The New Jersey ACDIS Chapter meets Thursday, April 27, hosted by Temple University Hospital. To download the agenda, click here. For information, contact Gina Stewart at gstewart@e4-services.com.
• The Colorado ACDIS Chapter meets on Thursday, April 27, 4.-6 p.m. at Centura Health in Englewood. View the flyer by clicking here.
• The Wisconsin ACDIS Chapter meets Saturday, April 29, 9 a.m. to 3:30 p.m. at the Wheaton Franciscan Medical Building Conference Center. To see the full brochure, click here.

May:

• The Arizona ACDIS Chapter plans on holding a get-together at the national ACDIS conference in Las Vegas, in the MGM Grand lobby. More details will be emailed to chapter members by the end of April.
• The California ACDIS Chapter set a tentative date of May 24 for their education conference call. For more information, visit their local chapter page and read Vol. 3 of their newsletter.

Save-the-date

• The Arizona ACDIS Chapter is planning its next big event tentatively for June 2017. Chapter members should send suggestions to Chapter President Alma Yap at rnalmay@gmail.com.
• The California ACDIS Chapter holds its third-annual conference Friday, September 15, 8 a.m. to 4 p.m., at Torrance Memorial Medical Center. For information, contact Rani V. Stoddard at stoddardrv@henrymayo.com.
• Missouri’s three ACDIS local chapters join for a full-day conference event on October 14, at the University of Kansas Hospital. For information, contact michael.mckelvey@bjc.org.

About 41% of CDI programs currently review medical records for quality improvement items, according to an online ACDIS membership poll.

But buzzwords related to “healthcare quality” represent a wide-range of initiatives from an equally wide-range of agencies—from government and private insurers to private companies crunching data for public reporting.

Looking to expand program efforts into quality, therefore, can prove daunting. It’s often helpful to hear from those who’ve delved into the process and have proved not only that it can work, but who can demonstrate how to adapt those focus areas to your own CDI programs.

That’s why ACDIS Advisory Board member Deanne Wilk, BSN, RN, CCDS, CCS, CDI manager at Penn State Hershey Medical Center brings along her team Marcy Miles, MT, (ASCP), MBA, manager of quality and process excellence, Melissa Macguire, RN, CDI educator, and Carol Houlihan, MHA, RHIA, quality informatics manager for a special ACDIS Live! webinar on Thursday, April 27.

In the program, Wilk will show how she and her CDI team moved from traditional CC/MCC capture to clinical support for severity of illness, to mortality reviews, to patient safety indicators, to readmission reduction and length of stay measures, to hospital-acquired conditions and present on admission conditions, all the way to value-based purchasing items, core measures, and even bundled payments.

Before joining Wilk and her team on the extended webinar, do a little background research by reading through the March/April edition of the CDI Journal which includes a number of articles from a variety of industry experts on ways CDI record reviews for quality-focused initiatives can yield a host of positive results.

Even with the addition of quality measures, CDI should still concentrate on documenting an accurate picture of the patient’s episode of care. As Tamara Hicks, RN, BSN, MHA, CCS, CDS, ACM, director of clinical documentation excellence at Wake Forest Baptist Health in Winston-Salem, North Carolina, says in the article “Foray into CDI for value-based purchasing,” “It’s not all about the money; it’s about getting it right.”

Only 9% of CDI programs currently have a presence in the outpatient arena, according to a recent ACDIS membership poll. But 24% plan to expand to some level of outpatient record reviews within the next six to 12 months.

With the growth in outpatient focus, however, many in the CDI profession feel at a loss for detailed direction.

“Outpatient CDI requires a different mindset from inpatient CDI,” said James S. Kennedy, MD, CCS, CCDS, CDIP, president of CDIMD – Physician Champions in Smyrna, Tennessee, on the April 11 episode of the Talk 10 Tuesday podcast by the ICD10 Monitor. This episode of the podcast sought to clear some of the fog through a panel of experts, including Kennedy, Cynthia Keith, CPC, and Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM.

While inpatient CDI programs have many different goals—financial, denial prevention, quality measures, general documentation improvement—outpatient should have one, according to Krauss.

“The goal of all your outpatient efforts should be documentation improvement,” he said. Additionally, the events taking place in the free-standing physician office directly affect any hospital outpatient services as many of those services require a referral from the general practitioner.

For hospitals, the referral can open them up to denials. This, according to Krauss, happens when the documentation from the physician’s office does not backup the necessity for that service. “Outpatient CDI really starts in the doctor’s office,” said Krauss.

One way to ensure the documentation stays up to snuff and audit proof is frequent self-audits. “Don’t just audit the documentation after claims are denied. Think of it as preventative medicine,” Keith said.

Since the coders use the progress notes to code the final bill rather than the superbill (an itemized form from the physician reflecting the services provided), the quality of the notes need frequent monitoring. “Physicians have to be more descriptive as to what they’re doing with their patients in the progress notes,” Kennedy said.

For CDI specialists coming from the inpatient side of the house, Kennedy warned that the outpatient world can be more complex. “An outpatient CDI specialist has a much broader focus. You have to look at things globally rather than in a discreet episode,” he said.

While inpatient documentation focuses on one particular incident, outpatient documentation and coding takes into account up to 12 months of care for that patient. Combined with the different payment methodologies, this broader focus can be quite daunting to the new outpatient CDI specialist.

To help clear up some of the mystery, Kennedy suggested opening communication with the individual payers. “Call them up and ask what they’re expecting,” he said. Facilities can also ask after their data collected by the payers to see where they need improving.

Though expanding into outpatient can be challenging and a bit scary, Krauss and Kennedy both suggested patience and education. “It takes a lot of time to educate and engage the physicians,” said Krauss.

Editor’s note: To listen to the complete Talk Ten Tuesday podcast, click here. To read a White Paper from the ACDIS Advisory Board about outpatient CDI, click here. To read an article about specificity in outpatient records, click here. To read a Q&A with one of the ACDIS 2017 conference speakers regarding outpatient CDI, click here.

Note: To access this free article, make sure to first register here if you do not have a paid subscription.

The Leapfrog Group released its 2017 hospital safety grades recently for 2,639 hospitals participating in the group’s annual survey, according to HealthLeaders Media. Of those participating hospitals, 31% earned an “A” and 27% earned a “B,” according to Leapfrog Group.

Each participating hospital receives a numerical score (which then translates to a letter-grade) based on a review of 30 patient safety measures. The data comes from a variety of sources including Leapfrog’s own surveys, CMS, and the American Hospital.

The grades are based on two different types of measures: process and outcome. The process measures include items such as hand hygiene and ICU staffing. The outcome measures include infections and patient falls.

Although the Leapfrog Group’s ratings were recently called into question, potential patients do still review the data when choosing a facility. Facilities should review the data for themselves and see where they fall in relation to those around them.

To review the report, click here. To read an article in the CDI Journal about publically reported quality data, see p. 14 in the March/April edition.

Though 93% of respondents to an ACDIS Radio poll review surgical and operative notes, this area can pose a daunting hurdle for CDI teams, said Frances Frank, RN, MBA/MSN/HCM, CPHQ, manager of CDI at Stanford (California) Health Care, on the March 22 episode, “ACDIS conference preview: Anatomy of a surgical note.”

“The more surgical and operative notes people review, the better they become” at the task, she said. “Our work is transforming. Our whole industry is transforming,” and CDI specialists need to be proficient at all types of record review in order to keep up, said Frank who joins Cheryl M. Manchenton, RN, BSN, CCS, senior inpatient consultant/project manager with 3M Health Information Systems on stage at the 10^th annual ACDIS conference, May 9-12, in Las Vegas, Nevada.

CDI specialists need a firm understanding of anatomy and physiology, to delve into extremely technical surgical notes, Frank said. Although additional training isn’t necessary for the CDI staff at Stanford because surgical documentation reviews are considered part of their original, typically assigned duties, she said.

CDI staff also need a positive attitude, and thick-skin, since physician engagement often proves the most difficult component of such reviews. Building relationships with the physicians, however, can help ease some of the tension, Frank said. One way to encourage relationship building is to “tap into the physicians’ desire to teach,” Frank said. “Surgeons love to teach and one way that can happen is by asking them ‘can you help me understand?’”

Surgical note templates often lead to coding confusion—the complication section especially so—so it also represents an area where CDI staff can step in and help, according to Frank. Surgeons often think that listing a condition as a complication equates to fault—that he or she did or didn’t do something during the surgery that led to an unplanned complication of the patient’s care.

“Working with the surgeons and proceduralists on updating the templates was essential,” for buy-in at her facility, Frank said. Clarifying those templates can help make the physicians’ and the CDI specialists’ lives a bit easier. 

Template improvement aside, Frank suggested approaching surgical CDI reviews from the aim of truly complete and accurate documentation. “It’s not only about querying so we can capture the codes. It’s about making sure the note is as clear as possible about what actually happened during that procedure,” said Frank.

Frank and Manchenton plan to dig into surgical and operative chart reviews more deeply during their presentation at the 10^th annual ACDIS conference on Day 2 in Track 1.

“We’re being playful with the presentation and excited to help people see things creatively,” Frank said. “I hope the audience will see the fun in it as well. We’re promising a good time in Las Vegas!”

Editor’s Note: To listen to the complete ACDIS Radio show from March 22, “ACDIS conference preview: Anatomy of a surgical note,” click here. To read the Q&A with Frank’s co-presenter, Cheryl Manchenton, click here. To read an article about query and education opportunities in surgical documentation, click here.

by James S. Kennedy, MD, CCS, CDIP

Coding Clinic for ICD-10-CM/PCS, First Quarter 2017, which became effective March 15, provides interesting perspectives regarding coding and documentation for Impell®, an implantable heart pump device that supports a patient’s circulation and, when implanted or removed, has a significant effect on MS-DRGs or APR-DRGs.

On the other hand, the ICD-10-PCS performance codes for Impella [5A0-] may have a different effect, or no effect at all, if not paired with an Impella insertion or removal code. Learn more about Impella here.

This advice in Coding Clinic, First Quarter 2017, pp. 10–14, makes it very clear that the insertion of an Impella device cannot be coded if it occurs after the start of a procedure and then is removed prior to or at the end of the procedure. The issue states (emphasis added): “Assign a code for the assistance only [5A0] when an external heart assist device such as the Impella is inserted intraoperatively and removed at the completion of the procedure. It would not be appropriate to assign a code for the insertion of the device.”

Coding Clinic emphasizes that “this is consistent with ICD-10-PCS guideline B6.1a which states that a device is coded only if a device remains after the procedure is ended.” In support, it also states that, “according to the National Quality Forum, ‘Surgery ends after all incisions or procedural access routes have been closed in their entirety, device(s) such as probes or instruments have been removed, and, if relevant, final surgical counts confirming accuracy of counts and resolving any discrepancies have concluded and the patient has been taken from the operating/procedure room.’”

Coding Clinic does allow us to code the insertion and/or removal of an Impella device if its removal occurs outside the confines of a surgical procedure. On p. 11, it states that these codes are assigned when an Impella device, implanted during surgery, is left in for a few hours postoperatively. In this case, Coding Clinic suggests that the following codes would be assigned:

• 02HA3RZ, insertion of external heart assist system into heart, percutaneous approach
• 02PA3RZ, removal of external heart assist system from heart, percutaneous
• 5A0221D, assistance with cardiac output using impeller pump, continuous

Coding Clinic reiterates this on pp. 11–12 when it advises the following codes for implantation of right- and left-side Impella devices with a percutaneous coronary intervention, with the left-side device being removed prior to the end of the procedure and the right-side device being left in for several days:

• 02HA3RS, insertion of biventricular external heart assist system into heart, percutaneous approach (for the insertion of the biventricular external heart assist device)
• 02PA3RZ, removal of external heart assist system from heart, percutaneous approach (for the removal of the right-side device—note that Coding Clinic does not allow a code for the removal of the left-side device, since its removal occurred prior to the end of the procedure)
• 5A0221D, assistance with cardiac output using impeller pump, continuous (for the assistance with the impeller pump)

I found it interesting that Coding Clinic explicitly states that this advice applied only to Impella and not to other devices, such as Swan-Ganz catheters or intra-aortic balloon pumps. Does this guidance indicate there are devices that can be implanted during surgery, removed prior to the end of surgery, and still be coded? I suggest that this issue be discussed with your inpatient coders.

Editor’s note: Kennedy is a general internist and certified coder specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. This article was originally published in JustCoding.

Due to the demands of the conference, the ACDIS offices will be closed through May 8-12.

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We’ll see you in Las Vegas!

Roughly 80% of U.S. children live within 30 miles of a level I or II center, while 88% live within 30 miles of a level I, II or III center, according to a recent study from the Government Accountability Office (GAO).

However, only 57% of the nation's 74 million children lived within 30 miles of a pediatric trauma center. “More children die of injury each year than from all other causes combined,” the report states, adding that while most children get care in hospital emergency departments many lack appropriately sized equipment.

Pediatric trauma centers have a lower mortality risk compared to adult trauma centers and other facilities, some studies found, and the GAO suggests that more information may be needed on outcomes other than mortality.

ACDIS member J. Douglas Campbell, MD, FAAP, MHA, CDI physician advisor at Wolfson Children’s Hospital/Baptist Medical Center in Jacksonville, Florida, is currently seeking additional information related to clinical documentation improvement efforts for pediatric trauma cases and recently posted to the ACDIS Forum looking for assistance. For additional information, email Doug.Campbell@bmcjax.com.