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cdiJournal
Review queries for ICD-10 focus, compliance
January 2014
Vol. 8 No. 1
Director’s Note
5
Dual coding
6
Staff retention
8
ICD-10 will take center stage
at May conference.
Coding for ICD-10 now
highlights areas for physician
education and concurrent
CDI opportunities.
Programs put bonus
models in place to keep
staff engaged through
ICD-10 implementation.
Homegrown training 10
Comprehensive efforts
lead to new team member
success.
Staff goals
12
EHR efforts
14
Meet a member
16
Physician corner
17
Clinical corner
20
Sample goals for new CDI
staff outline expectations
from three months to two
years.
Three specialists share
their EHR implementation
experiences.
Christina Raad, RN, CCDS,
receives her certification.
Trey La Charité, MD,
­discusses how CDI helps
prevent auditor denials.
Richard Pinson, MD, FACP,
CCS, revisits respiratory
failure documentation.
Survey results
24
Get the breakdown on how
programs are preparing for
the ICD-10 transition.
The results of a December ACDIS survey
show the CDI profession toddling toward the
ICD-10-CM/PCS transition, says founding
ACDIS advisory board member Gloryanne
Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS,
AHIMA-approved ICD-10-CM/PCS trainer
and HIM professional in Fremont, Calif. (See p.
24 for the complete survey results.)
“People seem to be getting there, but they’re
taking baby steps. That’s good, but now we really
need to be getting ready to jog and run,” she says.
Twelve percent of survey respondents indicated they received no information to raise their
awareness of ICD-10-CM/PCS documentation
improvement needs. Only 68% said they received
training on the code set, and 32% indicated their
CDI staff assists with ICD-10-related education
for physicians.
“Those who haven’t had any training whatsoever need to move ahead, start with an orientation
or awareness of ICD-10 code set,” Bryant says.
One of the simplest ways to do that is to
evaluate your queries and audit them for ICD10-CM/PCS opportunities. And the good news,
according to the survey results, is that many programs have already started doing so.
First steps
Fifty-eight percent of survey respondents
indicated they had reviewed their queries for type
and frequency as of December 2013. This is a
great first step, Bryant says. According to the
survey, facilities typically use templates for the
following queries (read the complete list of query
templates on p. 25):
»»Heart failure: 96%
»»Sepsis: 91%
»»Anemia: 90%
»»Malnutrition: 88%
»»Renal failure: 84%
»»Respiratory failure: 82%
Although only 37% of respondents indicated
that they have begun reviewing their forms for
ICD-10-CM/PCS documentation specificity,
another 29% indicated that they will begin doing
so during the first quarter of 2014.
“I would like to have seen the percentage of programs
revising their queries for ICD-10 to be a bit higher,” says
Bryant. “The more we focus now, the more we will learn
about where potential documentation gaps may be. The
sooner we incorporate those areas into our query efforts, the
better off we’ll be in terms of ensuring a smooth transition
to the new code set.”
“People [need to be] looking at what their documentation is today and how that should influence their actions
in relation to the ICD-10-CM/PCS implementation,” says
former ACDIS advisory board member Shelia Bullock, RN,
BSN, MBA, CCM, CCDS, CDI director at the University
of Mississippi Medical Center (UMMC) in Jackson. “Once
you take a good hard look at it, you’ll see which items are
really worth worrying about.”
While many facilities have contracted with consultants
or outside auditing companies to conduct a documentation gap analysis, this isn’t strictly necessary, and individual
CDI specialists can make progress, says Mary H. Stanfill,
MBI, RHIA, CCS, CCS-P, FAHIMA, vice ­president of
Advisory Board
ACDIS Director: Brian Murphy
[email protected]
Associate Director: Melissa Varnavas
[email protected]
Membership Services Specialist:
Penny Richards, CPC
[email protected]
HIM consulting services for United Audit Systems, Inc., in
Cincinnati, an AHIMA-approved ICD-10-CM/PCS trainer.
Even a lone CDI specialist with the most limited of training
budgets can, at the very simplest level, order an ICD-10CM coding manual and look up codes while dropping a
query to see what the definitions say, to identify areas where
additional documentation will be needed, Stanfill suggests.
Alternatively, set aside time to “pick a manageable percentage
of records and review them Fridays for ICD-10 opportunities,” she says.
Have the entire team participate and review all the different types of records, says Stanfill, not just the top DRGs.
“You want to be sure that everyone gains hands-on experience with documentation needed for the new code set across
various topic areas—not just the codes that result in a CC/
MCC, but all the floors and all the specialties, so you’re not
blind-sided during implementation,” she says.
Walk through policies to ensure compliance
ICD-10-CM/PCS hasn’t been the only new CDI program focus in recent years. Everything from electronic health
Dee Banet, RN, BSN, CCDS
Director of CDI
Robert S. Gold, MD
CEO
Norton Healthcare
Louisville, Ky.
[email protected]
DCBA, Inc.
Atlanta, Ga.
[email protected]
Susan Belley, MEd, RHIA, CPHQ
Project Manager
Sylvia Hoffman, RN, CCDS, CCDI,
CDIP
President, CEO
3M HIS Consulting Services
Atlanta, Ga.
[email protected]
Sylvia Hoffman CDI Consulting
Tampa, Fla.
[email protected]
Timothy N. Brundage, MD, CCDS
Physician Champion
Walter Houlihan, MBA, RHIA, CCS
Kindred Hospital North Florida
District
St. Petersburg, Fla.
[email protected]
Baystate Health
Springfield, Mass.
[email protected]
Fran Jurcak, RN, MSN, CCDS
Director, CDI Practice
Donald Butler, RN, BSN
CDI Manager
Huron Healthcare
Chicago, Ill.
[email protected]
Vidant Medical Center
Greenville, N.C.
[email protected]
Cheryl Ericson, MS, RN, CCDS, CDIP,
AHIMA-Approved ICD-10-CM/
PCS Trainer
CDI Education Director
HCPro
Danvers, Mass.
[email protected]
Trey La Charité, MD
Physician Advisor
University of Tennessee at Knoxville
Knoxville, Tenn.
[email protected]
James E. Vance, MD, MBA
CEO
Tamara Hicks, RN, BSN, CCS, CCDS
(2007–2010)
Physician Executive Management
Services, LLC
Highlands, N.C.
[email protected]
Robin R. Holmes, RN, MSN (2009–2011)
Donna D. Wilson, RHIA, CCS, CCDS
Senior Director
Compliance Concepts, Inc.
[email protected]
Previous ACDIS board members:
Cindy Basham, MHA, MSCCS, BSN,
CPC, CCS (2007–2010)
Gloryanne Bryant, BS, RHIA, RHIT, CCS,
CDIP, CCDS (2007–2010)
Shelia Bullock, RN, BSN, MBA, CCM,
CCDS (2008–2011)
Jean S. Clark, RHIA (2007–2010)
Wendy De Vreugd, RN, BSN, PHN, FNP,
CCDS (2007–2010)
James S. Kennedy, MD, CCS
(2010–2012)
Glenn Krauss, BBA, RHIA, CCS, ­­­­
CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS
(2010–2012)
Pam Lovell, MBA, RN (2007–2010)
Gail B. Marini, RN, MM, CCS, LNC
(2010–2012)
Shannon E. McCall, CCS, CCS-P, CPC,
CEMC, CPC-I, CCDS (2007–2010)
Lynne Spryszak, RN, CPC, CCDS
(founding member)
Colleen Stukenberg, MSN, RN, CMSRN,
CCDS (2008–2010)
Heather Taillon, RHIA (2007–2010)
Lena N. Wilson, MHI, RHIA, CCS, CCDS
(2010–2012)
Garri Garrison, RN, CPUR, CPC, CMC
(2008–2011)
Colleen Garry, RN, BS (2007–2010)
Robert S. Gold, MD (2007–2010)
William E. Haik, MD, FCCP (2007–2010)
CDI Journal (ISSN: 1098-0571) is published quarterly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $165/year for membership to the Association of Clinical Documentation Improvement Specialists. • Postmaster: Send address
changes to CDI Journal, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2014 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means,
without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857.
For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email: [email protected]. • Visit our website at www.cdiassociation.com. • Occasionally, we make our subscriber list available to selected companies/
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given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.
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2
January 2014
© 2014 HCPro, a division of BLR.
record implementation, Medicare reimbursement changes
such as hospital value-based purchasing, and quality reporting metrics have become front-burner topics and led to a
shift in some traditionally held CDI conceptions.
CDI programs that are solely financially focused may
need to make some adjustments, Bryant says. “The change
to ICD-10 is about expanding our ability to capture clinical
data, to improve the data quality we have in this country,” she
says. “There is going to be a host of reasons to expand the
purpose of CDI query efforts, such as severity of illness, risk
of mortality, and for research purposes; programs need to be
ready for that.”
CDI programs should already be reviewing their query
forms/templates on a regular basis, as recommended in
AHIMA’s 2008 practice brief “Managing an Effective
Query Process,” says Laurie L. Prescott, MSN, RN, CCDS,
CDIP, CDI education specialist for HCPro in Danvers,
Mass. Those facilities which already had such practices in
place most likely responded positively to December’s survey.
Although the practice brief does not specify the frequency of such reviews or the composition of the committee(s)
who should review them, annual or biannual auditing helps
for two reasons, according to Prescott: compliance with
industry recommendations and incorporation of the most
up-to-date clinical indicators.
Ensuring query forms comply with the latest CDIrelated industry recommendations is important. For
example, the 2013 ACDIS/AHIMA practice brief
“Guidelines for Achieving a Compliant Query Practice”
updates previous AHIMA releases in light of the forthcoming shift to the new ICD-10-CM/PCS code set. The
brief outlines ways in which so-called “yes/no” queries
can be compliantly drafted and describes use of multiplechoice queries.
Yes/no queries can be useful in ICD-10-CM coding
by establishing a cause-and-effect relationship necessary to
assign combination codes, writes Cheryl Ericson, MS, RN,
CCDS, CDIP, AHIMA approved ICD-10-CM/PCS trainer
and CDI education director at HCPro, in the book The
Clinical Documentation Improvement Specialist’s Guide to ICD-10.
At Swedish Medical Center in Seattle, Jennifer
Woodworth, RN, BSN, CCDS, director of CDI, and her
team reviewed their standard query formats—reducing their
templates to “just four or five ways in which we can ask the
physician a question in order to ensure compliance,” she says.
They also created easy step-by-step formats for queries
related to linking diagnoses, such as complications due to
diabetes, and contemplated the problem of “unlinking”
diagnoses as well.
“We know that linking one causal diagnosis to another
will be a concern withthe new code set,” says Woodworth,
“and we want to be sure to capture that information. Yet
we have to be aware of situations where the two diagnoses
really do not go together, and we need to know how to ask
that question without second-guessing the physician’s clinical
judgment.”
Reassessing query forms for ICD-10-CM/PCS isn’t just
about adding the right verbiage to the forms, she says; it’s
also about rethinking the query process.
“The word ‘template’ means different things to different
people. For us, it really meant taking a look at what the most
recent query practice brief indicates and incorporating the
additional underlying elements of the new code set. Really,
this isn’t just a matter of adding some language here and
there but updating our process, retooling our efforts,” says
Woodworth.
Having a multidisciplinary team vet query forms helps
to ensure compliance related to a broad range of concerns—clinical validity, regulatory compliance, and coding
accuracy.
Regular query template reviews “should be done by the
CDI and the coding staff with input from the compliance
officer or the compliance committee,” says Prescott.
Although 54% of survey respondents indicated that
their compliance department does not review new/updated
query forms, Bryant says such input is warranted.
“That [survey] result is sort of surprising considering
the emphasis of the various [ACDIS and AHIMA] query
practice briefs on compliance concerns. So this is an area for
CDI programs to improve, particularly in light of the work
required in revising query forms for ICD-10-CM/PCS,”
Bryant says.
Additionally, regular reviews of templates with input
from the CDI program’s physician advisor and/or facility medical staff can help to ensure forms reflect the
most recent clinical indicators, such as updates from the
“Surviving Sepsis” campaign, and recommendations published in the May 2012 Journal of the Academy of Nutrition and
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© 2014 HCPro, a division of BLR.
January 2014
3
Dietetics regarding diagnosing malnutrition.
“The CDI team needs to ensure that queries are accurate
and up to date with latest standards of practice,” Prescott
says, “and this is where a multidisciplinary team including a
physician advisor’s involvement would be useful.”
Nevertheless, 61% of survey respondents indicated that
their physicians did not review any new or updated queries.
In a related poll on the ACDIS website (http://tinyurl.com/
msgy854), only 13% indicated that a multidisciplinary team
defines which clinical standards should be used as general
query definitions for a given diagnosis.
“We really need to get back to the physician connection”
to CDI efforts, says Bryant, “not only because that connection is highly recommended in the industry, but because
we know that when physicians are involved in the process,
involved in helping to create the query forms, they tend to
support it.”
Expectations for productivity
Numerous speakers at the AHIMA conference in Atlanta
in October addressed projected coder productivity losses,
with estimates ranging from 20% to 60%.
In Canada, coder productivity dropped by 50% after
the country’s initial 2001 transition to ICD-10, said
Elaine O’Bleness, MBA, RHIA, CHP, AHIMA-approved
ICD-10-CM/PCS trainer and revenue cycle executive for
Cerner Corporation in North Kansas City, Mo. Coder
productivity has since only rebounded to approximately
80% of pre-ICD-10 levels. Consider, also, that Canada
did not have to deal with the procedure portion of the
code set—so the U.S. may be in for an even bigger productivity decline.
Why the slowdown? In part, since ICD-10 codes use
both numbers and letters, coders can no longer just use the
keypad to type in codes, said O’Bleness. But coding also
takes longer due to the greater analytical skills required from
the coder and the additional documentation needed from the
physician.
“According to the new coding guidelines for PCS, the
hospital cannot submit a bill unless all the characters within
that code are complete. With that came an expectation that
coders would spend 50% more time on these cases alone,”
says Paul Weygandt, MD, JD, MPH, MBA, CPE, vice president of physician services at J.A. Thomas and Associates,
Inc., a Nuance company.
That’s one reason many believe that procedure documentation could be an area ripe for regulatory review and intervention (denials).
“We were scared to death about the procedure coding
system until we started looking at the codes and the documentation requirements,” says Bullock.
After careful review, Bullock’s team found that many
of the documentation needs associated with ICD-10-PCS
could be resolved with simple amendments to either surgical
templates or physician order forms. For example, UMMC
updated its cardiology templates to include the type of contrast and number and location of vessels used, all of which
will reduce the number of queries needed later in the process.
At Swedish Medical Center, Woodworth and her team
developed a template that identifies which type of stent the
physician used during an angioplasty. They also amended
documentation templates to identify cemented versus noncemented hip replacement procedures to avoid the need for
queries.
“We are taking a look at what procedures our different specialty lines are doing day in and day out,” says
Woodworth.
“We’re looking to see what additional documentation is
going to be needed, and then seeing what solutions we can
come up with to capture that information in a relatively easy,
noninvasive way, using the tools the physicians currently use,”
she says. “It’s a different solution set but one we think will
actually solve the problem and keep us from having to query
for every little thing.”
Despite the anticipated increase in coder workload associated with ICD-10-PCS, Weygandt says much of the documentation may already be in the record or could be obtained
through simple template adjustments.
Part of the challenge of ICD-10 reviews is identifying
which items represent actual CDI focus areas and which
require a focus on coder theory and education, Weygandt
says. “There’s been a panic mentality, particularly in regards
to PCS,” he says, “but I don’t think we really need to panic.
We simply need to get on with the process, apply ICD10-PCS to the types of cases relevant to each hospital, and
identify the opportunities to improve documentation and
coding.”
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4
January 2014
© 2014 HCPro, a division of BLR.
Director’s note
What happens at ACDIS Las Vegas stays in Vegas—
except for the learning
You’ve probably heard the
expression “What happens in Las
Vegas stays in Las Vegas.” That’s
true of our upcoming annual conference at Bally’s Hotel in May.
I encourage you to let your hair
down and have fun while you’re
at Bally’s on the strip—it’s what
Vegas is all about!
But I can promise you that you’re also going to learn a
lot about CDI in three days, vital information that you can
take back and share with your colleagues or your medical
staff. We’ve got another great conference lined up in 2014,
and I thought I’d take a few moments to share just some
of the session highlights:
»»Inpatient psychiatry. A large percentage of patients
entering the hospital have some sort of mental illness,
depression being the most common. CDI staff can
emphasize the importance of having the physician and
staff nurse document accordingly and accurately to
improve patient outcomes. This session will identify
opportunities related to borderline personality disorder
and describe the impact of ICD-10 comorbid conditions related to mental health.
»»CDI in the ED. This session will detail how Stony
Brook Medicine designed a CDI program for its
emergency department with a focus on quality and
capturing present on admission indicators. It will also
explain how the effort required more than just physician engagement and support. Practical solutions and
best practices based on experience of starts and stops
will be offered.
»»Obstetrics. This session is focused on the obstetrics
service line, little explored and often misunderstood.
Most obstetrics patients are not Medicare, but many
opportunities for improved APR billing/coding exist
in this population. Participants will leave able to
i­dentify frequently missed secondary diagnoses, recognize common documentation pitfalls, define good
obstetrics documentation habits, and measure outcomes to ensure success.
»»Focus on ICD-10. As we highlight in a number of
the articles in this edition of CDI Journal, October
1 is looming larger and larger, and the ACDIS conference is the place to come to get prepared for the
deadline. We’re offering nearly two full days of ICD10 education, including a general session by Nelly
Leon-Chisen, executive editor of AHA Coding Clinic
for ICD-10—the authoritative source on the new
code set. Focus your efforts by learning about the top
20 ICD-10 documentation issues that cause DRG
changes.
»»Pre-conference reception. This is Vegas, after all, so
this year we’ve added our first pre-conference networking session to get everyone started in fine evening style.
Join us the night before the conference for an evening
welcome reception, complete with a complimentary
drink and appetizers, and get the networking started
together with your peers at the nation’s only conference
dedicated to CDI.
I hope to see you in May, and remember—what happens in Vegas stays in Vegas. Except for what you learn.
That will power you through another full year and get your
CDI program recharged for success.
Take care,
Brian D. Murphy, CPC
[email protected]
781-639-1872, Ext. 3216
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© 2014 HCPro, a division of BLR.
January 2014
5
ICD-10-CM/PCS
Implementation year begins with dual coding
Has your coding department begun dual coding ICD-9
and ICD-10-CM/PCS? If your answer is no, or if you don’t
know when your facility plans to start dual coding, you
could be already behind the curve.
According to a December 2013 poll on the ACDIS website (http://tinyurl.com/okwba9a), 45% of respondents expected their facility to begin dual coding in January, and another
17% indicated they expect to begin in April.
“If you have one New Year’s resolution, make it dual
coding,” says Mary H. Stanfill, MBI, RHIA, CCS, CCS-P,
FAHIMA, vice president of HIM consulting services for
United Audit Systems, Inc., in Cincinnati, and AHIMAapproved ICD-10-CM/PCS trainer.
Why? Because you cannot improve on an unknown, says
Paul Weygandt, MD, JD, MPH, MBA, CPE, vice president
of physician services at J.A. Thomas and Associates, Inc., a
Nuance company. “You need to do an assessment today. If
you don’t, then you are not going to have any idea how you
will perform under ICD-10.”
“You need to do an assessment today. If you don’t,
then you are not going to have any idea how you
will do with ICD-10.”
—Paul Weygandt, MD, JD, MPH, MBA, CPE
Yet every facility differs, Stanfill says, and every program’s transition plans need to reflect not only the priorities of the hospital but also the program’s CDI and coding
focus areas.
“We may think that everyone has already started dual
coding, but in reality some are starting January 1 and others
are waiting to start in March or April,” she says.
Other facilities are planning to use contracted or consulting staff to code a percentage of records using ICD-9-CM,
freeing up internal coders to practice reviewing records for
ICD-10-CM/PCS.
As an example, Stanfill cites one facility that used a
consulting firm to gradually take on more and more of the
facility’s ICD-9-CM coding over the course of 2014. By the
October 1 ICD-10 implementation, the firm will be coding
100% of the ICD-9 records.
“Those types of plans and the rates of records reviewed
will be very particular to a facility’s needs and where they are
in their implementation strategies,” she says.
The value of dual coding comes from the practical application of the code set and the lessons learned in advance of
the go-live date, says Stanfill.
“It may sound basic, but you have to see whether the
coders know how to apply the new code set, to see where
existing efforts are. If the coders have received training and
yet are not comfortable using the code set or aren’t using it
accurately, you have time to iron that out, but if you don’t
start looking at it now you won’t have time to work through
those kinks during go-live,” she says.
Study shows coding accuracy improvements needed
An October 2013 report from the Health Information
and Management Systems Society (HIMSS) and the
Workgroup for Electronic Data Interchange (WEDI)
tested coders’ efficiency in the new code set.
The report concluded that even though the volunteer
coders were AHIMA-approved ICD-10 trainers from
various facilities, they had an average accuracy rate of just
63%. (See the full report at http://tinyurl.com/pk36lds.)
Anecdotally, Stanfill relates the experiences of one
facility, which provided online ICD-10-CM/PCS training to its staff and then handed them records to code.
“They didn’t know how to do it,” she says. The facility had
to hire additional trainers to come in and provide extra
­education.
During the second round of training, “you could see the
light bulbs going off all over the room,” she says. “If you
start now, there will be plenty of time to circle back and provide extra education later on for the trouble spots.”
Most errors in the HIMSS/WEDI test “were functional [ones],” according to the report, such as case numbers not
matching up appropriately or mistakes made due to other
administrative errors.
However, the study also highlighted some interesting
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6
January 2014
© 2014 HCPro, a division of BLR.
areas for potential targeted improvement.
The study took redacted records and grouped them in
“waves.” In the pilot, the term “wave” was used to mean
“scheduled phases” in which each set of medical test cases
were sent to each of the participating organizations. Each
“wave” could contain upwards of 10 or more clinical scenarios. For example, scenario 19 in “wave 1” was for a case
related to ICD-9 code 250.40, diabetes with renal manifestations, Type 2 or unspecified type, not stated as uncontrolled; this scenario had an accuracy rate of 38%. Scenario
73 in “wave 11” related to ICD-9 code 486, pneumonia
only, and had an accuracy rate of 58%. (View the coding
efficiency rates and their example medical records online at
http://tinyurl.com/nqz9htq.)
“These were real clinical scenarios,” says Rhonda Taller,
BA, MHA, principal consultant for Siemens Healthcare,
who was involved in the report’s creation and worked
with the study group that organized the program during a
December 2013 “Talk Ten Tuesday” podcast.
Working through actual medical records to test coder
effectiveness is a vital piece of program preparedness, says
Mark Lott, principal of Lott QA Group, who is conducting
national testing of the new code set.
“You need to go over your own records and see how
many times the coders get the right answers across all
records,” says Lott, who also spoke during the “Talk Ten
Tuesday” session.
Canned scenarios are not optimal training tools, he says.
And don’t rely on the general equivalency mapping systems,
or GEMs, to do the work for you. “You need to make sure
that coders are using the codes the right way, not just mapping the codes,” Lott says.
Highlight skill sets to solve concerns
When coding and CDI teams work together, they can
optimize their practice by figuring out how ICD-10-CM/
PCS challenges will fit with certain skill sets, says Weygandt.
If coders cannot code due to gaps in physician documentation, and if they need to query the physician retrospectively
to resolve those gaps, several negative effects could occur—
among them delays in discharged/not final billed cases, as
well as additional declines in productivity due to the increase
in retrospective queries, says Stanfill.
“We need to be helping the physicians improve their
documentation, not simply increasing the number of queries
they need to answer,” says founding ACDIS advisory board
member Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP,
CCDS, AHIMA-approved ICD-10-CM/PCS trainer and
HIM professional in Fremont, Calif.
Other challenges will specifically relate to coding theory,
such as inpatient infant circumcision, where despite clear
documentation, ambiguity related to the application of ICD10 procedural coding principles could arise, says Weygandt.
“So facilities will need to identify those concerns also.”
Swedish Health Services in Seattle began reviewing
records for ICD-10-CM documentation improvement
opportunities in the final months of 2013, according to
Jennifer Woodworth, RN, BSN, CCDS, director of CDI.
“We really wanted to make sure that we had query templates ready for the common [CDI-related] concerns, and
that we clarified what documentation coders already had at
their fingertips,” Woodworth says.
Just as coders are dual coding, CDI specialists need to
start dual reviews, Stanfill says, examining the record not
only for documentation improvement opportunities needed
in ICD-9 but also in anticipation of those that will be needed for ICD-10-CM/PCS. As each team makes new discoveries, they will need to share the lessons they’ve learned.
An October 2013 report shows that coders from
various facilities had an average ICD-10-CM coding
accuracy rate of just 63%.
Nearly 75% of respondents to a December 2013
ACDIS ICD-10 survey indicated that CDI specialists
meet with coders regularly, and that most of those respondents—30%—meet monthly (read the report on p. 24).
Bryant calls the 25% which do not meet with coding staff
“disappointing” and hopes that the two teams will increase
meetings and collaboration in light of the ICD-10-CM/
PCS challenge.
“As you learn, you’ll update your queries, refocus, and
adjust your processes,” Stanfill says. “CDI is a key solution
to the ICD-10 transition and a critical enabler to challenges
related to the implementation. The CDI song, in terms of
ICD-10 implementation, is the same song the coders are
learning, it’s just a different verse.”
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January 2014
7
Bonus structures help programs retain staff through ICD-10
There is no doubt about it—CDI specialists will be taking on more work and a greater complexity related to that
work in 2014 due to the implementation of ICD-10.
The question for many CDI managers around the country is: How do I keep my staff intact, given that they’re facing a greater workload, competing pressures, and increased
career opportunities from other facilities and consulting
firms looking to hire?
“I know my staff is juggling responsibilities and doing
so much more than simple chart reviews,” says Samantha
Joy, one Illinois-based CDI director whose name has been
changed at the request of her facility.
Joy took over the program two years ago and grew its
staff by 50%. She now has 12 full-time CDI specialists. One
has been working at Joy’s facility for eight years; the newest
staff member started a few months ago. There are no plans
to hire additional staff members due to the ICD-10-CM/
PCS implementation.
Although Joy hasn’t had any trouble with staffing turnover in
the past, and salaries are in line with the ranges reported in her
area (read the 2013 Salary Survey results in the October edition
of the CDI Journal), she understands how valuable CDI expertise
will be in 2014 and wants to be ahead of the curve.
So when her facility’s ICD-10-CM/PCS steering committee began discussing retention bonuses for coding staff,
Joy began researching similar trends in the industry for
her staff as well.
She found only a few facilities who had developed retention bonuses for CDI staff, but that was enough to convince her it was a good idea. So she drafted a proposal, and
received approval in December.
According to the proposal, CDI specialists will receive an
incentive payment for remaining on as staff, staggered and
delivered in the following increments:
»»25% of the incentive payment once they start their ICD10-CM/PCS training
»»25% of the payment once they complete their training,
based on an 85% or higher proved competency rate
»»50% of the payment one year post-ICD-10
­implementation
If these staff members leave the facility for any reason.
they will have to pay back the money they’ve received; and,
of course, they must remain in good standing while on staff,
completing their regular workload and performing their
duties as appropriate, says Joy.
Training is expected to begin early in 2014 and take
about four or five months to complete. CDI specialists will
also review the components of physician training so they
understand what physicians have learned and have the ability
to fill in the gaps if necessary.
“The question is how to reward my staff for taking on
all this additional information, and how can I retain them
once I’ve trained them,” says Joy. “There are not a lot of
facilities doing this yet—either that or they haven’t thought
through to this level of planning so far. So I feel like I am
just one more step ahead.”
Joy may be ahead of the game, but she’s not alone.
Peacehealth System in Oregon has given some thought to
retention bonuses as well. In fact, it started doling them out
back in 2012.
“We are trying to encourage the staff that is here with us
already to stay with us,” says Juanita Carriveau, RN, CCDS,
director of clinical documentation integrity for the system.
“ICD-10-CM/PCS is going to require a lot of extra training, time, work.”
“Once we train our staff, we really can’t afford to lose
them,” adds Janice Schoonhoven, RN, MSN, CCDS, CDI
manager for Peacehealth’s West Network. “It behooves us to
not just stick our heads in the sand here.”
The bonuses—which are a set, flat dollar amount—are
distributed in June and are contingent upon staff members’
successful completion of their ICD-10-CM/PCS training.
Remediation will be provided for staff who do not successfully navigate the training, but in the end all staff members
will be required to pass a competency evaluation to remain
involved in CDI. This must be done by a specific date, which
Peacehealth CDI department has yet to set.
Peacehealth’s CDI staff includes 32 full-time employees
at five facilities; 15% of them are near retirement age (59.5
years old), so she is also looking into job-sharing strategies
and other measures to keep those staff members engaged and
on board.
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“You need to think about what you can do for those who
are near the retirement age,” she says.
Work-from-home arrangements are possible for facilities which have made the transition to a full electronic health
record, but PeaceHealth won’t be fully electronic until 2016,
Carriveau says.
“If we can hold onto those senior people who maybe
still love their jobs but don’t want to work full time, it could
really help us through this transition,” she says.
Retention bonuses and job sharing aren’t the only items
being scrutinized by Peacehealth administration when it
comes to staffing preparedness for ICD-10-CM/PCS
implementation. Carriveau recently instigated the realignment of her CDI staff ’s pay scale to coincide with the area’s
nursing staff since the team is made up entirely of nurses.
“We wanted to eliminate that discrepancy between union
and nonunion workers,” she says. “If we looked at our salaries compared to a bedside nurse’s, we were asking people to
take a cut in pay to become a CDI specialist. Nobody wants
to do that and it doesn’t send the message that we want them
to hear. We want them to know they are valuable members of
the Peacehealth team.”
Carriveau also worries about drops in CDI and coder productivity with the advent of ICD-10; she anticipates a need
for a 20%–50% increase in staff. Coders at Peacehealth began
dual coding in December (see the related article on p. 6) and
were impressed by the additional documentation necessary to
code even routine procedures, she says.
“So that means CDI professionals have to be on board to
get that missing information into the documentation before
it gets to the coders,” Carriveau says.
“We need to start querying related to ICD-10 and get
up to speed on the documentation needs,” says Schoonhoven.
“We need to be as strong as possible in our efforts.”
Add in rumors of CMS reimbursement delays of 30, 60,
or even 90 days, and any delay in discharged/not final billed
claims becomes an additional fiscal burden that facilities may
not be able to withstand, Carriveau says.
“You’re talking about a lot of money for hospitals all
across the country,” she says. “Hospitals with CDI programs
will be looking for additional staffing, and those without
programs will either be looking to start them or looking to
hire consulting firms to do the work for them.”
With an already limited supply of experienced CDI
professionals to pull from, and consulting and staffing
firms actively recruiting from hospitals’ CDI teams—flexible work times, job assignments geared to experience levels,
competitive pay and bonus incentives are needed for successful recruitment and retention as programs move into I-10.
Hospitals have long been incentivizing physicians due to
the provider shortages, and now this is lapping over into the
CDI nursing realm.
Schoonhoven says her staff seems pleased with the promises of bonuses, especially in light of the nation’s overall economic hardship. “Everyone has been through cut after cut
after cut,” in staffing she says, “so being in a group that is
getting something is huge, and it sends a message to the
staff that they are valued.”
And then there are the “intangibles, the soft benefits,”
Schoonhoven adds. As examples, she points to the system’s
strong identity and inclusive mission, her team’s camaraderie,
and staff members’ love of the CDI role.
“We have a lot of those, and they are definitely worth
a lot. We put a lot of energy into considering what we love
about our jobs and ensuring that our staff are both challenged and supported.”
Illustrated by David Harbaugh
“Doctor, this is Gretchen in records. Your documentation reads like
the Declaration of Independence—from compliance.”
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January 2014
9
CDI training
Collaborative approach works best when new staff start
In October 2013, when Lead Clinical Documentation
Specialist Rebekah Foster, RN, CCDS, hired four new
staff members (three full-time and one part-time) at
Kaweah Delta Medical Center in Visalia, Calif., she anticipated starting their training by enrolling them in ACDIS’
CDI Boot Camp. Unfortunately, the class sold out and
the next open session wasn’t until November. Foster
started to panic.
“I was nervous about how well I would explain what I
know. I worried about whether I would be a good teacher,”
she says.
But necessity is the mother of invention—and so, pressed
to do the best she could for her new team, Foster began
gathering educational items into a binder. While she worked,
she kept in mind all the lessons she had learned along the
way since starting in her role two years ago—as well as all
the lessons she hadn’t been taught.
“When I started, we had two weeks of training from
a consultant and then we were sort of on our own,” Foster
says. “When I started thinking about training my own staff,
I wanted to be sure I included items that I would have liked
to have learned, too.”
Since she hired nurses from her own facility, the new
staff members were familiar with the general concept of
CDI and already knew many of the physicians. But since
they were coming fresh from bedside nursing, they needed
to learn to see the medical record from an entirely different perspective—as a tool for coding, data mining, and
­reimbursement.
In her binder, Foster covered the basics by giving definitions for the foundational terms of the job, such as queries,
DRGs, and CCs/MCCs. For the first week, she sat with her
new hires daily.
“Anything I found useful from my own experiences, I
pulled in,” she says.
Together, they covered computer program basics,
reviewed PowerPoint presentations used to train physicians, and spent a day with the coding staff. The new specialists shadowed Foster as she reviewed records and were
free to ask questions during the process. At the end of
the first month, the new specialists shadowed other team
members one on one, rotating between team members to
gain an awareness of each CDI specialist’s various technique and style.
On Fridays the team, now consisting of seven CDI
staff members serving a 400-plus-bed acute care facility,
sat together and talked about the review process. Foster also
met with her new employees to review the week’s lessons and
reinforce key concepts.
“The poor guys were inundated,” she says. “They were
all shocked by how much information there was to learn.
They were amazed that the job wasn’t just about reviewing
records and talking to physicians.”
When the group finally got a chance to participate in the
CDI Boot Camp, Foster attended also.
“It turned out to be good that we waited a few weeks
before attending the Boot Camp. They were a little more
familiar with the information and had an opportunity to
see the process in the flesh, so they got more out of it.
Even I was amazed by how much there was to learn,”
she says.
Set learning goals for CDI growth
Northern Westchester Hospital in Mount Kisco, N.Y.,
recently hired two new CDI nurses. Kerry Seekircher, RN,
CCDS, documentation specialist supervisor there, followed a
training path similar to Foster’s by using her own experiences
as an overarching guide.
The 233-bed facility hired a consultant who came in and
trained the three-person team for two weeks, providing an
overview of CC/MCC basics, DRG definitions, and coding
guideline lessons.
Meanwhile, Seekircher pulled information from materials on the ACDIS website, downloaded items from the
Forms & Tools Library, and incorporated various AHIMA
physician query practice briefs into her own training material handbook. She crafted query exercises, compliance
quizzes, and learning objectives for the team, She also outlined a series of goals, which defined what the new staff
members should expect to understand at the three-month,
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six-month, one-year, and two-year marks. (Read the sample
goals, which you can adapt to your facility’s needs, on pp.
12–13.)
“Coming from bedside nursing, and coming from multiple years of clinical experience, there is a desire to feel reliable in the role, a need to feel like you can immediately do
everything and understand everything,” Seekircher says. “But
that simply isn’t a realistic expectation for a new CDI specialist. You cannot be at the two-year mark when you’ve only
been in the role for three months.”
Such an outline of expectations was “long overdue,” she
adds. “I know that we are going to need additional training
resources as time goes on. We need to illustrate those goals
and set timelines associated with them in order to make sure
the resources are available to help us meet those goals.”
Now three months into their roles, the new staff members have begun querying on their own.
“The hardest thing for me was not receiving that instant
gratification from the physicians,” says Sarah Thomas, RN,
BSN, one of the new team members. Physicians typically
respond quickly to nurses’ concerns on the floor—after all,
a patient’s life may depend on it, Thomas says. In comparison, although responding to queries is still important, it is
“urgent, not emergent,” she says.
Kathleen Foley, RN, one of the new CDI specialists,
was previously in a nurse manager role and has 18 years
of nursing experience. She watched her previous hospital
implement the CDI program and saw it grow. “Yet it’s
really different from what you expect once you get into it,”
Foley says. “Every day we’re learning something new. It’s
both a challenge and a blessing.”
Plan training to incorporate learning styles
The situation at Westchester and Kaweah Delta is similar
to events taking place throughout the country, says Laurie L.
Prescott, MSN, RN, CCDS, CDIP, CDI education specialist for HCPro in Danvers, Mass. When Prescott started in
the role, she received training from a consulting company
and was then immediately sent out to conduct reviews.
“The first time I looked at a chart, I had no idea what I
was looking for,” says Prescott. “I had no idea how to decide
what information was important. I’ve done a lot of things in
my life, but coming into the CDI profession was one of the
steepest learning curves I’ve ever encountered.”
Now, as one of the lead CDI Boot Camp instructors,
Prescott encounters many new professionals and tries to
make their educational experience a positive one.
The first piece of advice she reserves for CDI program
managers? Hire appropriately, she says.
“It isn’t about whether you know X or Y or Z,” Prescott
says, “but whether you have the right personality for the job.”
CDI specialists can come from nursing backgrounds or
they may come from case management, coding, or HIM,
she says. Because there is no CDI school and new staff
members need years of on-the-job experience, there will
always be a need to train them on one aspect of the role
or another.
The role of CDI specialist is best filled by an individual
who is outgoing, positive, eager to learn, and confident
enough to communicate the important facets of what he or
she knows to others, says Prescott.
“Finding someone with enough self-confidence to let you
know what they don’t know is so important in this role, too,”
she says.
When training new hires, managers need to understand
a person’s strengths and weaknesses and work to establish
the best learning strategies for him or her.
Don’t make assumptions about what an individual may
know, Prescott warns. For example, she once hired a former
case manager to the CDI role, assuming that the person
would be knowledgeable about the clinical picture of the
patient. Yet once in the role, the new staff member required
additional training on the particular clinical indicators relevant to the CDI processes.
So with that in mind, it’s important to conduct an
assessment of the individual’s skill set against the expectations of the position, says Prescott. If the new staff member comes from a nursing background, he or she will likely
require additional training on the revenue cycle and coding
basics. If the new staff member comes from coding or
HIM, he or she may need more information about how to
approach physicians and how to interpret clinical indicators
in a concurrent manner.
Once you’ve hired and assessed the individual, you need
to lay the groundwork for his or her training. For example,
when Prescott started she had no idea what a CC or MCC
was, so when such terms were used without explanation
­during her formal training, she immediately felt lost.
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January 2014
11
At a recent ICD-10 for CDI Boot Camp, Prescott taught
a woman who had been on the job for only three days. “I
tried to make sure I came back to her frequently during the
breaks to explain any of the key concepts she missed during
the lectures, but I knew that there was so much information
she was missing because of the advanced nature of the program,” she says.
So Prescott spoke with her manager and helped craft
follow-up training sessions; she also discussed the possibility of retaking the course online in a few months as a way to
review the information.
Prescott suggests that, managers should create an initial
competency checklist, and build on that to create a training
program that includes:
»»Daily assigned readings
»»Regular mentoring and job shadowing
»»Daily assigned homework
Those daily readings should include:
»»AHIMA and ACDIS physician query practice briefs
»»AHIMA and ACDIS Code of Ethics
»»Official Guidelines for Coding and Reporting
»»Key references from the AHA’s Coding Clinic for ICD-9-CM
»»Frequently used terminology such as CC/MCC,
MS-DRG, relative weight, Recovery Auditors,
compliance, etc.
Job shadowing regimens should include one-on-one
time with the manager for at least the first week and should
incorporate shadowing other CDI staff members in their
daily practices, similar to what Foster and Seekircher put
into place. The shadowing process should be three-fold, says
Prescott:
1. Listen: The new employee should round with his or her
coworkers, listening to their interactions with physicians
and other staff members and watching what they do.
2. Mirror: The new staff member and coworker should
review the record together, with the new employee offering suggestions while the mentor points out additional
review possibilities.
Sample goals
Clear goals provide training framework
The following goals were developed by Kerry Seekircher,
RN, CCDS, documentation improvement specialist supervisor at
Northern Westchester Hospital in Mount Kisco, N.Y., to help her
facilitate the training of two new CDI specialists who were hired
Three-month expectations
Upon completion of an extensive three-month fellowship program, the Clinical Documentation Specialist will be able to:
»» Independently perform chart reviews on selected patient care
in 2013. The goals allow the new staff to visualize where they
unit(s) (with the understanding that ongoing support is always
should be in their education at various points along the continuum.
available and expected to be utilized)
Objective
»» Select the most appropriate principal diagnosis as per the
current documentation and identify the need for a query to
The Clinical Documentation Specialist will be responsible for
facilitating concurrent and retrospective queries for documenta-
further support a higher-acuity diagnosis
»» Identify comorbid and major comorbid conditions as per the
tion necessary to capture all significant diagnoses in the inpatient
current documentation and identify the need for a query to
medical record.
further support higher-acuity diagnoses
The Clinical Documentation Specialist assists in improving the
accuracy of our facility’s publicly reported data as well as improv-
»» Effectively deliver queries in a compliant, non-leading manner
»» Maintain organization as evidenced by follow-up reviews,
ing financial reimbursement by capture of the most appropriate
timely responses to queries, and a final review to ensure
DRG assignment.
capture of all appropriate information in the CDIS database
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3. Review: The new staff member conducts record reviews
on his or her own while being shadowed by a manager or
experienced coworker.
“The first step is a learning, educational piece,” says
Prescott. “The second is a hands-on, next step process, and
the final piece is a testing of their learned skills and a reinforcement of their accrued abilities.”
Shadowing should also include time beside the inpatient
coding team, Prescott says. “Ask the inpatient coders to talk
through their process as they are coding the records. The
results can be enlightening for both sides of the experience.”
Shadowing can also be expanded to other areas, such
as case management and quality, so the new staff members
gain an understanding of how the CDI role affects various
departments.
Additionally, Prescott recommends new hires line up a
series of meetings with various department heads to discuss how clinical documentation affects their work. The
CDI manager can either set up the meetings or ask the new
»» Implement basic concepts of who, when, and when not to
staff member to arrange them. By taking meeting organization into his or her own hands, the new staff member gets
a chance to become comfortable with other professionals,
learns the role’s need for interactivity, and has an ­opportunity
to practice his or her interpersonal and investigative skills.
“This isn’t a meeting where the two individuals talk
about the weather, but where the CDI specialist is expected
to ask pointed questions about the role of the person sitting across from them and how CDI efforts can help,” says
Prescott.
Such meetings may take place once or twice a week; they
can include the HIM director, the nurse managers, the physician advisor, and even ancillary employees such as dietitians
or IT staff members.
“I am a big fan of the idea that you can’t do it alone,”
says Prescott. “So when people hire new staff, there really
needs to be that supportive environment built under them
to ensure their success. There is always something more to
learn, especially in this profession. That’s just one of the
things that makes it so rewarding.”
»» Certification is strongly encouraged following two years of
query as per the AHIMA practice brief “Managing an Effective
employment in order to:
Query Process” (2001)
‒‒ Foster professional growth and ongoing commitment to
Six-month expectations
‒‒ Increase the number of nurses with certification as per
excellence as a Clinical Documentation Specialist
»» As above
»» Achieve improved accuracy in DRG selection
»» Increase number of chart reviews, as discussed with
the current recommendation by the American Nurses
Credentialing Center for Magnet™ hospitals (CCDS is one of
the recognized certifications by Magnet)
supervisor, as well as achieve an increased number of
Two-year expectations
appropriate and compliant queries
»» Participate in the formulation of physician/nurse
»» As above
»» Serve as a mentor and role model for new hires
»» Serve as an educator and resource to both the coding and
practitioner education tools (providing input to
CDS newsletter/tip of the week and assisting with
presentations)
»» Participate in ongoing CDS training and preparation for
ICD-10
clinical staff
»» Obtain CCDS certification
»» Independently conduct ongoing education sessions for clinical
staff
One-year expectations
»» As above
»» Assist in implementation of ICD-10
»» Identify problem area(s) requiring additional attention
and focus and strategize in order to make necessary
improvements
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January 2014
13
EHR: Three implementation stories from the CDI front lines
First came the computerized physician order entry (CPOE)
system. Next staff implemented an electronic query/CDI system. Finally there was a move to a full electronic health record
(EHR). When Emory University Orthopedic & Spine Hospital
in Tucker, Ga., decided to phase out various elements of its traditional, paper medical record charts, it took things one piece
at a time, says Linda Franklin-Yildirim, RN, CCDS, a CDI
specialist at the facility.
Unfortunately, integration of the various systems was
far from seamless. For example, after composing a query,
Franklin-Yildirim and her CDI teammates would have to
leave a query notification in the EHR system’s “inbox” for the
physician, and then send the physician a pager message letting
them know a query was waiting for them.
“That’s how long ago we’re talking,” she says with a
laugh. “We were on pagers! The physician would get our
message, and they would go open their inbox and document
their response in the medical record if applicable.”
At the time, the physician query response rate was as low
as 63%, Franklin-Yildirim says. To combat this problem, the
team held in-services to explain how to access the queries
and maneuver within the EHR. Their response rates began
to steadily improve—today it’s roughly 98%.
The initial struggle for Emory’s CDI staff was getting
the query into a user-friendly format for the physicians.
“They want to make their records as complete as possible,
but it has to be simple for them,” says Franklin-Yildirim.
“CDI specialists really need to be the ones to help on this.
We need to make those highlighted points as to how to use
the system and why it’s necessary, to make it as easy and convenient as possible for them.”
Today, Emory’s physicians understand how to navigate
the EHR and can access their queries from their inbox at
their convenience. Some physicians opt to respond after they
get out of surgery, while others send Franklin-Yildirim their
answers late in the evening.
“For them, it’s about finding what suits their workflow
and lifestyle,” she says. “If it’s convenient for them, I’ll get
query responses sometimes at seven or eight at night.”
The key to successful implementation, Franklin-Yildirim
says, is the same no matter the project: Enlist individuals
who have energy and passion for the project to participate
in the rollout, educate peers, and work with the team to seek
methods of process improvement.
“Once they see how successful it can be, everyone wants
to get on board,” she says.
Simplifying the process
When Bernadine Darienzzo, RN, CCDS, CDI supervisor at Boston Medical Center (BMC), started at the 496-bed
academic facility three years ago, the team had to carry their
laptops to the hospital floors due to a lack of available floor
computers and work space. This arrangement led to communication problems. Laptop batteries would run out in a matter
of hours, and it proved difficult to review charts and engage in
conversations with the physicians during patient rounds.
“We tried to tag along, but rounds are fast paced and
focused on daily orders and discharge planning. Physicians
had mostly just come from seeing their patients, so they were
not going directly back to the charts. It just wasn’t the place or
time for us,” she says. “It just wasn’t efficient or productive.”
BMC is a private, not-for-profit facility and one of the
busiest trauma centers in New England, says Darienzzo. The
physicians supported the new program, but they felt it was
disrupting patient care.
As BMC became one of Boston’s first facilities to integrate an EHR, the CDI process migrated away from a floorbased approach. CDI specialists took to their own offices
and attached queries to emails. Physicians had 24 hours to
respond, and the team would send a reminder text message
to their pagers. If a physician did not respond, he or she
would receive another pager message and a follow-up email.
“This was just such an involved process,” Darienzzo says,
“and we wanted to improve our productivity as well as our
physician response rates.”
After BMC migrated to a fully electronic query system,
Darienzzo and her team didn’t rely on the new program to
solve their query problems. She worked with BMC’s IT team
and the vendor to ensure physicians received queries in an
effective yet unobtrusive manner. The IT team made sure that
whenever physicians entered the EHR to update their progress
notes, they first saw the queries attached to the note. They
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January 2014
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would read the content of the query, then scroll down to write
their note.
According to Darienzzo, the positive outcomes of this
new process were immediately apparent. They included:
»»A 70% decrease in follow-up queries
»»A 98% physician query response rate
»»Giving physicians the ability to respond to queries when
and where they document their progress note (e.g., in the
office, at home, or on the floor) rather than having to
remember a query and find it in an alternative system
Now BMC is embarking on an even bigger EHR shift—
transitioning multiple electronic software systems to one
comprehensive vendor over a two-year period. Two physicians
on the planning committee were adamant that they did not
want to lose the convenience of the current query interface,
so Darienzzo and her team have a seat at the transition planning table.
Thankfully, she says, the team is analyzing the workflow
to see how CDI specialists interface with the electronic
systems and how that information flows to physicians and
coders. “They really want to match interface to interface,”
Darienzzo says.
Those seeking to emulate BMC’s EHR success story may
opt to follow Darienzzo’s two-part advice. First, she says,
find a supportive IT partner who will listen to your needs
and help you brainstorm solutions. Second, remember your
own mission and keep physicians engaged by focusing on the
mission and not the almighty dollar.
Connecting systems at the start
The 300-plus bed Sibley Memorial Hospital, a member
of John Hopkins in Washington, D.C., specializes in obstetrics, oncology, and orthopedics. Like many facilities, Sibley
struggled at the outset of EHR implementation to bring the
various facets of multiple systems together into one unit.
“The ED has one system, the radiology department has
another, laboratory department uses something else, and billing and finance have yet another,” says Mark N. Dominesey,
RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, who now
works as the director of auditing and CDI services for Trust
HCS in Washington, D.C.
At Sibley, Dominesey explained how CDI fit into the
EHR implementation process and worked to gain allies
within the IT, HIM, and finance departments to prove that
CDI specialists needed to be involved. He also strove to
identify opportunities for collaboration with IT staff to
develop simple and effective in-house solutions where vendor
products proved too costly and/or cumbersome for the overall system.
CDI specialists need to serve as subject matter experts to
advocate for systemwide standards for certain controversial
clinical conditions, such as acute respiratory failure, sepsis,
and acute kidney disease—much as they would when developing systemwide query forms, Dominesey says.
Additionally, CDI staff can help IT integrate likely clinical scenarios based on indications, medications, and other
documented conditions. Finally, they can help integrate
necessary ICD-10-CM/PCS elements and craft easy-to-use
query templates.
Since physicians have become used to CDI specialists as
their go-to documentation team, most of them feel comfortable working through the EHR processes with the specialists.
CDI staff can provide physicians and other clinical staff with
information regarding EHR use and resource management;
they can also help clinicians see how their documentation gets
reflected in quality ranking scores.
“Having a designated CDI person as an EHR documentation resource person is a great idea, but that responsibility
should be written into a new staff member’s job description so
that aspect doesn’t overwhelm their typical chart review priorities,” notes Dominesey.
Although some may be “clinging to the paper chart,
the pre-EHR world just isn’t viable anymore. However, if
physicians are forced to point and click their way through
the EHR, then we will lose any of the benefit associated
with the transition,” Dominesey says. “CDI principles have
to be included during the outset of the process, and ongoing assessment of those tools needs to be developed into an
additional CDI target area. CDI principles need to be baked
into the electronic solution and not be sandwiched in later as
an afterthought.”
Editor’s note
Franklin-Yildirim is a former leader of the Georgia ACDIS chapter. She related her
experiences with electronic query implementation to the group during its fall 2013
meeting. Darienzzo presented a poster on this topic at the 2013 ACDIS national conference in Nashville. Dominesey was a speaker at the 2013 ACDIS conference. ACDIS
members can download his PowerPoint presentation from the Forms & Tools Library
at www.acdis.org.
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January 2014
15
Meet a member
What a trip: Member recounts CCDS exam experience
Christina Raad, RN, CCDS, works at Central DuPage
Hospital in Winfield, Ill., and has been a member of the
Northern Illinois ACDIS networking group and a CDI
specialist for 10 years. She has three wonderful children, two
lovely daughters-in-law, and three grandkids, with a fourth
on the way.
Raad recently wrote to ACDIS to say that, surprisingly,
she enjoyed taking the Certified Clinical Documentation
Improvement Specialist (CCDS) exam! So many people
write to express their worry or to say how daunting the exam
seems, but Raad has quite a different story.
CDI Journal: How did you come to ‘enjoy’ taking the CCDS
exam?
Raad: The night before the exam I was walking my dog,
Charlie, and I fell. I tripped over a bump on the sidewalk,
skidded on the cement, and knocked out a front tooth. I was
bleeding everywhere from numerous abrasions (mostly on
my face) and my glasses were badly scratched. Thankfully, I
wasn’t too badly injured. So I got up quickly, and was glad to
see Charlie right there waiting for me. I did not want someone to see me and call 911! I got myself home and was glad
to see I did not need stitches. I applied ice and went to bed
because I knew I was taking my test the next morning.
The next morning, I looked pretty sad. It wasn’t just a
bad hair day; it was a bad face day! My top lip was massively
swollen. I sort of looked like a duck. So to pass the test after
not sleeping very well and looking like I did, well, it meant
that my brain works pretty well and that I really do know my
stuff when it comes to my role in CDI.
I was looking forward to taking the test all week. I’m
65 and may be getting older, but my mind and spirit are just
fine. This year I received my Medicare card (a mandatory
process when you turn 65). It startled me to see the red,
white, and blue card which I previously associated with “old
people” there in my hands with my name on it. At any rate, I
knew halfway through the test that I would pass and that I’m
competent at CDI.
I’m very grateful to ACDIS for the information on their
website that I used to study for the exam.
CDI Journal: Not only did she pass, she scored an 87! Will you tell
us what prompted you to decide to sit for the credential?
Raad: I am not sure why I did not get the CCDS certification years ago, but I decided that if I could qualify for
Medicare, I should certainly get certified. I studied by using
my DRG book instead of the grouper for a month, and went
through many of the ACDIS blogs and old conference material. I was really excited to take the test.
CDI Journal: What did you do before becoming a CDI specialist?
Raad: After graduating from a three-year diploma
program (does anyone else remember what a hopper is?) I
worked in the ED. I also have worked in a psychiatric hospital, home health, staff development, in an allergy and asthma
clinic, case management, and in a nursing home.
Courtesy Photo
Christina Raad poses with her pet Charlie.
CDI Journal: Why did you decide to make the career switch to CDI?
Raad: I took a job as a case manager and was not very
happy, so when a coding position was created, I applied. The
job description was rather vague, but I really wanted to make a
move. It’s one of the best impulsive decisions I ever made.
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January 2014
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CDI Journal: What has been your biggest challenge? Raad: Developing the ability to see a medical record as
a coder interprets it, trying to discern what the physician
thinks he is documenting, then using my clinical knowledge
to connect it all together was a difficult thing to learn. The
interpersonal skills required were also difficult to manage.
You have to balance egos, feelings, personalities, compliance
issues, administrative goals, and still come out smelling like a
rose. And that’s not easy!
CDI Journal: How has the field changed since you began working
in CDI?
Raad: It has changed tremendously from a financially
based program, fairly limited in scope, to one that emphasizes quality documentation in many different areas. A CDI
program today can be very different from one institution to
another. I love the creativity I see among various programs.
CDI Journal: Can you mention a few of the gold nuggets of
information you’ve received from colleagues on “CDI Talk” or through
ACDIS?
Raad: I had been doing CDI for several years, but other
than my coworkers, I had met just a couple of other CDI
specialists. When ACDIS started up, I felt like I had found a
support group for my “non-dysfunctional problem!” Finally
there were people who could commiserate with my experiences, encourage me to keep at it—people who simply just
understood what it means to be a CDI.
Besides that, I am grateful to ACDIS for all the fine education, resources, and networking opportunities they have
provided. And I am grateful to the CDI nurses and the coders I work with for all they have taught me. Onward to the
next challenge: ICD-10!
CDI Journal: If you could have any other job, what would it be? Raad: A studio musician in a recording studio.
CDI Journal: Can you tell us about a few of your favorite things?
»»Vacation spots: Anywhere
»»Hobby: Sewing, quilting, knitting, crocheting
»»Non-alcoholic beverage: Diet Dr. Pepper
»»Foods: Mexican
»»Activity: Yoga/Pilates/meditation
Editor’s note
CDI Journal introduces an ACDIS member in each issue. If you would like to be featured or know someone who would, please email ACDIS Member Services Specialist
Penny Richards at [email protected].
Fight the Recovery Raiders!
Conduct reviews with Recovery Auditor denials in mind
by Trey La Charité, MD
Reducing mistakes and eliminating
fraud are the dual goals in today’s claims
auditing environment. While these goals
are admirable, the aggressive strategy
typically executed by Recovery Auditors
and other auditing agencies to achieve those goals is fundamentally flawed.
The reality is that our healthcare facilities are subjected to a myriad of “Recovery Raiders” that scrutinize
everything—from how many units of a drug were billed
to whether or not a patient actually needed to be admitted
to the hospital. Whether contracted by the federal or state
government or employed by the private insurance companies,
these entities lack appropriate oversight and accountability.
Coding is hard, our coding system is complex, and yes,
we humans make coding mistakes. However, honest coding
errors do not warrant the brazen tactics employed by auditors in an effort to grow their coffers at the expense of our
patients’ care.
The unfortunate reality is that most facilities do not have
the resources necessary to lobby Washington to correct the
current situation. Being pragmatists, we must do the best we
can with the resources we have.
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January 2014
17
One of the main goals of a CDI program is to help
audit-proof a facility’s medical records. To achieve this
objective, every denial must be turned into a learning
opportunity.
Over the years, my facility experienced all varieties of
denials, ranging from perfectly appropriate (i.e., we coded
it wrong!) to egregious attempts to paint our facility as
committing fraud. The observations that follow offer strategies to better protect your facility from auditors’ denial
attempts.
Defend single CC/MCC targets
An auditor’s sole reason for issuing denials is to recoup
a portion of a facility’s previously received reimbursements.
For example, if you have submitted a claim that has four
MCCs, the auditors are not going to waste time verifying
whether or not the clinical criteria for acute respiratory failure were met during that admission. Auditors are looking
for the most vulnerable charts they can find and exploit—
records that have only one CC or only one MCC listed on
the coding summary form, for example.
Unfortunately, auditors can easily discern which charts
fall into these categories from the UB-04 form. If the auditor can disprove, deny, or disallow that solitary CC or MCC
by some mechanism, the MS-DRG would be downgraded to
a lower-weighted submission, resulting in an auditor’s favorite statement: “An overpayment has been noted.” Therefore, a
submission with only one documented CC or MCC needs to
be absolutely bulletproof.
Although auditors do not issue denials to help you
improve your documentation and coding practices, that
doesn’t mean you cannot learn from their actions, adapt your
efforts, and audit-proof your records. The following is a list
of common Recovery Auditor tactics employed to remove a
single CC or single MCC from our records:
»»Challenging whether or not a diagnosis meets the
accepted criteria to be considered a legitimate, secondary
diagnosis. A valid secondary diagnosis must meet one of the
five following standards:
1. The condition required clinical evaluation
2. The condition required therapeutic treatment
3. The condition required diagnostic workup
4. The condition extended the patient’s length of stay
5. The condition increased the level of nursing care and/or
monitoring that the patient required
If the auditor can prove that a given diagnosis did not
touch on one of those five standards, they will deny your
claim, and should you choose to appeal that denial, you
will lose.
»»Challenging your provider’s definition of a clinical diagnosis based on criteria favorable to the auditor’s
­position. For example, some auditors have attempted to disallow the diagnosis of acute renal failure based on the outdated RIFLE criteria, completely ignoring the more recently
accepted definition of acute renal failure put forth by the
Acute Kidney Injury Network. When your facility collectively sets clinical standards that align with industry best
practice, you can use these standards to defend your claim.
Do not blindly accept an auditor’s stance.
»»Challenging the coding of a given diagnosis if
the auditor believes there was conflicting or contradictory documentation between providers regarding that
­diagnosis. For example, Provider #1 called something “X,”
but Provider #2 called the same thing “Q.” If you coded X
instead of Q (and removing X would result in an MS-DRG
downgrade), the auditor will deny the claim for X and state
that you should have queried prior to claim submission to
clear up the “conflicting or contradictory documentation.”
»»Challenging your medical staff ’s clinical judgment.
An auditor once stated they did not believe a patient had
an acute myocardial infarction, as diagnosed by one of my
board-certified cardiologists. The auditor’s position was that
the patient’s elevated troponin levels could have been due to
a number of other disease processes and not just the documented acute myocardial infarction.
The auditor ignored the fact that my cardiologist
had dictated in his consultation that “this patient’s elevated
troponins most likely represent a Type II acute myocardial
infarction.” The auditor further brushed aside the fact that
the cardiologist carried the diagnosis throughout the rest of
the chart and listed it in the discharge summary. These types
of situations should be appealed.
»»Challenging your coder’s selection of principal diagnosis. As you are aware, changing a given principal diagnosis
may alter which additional documented diagnoses qualify as
a CC or an MCC.
I’ll say it again: Coding is hard, and poor documenta-
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tion by providers makes it harder. However, due diligence
must be paid to this issue so that the final choice of principal diagnosis is as accurate as possible.
Remember, according to the Uniform Hospital
Discharge Data Set (UHDDS) Guidelines, the principal
diagnosis is the condition after study that occasioned the
admission. The principal diagnosis isn’t simply the reason
that the patient came to the hospital, but the condition
the physician determines to be the reason for that person’s
admission and the required level of treatment.
All post-discharge queries must be answered prior to final
claim submission. Our philosophy is quite simple—the more
eyes that review a given chart, the higher the probability a
potential liability will be discovered and addressed prior to
auditor review.
While this level of dedication is necessary in today’s
auditing environment, one must be prepared for the
increased volume of queries it generates. Provider frustration
due to increased post-discharge query volumes and our internal difficulties keeping track of those post-discharge queries
became issues we had to address.
Identify additional audit challenges
In addition to challenging a solitary CC or MCC, we
have seen other strategies auditors use to issue denials,
including the following scenarios:
»»Challenging coder selection for procedures. We have
noticed auditors have a particular penchant to deny anything considered a valid OR procedure, such as excisional
debridements and fiberoptic bronchoscopies. As valid OR
procedures have a huge financial impact on any given submission, auditors find these to be irresistible targets.
»»Challenging code selection through blatant guideline
misinterpretation and manipulation. When an auditor
quotes a citation from the AHA’s Coding Clinic for ICD-9CM or the Official Guidelines for Coding and Reporting, be sure
to reread the specific guideline in its entirety. We have seen
examples of auditors who take only a portion of a specific guideline and use the guidance out of context. If you
do not take the time to review the statements against the
actual guidelines, it can seem as if the auditor has a legitimate point.
Develop post-discharge query processes
Ideally, all of the above documentation questions would
be resolved prior to the patient’s discharge. However, most
facilities simply do not have enough CDI personnel required
to accomplish this lofty goal. Therefore, a strong post-discharge query process is an absolute imperative.
In our facility, we convert any unanswered concurrent
queries issued by our CDI specialists to post-discharge
queries. Additionally, any new documentation discrepancies
or diagnosis validation issues discovered by our coders are
addressed with the involved providers as post-discharge queries.
My ultimate hope is that our providers learn
that the need for queries, whether concurrent
or post-discharge, completely depends on their
documentation habits at the time they actually
take care of the patient.
In response, we created a new position within our CDI
program: a CDI clerk. This person’s responsibilities include
post-discharge query distribution, query tracking, and query
collection upon provider completion. Our providers are now
more comfortable with the post-discharge query process as
they have a consistent and familiar representative available
to answer their questions. Additionally, we now know where
every query is in the hospital at any given moment.
In summary, Recovery Auditors’ efforts are a painful reality for all healthcare facilities. Fighting every incorrect and
inappropriate denial is a necessity to preserve your institution’s bottom line and facilitate your patient care mission. In
my opinion, the best defense against the Recovery Auditors
is a good offense, as the adage goes. Therefore, my advice is
to ensure that the auditors are never able to issue a denial in
the first place.
My ultimate hope is that our providers learn that the
need for queries, whether concurrent or post-discharge, completely depends on their documentation habits at the time
they actually take care of the patient.
Editor’s note
La Charité is a hospitalist with the University of Tennessee Hospitalists at the
University of Tennessee Medical Center at Knoxville (UTMCK) and an ACDIS advisory
board member. His comments do not necessarily reflect those of UTMCK or ACDIS.
Contact him at clacha­[email protected].
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January 2014
19
Clinical corner
Revisiting respiratory failure
by Richard D. Pinson, MD, FACP, CCS
The diagnosis and documentation of
respiratory failure continues to be challenging for coders, documentation specialists, and
physicians. Many physicians, including pulmonologists, are unaware of the current clinical standards for diagnosing acute respiratory failure and commonly overlook the
presence of chronic respiratory failure. Yet they typically identify multiple clinical criteria and provide appropriate management for respiratory failure, which creates query opportunities.
In this article, we will discuss a variety of clinical indicators for respiratory failure and identify a number of common documentation improvement opportunities.
Definition of acute respiratory failure
Acute respiratory failure is classified as hypoxemic (low
arterial oxygen levels), hypercapneic (elevated levels of carbon dioxide gas), or a combination of the two. In most cases
one or the other predominates. For ICD-9, these terms,
being “nonessential modifiers,” are irrelevant for code assignment. ICD-10, however, has codes that permit a distinction
(see Table 1), but the distinction is not a requirement and
queries for it will not alter its MCC classification. The clinical criteria for diagnosing acute respiratory ­failure are:
»»Hypoxemic: Partial pressure of oxygen (pO2) level less
than (<) 60 millimeter(s) of mercury (mmHg) (oxygen
saturation [SpO2] < 91%) on room air, or pO2/fraction of inspired oxygen (FIO2) (P/F) ratio < 300, or 10
mmHg decrease in baseline pO2 (if known)
»»Hypercapnic: Partial pressure of carbon dioxide (pCO2)
>50 mmHg with pH < 7.35, or 10 mmHg increase in
baseline pCO2 (if known)
With the exception of the P/F ratio, these criteria have
also been offered as assistance to coders and documentation
specialists for recognizing possible acute respiratory failure
(see AHA’s Coding Clinic for ICD-9-CM, Third Quarter 1988,
p. 7; and Second Quarter 1990, p. 20).
Management that requires endotracheal intubation and
mechanical ventilation or initiation of biphasic positive air-
way pressure (BiPAP) nearly always means the patient has
acute respiratory failure, but these measures are not required
for the diagnosis. Similarly, providing 40% or more supplemental oxygen implies that the physician is treating acute
respiratory failure since only a patient with acute respiratory
failure would need that much oxygen.
Acute hypoxemic respiratory failure
The gold standard for the diagnosis of hypoxemic
respiratory failure is an arterial pO2 on room air less than
60 mmHg measured by arterial blood gases (ABG). In the
absence of an ABG, SpO2 measured by pulse oximetry on
room air can serve as a substitute for the pO2: SpO2 of
91% equals pO2 of 60 mmHg. These criteria may not apply
to patients with chronic respiratory failure (e.g., severe chronic obstructive pulmonary disease [COPD]), because their
room air pO2 is often less than 60 mmHg (SpO2 < 91%).
Chronic respiratory failure patients are treated with
supplemental oxygen on a continuous outpatient basis to keep
arterial oxygen above these levels. However, if the baseline
pO2 is known, a decrease by 10 mmHg or more indicates
acute hypoxemic respiratory failure in such a patient.
The P/F ratio
The P/F ratio is a powerful objective tool to identify
acute hypoxemic respiratory failure at any time while the
patient is receiving supplemental oxygen, a frequent problem
faced by documentation specialists where no room air ABG
is available, or pulse oximetry readings seem equivocal.
The P/F ratio equals the arterial pO2 (“P”) from the
ABG divided by the FIO2 (“F”)—the fraction (percent)
of inspired oxygen that the patient receives expressed as a
­decimal (40% oxygen = FIO2 of 0.40). A P/F ratio less
than 300 indicates acute respiratory failure.
Most physicians have never heard of the P/F ratio, but
it was validated and has been used in the context of acute
respiratory distress syndrome (ARDS) for many years, where
acute respiratory failure is called “acute lung injury.” A P/F
ratio < 300 indicates mild ARDS, < 200 is consistent with
moderate ARDS, and < 100 is severe ARDS. The P/F ratio
indicates what the pO2 would be on room air:
»»P/F ratio < 300 = a pO2 < 60 mm Hg on room air
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»»P/F ratio < 250 = a pO2 < 50 mm Hg on room air
»»P/F ratio < 200 = a pO2 < 40 mm Hg on room air
As an example, suppose the pO2 is 90 mmHg on 40%
oxygen (FIO2 = .40). The P/F ratio = 90 divided by .40
= 225 (rather severe acute respiratory failure). The pO2 on
room air in this case would have been about 45 mmHg (well
below the “cutoff ” of 60 mmHg).
The validity of the P/F ratio is not limited to ARDS.
It simply expresses a consistent physiologic relationship
between inspired oxygen and arterial pO2 regardless of
cause. Authoritative applications of the P/F ratio in settings other than ARDS include pneumonia and sepsis. The
Infectious Disease Society of America and the American
Thoracic Society recognize a P/F ratio less than 250 as one
of the 10 criteria for “severe” community-acquired pneumonia
that may require admission to intensive care. The International
Sepsis Definition criteria (2001) and the Surviving Sepsis Severe Sepsis Guidelines (2008 and 2012) use a P/F ratio <
300 as an indicator of acute organ (respiratory) failure.
SpO2 may be translated to pO2
The arterial pO2 measured by ABG is the definitive
method for calculating the P/F ratio. However, when the
pO2 is unknown because an ABG is not available, the SpO2
measured by pulse oximetry can be used to approximate the
pO2, as shown in Table 2. It is important to note that estimating the pO2 from the SpO2 becomes unreliable when
the SpO2 is greater than 97%.
For example, suppose a patient on 40% oxygen has a
pulse oximetry SpO2 of 95%. Referring to Table 2, SpO2
of 95% is equal to a pO2 of 80 mmHg. The P/F ratio =
80 divided by 0.40 = 200 (quite severe acute respiratory
failure). The patient may be stable receiving 40% oxygen, but
still has acute respiratory failure. If oxygen were withdrawn,
leaving her on room air, the pO2 would only be 42 mmHg
(much less than 60 mmHg on room air).
Translating supplemental oxygen
since only such a patient would need that much oxygen.
A nasal cannula provides oxygen at adjustable flow rates
in liters of oxygen per minute (L/min or LPM). The actual
FIO2 (percent oxygen) delivered by nasal cannula is somewhat variable and less reliable than with a mask, but can be
estimated as shown in Table 3. The FIO2 derived from nasal
cannula flow rates can then be used to calculate the P/F ratio.
For example, a patient has a pO2 of 85 mmHg on ABG while
receiving 5 L/min of oxygen. Since 5 L/min is equal to 40%
oxygen (an FIO2 of 0.40), the P/F ratio = 85 divided by
0.40 = 212.5 (clearly severe acute respiratory failure).
Acute hypercapneic respiratory failure
The hallmark of acute hypercapneic respiratory failure is
Table 1: ICD-10-CM codes for
respiratory failure
The following codes are applicable for respiratory failure
under ICD-10-CM:
»» J96.0: Acute respiratory failure (MCCs)
ΩΩ J96.00: unspecified whether with hypoxia or
­hypercapnia
ΩΩ J96.01: with hypoxia
ΩΩ J96.02: with hypercapnia
»» J96.1: Chronic respiratory failure (CCs)
ΩΩ J96.10: unspecified whether with hypoxia or
­hypercapnia
ΩΩ J96.11: with hypoxia
ΩΩ J96.12: with hypercapnia
»» J96.2: Acute and/on chronic respiratory failure (MCCs)
ΩΩ J96.20: unspecified whether with hypoxia or
­hypercapnia
ΩΩ J96.21: with hypoxia
ΩΩ J96.22: with hypercapnia
»» J96.9: Respiratory failure, unspecified
Supplemental oxygen may be administered by mask
or nasal cannula. A Venturi mask (Venti-mask) delivers a
controlled flow of oxygen at a specific fixed concentration
(FIO2): 24%, 28%, 31%, 35%, 40%, and 50%. The nonrebreather (NRB) mask is designed to deliver approximately
100% oxygen. Providing 40% or more ­supplemental oxygen
implies that the physician is treating acute respiratory failure
ΩΩ J96.90: Respiratory failure, unspecified, (unspecified
whether with hypoxia or hypercapnia)
ΩΩ J96.91: Respiratory failure, unspecified with hypoxia
ΩΩ J96.92: Respiratory failure, unspecified with hypercapnia
(excludes newborn, postprocedural, ARDS, respiratory
arrest, and cardiorespiratory failure)
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elevated pCO2 due to retention/accumulation of carbon dioxide gas resulting in an acidic pH less than 7.35. There are many
causes, but severe COPD is the most common. Physicians can
establish a diagnosis by viewing a pCO2 greater than 50 mmHg
with a pH less than 7.35. If the pH is greater than 7.35, the
patient has chronic (not acute) respiratory failure.
Physicians often identify this clinical condition as “respiratory acidosis,” which is the same thing as acute hypercapneic
respiratory failure. Unfortunately, the code for “respiratory acidosis” is 276.2, which is a CC, in contrast to the MCC status of
acute respiratory failure—hence the need for clarification.
Also, if the baseline pCO2 is known, an increase of 10
mmHg or more indicates acute hypercapneic respiratory
failure. Finally, an exacerbation of symptoms requiring an
increase in chronic supplemental oxygen indicates an “acute
exacerbation” of chronic respiratory failure, which would be
Table 2: Conversion of SpO2 to pO2
to pO2:
pO2 (mmHg)
85
50
86
51
87
52
88
54
89
56
90
58
91
60
92
64
93
68
94
73
95
80
96
90
97
110
Note: Estimating the pO2 from the SpO2 becomes unreliable when the SpO2 is greater than 97%.
Chronic respiratory failure
Chronic respiratory failure is very common in patients
with severe COPD and other chronic lung diseases such as
cystic fibrosis and pulmonary fibrosis. It is characterized
by a combination of hypoxemia, elevated pCO2, elevated
bicarbonate level, and normal pH (7.35–7.45). The most
important tip-off to chronic respiratory failure is chronic
dependence on supplemental oxygen (“home O2”).
Patients who qualify for home O2 almost always have
chronic respiratory failure. Another clue is an elevated bicarbonate level on the basic metabolic panel (BMP) in a COPD
patient, especially helpful when no ABG was obtained.
For example, consider a patient admitted with CHF
exacerbation and a history of severe COPD. ABG on room
air shows pH 7.40, pCO2 52 mmHg, and pO2 70 mmHg;
bicarbonate level on BMP is elevated at 42. This is classic
chronic respiratory failure: normal pH, elevated pCO2 and
bicarbonate, with hypoxemia—but no acute criteria.
Acute-on-chronic respiratory failure
The following chart illustrates the conversion of SpO2
SpO2 (percent)
classified as acute-on-chronic respiratory failure if properly
documented.
When a patient experiences an acute exacerbation or
decompensation of chronic respiratory failure, he has
­“acute-on-chronic” respiratory failure. It is recognized by any
of the following:
»»Worsening symptoms
»»Greater hypoxemia (hypoxemic)
»»Elevated pCO2 with pH < 7.35 (hypercapneic)
During an acute exacerbation, acidic carbon dioxide
(pCO2) may accumulate rapidly (“CO2 retention”), causing
acidosis with a pH < 7.35 (acute hypercapneic respiratory
failure). This would be acute-on-chronic respiratory failure.
Worsening of symptoms requiring an increase in supplemental oxygen also indicates an “acute exacerbation” of chronic
respiratory failure.
Use hypoxemic criteria (pO2, SpO2, and P/F ratio) in
patients with chronic respiratory failure with caution. Many
of these patients always have a pO2 < 60 mmHg on room
air, which is the reason they use supplemental oxygen. For
such patients, the pO2/SpO2 criterion can be applied, not
on room air, but while receiving their usual supplemental
oxygen flow. Why? Because home O2 is adjusted to maintain
a pO2 > 60 mmHg (SpO2 > 91%). Therefore, if the pO2
is < 60 mmHg on the usual supplemental oxygen flow rate,
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acutely decompensated respiratory failure has occurred.
Do not use the P/F ratio to diagnose acute-on-chronic
respiratory failure since it is typically < 300 in these patients
at baseline. It may be used to monitor the patient’s clinical
progress over time; if it keeps dropping, the patient is getting
worse and needs more aggressive treatment.
Post-procedural respiratory failure
The diagnosis of respiratory failure following surgery has
profound regulatory and quality of care implications. If identified as “postop,” “due to,” or “complicating” a procedure,
respiratory failure is classified as one of the most severe, lifethreatening, reportable surgical complications a patient can have.
This diagnosis adversely affects quality scores for both the
hospital and the surgeon. On the other hand, the diagnosis and
coding of post-procedural respiratory failure (an MCC) often
results in large payment increases for hospitals. If improperly
diagnosed without firm clinical grounds, it may become the
basis for regulatory or contractual audits, penalties, sanctions,
and even legal action affecting the hospital and the physician.
Post-procedural respiratory failure is a lucrative Recovery
Auditor target. Facilities should have a policy that governs
the coding of any condition (including respiratory failure)
not supported by clinical criteria in the medical record.
To validate the diagnosis, the patient must have acute
pulmonary dysfunction requiring nonroutine aggressive
measures. A patient who requires a short period of ventilator
support during surgical recovery does not have acute respiratory failure; do not assign a code in this instance. The same
is true for any duration of mechanical ventilation that is
usual or expected following the type of surgery performed,
unless there truly is underlying acute pulmonary dysfunction.
A further difficulty arises because coding rules inexplicably
call for coding of postop respiratory failure as a complication
of care even when terms that seem clinically innocuous to physicians are used in the postop setting, such as pulmonary insufficiency (acute or not) and acute respiratory insufficiency. To
avoid confusion and improper code assignment, instruct your
physicians not to use such terms in the postoperative setting
unless the patient actually has acute respiratory failure.
If the patient has acute respiratory failure following surgery, but it is truly due to, primarily the result of, or related
to a preexisting medical condition (such as COPD, CHF,
a neuromuscular disorder, etc.), ask the physician to clearly
document this connection to avoid the incorrect assignment
of a code for post-procedural respiratory failure. For example, something like: “acute respiratory failure in the postop
setting primarily due to preexisting CHF.”
Summary
Understanding the pathophysiology and authoritative
clinical criteria for the several types of respiratory failure
empowers coders and documentation specialists to confidently recognize, query, validate, and compliantly code
these conditions. The two basic types of respiratory failure
are hypoxemic and hypercapneic, sometimes occurring in
combination. The distinction is clinically important but not
required for correct coding using either ICD-9 or ICD-10.
The P/F ratio is a powerful diagnostic, prognostic, and clinical management tool: P/F ratio < 300 indicates acute respiratory failure. However, the acute hypoxemic criteria (pO2/SpO2
and P/F ratio) must be applied with caution to the diagnosis
of acute-on-chronic respiratory failure since they are frequently
abnormal in the patient’s stable, chronic, baseline state.
Carefully consider the implications of diagnosing and
coding post-procedural respiratory failure; clarify any potential relationship to preexisting conditions when present.
Editor’s note
Pinson is a certified coding specialist and a principal partner at HCQ Consulting
(www.hcqconsulting.com). He is coauthor of The CDI Pocket Guide and the CDI+ and
CDI+MD mobile apps.
Table 3: Conversion of nasal cannula
oxygen flow rate to FIO2
The following figures illustrated the conversion of nasal
cannula oxygen flow rate to FIO2:
Flow Rate
FIO2
1 L/min
24%
2 L/min
28%
3 L/min
32%
4 L/min
36%
5 L/min
40%
6 L/min
44%
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December ACDIS ICD-10-CM/PCS query preparation survey results
1. To date, have your CDI staff received information to raise their awareness of ICD-10 implementation and documentation
improvement needs?
Answer options
Response percent
Response count
Yes
87.7%
100
No
12.3%
14
Other (please specify)
0
answered question
skipped question
114
0
2. To date, have your CDI staff received ICD-10 training on the code set?
Answer options
Response percent
Response count
Yes
67.5%
77
No
32.5%
37
Other (please specify)
0
answered question
skipped question
114
0
3. To date, have your CDI staff assisted with the ICD-10 education of physicians?
Answer options
Response percent
Response count
Yes
31.5%
35
No
68.5%
76
Other (please specify)
3
answered question
skipped question
111
3
4. Have you to date, or do you plan to, train CDI staff on the actual ICD-10 code set?
Answer options
Response percent
Response count
Yes
90.8%
99
No
9.2%
10
Other (please specify)
7
answered question
skipped question
109
5
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5. Which of the following query templates do you use in your organization today?
Answer options
Response percent
Response count
Anemia
89.5%
85
Angina
36.8%
35
CAD
32.6%
31
Cause and effect
54.7%
52
Coma
21.1%
20
Complication
47.4%
45
Diabetes
50.5%
48
Diabetes, controlled or uncontrolled
41.1%
39
Fracture
31.6%
30
Heart failure
95.8%
91
Liver failure
14.7%
14
Malnutrition
88.4%
84
Renal failure
84.2%
80
Respiratory failure
82.1%
78
Sepsis
90.5%
86
Other (please specify)
26
answered question
95
skipped question
19
6. Have you conducted an inventory of your physician queries by type and frequency?
Answer options
Response percent
Response count
Yes
37.5%
42
Yes, by type
11.6%
13
Yes, by frequency
8.9%
10
No
34.8%
39
Don’t know
7.1%
8
Other (please specify)
1
answered question
skipped question
112
2
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December ACDIS ICD-10-CM/PCS query preparation survey results (cont.)
7. Have you started to audit (review) and update queries for ICD-10 language changes?
Answer options
Response percent
Response count
Yes
18.2%
20
Yes, we have audited our queries
8.2%
9
Yes, we have audited our queries and updated them for ICD-10
10.9%
12
No
30.9%
34
No, but we plan do this in the first quarter of 2014
29.1%
32
Don’t know
2.7%
3
Other (please specify)
7
answered question
skipped question
110
4
8. Does your compliance department review new/updated physician queries to ensure they are compliant?
Answer options
Response percent
Response count
Yes
29.5%
33
No
53.6%
60
Don’t know
17%
19
Other (please specify)
5
answered question
skipped question
112
2
9. Do your physicians review new/updated queries?
Answer options
Response percent
Response count
Yes
5.5%
6
Yes, our physician advisor reviews all new/updated queries
20%
22
Yes, our physicians review any new/updated queries by specialty
5.5%
6
No
61.8%
68
Don’t know
7.3%
8
Other (please specify)
7
answered question
skipped question
110
4
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10. Does your CDI program staff meet regularly with your HIM/coding staff?
Answer options
Response percent
Response count
Yes
19.1%
21
Yes, weekly
10%
11
Yes, monthly
30%
33
Yes, quarterly
15.5%
17
No
24.5%
27
Don’t know
0.9%
1
Other (please specify)
5
answered question
skipped question
110
4
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January 2014
27