Transcript
JULY 2015
Preventing Healthcare’s Top
Four Documentation Disasters
24 Reinvigorating Your CDI Program
46 Best Practices in the Art of CDI
52 CDI in the Outpatient Setting
Welcome
TO THE DIGITAL EDITION OF THE
JOURNAL AHIMA
OF
Video Extra—The Role of CDI in ICD-10
Two experts give their best advice on CDI prep for ICD-10.
Reinvigorating
YOUR CDI PROGRAM
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WE’VE BEEN PREPARING FOR YEARS
With ICD-10 right around the corner – we continue to recruit, train and support the most
dedicated staff around. In the last year alone we have recruited more than ten top individuals to
add to our growing HIA family. This commitment to our clients will ensure we are ready to support
you and the higher demand ICD-10 will bring. Together we will move forward with confidence.
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Contents July 2015
Cover
18
Preventing Healthcare’s Top Four
Documentation Disasters
By Mary Butler
Vol. 86, no. 7
Departments
8
President’s Message
The New Frontier of Clinical
Documentation Improvement
10
Bulletin Board
pg. 24
ICD-10 and increasing documentation audits are causing some to
make over their CDI programs.
Features
24
Reinvigorating Your CDI Program
By Kristen Geissler, MS, MBA, CPHQ, and Joni Dion, RHIA, CDIP,
CCDS, CPC
28
Closing the Loop on Quality and CDI
Refocusing programs to ensure an accurate
picture of clinical care
By Joseph J. Gurrieri, RHIA, CHP; Cassie Milligan, RHIT, CCS; and
Paul Strafer, RHIA, CCS
32
Survey Predicts Future HIM
Workforce Shifts
HIM industry estimates the job roles, skills
needed in the near future
By Ryan Sandefer, MA, CPHIT; David Marc, MBS, CHDA;
Desla Mancilla, DHA, RHIA; and Debra Hamada, MA, RHIA
14
Word from Washington
Advancing Stage 3 Meaningful Use and
2015 EHR Certification Criteria
17
Inside Look
Linking the Right Info and the Right
Person… at the Right Time
60
Calendar
61
Keep Informed
62
Volunteer Leaders
65
AHIMA Career Center
68
Addendum
Battle of the Century:
Watson vs. Big Data
Contents July 2015
Working Smart
36
42
By Kathy Downing, MA, RHIA, CHPS, PMP, and
Jessica Mason
By Katherine Lusk, MHSM, RHIA
Navigating Privacy and Security
ONC Targets Information Blocking
40
e-HIM Best Practices
Clinical Documentation
Improvement’s Main Ingredient:
‘Physicians First’
Standards Strategies
Clinical Definition Standards
Case Study
44
Quality Care
The New CDI Challenge:
Adjusting to Quality, Not Quantity
By Brian Murphy, CPC
By Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA,
FAHIMA
Coding Notes
Quizzes
52
AHIMA members may earn continuing
education credits by successfully completing
the following quizzes at www.ahimastore.org
Clinical Documentation Improvement in the
Outpatient Setting
By Danita Arrowood, RHIT, CCDS, CCS; Laurie M. Johnson, MS, RHIA, FAHIMA;
and Michelle Wieczorek, RN, RHIT, CPHQ
56
27
“Reinvigorating Your CDI Program”
Domain: Performance Improvement
DRG Grouping and ICD-10-CM/PCS
35
By Margaret M. Foley, PhD, RHIA, CCS
“Survey Predicts Future HIM Workforce Shifts”
Domain: Performance Improvement
Practice Brief
59
46
Best Practices in the Art and Science of Clinical
Documentation Improvement
4 / Journal of AHIMA July 15
“DRG Grouping and ICD-10-CM/PCS”
Domain: Clinical Data Management
http://journal.ahima.org
Time to Focus on 10 —
Coders at Baystate Health
have ditched dual coding and
one day a week code records
in only ICD-10 as part of
their training. Read how this
readiness process is achieved
without impacting revenue,
and its benefits.
The Role of CDI in ICD-10
Two experts give their best advice on CDI prep
for ICD-10.
Live Coverage of AHIMA’s 2015 CSA
Leadership Symposium
Component state association leaders will engage in two
days of discussions about the future of HIM.
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Journal of AHIMA July 15 / 5
The Journal of AHIMA is an official publication of AHIMA
AHIMA CEO
EDITORIAL DIRECTOR
EDITOR-IN-CHIEF
Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA
Anne Zender, MA
Chris Dimick
ASSISTANT EDITOR/
ADVERTISING COORDINATOR Sarah Sheber
ASSOCIATE EDITOR
Mary Butler
CONTRIBUTING EDITORS
Sue Bowman, MJ, RHIA, CCS, FAHIMA
Patricia Buttner, RHIA, CDIP, CCS
`
Angie Comfort, RHIA, CDIP, CCS
Crystal Clack, MS, RHIA, CCS
Julie Dooling, RHIA, CHDA
Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, CDIP,
FAHIMA
Katherine Downing, MA, RHIA, CHP, PMP
Deborah Green, MBA, RHIA
Jewelle Hicks
Lesley Kadlec, MA, RHIA
Carol Maimone, RHIT, CCS
Paula Mauro
Anna Orlova, PhD
Kim Osborne, RHIA, PMP
Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA
Angela Rose, MHA, RHIA, CHPS, FAHIMA
Donna Rugg, RHIT, CCS
Maria Ward, MEd, RHIT, CCS-P
Diana Warner, MS, RHIA, CHPS, FAHIMA
Lydia Washington, MS, RHIA
Lou Ann Wiedemann, MS, RHIA, CHDA, CDIP, CPEHR,
FAHIMA
ART DIRECTOR Graham Simpson
EDITORIAL ADVISORY BOARD
Linda Belli, RHIA
Gerry Berenholz, MPH, RHIA
Carol A. Campbell, DBA, RHIA
Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FAHIMA
Teri Jorwic, RHIA, CCS
Diane A. Kriewall, RHIA
Frances Wickham Lee, DBA, RHIA
Glenda Lyle, RHIA
Susan R. Mitchell, RHIA
Daniel J. Pothen, MS, RHIA
Cheryl Tabatabai Stachura, RHIA
Tricia Truscott, MBA, RHIA, CHP
Carolyn R. Valo, MS, RHIT, FAHIMA
Valerie Watzlaf, PhD, RHIA, FAHIMA
ADVERTISING REPRESENTATIVES
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Copyright © 2015 American Health Information Management Association ® Reg. US Pat. Off.
6 / Journal of AHIMA July 15
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7
President’s Message
The New Frontier of Clinical
Documentation Improvement
By Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA
THE HEALTH INFORMATION management (HIM) profession reached a new
milestone in 2014 with over 79 percent of
clinical documentation improvement (CDI)
programs now led by HIM professionals.
The 2014 AHIMA Workforce Survey
revealed strong similarities between the
priorities of HIM professionals and employers when it came to ranking the importance of the top 10 HIM skills both
now and 10 years from now. Data integrity and CDI were ranked respectively
by employers as numbers four and six
now, and numbers five and eight in 10
years. The delays in the ICD-10-CM/PCS
transition, coupled with healthcare reform initiatives, has given organizations
a chance to implement, revitalize, overhaul, and expand CDI programs.
I had the opportunity to pave the way
in my own hospital system years ago
by establishing a new CDI program in
a field dominated by clinician leaders.
I truly felt that my pathway to success
was demonstrating the business and
clinical case for improvement in clinical
documentation to the stakeholder group
and senior leaders.
I accomplished this task through the
selection and education of outstanding
physician champions and the establishment of a partnership with the medical
staff and clinicians. These relationships
helped us to achieve an impressive return on investment while improving our
ability to accurately tell the patient’s
story.
Our hybrid team of nurses and HIM
professionals didn’t just chase after a
higher weighted DRG, but instead focused on ensuring the documentation
supported the clinical presentation,
treatment, and clinical course. The CDI
team monitored the accuracy of the
problem list, accurately captured any
conditions “present on admission,” and
8 / Journal of AHIMA July 15
had crucial conversations with the physicians to demonstrate through their
own case examples why documentation really matters.
I am proud of my HIM colleagues facilitating the improvement of the integrity, specificity, appropriateness, and
relevancy of documentation for sound
clinical decision making. Excellent documentation will support transitions of
care and enable a medical group, hospital, and health system to capture the
diagnostic and procedural information
to support accurate reimbursement, research, comparative and quality reporting, and value-based purchasing.
If HIM is not at the CDI table in your organization, now is the time to showcase
your talents in assisting with clinical content redesign. With just a few months left
prior to the transition to ICD-10, it is essential to ensure there is excellent communication, reconciliation, and an educational process between the CDI and
coding teams.
CDI is moving beyond a traditional
model to include all payers and settings
of care. As the care delivery and payment models continue to shift, putting
the CDI team in an ambulatory setting
to ensure accurate, reliable, timely, relevant, and appropriate documentation at
the point of care will ensure an optimal
patient experience, minimize chasing of
documentation after the fact, speed up
payments, and minimize denials.
Now is the time to realize your CDI vision by sharpening your skills and gaining new knowledge. AHIMA has plenty of
resources to offer in support, from a CDI
Bootcamp to Practice Briefs, toolkits,
and query guidance. ¢
Cassi Birnbaum (
[email protected]) is
senior vice president of HIM and consulting at
Peak Health Solutions.
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Bulletin Board what’s happening in healthcare
Ponemon Study: Criminal Attacks Leading Cause
of Healthcare Data Breaches
Criminal attacks are now the number
one cause of data breaches in healthcare, showing a shift in the root cause
of breaches from accidental to intentional, according to a new Ponemon
Institute study. The “Fifth Annual
Benchmark Study on Privacy and Security Data,” released by Ponemon in
May, showed that criminal attacks on
healthcare organizations are up 125
percent compared to five years ago. In
the study, which included 90 HIPAAcovered healthcare entities as well as
88 business associates, 45 percent
of healthcare organizations said the
root cause of their data breaches was
criminal attack and 12 percent said
they were due to a malicious insider.
For business associates, 39 percent said a breach was caused by a
criminal attacker and 10 percent said
a breach was caused by a malicious
insider. The previous cause leader for
data breaches was lost or stolen laptops and other computer devices.
More than 90 percent of the healthcare organizations represented by
the study said they had experienced
a data breach, with 40 percent saying
they had experienced more than five
data breaches in the past two years.
While privacy criminal attack inci-
Pediatric EHR Adoption Faces Roadblocks
A lack of electronic health records
(EHRs) customized to the needs of
pediatric patients is hindering overall
EHR adoption, and the “meaningful
use” EHR Incentive Program requirements are making it difficult for vendors to respond. These were just a
couple of the findings discussed in
a recent wide-ranging Agency for
Healthcare Research and Quality
(AHRQ) technical brief, which notes
that “EHRs used in the care of children
may increase patient safety through
standardization of care and reducing
errors and variability in documentation and communication of patient
data. However, adoption has lagged,
and lack of pediatric functionality is
often cited as a reason for the lower
rates of adoption in pediatrics.”
Furthermore it explains that while
the Health Information Technology
for Economic and Clinical Health
(HITECH) Act bolstered adoption of
EHRs, “development and implementation of functionality to promote
quality of pediatric care specifically
10 / Journal of AHIMA July 15
has been inconsistent, even among
supporters of EHR implementation.”
The report identified numerous
challenges facing pediatric EHRs, including:
Vaccine functionality in EHRs is
hindered by factors such as noncentralized, proprietary databases that cause fragmentation of
vaccination records
Clinical decision support does
not perform well when documentation is incomplete and can
prompt physicians to give immunizations unnecessarily
Finding ways to ensure various databases communicate well and that
one complete and correct record is
available are particular challenges to
properly implementing vaccination
procedures in the EHR. In terms of
medication management, enhancing
an adult-focused CPOE system for
safe pediatric medication management is an intense and sophisticated
task and has limitations. ¢
dents are high, criminal-based security
incidents were even higher. Web-born
malware attacks caused security incidents for 78 percent of healthcare organizations and 82 percent of business
associates, according to the study.
An issue raised by the study is that
despite the changing threat environment, healthcare organizations and
their business associates are not
changing their privacy and security
behavior—and are therefore unprepared to address new threats or provide adequate resources to protect
patient data.
Only 40 percent of healthcare orga-
Center for Healthcare
Transparency Opens
The Center for Healthcare Transparency
has launched with the goal of providing
information on the relative quality and
cost of healthcare services. The center
was created through a national network
of locally governed regional entities.
“Despite years of measurement efforts,
patients, employers, public purchasers,
health plans and even providers, have
almost no reliable information about the
relative cost and quality of healthcare
services,” states the center’s website.
“Without transparent performance information we won’t know if or how to pay
for the right care at the right cost. Valuebased healthcare requires transparency.”
The center aims to enable access to information for employers, public purchasers, and health plans to pay for value and
purchase high-quality healthcare at a fair
cost; providers and health systems to improve their care, enhance provider and
patient communication, and make more
informed referrals; and patients to make
informed choices and engage in healthcare decisions. ¢
nizations and 35 percent of business
associates said they are concerned
about cyber attackers. Even though
there is an increase in criminal attacks, employee negligence remains
a top concern when it comes to exposing patient data.
Data breaches in healthcare continue to be extremely costly, the study
found. An estimated $6 billion is lost
each year on healthcare data breaches. The average cost of a data breach
for an organization is estimated to be
more than $2.1 million. The average
cost of a healthcare data breach to
a business associate is more than $1
million, according to the study.
But despite the risk, organizations
aren’t spending the money they need
to combat breaches.
According to the report, 56 percent of healthcare organizations and
59 percent of business associates
don’t believe their incident response
process has adequate funding and
resources. Also, the majority of both
types of organizations fail to perform
a risk assessment for security incidents, despite the federal mandate to
do so.
When it comes to electronic information, 65 percent of healthcare organizations said they had multiple security incidents in the past two years
involving the exposure, theft, or misuse of electronic information. ¢
Mobile Health Intervention Adoption Lags
in Urban, Rural Clinics and Health Centers
Despite the potential benefits, a 2013 survey of “safety net” providers from the
Commonwealth Fund found that adoption of mobile health intervention tools
was low for urban and rural community health centers and clinics. “Providers
have the opportunity to enhance care delivery and strengthen patient engagement using these new forms of interactive health services that facilitate greater
connectedness between patients and their care team,” wrote the authors of the
issue brief that summarized the survey findings. The responses of 181 providers
were included in the final analysis, only 27 percent of which reported using cell
phones in care delivery. The providers’ responses regarding strategies for the
development of mobile interventions are shown in the graph below. ¢
70%
Strategies for Mobile Interventions Development
60%
nD
eveloped proprietary technical and/or
50%
nA
dapted open source or shared
content solutions
public access resources to develop
proprietary solutions
40%
nC
ollaborated with other health service
organizations to co-develop technical
and/or content elements
30%
Philips Healthcare and the Massachusetts
Institute of Technology have announced a
five-year research collaboration to create innovative healthcare technology.
The Board of Pharmacy in North Carolina
has proposed allowing pharmacists to
fill prescriptions from physicians who
treated their patients via telemedicine
techonology.
Arkansas Urology and Arkansas Heart
Hospital are implementing a secure text
messaging application from Pingmd.
The Food and Drug Administration has
issued a release alerting users of the
Hospira LifeCare PCA3 and PCA5 Infusion Pump Systems that security vulnerabilities in these devices have been
identified, though no adverse events
have been found by the agency.
Baylor College and Mayo Clinic researchers are collaborating to examine Mayo
biobank members and genomic markers to identify possible drug interactions.
The state of Oregon has awarded grant
funding for five separate one-year
telehealth projects aimed at supporting the state’s healthcare system with
population health improvements.
The Centers for Medicare and Medicaid
Services is making its data available to
private companies for research.
The Department of Health and Human
Services has implemented a redesign of
HealthData.gov that will make the website’s data sets more accessible to the
public, researchers, and technology
developers. ¢
nE
HR platform supports applications
20%
on specific mobile device operating
systems
10%
0
The Centers for Medicare and Medicaid
Services reported that the acceptance
rate for ICD-10 test claims improved
during their second testing period April
27 to May 1.
nC
ontracted with mobile health solution
21.4%
11.9%
23.8%
61.9%
21.4%
providers for proprietary content and/or
technical services
Source: Broderick, Andrew and Farshid Haque. “Mobile Health and Patient Engagement in the Safety Net: A Survey of
Community Health Centers and Clinics.” The Commonwealth Fund, May 2015. www.commonwealthfund.org/publications/
issue-briefs/2015/may/mobile-health-and-patient-engagement-in-the-safety-net?title=Cell+phones+have+emerged+as+
potentially+powerful+tools+to+engage+patients+in+the+safety+net.
Journal of AHIMA July 15 / 11
Bulletin Board what’s happening in healthcare
Survey: Vast Majority Still Not Using
Data Analytics
THE EMPIRICAL EVIDENCE FOR THE
TELEMEDICINE INTERVENTION IN
DIABETES MANAGEMENT
http://online.liebertpub.
com/doi/abs/10.1089/
tmj.2015.0029?journalCode=tmj
A study published online in Telemedicine and e-Health found that telemedicine interventions helped diabetes
patients with glycemic control. The
interventions were also shown to help
in reducing patient body weight and
increasing exercise. “Overall, there
is strong and consistent evidence of
improved glycemic control among
persons with type 2 and gestational
diabetes as well as effective screening
and monitoring of diabetic retinopathy,” the authors wrote.
APPROPRIATENESS OF ADVANCED DIAGNOSTIC IMAGING ORDERING BEFORE AND AFTER
IMPLEMENTATION OF CLINICAL DECISION
SUPPORT SYSTEMS
While data analytics tools are seen by
many in healthcare as a means to improve both efficiency and quality, only a
small fraction of the industry is actually
using these capabilities to their fullest
potential, according to a new survey
by KPMG. The survey asked more than
270 healthcare professionals “Where
is your organization in the business
and data analytics roadmap?” and
found that only 10 percent are using
advanced tools for data collection with
analytics and predictive capabilities.
Twenty-one percent said they are still
only “planning their journey.”
Among those actually using data
analytics, 16 percent said they are using data in strategic decision making,
28 percent are relying on data warehouses to track key performance indicators, and 24 percent are using data
marts, the survey found. Business in-
telligence, improved clinical outcomes,
and lowered costs were seen as the
benefits of data analytics.
“Many organizations are not where
they need to be in leveraging this
technology,” said Bharat Rao, PhD,
KPMG’s national leader for healthcare
and life sciences data analytics, in a
press release. “Healthcare organizations need to employ new approaches
to examining healthcare data to uncover patterns about cost and quality,
which includes safety, to make better
informed decisions.”
Despite seeing the benefits, respondents also indicated that there are obstacles to properly implementing data
and analytics tools, including having
non-standardized data in silos (37 percent), lack of technology infrastructure
(17 percent), and data and analytics
skill gaps (15 percent). ¢
http://jama.jamanetwork.com/article.
aspx?articleid=2300591
A study from the RAND corporation, published in the Journal of the
American Medical Association, found
that clinical decision support tools
led to an increase in the number of
ordered advanced imaging tests rated
as “appropriate.” The full report based
on the study, submitted by RAND to
Congress, outlines a series of improvements to decision support tools that
could lead to further reductions in
unnecessary tests.
QUALITEST ICD-10 SURVEY RESULTS—
APRIL 2015
www.qualitestgroup.com/resources/
document/qualitest-icd-10-surveyresults-april-2015/?doc=eyJyaWQiOj
YxMDMsImRpZCI6NjEwMywiZmlkIjo2
MTA0fQ=
A survey from software testing company QualiTest finds that the vast
majority of responding organizations—
over 80 percent—believe that ICD-10
will not experience further delays.
According to the survey, 28 percent of
responding hospitals have conducted
ICD-10 revenue impact testing with
payers and 67 percent have conducted
testing with clearinghouses. ¢
12 / Journal of AHIMA July 15
Influential Committee Changes Tune on
Data Segmenting
In May, a federal health IT advisory
group pushed for greater caution than
it previously has in the sharing of highly
sensitive behavioral health information
between providers and accountable
care organizations (ACOs).
In a May meeting of the Health IT
Policy Committee, a group convened
to advise the Office of the National
Coordinator for Health IT (ONC), members said that voluntary testing and
certification of metadata tags, or data
segmenting “may create confusion
among providers,” Modern Healthcare
reported.
A better option, according to the
group, would be to educate providers
and electronic health record (EHR) vendors about the limits of Data Segmenting for Privacy (DS4P) technologies,
and to conduct more pilot programs to
perfect these methods.
A year ago the Health IT Policy Committee recommended—and the US Department of Health and Human Services (HHS) endorsed—voluntary testing
of systems that placed metadata tags
on health records containing sensitive
information.
Extra protection is required for health
records containing details about federally funded substance abuse treatments and behavioral health issues.
Metadata tags enable providers to
share the records with other providers
without a patient’s written consent.
In March, ONC issued a proposed
rule that included a DS4P testing rule.
Most of the proposed provisions will
not be implemented until 2018, according to Modern Healthcare. According
to a chairwoman quoted in the article,
new committee appointees objected to
the prior recommendations. ¢
FDA Adopts LOINC Standard
The Food and Drug Administration
(FDA) has recommended that all pharmaceutical and biological submissions
to the agency use the Logical Observation Identifiers Names and Codes
(LOINC) standard.
The use of LOINC will standardize the
communication of tests, measurements,
and observations within the submissions, helping to ensure all clinical research data standards are in line with
US health information technology programs, according to Regulatory Focus
and SmartBrief. Specifically, the agency
has requested that the standard be used
for “laboratory test results in investigational study data provided in regulatory
submissions submitted to the Center for
Drug Evaluation and Research and to
the Center for Biologics Evaluation and
Research,” according to an entry from
the FDA in the Federal Register. The
LOINC codes would need to be included in regulatory submissions, new drug
applications, abbreviated new drug applications, and biologics license applications. “The decision to adopt LOINC
for lab test results is part of a larger FDA
effort to align the use of data standards
for clinical research with ongoing nationwide health information technology
initiatives,” said the Federal Register
entry. It went on to note that “(1) LOINC
is widely used among clinical laboratories, (2) LOINC-coded lab data make the
information easier to understand and
analyze, and (3) the currently supported
exchange standard for laboratory test
results in clinical trials… already supports the exchange of LOINC codes.” ¢
Telemedicine Brings Specialists, Patients
Closer in L.A. County
Low-income and uninsured patients in
need of specialty care had been facing extensive waiting periods, stretching between weeks and months, in Los
Angeles County.
Looking to remedy the situation, in
which sick patients got sicker as they
waited for care and treatments became
more costly as a result, local officials
have turned to telemedicine to develop
a cost-effective and timely solution.
The program, called eConsult, is modeled after a similar system at San Francisco General Hospital, and functions
to streamline the referral process, according to an article in the Los Angeles
Daily News.
Through the program, primary care
doctors and specialists communicate
via a web-based platform that “can include the exchange of medical records
and photographs.” Specialists can
then review the information and deliver
a decision on a referral, and appointments can be scheduled with a more
informed perspective on which patients need to be seen and how quickly. E-consulting has also allowed more
patients to get necessary testing done
ahead of time, leading to more efficient
appointments with specialists.
Three years after implementation,
the program has helped to alleviate
some of the bottleneck for Los Angeles
County patients. While there’s still a line
to see the specialist, the program has
helped to alleviate some of the burden
and has even determined that about 30
percent of patients referred don’t actually need an in-person appointment—
consultation and continued care with a
primary physician can suffice.
“Electronic consultation by itself
can’t resolve the access problem for
poor patients,” said Nwando Olayiwola, MD, associate director of UC San
Francisco’s Center for Excellence in
Primary Care, in the article. “It solves a
huge part of the problem but it doesn’t
solve all of it.” ¢
TEXTBOOK EXAMINES CDI PROGRAM
PRINCIPLES
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Documentation Improvement: Principles and Practice, defines and explains
the importance of clinical documentation improvement (CDI). It also presents
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that can be applied reliably to any
healthcare organization’s CDI program.
The author identifies key users of clinical documentation and addresses how
a strong CDI program affects them all.
CLINICAL DECISION SUPPORT TOOL
www.mckesson.com
An updated clinical decision support
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as well as updates to include first admissions criteria and comorbidities, criteria for 29 new specialty drugs, and 33
new molecular diagnostic tests. Gene
panels are also supported in InterQual
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FREE INFORMATION GOVERNANCE
RESOURCES AVAILABLE
www.ahima.org/topics/infogovernance
Adoption of an information governance
(IG) program underscores a healthcare
organization’s commitment to managing its information as a valued strategic asset. AHIMA has several free IG
resources available, from an IG framework to tools and guidelines. White papers and an infographic are also available on the website. ¢
Journal of AHIMA July 15 / 13
Word from Washington
Advancing Stage 3 Meaningful Use
and 2015 EHR Certification Criteria
Why HIM Professionals Hold the Key
By AHIMA’s Advocacy and Policy Team
THIS PAST SPRING, the HIM profession saw many important regulatory
changes. For starters, on March 20 the
Department of Health and Human Services (HHS) announced a notice of proposed rulemaking (NPRM) for stage 3 of
the “meaningful use” EHR Incentive Program. At the same time, the Office of the
National Coordinator for Health Information Technology (ONC) also released its
proposed 2015 edition for EHR certification criteria. On April 10, HHS released a
proposed rule to revise meaningful use
in 2015 through 2017.
Overview of NPRM for MU Stage 3
The proposed third—and final—stage of
meaningful use includes many opportunities for HIM professionals to help propel their organizations forward with success. As proposed, stage 3 meaningful
use includes the following goals:
Increase interoperable health data
sharing
Promote advanced use of EHR
technology to improve patient engagement and coordination of care
Improve program efficiency, effectiveness, and flexibility by aligning
the EHR Incentive Program with other Centers for Medicare and Medicaid Services (CMS) quality reporting programs that use certified EHR
technology (i.e., the Hospital Inpatient Quality Reporting and the Physician Quality Reporting System)
Note that stage 1 attestation will be
eventually phased out. In 2016, providers using EHR technology certified
in whole or in relevant part to the 2014
certification criteria may attest to either
stage 1 or stage 2, but only if they’re
demonstrating meaningful use for the
first time or had demonstrated it for the
first time in 2015. Otherwise, they must
14 / Journal of AHIMA July 15
attest to stage 2 objectives. Providers
using EHR technology certified in whole
or in relevant part to the 2015 certification criteria must attest to either stage 2
or 3 if they demonstrated meaningful use
for the first time in any year prior to 2015.
Under the proposed rule, all providers
must attest using stage 3 criteria by 2018
regardless of their previous levels of participation or face a downward payment
adjustment—also known as a financial
penalty. In addition, providers must report
on meaningful use measures for a full calendar year beginning in 2017. The only
exceptions will be providers participating
in the Medicaid EHR Incentive Program
that are attesting to meaningful use for
the first time. These providers will have
a 90-day reporting period. By requiring a
single EHR reporting period based on the
calendar year, HHS can more easily align
meaningful use attestation with other
quality reporting programs.
HIM Should Take Action Now
HIM professionals must work with IT
and their EHR vendors to ensure that
the technology will be updated to reflect
proposed stage 3 criteria by 2018. The
next few years will go by quickly, and it’s
wise to start making preparations now.
Depending on the organization’s current
level of participation, this shift may require significant workflow changes that
must be addressed.
Consider the following questions:
How does the proposed stage 3
meaningful use criteria compare with
the organization’s current stage?
Note that stage 3 includes a marked
difference from stages 1 and 2.
Which providers and staff members
may require additional education to
ensure compliant reporting?
Which policies must be updated to
reflect new practices?
Word from Washington
Notable is the fact that HHS will increasingly remove earlier
iterations of objectives and measures that were designed to
support the beginning stages of EHR implementation, such
as allowing providers the option to include paper-based formats. The proposed rule states that paper-based formats
would not be allowed for purposes of stage 3 meaningful use
attestation. However, the agency also acknowledges that
some patients may want to receive education or reminders
on paper or using some other non-electronic method. HHS
encourages all providers to use the method that “is most relevant for each individual patient and easiest for that patient
to access.”
HIM professionals can help answer these questions:
How many patients currently prefer paper-based and
other non-electronic formats of communication? Why
do patients prefer these formats? What are the barriers?
Are these patients willing to receive electronic notifications and reminders?
If not, how might this potentially affect stage 3 attestation?
What type of outreach can the organization use to better engage patients via an electronic medium?
Eight Important Stage 3 Objectives
The proposed rule includes eight objectives that align with
HHS’ goals to advance interoperability and quality. The following is a summary of these objectives, many of which will
require the strength and knowledge of HIM professionals.
1. Protect patient health information. This includes using
certified EHR technology to implement technical, administrative, and physical safeguards.
2. Generate and transmit electronic prescriptions via eprescribing.
3. Implement clinical decision support to improve highpriority health conditions.
4. Use computerized physician order entry (CPOE). In particular, providers must use CPOE for medication, laboratory, and diagnostic imaging orders directly entered by
a licensed healthcare professional, credentialed medical
assistant, or credentialed medical staff member.
5. Provide patients with access to their health information.
6. Engage with patients. Providers must use communication functions within certified EHR technology.
7. Provide a summary of care record. This document must
be available when providers transition or refer patients
to another setting of care. All providers must also be
able to incorporate summary of care information from
other providers into their own EHR.
8. Actively engage with a public health association or clinical data registry using certified EHR technology. Hospitals must attest to four of the following six measures:
Immunization registry reporting
Syndromic surveillance reporting
Case reporting
Public health registry reporting
Clinical data registry reporting
Electronic reportable lab results
Proposed 2015 EHR Certification Criteria
The new proposed EHR criteria incorporates elements of the
2011 and 2014 editions, and it aligns with ONC’s draft Nationwide Interoperability Roadmap that calls for expanded
use of interoperable health IT by 2020. By 2024, the goal is to
achieve a nationwide learning health system. Such a system
would enable longitudinal records, precision medicine, and
more efficient and targeted care.
The 2015 edition includes provisions that address certification criteria to support population health management,
interoperability, data portability and access, improved transparency, and enhanced privacy and security capabilities.
The criteria also include a path for certification of technology
designed for healthcare settings in which providers are not
typically eligible to qualify for meaningful use payments.
HIM professionals should note the following:
Changes to criteria for transitions of care. ONC proposes to revise the 2014 edition’s requirement to demonstrate both “content” and “transport” to reflect two
separate testing and certification opportunities. This will
create potentially more opportunities for health information exchange entities to certify transport capabilities.
Adoption of new minimum standard code sets. ONC
proposes to adopt newer versions of four previouslyadopted minimum standard code sets (i.e., the September 2014 release of the US Edition of SNOMED CT;
LOINC version 2.50; the Feb. 2, 2015 monthly version of
RxNorm; and the February 2, 2015 version of the CVX
code set). It also proposes to adopt two new minimum
standard code sets—the National Drug Codes (NDC)
and the Centers for Disease Control and Prevention’s
Race and Ethnicity Code System.
Discontinuation of the complete EHR definition. The
original definition required that providers use certified
technology that met all of the setting-specific certification criteria. Under the CEHRT definition for fiscal/calendar year 2014 and beyond, providers only need EHR
technology certified to the 2014 rule that meets the base
definition (i.e., possessing a finite set of capabilities) and
includes only the other capabilities they need for the
meaningful use stage to which they are attesting.
In 2017, providers may use EHR technology that is certified
using either the 2014 edition or the new proposed 2015 edition. But for the reporting period in 2018, all providers must
use an EHR that has been certified with the 2015 criteria.
To view the proposed meaningful use stage 3 rule, visit
www.gpo.gov/fdsys/pkg/FR-2015-03-30/pdf/2015-06685.
pdf. To view the proposed 2015 certification criteria, visit
www.gpo.gov/fdsys/pkg/FR-2015-03-30/pdf/2015-06612.
pdf. To view the proposed modifications to meaningful use
for 2015 to 2017, visit www.gpo.gov/fdsys/pkg/FR-2015-0415/pdf/2015-08514.pdf. ¢
The AHIMA Advocacy and Policy Team (
[email protected])
is based in Washington, DC.
Journal of AHIMA July 15 / 15
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Inside Look
Linking the Right Info and the Right
Person… at the Right Time
By Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA, chief executive officer
WITH ITS ROOTS in DRGs, the prospective payment system, and value-based
purchasing, clinical documentation improvement (CDI) can seem like a practical administrative task. The process of
ensuring accurate clinical documentation is—like so many HIM functions—often done in the background rather than
the spotlight.
But it’s important to remember that CDI
is a vital link in the chain that gets the
right information to the right person at the
right time. In fact, in a white paper published by AHIMA following last year’s CDI
Summit, CDI was identified as a priority
for organizations and providers.
“Top priorities during the next 12 months
include identifying documentation gaps,
achieving documentation excellence,
and providing ongoing education to clinical providers,” the paper says. “Accurate
documentation of patient encounters is
the foundation for telling the patient’s story, appropriate reimbursement, and quality reporting. As healthcare reform moves
quickly towards quality-driven reimbursement, organizations and providers will
have to continue to justify care plans and
treatment options as well as successfully demonstrate quality outcomes and
patient safety. Consistent, complete, and
accurate documentation is the key to the
economic health of the organization and a
key indicator of physician quality.”1
HIM professionals have long known that
improving clinical documentation has a
direct effect on patient care. Now, as the
role of CDI specialist becomes increasingly prevalent in our organizations, more
of us can start telling that story as well.
The articles in this month’s Journal give
us additional material.
In our cover story, “Preventing Healthcare’s Top Four Documentation Disasters,” Mary Butler talks to CDI professionals about the top documentation
errors they’ve seen repeatedly committed in healthcare facilities. The article looks at why these documentation
mistakes are made in the first place
and the best ways for CDI specialists
to identify and fix them. Joseph Gurrieri, RHIA, CHP, Cassie Milligan, RHIT,
CCS, and Paul Strafer, RHIA, CCS, describe how coding and CDI programs
should connect to an organization’s
quality improvement efforts in “Closing the Loop on Quality and CDI.” And
Kristen Geissler, MS, MBA, CPHQ, and
Joni Dion, RHIA, CDIP, CCDS, CPC, offer tips to launch or relaunch an effective CDI program that features strong
leadership practices and focuses on improving the quality of the health record
in “Reinvigorating Your CDI Program.”
Finally, in this issue AHIMA releases the results of its latest workforce
study. Ryan Sandefer, MA, CPHIT, David Marc, MBS, CHDA, Desla Mancilla,
DHA, RHIA, and Debra Hamada, MA,
RHIA, discuss the current state of the
HIM workforce, what we hope the future
state will be, and how education and
training will fill the gap in “Survey Predicts Future HIM Workforce Shifts.”
If you’re looking for still more on CDI,
AHIMA’s annual CDI Summit takes place
August 6 to August 7 in Alexandria, VA.
Join us as we continue the journey to improve clinical documentation. ¢
Note
1. Buttner, Patty et al. “Leading the
Documentation Journey: A Report from the AHIMA 2014 Clinical
Documentation Improvement Summit.” 2014. http://perspectives.
ahima.org/leading-the-documentation-journey-a-report-from-theahima-2014-clinical-documentation-improvement-summit/#.
VUzevpMVZj8.
Journal of AHIMA July 15 / 17
Preventing Healthcare’s Top
Four Documentation Disasters
By Mary Butler
18 / Journal of AHIMA July 15
Preventing Healthcare’s Top
Documentation Disasters
ONE OF THE most famous cases in medical history that led to
regulation of the number of hours that resident physicians are
allowed to work is also a case study in clinical documentation
failures.
In 1984, a college student in New York, NY named Libby Zion
was admitted to a Manhattan emergency room (ER) with a high
fever and agitation. After consulting with her family physician,
the residents who evaluated Zion in the ER administered a sedative and painkiller. What none of the caregivers knew—because
Zion didn’t disclose the information at the point of care—was
that she was taking an anti-depressant that was dangerously
contraindicated with the drugs the physicians gave her in the
ER. The drug combination ultimately proved fatal and Zion died
from cardiac arrest.1
While the legal fallout from this case centered on the hours
that doctors work and how closely Zion was monitored by the
ER staff, it serves as a cautionary tale for physicians who frequently treat patients in the ER without having full, up-to-date
medical histories where and when they need it. Even though
electronic medication reconciliation practices that weren’t
even possible in 1984 are standard today, an incomplete patient record can have the same disastrous consequences now
that it did then.
Patient safety is just one of the many reasons that formal clinical documentation improvement (CDI) programs are flourishing. The growth of CDI is also being driven by the increased
specificity needed for ICD-10-CM/PCS, as well as the transition
to pay-for-performance versus fee-for-service payment methodologies. Payers and outside auditors such as recovery audit
contractors (RACs) and Medicare audit contractors (MACs) are
scrutinizing claims and health record documentation for proof
of medical necessity and quality indicators.
The best way to prevent a documentation disaster is by recognizing the most frequent kind of documentation errors and
putting procedures in place to stop them before they can strike.
According to several HIM experts, the top four documentation
mistakes are:
Mixed messages from a physician vis á vis misunderstood
dictation or illegible handwriting
Misuse of copy and paste or copy forward functions in the
electronic health record (EHR)
Incomplete or missing documentation
Misplaced documentation
Documentation Disaster #1: Mixed Messages
Among the arguments for adopting technologies
such as EHRs and the dictation program Dragon
was the notion that they would eliminate problems
like illegible handwriting and hard-to-understand dictation.
Sheila Burgess, RN, RHIA, CDIP, CHTS-CP, director of CDI at
Sutherland Global Healthcare Solutions, says that despite recent advances old habits die hard.
Common transcription mistakes include typing “hyper” instead of “hypo” or vice versa, and typing “he” instead of “she.”
This is a problem Burgess has seen since the 1990s. Or physicians that are in a hurry will dictate a note into the wrong patient’s chart, and the coder doesn’t catch the error because they
are just coding without checking to see if the note matches the
rest of the chart. Most times, if the CDI staff is well trained, this
kind of mistake will be caught—but it can be costly when it’s not.
“If a patient comes into the ER unconscious they could be
emergently treated for a condition they don’t have if a physician
pulls up their record and the documentation is incorrect or it’s
the wrong patient’s information,” Burgess says. “That’s one thing
that could be detrimental.”
She notes that sometimes when a wrong diagnosis gets embedded in a patient’s chart, that can get carried on when that
patient changes insurance companies and a pre-existing condition is noted. The patient can be mistakenly put on a waiting period for insurance due to that kind of mistake if it’s not
cleared up.
Burgess says electronic prescribing has helped eliminate
some of the problems related to sound-alike medications, such
as Xanax and Zantac, but it can be a problem for nurses who
take orders over the phone. On the whole, she’s seen this problem diminish. Lots of hospital HIM departments post lists of
frequently confused medical terminology and medications to
prevent those kinds of slipups.
Many have argued that EHRs also eliminate the problem of
illegible physician handwriting, but Dr. Jon Elion, MD, FACC,
president and CEO of ChartWise, and associate professor of
medicine at Brown University, argues that electronic records
can also be difficult if not impossible to interpret.
“Just because you can read the letters doesn’t mean you can
decipher what they’re saying,” Elion says. “In this world of Twitter and text messages, people are using horrendous shorthand.
And very, very illegible notes are coming out of that. So that’s
certainly a danger.”
Widely used abbreviations can cause problems in paper and
electronic documentation. For example, “q.i.d.,” which means
that medication must be taken four times a day, can look and
sound a lot like “q.d.,” which means that a medication has been
prescribed to be taken once a day. Elion says doctors are discouraged from using the abbreviation “MS” because it has multiple meanings. It can be used to refer to the drug morphine
sulfate, to refer to the disease multiple sclerosis, to note altered
mental status, or to denote the cardiology term mitral stenosis.
“To type the note more quickly, they [physicians] might abJournal of AHIMA July 15 / 19
Preventing Healthcare’s Top
Documentation Disasters
Natural Language Processing Boosts CDI Capabilities
EVEN WITH A robust remote clinical documentation improvement (CDI) workforce, HIM leaders at Baystate Health, based
in Springfield, MA, decided they wanted members of their
CDI team to query far more than one out of every five records they review at their flagship facility. Walter Houlihan,
MBA, RHIA, FAHIMA, director of health information management (HIM) and clinical documentation at Baystate Health,
and Jennifer Cavagnac, CCDS, Baystate’s assistant director
of clinical documentation improvement, wanted CDI staff to
boost their query rate from 20 percent to 75 percent. More
specifically, they wanted to be able to identify cases with the
most “opportunity” for clarification, Houlihan and Cavagnac
say, such as patients with anemia, congestive heart failure,
COPD, certain types of infections, and patients who meet
various criteria for sepsis.
The tool they’ve chosen to help meet this goal is natural
language processing (NLP), which is computer software that
uses algorithms to look for a variety of different variables including words and phrases that can be sent to CDI specialists in real time for validation. NLP is similar to computer-assisted coding (CAC) applications, which searches charts for
individual words and assigns a code. According to Cavagnac
and Houlihan, the learning curve is far steeper for CAC, which
can take coders a couple months to get used to. With NLP,
CDI specialists had one day of training and were easily able
breviate things that only they know what they really mean. So
that hampers documentation,” adds Susan Wallace, MEd, RHIA,
CCS, CDIP, CCDS, FAHIMA, director of compliance at Administrative Consultant Service. She says another frequent shortcut
is physicians who document “multi-organ failure” rather than
citing the specific organs, which can fail to reflect the severity of
an illness, thereby impeding accurate reimbursement and appropriate patient care.
Disaster #2: Copy and Paste Carelessness
The easiest way to cause a ruckus at a CDI conference is to utter three words: “copy and paste.” And
for good reason. It’s the function in many EHRs
that allows users to re-use all or parts of the detailed narrative
portion of a health record, which is seen by others who may
access the record down the line. While it can save physicians
time, it’s a breeding ground for documentation errors. When it’s
used incorrectly, copy and paste can make it difficult to track
the progression or resolution of an illness, which can result in
over- or under-reimbursement and send up red flags for auditors looking for fraud. Misplaced or incorrect documentation in
a patient’s record can also cause severe physical harm and even
death.
An example of a copy and paste error that Burgess came across
recently involved a newborn that had a slight hematoma of the
head right after delivery.
“It was really minor [injury] but the doctors kept cutting and
pasting so it looked like they were really monitoring this baby,
20 / Journal of AHIMA July 15
to use it handily within days.
The NLP application works like a search engine, scanning
charts as soon as they are entered into Baystate’s electronic
health record (EHR) system then sending the findings to the
online portals of CDI specialists for review. Since the NLP system runs 24 hours a day, CDI specialists log in to their portals
when they start their shift at 6 a.m. and the application will
have already created their work list of charts to review.
At press time, Baystate only had NLP up and running for
a little over a month, but Houlihan and Cavagnac say they
are already pleased with the results. NLP can help CDI identify common documentation errors such as those generated
through copy and paste.
“NLP can identify instances in which something may be
noted multiple times. We’d look at that in conjunction with
a CAC tool,” Cavagnac says. “Once a patient’s been identified we can use the CAC tool to actually get a true count on
a phrasing or condition or a lab value that’s used repeatedly
throughout the record.”
It also can help weed out unapproved abbreviations
doctors might use in their notes, which can prevent medication errors.
“I’d strongly encourage other hospitals to look at these
types of applications, just for the benefit of being able to locate information in an EMR,” Cavagnac says.
this neonate, for head trauma the whole time. But they weren’t.
And that was because of copy and paste and lazy documentation,” Burgess says.
Wallace says that one time she observed a case where “for a
whole week, the patient appeared to be on ‘post-operative day
three’ because the entire note was just copied forward, copied
forward, including the heading [on the chart], when that clearly
was not the case.” That kind of mistake implies that a patient has
made no progress from their surgical procedure when in fact
they have.
Elion, however, notes that there are two specific circumstances under which physicians can use copy and paste to win the appreciation of coders and CDI teams. The first is when documenting the findings of a radiology report in a progress note. Since
you can’t code from a radiology report, Elion says, the doctor
should copy the whole note, paste it into the progress note, and
then add a line or two that says “I’ve personally reviewed the Xray and discussed the findings with the radiologist. I agree with
his description of the location and nature of the fracture.” Doing
this will make a coder “fall in love with you,” he says.
“Ditto with anatomic pathology. How many times do we see
the note that says ‘brochial biopsy was positive. I’ll schedule oncology to see the patient as an outpatient?’ That’s useless. You
can’t code from that. Copy and paste the anatomic pathology
report, document stage 2 bronchial carcinoma, whatever it is.
Those kinds of things are very important,” Elion says.
Not only can copy and paste perpetuate errors, it can add pages upon pages to a patient’s record which can slow down any
Preventing Healthcare’s Top
Documentation Disasters
number of processes a chart is used for—from being able to read
through it quickly in an emergency to coding from it.
According to Dr. William Haik, MD, FCCP, CDIP, a practicing
physician and director of DRG Review, EHRs generate so much
data that finding the pertinent information when he needs it
is tedious.
“That’s a problem for auditing records, which I do, and I imagine it’s an enormous problem for coders. As a physician, I’m
not about to dig through 10 pages of a progress note. Or worse,
the nursing notes. The day is gone when you can look at a nursing note and figure out what happened to a patient in one day’s
worth of nursing notes,” Haik says.
Disaster #3: Incomplete Documentation
In a perfect world, caregivers would chart every patient encounter as if that record had to stand alone
10 years down the road or more, and in such a way
that it tells the patient’s whole story. But the reality is that too
many clinicians use vague terminology like “unspecified” and
“not otherwise specified,” or records get passed off to so many
different parties that something critical goes missing. Having
incomplete documentation can have patient safety impacts like
those discussed at the beginning of this article, as well as negative reimbursement impacts.
CDI specialists are well positioned to fix incomplete documentation errors when it comes to clarifying whether certain
conditions were present when a patient was admitted, says
Haik. A good example is when a patient is admitted to the hospital with complications related to chronic obstructive pulmonary disease (COPD), but the admitting physician doesn’t know
that upon admission that same patient already had a decubitus
(or pressure) ulcer. If a patient develops an ulcer like that while
they’re an inpatient, both the physician and hospital can receive
a reimbursement penalty. Therefore, making sure this is noted
as “present on admission” is important.
Jamie Wilding, MBA, RHIA, coding compliance manager at
Esse Health, says incomplete documentation to support a diagnosis can invite calls from Medicare auditors and insurance
companies looking for documentation that supports medical
necessity for an overnight stay. From an auditor’s perspective,
if it’s not documented, it didn’t happen. A frequent documentation weak spot, says Wilding, is not recording a patient’s
chief complaint.
“Chief complaints are sometimes an issue because ancillary
staff is entering in chief complaints, so sometimes it’s missing,”
Wilding says. Wilding notes that chief complaints are critical because they help support medical necessity. “Without the proper
chief complaint, Medicare must view that as invalid and known,
and I’ve read reports that Medicare will recoup money if chief
complaint is missing,” Wilding says.
Elion says there are two simple phrases that could go a long
way in improving progress notes if CDI specialists could get
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Preventing Healthcare’s Top
Documentation Disasters
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physicians to do it: “due to” or “manifested by.” With reimbursement changes and ICD-10 on the way, writing “due to” instantly
forces the documenter to add the needed specificity. “You can’t
just say ‘anemia and GI bleed,’ you have to say the ‘anemia is
due to a GI bleed.’ You can’t just say ‘GI bleed,’ you have to say
the ‘GI bleed is due to a bleeding gastric ulcer,’” Elion says. “‘Due
to’ is really a game changer in the way doctors approach documentation. It’s more complex and comprehensive than that—if
you can get the doctors to use those two words, the notes just got
massively better.”
The phrase “manifested by” offers similar improvement. For
example, rather than generically saying a patient has diabetesrelated problems, a better note would say “the patient has complicated diabetes manifested by neuropathy and nephropathy,
and retinopathy,” according to Elion.
Getting physicians to make these changes requires communication with CDI teams, says Cortnie Simmons, MHA, RHIA,
CCS, CDIP, managing director of education services at himagine
solutions inc.
“You have a lot of physicians that code, whether they run a
practice or even at hospitals they’re assigning codes through the
EHR systems, and you want to make sure their job is more about
the documentation and less about the coding, and be available
to them,” Simmons says.
She says the best way to do this is to sit down with physicians
and show them examples of where they’re struggling. CDI specialists also need to be willing to match their own communication style with the physician. “Because, usually, there’s been
pushback from docs on queries, we have to find new ways to
jump in front of physicians,” Simmons says.
Disaster #4: Misplaced or
Conflicting Information
From data entered into the wrong field in an EHR to
scrounging for missing pieces in a hybrid health record environment, misplaced information is still a problem that
haunts health information management.
A frequent example, according to Burgess, is that procedure
notes end up in the progress note portion, or physicians who
are unhappy with a current EHR’s set up start bringing in their
own templates.
“It is common that things will end up in the wrong place in the
record, and you have to search for it. For coders and for CDI, you
have to think, ‘What did this patient come in for?’ If you cannot
find a procedure note where it’s supposed to be, look in the rest
of the chart,” Burgess advises.
That kind of misplaced information, while frustrating and
time consuming, is less harmful than health information spread
across a variety of formats. Elion worries that until a given provider is 100 percent electronic, the risk to patients is significant
since portions of the complete record may go unnoticed. Many
hospitals are still transitioning.
“My own hospital was 90 to 95 percent electronic for several
years, which was very dangerous, because I got in the habit of
only looking at the electronic [records] and not looking at the
Preventing Healthcare’s Top
Documentation Disasters
Outpatient Coding Challenges in CDI
GETTING PHYSICIANS TO document in a way that proves
medical necessity for a given visit or treatment is a CDI battle waged in inpatient and outpatient coding, but the outpatient side offers a few extra challenges.
Jamie Wilding, MBA, RHIA, coding compliance manager
at Esse Health, says that in the outpatient setting physicians do more of their own coding than hospital physicians,
which requires more training on coding and electronic
health records (EHRs). To keep the documentation up to
snuff, “We have to be a little more invasive with our training
for our physicians and mid-level staff,” Wilding says.
Outpatient coding also raises the stakes on specificity of
documentation. In outpatient coding, “We are not to code
for conditions that are deemed unconfirmed or presumed,
so if a physician said, ‘I suspect there to be pneumonia,’
he would not be able to code that per outpatient [guidelines] as opposed to inpatient [guidelines] for pneumonia.
They code for the finer symptoms until that definitive X-ray
comes back,” Wilding says.
One technique that has improved outpatient documentation is the use of medical scribes, according to Wilding.
Scribes can significantly reduce a physician’s time spent on
paperwork and documentation.
Ironically, though, the same documentation errors that
run rampant without scribes are the same ones that occur
with scribes, including copy and paste errors and incomplete documentation.
“The errors we find are an increase in the same errors a
doctor would make. So whenever labs are ordered they’ll
often forget to jot down the planning piece for that diagnosis; ‘Lab ordered today, lipid panel ordered’ under a diagnosis for hyperlipidemia,” Wilding says. “Without that piece
of the puzzle” external auditors and insurance companies
would argue that there’s no documentation to support the
services rendered, she says.
paper,” Elion says. “Some documents were still in a three-ring
binder that was not available electronically.”
Because of this, physicians and nurses often are working
with incomplete information—lab work, radiology reports,
family histories—that aren’t available when the patient is in
front of them. Hybrid environments, that is, providers using
both paper and electronic records, can also breed conflicting information.
For example, the problem list presents its own set of problems,
Wallace says. Physicians have been making a solid effort to try
and incorporate that information into the body of the patient’s
medical record. However, Wallace says she often sees records
where the problem list has been brought forward, but the status
of the problem has not been updated.
In one case Wallace witnessed, the problem list was copied
into the progress note and “the coder assigned a code of a stroke
for that patient when in fact they had a stroke six months ago
on a prior visit, but because the problem list listed CVA (cerebrovascular accident), they thought it was a current condition.”
Conflicting information is often a side effect of having a large
care team collaborating on the same patient, which is the case
in hospitals that have a lot of hospitalists. When each one updates a chart, they might use different terminology to explain
the same condition. For example, one physician might document that a patient has acute renal failure, and the physician
who does the discharge summary might write that the patient
has acute renal insufficiency.
“That’s a huge issue because it affects how you code it, how
you get paid, and it affects what condition is going to be the
principal diagnosis in some instances,” Wallace says.
Preparation the Best Way to Avoid or Manage Disaster
There are several things CDI specialists can do that will prevent
many, if not all, of these four documentation disasters. There are
technology tools such as natural language processing (see sidebar on page 20), computer-assisted coding, scribes (see sidebar
at left), and software, some of which offer an electronic physician query platform and helps provide suggestions for missing
diagnoses.
Elion says that in a recent presentation he advised CDI specialists to “train your doctors to write a good note wherever they are
and whoever they are seeing. You don’t write one style of note
for a Medicare patient and another style for a BCBS patient. You
don’t write a different style of note for an outpatient than you do
for an inpatient… don’t guess what the payer is looking for.”
Having a physician champion as part of the CDI team can
work wonders in getting physicians to take documentation improvement seriously—and understand the disastrous consequences if they don’t.
“With physician champions or advisers, you can have physician to physician communication which is sometimes a lot
easier of a position,” Burgess says. “I know some hospitals can’t
afford to hire physician champions. But possibly take your physician who is marked for case management and utilization review, and make this part of their role.” ¢
Note
1. Lerner, Barron H. “A Case That Shook Medicine.”
Washington Post. November 28, 2006. www.washingtonpost.com/w p-dy n/content/art icle/2006/11/24/
AR2006112400985.html.
Mary Butler (
[email protected]) is associate editor at the Journal of
AHIMA.
Read More
More CDI Tips Online
www.ahima.org
For more answers to CDI questions, read “CDI Tips Developed to
Maximize ICD-10-CM/PCS” in AHIMA’s HIM Body of Knowledge at
http://library.ahima.org/xpedio/groups/secure/documents/ahima/
bok1_050815.hcsp?dDocName=bok1_050815.
Journal of AHIMA July 15 / 23
Reinvigorating
YOUR CDI PROGRAM
By Kristen Geissler, MS, MBA, CPHQ, and Joni Dion, RHIA, CDIP, CCDS, CPC
24 / Journal of AHIMA July 15
Reinvigorating Your
CDI Program
LONG GONE ARE the days of “grab and go” coding, finding the
CC/MCC to push reimbursement to the next level and then moving
on to the next record. Today, in addition to reimbursement, clinical data drives quality initiatives, hospital and physician profiles,
and medical necessity. Clinical documentation is the cornerstone
of clinical data management. It also represents resources used and
patient care rendered when reviewed by external auditors. Another key factor impacting clinical documentation is the adoption of
ICD-10-CM/PCS, scheduled for October 1, 2015. Greater specificity in clinical documentation has never been more important.
Since clinical documentation is vital to the success of any
healthcare organization, now is the time to step up clinical
documentation improvement (CDI) programs. Whether kickstarting a CDI program or reinvigorating one, you will want to
build a strong foundation for sustainable success.
Comprehensive, Role-Based eLearning
for Efective Coding and
Clinical Documentation Improvement
Formalize Efforts with a Steering Committee
The first step should be to establish a CDI steering committee
that includes key interdisciplinary leadership impacted by CDI.
While every organization is unique, most committees should include the following representatives:
Chief financial officer
Chief medical officer
Physician champion
Director of the clinical documentation improvement program
Director of health information management
Director of coding compliance
Director of continuum of care
Director of quality
Vice president of nursing
The first project for the committee should be to clearly define
the objectives and expected outcomes of the CDI program. Identify and monitor key metrics and develop dashboards for reporting. At a minimum, the dashboard should include the following:
Documentation review rate
Query rate
Response rate
Impact
Case mix index (CMI) trend
Measure Progress to Sustain Momentum
The CDI program head must measure progress, recognize the
challenges, and take corrective action as needed. As the CDI program matures, the data captured can be increased to expand the
dashboard presented to the CDI steering committee. Other areas
to monitor include the query response rate by physician, types of
queries generated, and trend CC and MCC capture rate. The metrics can be used to pinpoint opportunities for education.
A physician advisor is paramount to a successful CDI program. The physician advisor serves as a CDI advocate, resource,
educator, and a liaison for documentation specialists, coders,
and providers. The physician may also participate in reviewing
denials and assisting with appeals. Participation as a member
of the CDI steering committee should be included in the roles
Accurate, complete coding and clinical documentation
are critical to a healthcare organization’s mission
and operations, impacting both quality of care and
fnancial viability.
That’s why targeted training from Elsevier is so
important.
ICD-9 Coding
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Journal of AHIMA July 15 / 25
Reinvigorating Your
CDI Program
and responsibilities of the physician advisor since they should
be well versed in all aspects of the clinical documentation improvement program. It is also important to cultivate unofficial
physician supporters; front-line physician support can speak in
support of CDI efforts while interacting with the medical staff.
Don’t Make It About the Money
The clinical documentation specialist (CDS) has many roles, but
none more important than a complete and thorough concurrent
record review. Many CDI programs are implemented for the sole
purpose of capturing documentation for reimbursement. While
accurate reimbursement is a benefit, the CDS must also understand the far-reaching impact of the clinical documentation on
care accuracy and quality. This is typically the biggest selling
point—improved patient care—that a CDS has when trying to
convince busy physicians to provide better documentation.
CDI programs should start simple. One of the basics that clinical documentation improvement practitioners should know
and understand is the “present on admission (POA)” definitions. POA has the potential to impact reimbursement as well as
quality reporting. POA categories include:
Y – condition was present on admission
N – condition was NOT present on admission
W – provider is unable to clinically determine whether
condition was present on admission or not (Note: “W” will
be treated the same as “Y” by the Centers for Medicare
and Medicaid Services (CMS))
U – documentation is insufficient to determine if condition is present on admission (Note: “U” will be treated the
same as “N” by CMS)
E – diagnosis is exempt from POA reporting
POA is federally defined as “present at the time the order for
inpatient admission occurs.” Conditions that develop during an
outpatient encounter, including emergency department, obser-
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vation stays, and same day surgery are considered to be present
on admission. Timing of the documentation does not matter.
The physician may document that a diagnosis was present on
admission at any time, such as in the discharge summary or in a
post-discharge query. If the documentation is unclear, then the
CDS must query the physician for clarification.
CMS has a number of quality programs that require complete and accurate documentation as an important reporting
component. Claims-based measures originate from clinical
documentation and have a vital role in quality initiatives.
These programs include:
Inpatient Quality Reporting (IQR)
Value-Based Purchasing (VBP)
Hospital Readmission Reduction Program (HRRP)
Hospital-Acquired Conditions (HAC)
Work closely with the organization’s quality department to
better understand the role clinical documentation specialists
play in helping meet these quality initiatives.
Spice Up Your Program with PEPPER, Other Tools
Take advantage of the findings from the Program for Evaluating Payment Patterns Electronic Report (PEPPER). The report is
published quarterly and includes statistical claims data for MSDRGs at risk for improper payment due to issues with billing,
coding, and/or medical necessity. The report compares data at
the national and state level, and identifies a hospital’s outlier
status of high, low, or in the expected range. The findings from
PEPPER can be used to develop auditing, monitoring, and action plans at your hospital or facility as needed.
The Office of Inspector General (OIG) is responsible for protecting the integrity of US Department of Health and Human
Services (HHS) programs by detecting and preventing fraud,
waste, and abuse. The OIG Work Plan is published annually
with an overview of the reviews and activities the OIG plans to
adopted by thousands of users to achieve
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Reinvigorating Your
CDI Program
pursue. Review the OIG Work Plan to understand the hospitalrelated policies and procedures and the areas targeted for review. Then, implement an internal data mining process to identify areas of vulnerability included in the OIG plan and develop
a corrective action plan.
The importance of collaboration cannot be overstated. The
CDS has valuable insight into the clinical documentation
beneficial to the revenue cycle team. CDI staff should consider participating on the denials team to understand what
is being denied due to documentation and how to proactively assist with documentation up-front. Is the revenue cycle
team holding claims due to unanswered queries? Having a
good rapport with the medical staff helps facilitate a prompt
response to queries. There are many quality initiatives that
depend on clinical documentation and the CDS needs to stay
informed in order to understand the impact documentation
has on quality initiatives.
Partner with coders to build and strengthen the CDI program.
Monthly team meetings to review rules and regulations that
govern coding, query development and compliance, and record
reviews foster team building and provide opportunities to share
knowledge and skills. Evaluate which queries are being generated retrospectively and review to determine if the queries can
be generated concurrently.
Contribute to the development of query templates and review
queries generated to promote compliance. Also, CDS and coding team members can collaborate on data mining projects to
identify accounts that may be included in the PEPPER or OIG
Work Plan focus. Assess the documentation and the final coding to confirm complete and accurate information. If a trend is
identified, it may be beneficial to proactively review vulnerable
accounts before the final coding is submitted.
A second-level review by a coder and a clinical documentation
specialist can decrease denials. Accounts with HACs should also
be referred to the quality department for review prior to the final
coding in order to determine if the condition was present on ad-
Journal of AHIMA Continuing Education Quiz
Quiz ID: Q1518607 | EXPIRATION DATE: JULY 1, 2016
HIM Domain Area: Performance Improvement
Article—“Reinvigorating Your CDI Program”
mission or hospital-acquired. In addition, the review should include clinical evidence to support the validity of the diagnosis. A
solid CDI program is one that moves out of a silo and develops a
team-based approach, promoting efficiency and accuracy.
The CDS must take the responsibility to review every record
from a holistic perspective, including for POA and clinical validation. When the patient goes home the record must stand on
its own. CDS professionals should ask themselves, “Does this
record clearly and accurately reflect the condition of the patient
and services rendered?” If the answer is yes, then congratulations on a job well done. ¢
References
AHIMA. Clinical Documentation Improvement Toolkit. Chicago,
IL: AHIMA Press, 2014. http://library.ahima.org/xpedio/
groups/secure/documents/ahima/bok1_050585.pdf.
Centers for Medicare and Medicaid Services. “HospitalAcquired Conditions and Present on Admission Indicator
Reporting Provision.” Medicare Learning Network.
September 2014. www.cms.gov/Outreach-and-Education/
Med ic a re-L ea r n i ng-Net work-M L N/M L N P roduc t s/
downloads/wPOAFactSheet.pdf.
Russo, Ruthann. Clinical Documentation Improvement:
Achieving Excellence. Chicago, IL: AHIMA Press, 2010.
TMF Health Quality Institute. “PEPPER: Short-term Acute
Care Program for Evaluating Payment Patterns Electronic
Report, User’s Guide, Sixteenth Edition.” 2014. www.
pepperresources.org/Portals/0/Documents/PEPPER/ST/
STPEPPERUsersGuide_Edition16.pdf.
US Department of Health and Human Services Office of Inspector
General. “Work Plan Fiscal Year 2015.” http://oig.hhs.gov/reportsand-publications/archives/workplan/2015/FY15-Work-Plan.pdf.
Kristen Geissler (
[email protected]) is managing director and Joni
Dion (
[email protected]) is associate director and an AHIMA-approved
ICD-10-CM/PCS trainer at Berkeley Research Group, in Hunt Valley, MD.
TAKE THE QUIZ AT WWW.AHIMASTORE.ORG
NOTE: MAILED-IN PAPER QUIZZES WILL NO
LONGER BE ACCEPTED
REVIEW QUIZ QUESTIONS AND TAKE
THE QUIZ BASED ON THIS ARTICLE
ONLINE AT WWW.AHIMASTORE.ORG
NOTE: AHIMA CE QUIZZES HAVE
MOVED TO AN ONLINE-ONLY FORMAT.
Journal of AHIMA July 15 / 27
CLOSING THE
LOOP ON
QUALITY
AND CDI
REFOCUSING PROGRAMS TO
ENSURE AN ACCURATE PICTURE
OF CLINICAL CARE
By Joseph J. Gurrieri, RHIA, CHP; Cassie Milligan, RHIT, CCS;
and Paul Strafer, RHIA, CCS
THE ULTIMATE GOAL of most CDI programs is to improve the
quality of patient care through more accurate and complete
clinical documentation. A potential increase in revenue is, of
course, a positive byproduct of doing so—which makes sense.
If organizations can demonstrate severity of illness (SOI) more
completely, reimbursement should follow suit.
Although some CDI programs continue to narrowly focus on
CC/MCC capture solely to drive revenue increases, the healthcare industry as a whole has started placing greater emphasis
on clinical communication, provider collaboration, and quality outcomes. For example, value-based purchasing (VBP) provides financial incentives for care that yields better clinical outcomes over time and across care settings. VBP promotes a more
holistic approach that places patient safety and quality of care
at the forefront—and relies heavily on clinical documentation.
What role does CDI play in these evolving reimbursement
models and quality programs? To start, CDI programs can refocus priorities to align with the healthcare industry’s overarching
goals mentioned above—including the Institute for Healthcare
Improvement’s Triple Aim Initiative, which aims to improve pa28 / Journal of AHIMA July 15
tient quality and satisfaction, improve the health of populations,
and reduce the cost of healthcare. CDI specialists are strategically placed to help drive this effort.
By reviewing clinical documentation concurrently and identifying communication gaps as they occur, CDI specialists are
best positioned to gather additional details necessary for better
clinical handoffs and improved quality of care while also supporting HIM’s coding initiatives. CDI helps the healthcare industry close the loop on quality.
Reasons for a Quality Focus
CDI programs nationwide have experienced a growth spurt
thanks to ongoing third-party auditor scrutiny of documentation
as well as the impending transition to ICD-10-CM/PCS. Organizations that couldn’t afford a CDI program in the past have found
the budget to create one. They’ve realized that a lack of specificity
and clinical validation to support documented/coded diagnoses
guarantees more claims denials and future payment recovery audits. Working to ensure quality data, produced through the clinical documentation process, is seen as the “golden ticket” for long-
Closing the Loop on
Quality and CDI
term success in an increasingly regulatory-driven environment.
Congruent with CDI expansion is broader acceptance and
implementation of EHRs. With 4,811 hospitals and 530,756 total providers now registered in the Centers for Medicare and
Medicaid Services’ (CMS’) “meaningful use” EHR Incentive
Program, the healthcare industry has spurred a “Big Data”
revolution.1 Today’s coded data is used to calculate reimbursement as well as paint pictures of the quality of care provided.
Easy access to quality outcomes data increases the power of
consumer choice.
Organizations must ensure their data accurately reflects quality care and is of the highest quality—and CDI specialists play
an important role. Below are three specific examples.
Consumer Comparisons
CMS’ Hospital Compare is a website where consumers can
“shop around” to select healthcare providers online. The website presents easily accessible provider information on 27 inpatient quality measures, including 24 clinical processes of care
measures and three clinical outcome measures. If hospitals
don’t capture these measures via quality documentation and
accurately coded data, the information portrayed to consumers
is erroneous.
For example, one process of care quality measure pertains to
aspirin at arrival. Patients who present with an acute myocardial
infarction must receive an aspirin within 24 hours before or after hospital arrival, assuming there are no aspirin contraindications. If this measure isn’t performed, documented, and coded,
then it may appear as though the hospital doesn’t comply with
safety protocols.
CDI specialists can ensure documentation reflects the fact
that aspirin was prescribed within this timeframe. Doing so enhances the data on which measures, outcomes, and public profiles are based.
Safety Indicators
Outcomes measures are driven, in part, by Agency for Healthcare Research and Quality (AHRQ) patient safety indicators
(PSIs). In particular, PSI 04 (death among surgical inpatients
with serious treatable complications) and PSI 90 (complication/
patient safety for selected indicators) play an important role in
the data used to generate information on consumer comparison websites.
CDI specialists can play a key role in the capture of PSIs. The
Leapfrog Group uses 28 national performance measures—many
of which are drawn from CMS data—to assign a single composite safety score that denotes a hospital’s overall performance in
keeping patients safe from preventable harm and medical error.
Healthgrades relies on similar data, including data from AHRQ,
to recognize hospitals for excellent performance in safeguarding patients from potentially preventable conditions during
hospital stays.
Case Mix Index
A final reason to take a more holistic approach to CDI is to enJournal of AHIMA July 15 / 29
Closing the Loop on
Quality and CDI
sure an accurate case mix index (CMI). CDI specialists must
capture all CCs and MCCs regardless of their impact on reimbursement. Doing so guarantees that an organization’s CMI
reflects its patient population. A lower—and inaccurate—CMI
can lead to a lower base rate for payment, which can be catastrophic for the organization over time.
Whether for quality outcomes, patient safety, or case mix, incorrect data casts a negative light on patient care and represents
a false reality—one that is much bleaker than occurs in most
hospitals today. Quality-focused CDI programs help mitigate
this risk.
Expanding the CDI Scope
Transform your Clinical
Documentation
•
•
•
•
stronger financial impact
improved data quality
increased physician engagement
average ROI over 700%
Many CDI programs begin with a focus on recovery audit contractor (RAC) and other auditor findings. Although this is an
effective way to ensure an immediate return on investment
and target high-risk areas of compliance, programs can—and
should—expand beyond this scope to include:
SOI and Risk of Mortality (ROM)
These calculations are based on the interaction of multiple comorbidities and disease progressions, and are vital for public
reporting as well as APR-DRG reimbursement methodology.
Conditions can affect SOI and ROM regardless of whether they
are CCs and MCCs. Therefore, CDI specialists should focus on
accurate documentation for all diagnoses that affect a patient’s
stay rather than those that simply increase the DRG weight.
Present on Admission (POA) Indicators
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30 / Journal of AHIMA July 15
These indicators denote whether a condition was POA or developed during the hospital stay. If the POA is not documented
and/or coded correctly, a hospital’s patient safety indicators
rate could be improperly inflated. It’s not realistic for CDI specialists to focus on reviewing POA accuracy for every diagnosis. Instead, they should focus on capturing the correct POA for
infectious diseases, hospital-acquired conditions, and cases in
which patients are transferred from another facility.
Patient Safety Indicators (PSIs)
Through concurrent reviews of PSIs, CDI specialists can quickly
notify case managers and providers in real time to ensure clinical protocols are followed. For example, PSI 90 is a composite
indicator that includes data compiled from the following other
PSIs, each of which can be improved with the help of CDI:
PSI 03: Pressure ulcer rate
PSI 06: Iatrogenic pneumothorax rate
PSI 07: Central venous catheter-related blood stream infection rate
PSI 08: Postoperative hip fracture rate
PSI 09: Perioperative hemorrhage or hematoma rate
PSI 10: Postoperative physiologic and metabolic derangement rate
PSI 11: Postoperative respiratory failure rate
PSI 12: Perioperative pulmonary embolism or deep vein
thrombosis rate
PSI 13: Postoperative sepsis rate
Closing the Loop on
Quality and CDI
PSI 14: Postoperative wound dehiscence rate
PSI 15: Accidental puncture or laceration rate
For PSI 03, CDI specialists can check for documentation that
reflects whether the pressure ulcer is POA. This involves ensuring that a thorough skin assessment is performed and documented on the first day of the patient’s stay.
For PSI 09, CDI specialists can clarify whether a hemorrhage
or hematoma occurs during or after the operation. They can
also clarify whether the patient had ecchymosis (flat bruising of
the skin) or an actual hematoma (bruising with mass).
Related to PSI 13, CDI specialists can ensure that documentation supports a confirmed diagnosis of sepsis.
For PSI 15, CDI specialists can ensure that documentation
supports whether the patient truly experienced a laceration as
a complication or whether the laceration was intentional. They
can also clarify whether any diagnoses that could potentially
trigger PSI 15 were eventually ruled out (i.e., rule-out pneumothorax vs. actual pneumothorax).
For more information about coding and documentation issues pertaining to each PSI, refer to AHRQ’s guide “Documentation and Coding for Patient Safety Indicators” available at www.
ahrq.gov/professionals/systems/hospital/qitoolkit/b4_documentationcoding.pdf.
Outpatient/Emergency Documentation
Many organizations are turning their attention toward outpatient documentation as it directly impacts medical necessity
justification for inpatient care. With emergency medicine documentation, CDI specialists can ensure that residents and others
provide a thorough history of present illness as well as documentation to support the POA indicator.
Three Strategies to Build a Quality-Driven CDI Team
There are many ways in which organizations can refocus CDI
programs to better incorporate the above mentioned types of
data that will directly affect quality measures and quality-related public reporting.
Consider the following three strategies:
1. Rebrand CDI as clinical documentation integrity. Quality-focused CDI is all about the integrity and accuracy of
the data. Make sure providers understand CDI is not about
increasing revenue for the hospital even though it may be
an indirect byproduct of quality enhancement.
2. A lign CDI with coding and quality. In many organizations, CDI, coding, and quality staff report to entirely different departments. CDI often reports to case management or utilization review. Coding may report to HIM or
finance/revenue cycle. Quality may be an entirely separate department of its own. Even though these silos may
exist, organizations should strive to break down the walls
that prohibit collaboration and communication.
Consider forming a task force including the HIM, nursing, quality, and CDI departments, and a physician champion. Having a consistent message across multiple departments is essential. Ideally, this team would be led by the
CFO, resulting in a “top down” approach to CDI.
3.
Be mindful of CDI specialists’ limitations; successful CDI programs are a team effort. Organizations may
need to consider hiring additional CDI staff to accommodate for a longer list of documentation elements to be reviewed. As that list expands to include quality elements,
CDI specialists may become overwhelmed and inadvertently compromise quantity over accuracy. Providing sufficient support can help mitigate this risk.
Also keep in mind that CDI shouldn’t fall on the shoulders
of one person or one department. It’s about taking a team approach to what is considered a complex and detailed process.
Other members of a CDI task force can further foster a qualitydriven CDI program.
For example, coders can share their knowledge about coding
guidelines and sequencing with CDI specialists. Coders working concurrently can also bring documentation challenges to
CDI specialists’ attention to resolve the issue jointly. In addition, case managers and utilization review specialists can work
closely with CDI to remind providers of timely clinical protocols
and other measures.
Finally, physicians are an important part of CDI because they
provide the documentation upon which all coded data is based.
The most successful CDI programs are those that incorporate
quarterly physician education to avoid repeating the same mistakes or omissions. If physicians don’t receive this education,
organizations won’t reap the rewards of their CDI programs regardless of how effective those programs may be.
Listen to What the Data Are Saying
Quality-driven CDI programs provide significant insight into a
hospital’s performance, including areas for improvement. As
organizations continue to focus on quality, it’s equally important to look at the stories behind the numbers—what the data
are saying and why. For example, an increased focus on the POA
indicator could suggest a rise in hospital-acquired conditions.
This may have nothing to do with the clinical care provided.
Rather, it could have everything to do with employing a more
intense data review.
When tying CDI with quality, be sure to develop clear communication strategies with patients, insurers, and others to avoid
misinterpretation of information. Understanding the context of
the data is critical. ¢
Note
1. Centers for Medicare and Medicaid Services. “EHR Incentive Program: Active Registrations.” March 2015. www.
cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/March2015_SummaryReport.pdf.
Joseph J. Gurrieri (
[email protected]) is vice president and chief
operations officer, Cassie Milligan (
[email protected]) is
manager of coding quality improvement, and Paul Strafer (paul.strafer@
himoncall.com) is coding and education manager at H.I.M. On Call.
Journal of AHIMA July 15 / 31
Survey Predicts
Future HIM
Workforce Shifts
HIM INDUSTRY ESTIMATES THE JOB ROLES, SKILLS
NEEDED IN THE NEAR FUTURE
By Ryan Sandefer, MA, CPHIT; David Marc, MBS, CHDA; Desla Mancilla, DHA, RHIA; and Debra Hamada, MA, RHIA
THE AMERICAN HEALTH Information Management Association (AHIMA) conducted a study to assess the future needs
of the health information workforce. The study was intended
to define the current reality of HIM within the healthcare industry, how the market is shifting to meet future needs, and
what knowledge, skills, education, and credentials will be
necessary to perform successfully as an HIM practitioner in
the future. The study consisted of a survey of HIM and related
stakeholders and multiple focus groups. This article summarizes key findings from the survey.
Who Took the Survey
Between September 11, 2014 and October 3, 2014, the survey
32 / Journal of AHIMA July 15
was sent to 59,029 health information management (HIM) professionals and related stakeholders, yielding 6,475 survey views,
of which 3,370 responses were included in the final analysis. A
total of 58 percent of the respondents were HIM professionals,
with the remainder consisting of employers, healthcare professionals, students, educators, and other related groups. AHIMA
members made up 89 percent of respondents, 75 percent of respondents were over the age of 45, and 91 percent were female.
A total of 60 percent of respondents worked in an acute care
setting, with the percentage of respondents from each of the
other settings under 10 percent. Approximately 35 percent of
respondents had an RHIT credential, 28 percent had an RHIA
credential, and 23 percent had a CCS credential.1
Survey Predicts Future HIM
Workforce Shifts
Survey Findings Chart HIM Role Change
The findings from the study illustrate that the health information profession is experiencing significant change, partly
spawned by the conversion from paper to electronic health
records and the impact of state and federal regulations. Most
in the industry acknowledge that HIM professionals will continue to see changes in where they work, how they work, the
technology they work with, and the quantity and types of data
they are asked to manage. The survey aimed to assess the impact of this change by asking health information professionals
to rate the percentage of their time spent on specific tasks currently, and how much time they expect to spend on the tasks 10
years in the future. The overall mean difference in responses
were calculated and graphed regarding the percentage of time
the respondents anticipated they will spend on these tasks in
the future minus the percentage of time they spend on these
tasks currently.
As shown in Figure 1, the most significant result was that respondents anticipated they will spend a lower percentage of
their time on diagnosis and procedural coding in the future.
Nearly two-thirds of HIM professionals currently spend a portion of their time on coding-related tasks—meaning this change
will significantly impact the roles and responsibilities of future
HIM professionals. Leadership was identified as the task that
will increase the most significantly, followed by teaching and
informatics. These findings indicate that HIM professionals perceive unique opportunities in diverse settings—management,
higher education, and information technologies.
In addition to asking about current and future tasks performed by respondents, the survey also asked respondents two
questions to rate the current and future importance of a variety
of health information-related competencies. Figure 2 on page
34 visualizes the results from these two questions.
Respondents rated privacy and security, EHR management,
and data integrity as the overall most important competencies
in the future, while business analytics and research were rated
the least important. Of particular note is the perceived decline
in the importance of diagnostic and procedural coding and records processing in the future.
Survey Shows Decline in ‘Bread and Butter’ HIM Roles
Figure 3 on page 34 displays the difference in the ratings of competency importance for the future compared to present day.
Evidently, the largest growth of future importance is in Big Data
analysis, informatics, and data mining. However, the largest decline of future importance is in typical “bread and butter” types
of HIM operations, including coding, records management, and
administration/staff supervision.
Employer opinions were sought as an additional facet of the
study. Like HIM professionals, employers identified coding as
Figure 1. Areas HIM Expects to Focus on
in the Near Future
THIS GRAPH SHOWS the mean difference in responses regarding the percentage of time the respondents anticipate
they will spend on these tasks in the future minus the percentage of time they spend on these tasks currently. A higher number indicates that respondents anticipate they will
spend a greater percentage of time on the task in the future.
Leadership
Teaching
Informatics
Legal
Quality
Standards
Compliance
Revenue
Biz/Clin Analysis
Privacy
Analytics
Coding
-6
-4
-2
0
2
Mean Differences in Responses
4
the most important skill for the profession today and agreed
that its importance will diminish in the future. Globally, the
study revealed strong agreement between employers and HIM
professionals regarding current and future skill prevalence
and importance. The harmony between employers and HIM
professionals reinforces the recognition of the changing professional landscape.
Journal of AHIMA July 15 / 33
Survey Predicts Future HIM
Workforce Shifts
Figure 2. Average Rated Importance for
Each Competency Today and in the Future
THIS GRAPH SHOWS how respondents view the importance of a variety of HIM-related competencies—both today
and 10 years in the future.
Privacy/Security
Current
Future
EHR Management
Data Integrity
Critical Thinking
Problem Solving
Communication
Quality Assurance
Data Analysis
Informatics
Leadership
Fraud
CDI
Interoperability
HIM Standards
Efficiency
IT Support
IG
Coding
System Development
Project Management
Data Mining
Auditing
Med Term/Pharma
Big Data Analysis
IT Networking
Risk Management
IT/Programming
Pt/Clinician Ed
Statistics
Compliance/VBP
Change Management
Assess Processes
Admin
Design/Innovation
Financial Management
Records Processing
Consumer Engagement
Negotiation
Business Analytics
Research
34 / Journal of AHIMA July 15
4.0
4.5
Average Response
THIS GRAPH SHOWS the mean difference in responses
regarding the rating of importance of competencies in the
future minus the rating of importance of competencies in
the present. A higher number indicates that the importance
of a competency is greater in the future compared to today.
Big Data Analysis
Informatics
Data Mining
System Development
Interoperability
IG
Data Analysis
Efficiency
Design/Innovation
Fraud
Consumer Engagement
IT Networking
HIM Standards
IT/Programming
Project Management
Statistics
EHR Management
Assess Processes
Leadership
Pt/Clinician Ed
Data Integrity
IT Support
Analytical Thinking
Research
Risk Management
Privacy/Security
Business Analytics
Critical Thinking
Compliance/VBP
Auditing
Quality Assurance
Problem Solving
Negotiation
Financial Management
Change Management
CDI
Communication
Med Term/Pharma
Admin
Records Processing
Coding
Analytical Thinking
3.5
Figure 3. Skills That Will Be More
Important in the Future Than Today
5.0
-0.2 -0.1 0.0 0.1 0.2 0.3
Mean Differences in Responses
0.4
Survey Predicts Future HIM
Workforce Shifts
Chasm Exists Between Future Jobs
and Future HIM Skills
One of the major findings from this study is the apparent chasm
between the tasks on which HIM professionals expect to spend
time 10 years in the future and the rated importance of future
workforce competencies related to those tasks. While HIM professionals rated data analytics and related competencies as an
area that will be very important in the future, HIM professionals
did not report that they anticipate they will spend a large percentage of their time on data analytics in the future. In other
words, HIM professionals, overall, do not perceive themselves
stepping into data analytics roles. This leaves us with an important question: why not?
The future of HIM is highly dependent upon leveraging data
as an asset. Because of this, AHIMA has established “information governance” as a strategic priority for the association. One
of the key drivers of information governance in healthcare is the
need for clinical and business analytics. According to a recent
AHIMA survey, across the healthcare industry 65 percent of
professionals recognized a need for a formal information governance program, yet only 43 percent of organizations have initiated the development of such a program.2
What these findings indicate is that for information governance
to be successful, organizations must adopt and support the tools
and resources that allow professionals to gain more value from
the data. In short, information governance programs must clearly
demonstrate a value added in terms of quality improvement, cost
savings, and overall business understanding. In order to demonstrate this value, HIM professionals must be more comfortable
with the competencies related to data analytics, such as business
intelligence, database administration, inferential and descriptive
statistics, health information technology, and project management. The interdisciplinary nature of health information creates
an environment of multiple stakeholders all needing information
for a wide variety of reasons. At the same time there is scant direction in healthcare organizations about who the information
management experts are in this age of Big Data. With increased
use of technology and the data it creates, HIM professionals must
Journal of AHIMA Continuing Education Quiz
Quiz ID: Q1528607 | EXPIRATION DATE: JULY 1, 2016
HIM Domain Area: Performance Improvement
Article—“Survey Predicts Future HIM Workforce Shifts”
be able to demonstrate the skills needed to analyze data in a way
that creates meaningful information upon which other healthcare stakeholders can take action.
HIM Poised to Fill Workforce Data Niche
Data analytics is a newer, widely misunderstood domain within
the healthcare ecosystem. The projected growth of data analytics is expected, but defining the roles to meet this demand is
difficult. However, HIM professionals are perfectly geared to fill
this “data” niche because they have a very strong understanding of healthcare data, operations, and clinical processes. Such
expertise is often lacking among applicants who are looking to
fill analytics roles.
To meet future healthcare market needs and better define
healthcare analytics roles, HIM professionals need to exploit
their knowledge. If HIM professionals take a leadership role in
this domain, healthcare organizations will be more effective at
implementing information governance programs and achieving
desired outcomes. ¢
Notes
1. AHIMA. “Results of the AHIMA 2014 Workforce Study.”
March 2015. http://bok.ahima.org/doc?oid=300801#.
VV4b7k2UBGE.
2. Cohasset Associates and AHIMA. “2014 Information Governance in Healthcare: Benchmarking White Paper.” 2014.
www.ahima.org/~/media/AHIMA/Files/HIM-Trends/
IG_Benchmarking.ashx.
Ryan Sandefer (
[email protected]) is chair and assistant professor in the
department of health informatics and information management and David Marc (
[email protected]) is assistant professor of health informatics and
graduate program director at the College of St. Scholastica. Desla Mancilla
(
[email protected]) is senior director of academic affairs at the AHIMA Foundation. Debra Hamada (
[email protected]) is
chair of health informatics and information management and assistant
professor, program director of the health informatics master’s program at
Loma Linda University.
TAKE THE QUIZ AT WWW.AHIMASTORE.ORG
NOTE: MAILED-IN PAPER QUIZZES WILL NO
LONGER BE ACCEPTED
REVIEW QUIZ QUESTIONS AND TAKE
THE QUIZ BASED ON THIS ARTICLE
ONLINE AT WWW.AHIMASTORE.ORG
NOTE: AHIMA CE QUIZZES HAVE
MOVED TO AN ONLINE-ONLY FORMAT.
Journal of AHIMA July 15 / 35
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ONC Targets
Information
Blocking
By Kathy Downing, MA, RHIA, CHPS, PMP, and Jessica Mason
A
A NEW REPORT to Congress from the Office of the National Coordinator for Health IT (ONC), released in April, has put information blocking in the spotlight.1 The ONC report comes out on
the heels of a recent article written by five US senators titled,
“Where Is HITECH’s $35 Billion Dollar Investment Going?”2
That article questioned the current state of the program and
ONC’s Roadmap to Interoperability.3
The senators wrote that there was “inconclusive evidence that
the program [HITECH] has achieved its goals of increasing efficiency, reducing costs, and improving the quality of care.”
The senators singled out interoperability as the key factor in restraining success. They argued that the ONC Roadmap lacked
specifics for how to achieve true interoperability and sustain
meaningful use of electronic health records (EHRs).
In a HealthIT.gov blog post on April 10, 2015, ONC Director
Karen DeSalvo, MD, MPH, MSc, and Jodi Daniel, director of the
ONC Office of Policy, announced the release of the “Report to
Congress on Health Information Blocking.”4
In the post they wrote that “The secure, appropriate, and efficient sharing of electronic health information is the foundation
of an interoperable learning health system” and that information blocking hinders progress toward that goal. The report was
compiled at the request of Congress as outlined in the Consolidated and Further Continuing Appropriations Act of 2015,
signed by the President on December 16, 2014.
The legislation required a detailed report from ONC regarding the extent of the information-blocking problem, including
an estimate of the number of vendors or eligible hospitals or
providers who block information. The act further required a
comprehensive strategy on how to address the information
blocking issue.
36 / Journal of AHIMA July 15
Information Blocking Defined
Requirements under HITECH and the “meaningful use” EHR
Incentive Program state that certified EHRs need to provide for
the transmission of data. In the case of information blocking,
the vendor (health IT developer), health system, hospital, or accountable care organization (ACO) has opted not to send data
electronically even when they can. While the report acknowledges that not all information blocking is intentional or misplaced, certain practices fall under the definition of intentional
information blocking and interference, including:
Setting contract terms, policies, or other business or organizational practices that restrict individuals’ access
to their electronic health information, or restrict the exchange or use of that information for treatment and other
permitted purposes
Charging prices or fees (such as for data exchange, portability, and interfaces) that make exchanging and using
electronic health information cost prohibitive
Developing or implementing health IT in non-standard
ways that are likely to substantially increase the cost,
complexity, or burden of sharing electronic health information, especially when relevant interoperability standards have been adopted by the Secretary of the US Department of Health and Human Services (HHS)
Developing or implementing health IT in ways that are
likely to “lock in” users of electronic health information;
lead to fraud, waste, or abuse; or impede innovations and
advancements in health information exchange and health
IT-enabled care delivery
Information blocking is the antithesis of interoperability goals
for healthcare information exchange. According to the report,
information blocking “occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of
electronic health information.” ONC was careful to note the difference between intentional blocking and inadvertent technical
or practical issues.
The report outlines three criteria that define intentional blocking: interference, knowledge, and unreasonable justification.
True information blocking involves “conduct that interferes with
the ability of authorized persons or entities to access, exchange,
or use electronic health information.” Further, the decision to
engage in information blocking must be made knowingly. Finally, not all conduct that knowingly interferes with electronic
health information exchange is information blocking. Rather,
information blocking involves conduct that is objectively unreasonable in light of public policy.
The Extent of the Problem
ONC recognizes that the full extent of the information blocking
issue is difficult to assess. Their documentation is derived from
complaints, anecdotal evidence, and survey-derived data analyzing the adoption of exchange functionalities and capabilities.
Otherwise, empirical data on information blocking is limited at
present. Still, from the evidence available, ONC concludes it is
“readily apparent that some providers and developers are engaging in information blocking.”
In 2014, ONC received approximately 60 unsolicited complaints regarding information blocking. ONC also reviewed
documented incidences, interviewed a variety of stakeholders,
and conducted in-person discussions and phone calls related
to the issue.
On the whole, most complaints of information blocking were
directed at health IT developers. These complaints largely centered on developer fees. Developers are accused of charging
prohibitive fees to:
Send, receive, or export electronic health information
stored in EHRs
Establish interfaces that enable such information to be exchanged with other providers, persons, or entities
Send, receive, or query a patient’s electronic health information
Establish certain common types of interfaces
E xtract data from EHR systems or move to a different EHR
technology 6
The report acknowledges concerns about wide variation in developer fees. Though fee variation may reflect differences in developer technology and services, it cannot adequately explain all
the variation in prices reported to ONC. The report considers that
Journal of AHIMA July 15 / 37
Working Smart a professional practice forum
Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / Quality Care
developers may be engaging in opportunistic pricing practices.
Other complaints aimed at developers allege that some EHR
developers either prohibit or make it unnecessarily difficult or
expensive for their customers to connect to third-party health IT
modules, even when such modules have been certified by ONC.
The report cites recurring complaints that developers prevent
the exchange of health information with competitors or with
specific providers by refusing to establish interfaces or connections with certain technologies or entities.
Healthcare providers do not escape scrutiny in the report.
Providers are also accused of information blocking. A recurring
complaint is that some hospitals or health systems block information to control referrals and augment their standing in the
market. Providers typically claim this is to comply with privacy
and security requirements. However, ONC finds that privacy
and security laws are cited in circumstances in which they do
not in fact impose restrictions. Other complaints charge that
providers are information blocking by coordinating with developers to restrict exchange with unaffiliated providers.
Strategy and Action
The report includes a comprehensive approach to addressing information blocking. ONC believes both target actions and broad
strategies will be necessary to combat information blocking.
There are actions that interfere with the exchange and use of
electronic health information, but that do not meet the criteria
for information blocking. ONC believes that these actions, along
with systemic barriers to interoperability and exchange, require
a broad approach, including:
Continued public and private sector collaboration to develop and drive the consistent use of standards and standards-based technologies that enable interoperability
Establishing effective rules and mechanisms of engagement and governance for electronic health information
exchange
Fostering a business, clinical, cultural, and regulatory environment that is conducive to the exchange of electronic
health information for improved healthcare quality and
efficiency
Clarifying requirements and expectations for secure and
trusted exchange of electronic health information—consistent with privacy protections and individuals’ preferences—across states, networks, and entities7
The report further outlines the targeted actions developed by
ONC to address information blocking, including:
Strengthen surveillance of certified health information
technology
Promote greater transparency in certified health IT products and services
Establish governance rules that deter information blocking
Work in concert with the HHS Office for Civil Rights to
38 / Journal of AHIMA July 15
improve stakeholder understanding of the HIPAA privacy
and security standards related to information sharing
Coordinate with the HHS Office of Inspector General (OIG)
and the Centers for Medicare and Medicaid Services (CMS)
concerning information blocking in the context of the federal anti-kickback statute and physician self-referral law
Refer illegal business practices to appropriate law enforcement agencies
Work with CMS to coordinate healthcare payment incentives and leverage other market drivers to reward interoperability and exchange, and discourage information blocking
Promote competition and innovation in health IT and
healthcare
Constrain standards and implementation specifications8
The report examines concerns that may lie beyond the scope of
ONC. The discovery of information blocking practices requires
direct access to potentially sensitive documentation. ONC notes
in the report that it has no authority to demand the production
of relevant documentation or access to information. The agency
does note that there are, however, avenues open to Congress
that could effectively address information blocking practices. ¢
Notes
1. Office of the National Coordinator for Health IT. “Report
on Health Information Blocking.” April 2015. http://healthit.gov/sites/default/files/reports/info_blocking_040915.
pdf.
2. Thune, John et al. “Where Is HITECH’s $35 Billion Dollar
Investment Going?” Health Affairs. March 4, 2015. http://
healthaffairs.org/blog/2015/03/04/where-is-hitechs35-billion-dollar-investment-going/.
3. Office of the National Coordinator for Health IT. “Connecting Health and Care for the Nation: A Shared Nationwide
Interoperability Roadmap.” 2015. www.healthit.gov/sites/
default/files/nationwide-interoperability-roadmap-draftversion-1.0.pdf.
4. DeSalvo, Karen B. and Jodi G. Daniel. “Blocking of health
information undermines health system interoperability
and delivery reform.” Health IT Buzz. April 10, 2015. www.
healthit.gov/buzz-blog/from-the-onc-desk/health-information-blocking-undermines-interoperability-deliveryreform/.
5. Office of the National Coordinator for Health IT. “Report
on Health Information Blocking.”
6. Ibid.
7. Ibid.
8. Ibid.
Kathy Downing (
[email protected]) is a director of HIM practice excellence at AHIMA. Jessica Mason (jessicamason.chicago@gmail.
com) is a recent graduate of the University of Illinois at Chicago.
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Clinical Documentation
Improvement’s Main Ingredient:
‘Physicians First’
By Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, FAHIMA
W
WHAT’S THE MAIN ingredient in your clinical documentation improvement (CDI) program? CDI programs are not new
to healthcare, and depending on the organization they can
look different from facility to facility. Over the past 10 years
CDI programs have increased in size and scope due to changes in reimbursement, increased scrutiny by third party payers,
and fraud and abuse activities.
Physicians are not taught documentation in medical school,
and in most cases physicians remain uniformed about why
CDI is important. In a competitive healthcare environment,
with acronyms such as DRG, MCC, CC, and POA, a physician’s
place in the recipe for a successful CDI program can become
lost. When mixing up healthcare’s veritable alphabet soup of
ingredients to bake a CDI program, consider placing physicians as the main ingredient.
It’s a Quality Thing
When making a cake, the baker never hopes for a flat, dry final
product. They expect a high quality moist cake that customers
enjoy. Baking a CDI program is no different—quality patient care
is the expected end result. Most will agree that good documentation is important for patient care. In CDI programs, it is not just
good documentation that is important; it is specificity in documentation that is required. As integral as they are to the process,
physicians may not understand the need for specificity in documentation. Lack of specificity on a hospital claim can have a dramatically different impact than a lack of specificity on a physician
claim. The key is to engage physicians on the common theme of
quality. In the end, the hospital and physician can agree that providing high quality care to patients is the main focus.
Physicians know the documentation they need for treat40 / Journal of AHIMA July 15
ment, but CDI programs are aimed at increasing detail that
will accurately tell the patient’s story. Physicians know the patient, their history, and current course of treatment. CDI specialists have knowledge of documentation requirements and
code assignment. Physicians are typically the first member of
the clinical care team to document in a patient’s health record
by writing physician orders. Other clinical team members
continue to build off the initial order to create a bigger picture.
Physicians and CDI specialists who work in tandem will provide a win/win scenario for everyone involved.
Advantages of Modern Day Documentation
Just like the days of writing recipes on a note card are gone, also
gone are the days of paper documentation, when physicians
were writing voluminous pieces of documentation within each
patient’s record. Gone are the laborious days of writing an order,
then progress note, then dictating a discharge summary—all of
which tie up a physician’s time as well as the chart.
Technology is also dramatically changing the way healthcare is provided, shortening lengths of stays, improving outcomes, and affecting where and how care is provided. Why
mix by hand when a blender is available? The modern day provider is a computer-savvy individual who is taking advantage
of new tools and methods to simplify documentation efforts.
By promoting workflow redesign and technology tools, CDI
programs today can save massive amounts of time and still receive quality documentation.
A CDI program designed to include electronic health record
(EHR) tools such as drop down menus, pick lists, or structured
data entry can increase quality documentation and reduce errors.
The primary goal of an EHR should be concise, history-rich docu-
mentation used to support patient care. Great CDI programs consider the EHR as an active member of the healthcare team rather
than the passive recipient seen previously in paper records.
Mix for Success
Hospitals and physicians today have their work cut out for
them. Mixing business with patient care does not always come
with a cookie cutter recipe for success. As value-based purchasing, ICD-10-CM/PCS, and quality measures all require
providers to produce more robust, complete, and detailed information, healthcare is turning to CDI to bridge the gap.
Having all of the ingredients on the counter will not create a
better cake unless the baker mixes them correctly and at the
right time. CDI programs should be developed with the organization’s specific needs in mind, as well as the input of physicians. Trying to implement CDI without physician input and
buy-in will create a program flatter than the proverbial pancake.
Physicians, CDI specialists, and coding professionals working
together can provide the right program. Keeping the program
focused on quality outcomes will ensure that clinical documentation is at the core of every encounter. Allocating the appropriate resources to a CDI program can provide physicians the documentation training they need to create a patient picture as well
as support the hospital’s need for accurate code assignment.
Integrating CDI efforts throughout the organization can provide
PJ &A
the consistent messaging needed to ensure everyone understands
the benefits of the program. Keeping the physicians first ensures
that the primary person responsible for documentation is using the
tools and resources available to make their job easier. ¢
References
Bresnick, Jennifer. “Clinical Documentation Improvement,
Quality Combine for Revenue.” Health IT Analytics. March
30,
2015.
http://healthitanalytics.com/news/clinicaldocumentation-improvement-quality-combine-for-revenue.
Dimick, Chris. “Shadowing Physicians for Documentation
Improvement.” Journal of AHIMA. September 1, 2009. http://
journal.ahima.org/2009/09/01/shadowing-physicians-fordocumentation-improvement/.
Towers, Adele L. “Clinical Documentation Improvement—A
Physicians Perspective: Insider Tips for Getting Physician
Participation in CDI Programs.” Journal of AHIMA 84, no. 7
(July 2013): 34-41.
Clinical Documentation.net. “The Advantage of Modern
Day Clinical Documentation.” July 31, 2014. http://
clinica ldocumentat ion.net/advantage-modern-dayclinical-documentation/.
Lou Ann Wiedemann (
[email protected]) is vice president
of HIM practice excellence at AHIMA.
Perry Johnson & Associates, Inc.
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Journal of AHIMA July 15 / 41
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Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / Quality Care
Clinical Definition Standards
Case Study
By Katherine Lusk, MHSM, RHIA
W
WITH THE OCTOBER 1, 2014 date for prospective payment
for inpatient pediatric Medicaid discharges looming, Children’s Health System of Texas identified an organizational
need to reboot and formalize its clinical documentation
improvement (CDI) program. The journey began with three
core tenets:
1. No additional full time equivalents
2. Leverage technology
3. Work smart
To prepare for reimbursement changes, an initiative was
launched across the organization to increase operational efficiency and hold firm on staffing levels. As an organization,
Children’s Health has a long history of leveraging technology to
improve operational efficiency. The capital outlay of $65 million
for the electronic health record (EHR) was paid back in five years
based on efficiencies gained with the EHR. This journey created a
culture of pushing technology and work flow redesign to improve
operational efficiency.
Historically, the health information management (HIM) department’s work with CDI had been focused on record hygiene,
regulatory compliance, and efficiency. However, classifying patient encounters—with deference to accurately reflecting patient
acuity with resultant appropriate reimbursement—had not previously been a focus. Assuring financial stability with the upcoming
reimbursement changes created a sense of urgency. The organization quickly recognized there was a need to standardize clinical
definitions and incorporate those into the CDI plan.
Standardizing the Clinical Definition of Malnutrition
In reviewing medical records, the CDI team found diagnostic
42 / Journal of AHIMA July 15
terms that were inconsistent with symptoms, manifestations,
and documentation irregularities. The initial clinical definition
standard development encompassed malnutrition—the team
believed this diagnosis was significantly underused. Clinical
malnutrition documentation included terms such as “wasted,”
“poor weight gain,” “failure to thrive,” “light for age,” and “underweight”—with only an occasional definitive diagnosis. An
evaluation of the data revealed 56 inpatient encounters with a
diagnosis of malnutrition against total inpatient discharges of
18,280 in 2011.
Children’s Health provides services to the Dallas County market with 55-plus subspecialties, primary care clinics, and a financial mix comprised of 65 percent Medicaid patients. The
organization’s data showed that subspecialty delivery included
populations where malnutrition is known to be an associated
co-morbid condition. It became clear that the low number of
malnutrition diagnoses was not an accurate depiction.
This hypothesis was validated through further consultation
with the nutrition department, which confirmed that the number of diagnoses did not reflect the services delivered by their
department. Finally, conversations with the provider community revealed there were issues with reimbursement for patient
care services due to a lack of definitive diagnosis, and inconsistency with the malnutrition diagnosis. This knowledge, coupled
with the nutrition department view, provided the CDI team with
the leverage to engage providers in establishing a clinical definition standard for malnutrition.
The team assembled a multidisciplinary workgroup comprised of physicians, advance practice nurses, nutrition professionals, coders, and CDI specialists. The work effort began
with the team defining the problem and conducting an exten-
sive literature review. It then secured a physician champion
from the gastrointestinal division and sought participation
from disciplines to serve as subject matter experts.
The CDI specialist facilitated the meetings, pulled the information together, and wrote/managed the multiple drafts of
the case definition of malnutrition. Then the case definition
document was socialized, which enabled the team to receive
valuable feedback. The socialization process included meeting with providers one on one, holding department meetings,
presenting case studies, creating posters, and hosting lunchand-learn engagement sessions. The latter were hosted for
the provider community on a weekly basis, providing the CDI
team face time with a diverse audience.
The resulting case definition document was then triangulated against literature review to ensure a solid scientific base.
With the vetting process being tied to scientific evidence, the
team was able to accomplish and sustain the culture change
necessary to gain adoption of a standardized documentation
of malnutrition.
Remarkably, throughout the vetting process and socialization process, use of the clinical diagnosis “malnutrition” grew.
In 2012 there were 176 patients with the diagnosis of malnutrition—a three-fold increase from the 56 diagnoses in 2011. It’s
important to note that this increase was not due to a change in
the population served, but rather a vetting process that gave the
clinical community a standard for representation of malnutrition diagnosis.
In 2013, the team finalized the document “Malnutrition
Clinical Definition,” published it on an internal website
dedicated to physicians, and circulated it to the medical
community. In 2013, there were 878 patients with the diagnosis of malnutrition and 1,104 in 2014. Children’s Health
believes these statistics are the result of acceptance across
the disciplines and recognition of the value of a standard
definition for malnutrition in the pediatric population.
Table 1 on this page illustrates the progression of the process,
growing acceptance, and sustainability.
Putting the Standard to Use
Standard clinical definitions have been incorporated into
resident and new provider on-boarding and training within
respective disciplines. This serves as a means to standardize
clinical communication and ensure sustainability. To further
promote sustainability, queries from the CDI team and coders to the provider community reference the definitions as appropriate. Finally, standard clinical definitions are included
in division-specific materials for resident and fellow training,
and the definitions are included in examples when training on
the use of the EHR.
The journey did not end there. The organization continues
the process of identifying clinical terms that lack standardization across its community. The process has been successfully
Table 1: Malnutrition Diagnosis
Assignment Growth
1200
1,104
1000
878
800
600
400
200
0
56
176
2011
2012
2013
2014
Malnutrition Diagnoses
replicated in other areas by defining standards in the clinical
diagnoses of obesity, anemia, respiratory failure, heart failure,
sepsis, epilepsy, asthma, and renal failure. Because clinical
definition standards are an accepted practice in the medical
community, the process was endorsed by the medical staff.
It’s also clear that the value of streamlining clinical communication with a succinct, standard definition has been well
received.
Finally, as an added financial bonus, this process ensures
the provider and the hospital are accurately represented with
patient acuity. ¢
Katherine Lusk (
[email protected]) is chief health information management and exchange officer at Children’s Health System
of Texas.
Share Your Story
[email protected]
If you are interested in sharing your organization’s story
about the role of HIM professionals in setting standards for clinical
documentation improvement, please contact AHIMA’s Diana Warner at
[email protected]. Your story could be shared in an upcoming
Journal of AHIMA Standards Strategies column.
Journal of AHIMA July 15 / 43
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Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / Quality Care
The New CDI Challenge:
Adjusting to Quality, Not Quantity
By Brian Murphy, CPC
I
IT’S NO SECRET that healthcare is undergoing a profound
transformation. While fee-for-service delivery remains the current model for acute care hospital payment, the transition to
paying for quality over quantity is happening before our eyes.
In January, the Centers for Medicare and Medicaid Services
(CMS) announced its goal of tying 30 percent of its traditional
fee-for-service payments to quality models such as accountable
care organizations (ACOs) and bundled payment arrangements
by the end of 2016. CMS plans to increase that to 50 percent by
2018. The agency also announced a goal of tying 85 percent of all
traditional Medicare payments to quality or value by 2016, and
a whopping 90 percent by 2018, through programs like the Hospital Value-Based Purchasing (HVBP) program and the Hospital
Readmissions Reduction Program (HRRP).
So what does this paradigm shift mean for clinical documentation improvement (CDI) specialists? It means their knowledge
base and job description will need to broaden to adapt to these
changes. CDI specialists are increasingly learning to review documentation from a quality perspective, either in addition to or
as a replacement for the traditional model of DRG validation.
They need to be as comfortable with acronyms like HVBP, ACO,
and HRRP as they are with the old standbys like DRGs (diagnosis related group), POA (present on admission), and IPPS (inpatient prospective payment system).
Providers Upping the CDI Ante for Quality
Many CDI departments, seeing this looming change on the horizon, have begun to proactively review records with an eye on
quality. For example, Yale New Haven Health System in New
Haven, CT developed a brand new role called the CDS Quality
and Performance Lead. Working closely with the quality depart44 / Journal of AHIMA July 15
ment, these two staffers are focused on improving quality outcomes for the hospital as well as physician report cards by reviewing elements of patient safety indicators such as deep vein
thromboses, pulmonary embolisms, iatrogenic pneumothorax
cases, and accidental punctures and lacerations.
Yale New Haven has had a CDI program in place for 12 years,
and prior to implementing this new role had been focused on
a review of principal diagnoses and complications and comorbidities (CC) and major complications and comorbidities
(MCC) capture. It also transitioned from reviewing Medicare
patients only to all-payer review.
“Many CDI departments are looking for the ‘next step,’ i.e., how
to expand the impact of CDI beyond DRG validation and leverage the expertise many CDIs possess, particularly those with a
clinical background,” says Cheryl Ericson, MS, RN, CCDS, CDIP,
CDI education director for HCPro, Inc. and associate director
of education for the Association of Clinical Documentation Improvement Specialists (ACDIS). “CMS quality metrics are an
ideal fit with CDI because it encourages physician engagement,
[as physicians] are often more concerned with profiling than reimbursement, and [CMS metrics] incorporates the patient care
aspect of documentation.”
An example of this emerging CDI-quality connection and its
relationship to clinical care is the 1,069-bed NYU Langone Medical Center in New York City, NY. A few years ago NYU created
hard stops for coders on hospital-acquired conditions (HAC)
cases, meaning that if a condition triggers a HAC, the case is
flagged and the coder cannot release the bill. Instead, the case is
referred to a coding manager for a second review. If additional
clarification is needed, CDI is engaged. If CDI determines that
the case is a HAC, it is then sent to the department of clinical
quality and effectiveness (CQE). If that department does not
agree, additional discussion and follow-up is required.
Langone follows a similar review process for patient safety indicators and also has created a CDI-coding liaison position—a
foreign trained physician and certified coding specialist who reviews all hospital-acquired conditions and patient safety indicator (PSI) 90 cases and works closely with the department of
clinical quality effectiveness. This liaison validates coding and
educates coders and CDI specialists on the subject of patient
safety indicators. The liaison also queries as needed or, if the
case was previously reviewed by a CDI specialist, discusses the
case and requests a query by the original reviewer.
CDI’s New Core Competencies
In response to these changes, ACDIS issued a job analysis survey
to its more than 2,300 holders of the certified clinical documentation specialist (CCDS) credential. The survey asked CCDSs to
both confirm their current job functions and knowledge bases,
as well as gauge their knowledge of the “Impact of Reportable
Diagnoses on Quality of Care,” a proposed new category for the
CCDS exam.
Some 277 respondents completed the survey, with a more
than 10 percent response rate. Respondents to the survey were
asked to rate on a scale of 0-5 the importance of a series of tasks
and areas of knowledge related to CDI practice. The scale was
as follows: 5 = extreme importance, 4 = above average importance, 3 = average importance, 2 = below average importance,
1 = minimal importance, and 0 = not important.
CDI specialists operating in this new quality of care arena are
now expected to perform the following functions and/or maintain a working knowledge of the following quality-based initiatives. Each of these 10 quality items rated a 3.5 or higher on
the survey, indicating that they are now considered average to
above average importance for a CDI specialist to know:
1. Demonstrate knowledge of the significance of documentation and code assignment upon mortality index
2. Demonstrate knowledge of mortality reviews and interpreting observed/expected ratios
3. Define how quality data is acquired through both record
abstraction and claims data
4. E xplain the significance of these different types of quality
metrics used by CMS:
Hospital value-based purchasing
Hospital-acquired condition reduction programs
Hospital readmissions reduction programs
30-day mortality measures
5. A nalyze the financial impact of the Hospital Inpatient
Quality Reporting Program on an organization, and the
role of CDI regarding this CMS quality initiative
6. Demonstrate an understanding of CDI impact on documentation and code assignment in relation to hospital
value-based purchasing
7. Identify components of PSI 90 and its impact as a quality
measure
8. Identify other patient safety indicators beyond or in addition to PSI 90 and their impact as a quality measure
9. Identify coded data elements that can impact the reporting of patient safety indicators in regards to Medicare
claims
10. Compare and contrast hospital-acquired infections (HAI)
from documentation that supports the assignment of a
“complication code”
CDI Specialists Must Know Quality Metrics
The results of this survey clearly indicate that new CDI specialists entering the field must be well-versed in quality metrics and
the basics of performing a chart review that includes patient
safety indicators, hospital-acquired conditions, mortality measures, and readmissions.
“It [the survey] reflects the expansion of the CDI profession
beyond its coding origins as precise documentation is required
to accurately capture the complexity of healthcare through coded data,” Ericson says. “As CMS continues to move healthcare
towards a less segmented process, CDI can be the ‘glue’ that creates cohesion between the complicated clinical world of healthcare and the binary world of coded data.” ¢
Brian Murphy (
[email protected]) is the director of the Association of
Clinical Documentation Improvement Specialists.
Journal of AHIMA July 15 / 45
PRACTICE BRIEF
practice guidelines for managing health information
Best Practices in the Art and Science of
Clinical Documentation Improvement
C
CLINICAL DOCUMENTATION IMPROVEMENT (CDI) is an
entire discipline focused on improving the clinical clarity of the
health record. Practiced by health information management
(HIM) professionals, registered nurses, and a host of other clinically oriented professions, CDI has emerged as one of the most
important vehicles for bridging the gap between the clinical
documentation contained in the health record and the resulting
clinical and claims data utilized for reimbursement, research,
and outcomes management.
The impact of CDI programs is as vast as the types of professionals that perform the function. This impact includes a more
accurate depiction of patient severity and acuity as measured
by case mix index, severity of illness (SOI) and risk of mortality
(ROM) scores, reductions in clinical denials for medical necessity, and improved clinical outcomes and overall optimal continuity of care for patients as a result of capturing all diagnoses
and procedures supported by clinical documentation—and ultimately reflected through final code assignment.
While financial benefits are often key to demonstrating a measureable value proposition for a CDI program, chief quality officers, patient safety officers, chief information officers, and chief
medical officers are counted among the stakeholders realizing
tangible benefits from CDI programs. Mature CDI programs
have been able to synchronize clinical workflow with clinical
documentation, as well as enhance physician productivity and
satisfaction with electronic health record (EHR) systems. CDI
programs can also assist in reducing clinical ambiguity and
clarifying conflicting documentation between all care providers. The astute and well trained eye of a clinical documentation
improvement specialist (CDS) can often tie together multiple
disparate pieces of clinical information into a cohesive fact pattern, which can be the catalyst for a clinician to provide more
specific and descriptive diagnoses and/or procedures.
The discipline of CDI, whether practiced by clinicians or
coding professionals, has the potential to deliver great value to
the healthcare system—including to the patient, who deserves
a clear, concise, consistent, and accurate health record to support continuity of care.
Essential Characteristics of the CDS
Professional Skill Set
Recruiting ideal individuals to launch and nurture a CDI program
is critical to the success of the program. The ideal candidate should
46 / Journal of AHIMA July 15
have a combination of coding competence and clinical expertise.
Additional skills can assist in moving the program forward and establishing the foundation for a results-driven program. Aptitude for
critical/analytical thinking, along with effective communication
and interpersonal skills, are essential traits for a CDS. Individuals
who are able to correlate coding knowledge with clinical practice
and expertise are vital to a CDI program’s success. There are important attributes to keep in mind when recruiting new staff or
evaluating current staff. A CDS professional must possess advanced skills to perform their job, including but not limited to:
Strong clinical skills, ability to interpret clinical indicators
found among test results, recognize/understand disease
processes, and identify therapeutic and diagnostic orders
that demonstrate attention to undocumented conditions
Understanding the structure and format of ICD-9-CM,
ICD-10-CM, ICD-10-PCS, and/or CPT/HCPCS
Applicable knowledge of code assignment requirements,
the Official Conventions and Guidelines from the Centers
for Medicare and Medicaid Services (CMS), Coding Clinic
from the American Hospital Association, CPT Assistant
from the American Medical Association, etc.
Success in CDI is achieved by taking the fundamental knowledge and advancing it through critical thinking and formulating
the big picture. The following attributes foster growth within the
CDI program and prepares an institution for maintaining data
integrity, compliance, and quality revenue management:
Ability to interpret regulatory initiatives and promote development of practices that support compliance of these
initiatives
Analytical and critical thinking skills
Detail-oriented mentality
Ability to understand the uses and significance of complete and accurate coded data
Ability to perform data analysis and reporting
CDS professionals must possess effective communication
skills as they interact with leaders, physicians, clinicians, coders, auditors, etc. The CDS of the future is a facilitator of communication between multiple caregivers, ancillary staff, and
the revenue cycle team. Appendix A, included in the online version of this Practice Brief in AHIMA’s HIM Body of Knowledge
at www.ahima.org, provides some examples of the CDS career
Practice Brief
ladder, from entry level to CDI manager/director.
Essential Job Duties of the CDS
The CDS is responsible for having documentation clarified in
the health record so that the facility can report accurate, complete, and timely data. Health record data should represent the
resources utilized for patient care, aid in improving the quality of
care, and ensure data is both clinically supported and clinically
significant—which will in turn support appropriate reimbursement. Patient outcomes data will be more accurately reflected
through reporting when clinical documentation practices are
performed in a manner that facilitates coding to capture information describing patients’ acuity, severity of illness, and risk of
mortality. The CDI professional can bring about these changes
by consistently performing the essential duties of reviewer, educator, analyst, and collaborator. The CDS must also be congenial, engaging, and assertive to deliver in these roles.
CDS Duties: Reviewer
The CDS reviews health records daily to identify opportunities
to clarify insufficient, contradictory, and/or inconsistent documentation. The CDS must be cognizant of changing guidelines,
regulations, and advice for querying, coding, and documentation practices in order to perform these tasks compliantly. Review of data for trends in coding and diagnosis-related groups
(DRGs) assignments is needed as well as the annual coding and
DRG updates to identify new query opportunities or to fine tune
existing queries. The CDS may also be charged with the review
of retrospective DRG validation from third parties.
CDS Duties: Educator
The CDS uses multiple mediums and avenues to deliver training and information to the provider and others within the institution. A major contribution to a successful CDI program is
the ability to demonstrate the impact of the CDI program to a
large percentage of the facility’s staff. At a minimum, the CDS
will provide education to:
Clinicians through the querying process so they understand the impact of their documentation practices on
quality reporting, accurate reporting of a patient’s clinical
information, and reimbursement
Provide ongoing education throughout the facility
through presentations of data, examples of best practice
documentation, and demonstration of the impact that
documentation has on data reporting
Identification and reporting of documentation practices
on negative trends
Collaborative development and reporting of quality measures including practitioner-specific data
Education on clinical topics such as disease impact,
drugs, and current medical practice and the correlation
to code assignment
CDS Duties: Analyst
The CDS needs to understand data and be able to collate it into
meaningful information. Data collected on a daily basis as part
of their job tasks will promote understanding of program efficacy, the impact of documentation changes, and trends on the
reporting of patient outcomes as well as how these trends impact organizational efforts. The CDS must be able to review the
data, looking for trends or patterns over time as well as any variances that require further investigation. DRG shifts are reflected
in the documentation of comorbid conditions and complications that could move a diagnosis into a higher paying DRG. CDI
programs must be constantly vigilant in tracking and trending
program data to be aware of these payment patterns.
CDS Duties: Collaborator
The CDS must be able to collaborate with clinicians and ancillary staff across the institution including medical staff and
leadership, executives, administrators, coding, and other support departments. A CDI program can only provide meaningful
and sustained change when the CDS is able to work cooperatively to identify and solve difficult documentation issues. Clinicians who are working on reducing hospital-acquired conditions (HACs), patient safety indicators (PSIs), and other quality
measures will be more effective in creating change when they
understand the dynamics of documentation and how it impacts
code selection and, ultimately, the facility’s performance measures. Collaboration with the coding staff is critical as the exchange of clinical and coding knowledge and information will
result in the most appropriate documentation that presents a
true clinical picture of the patient’s conditions and treatments
during the hospitalization.
CDI Reporting Structure
CDI departments tend to have a wide range of upward reporting requirements. The 2014 AHIMA Foundation’s “Clinical
Documentation Improvement Job Description Summative Report” identified that most CDS professionals report to the HIM
department, while others may report to the nursing, revenue/
finance, or quality management department.
CDI can be successful under most organizational structures
if the following fundamental elements are met:
Executive oversight (CMO, CFO, COO)
CDI steering committee (monthly/quarterly reporting)
Physician advisor
Physician engagement
Key performance indicator (KPI) tracking
Quarterly or annual CDI audits/opportunity revitalization
CDI program analytics
HIM coder communication/interaction (formal and informal)
Compliance and denial management team player
An essential component of a CDI program is to have focused and
collaborative leadership that understands how the activities of the
various departments impact the overall initiatives of the institution.
Measuring CDI’s Financial Impact
A solid CDI program can yield improved quality scores, expedient
coding, increased accuracy in case mix indices, the capture of appropriate revenue, indicators of potential DRG problem areas, and,
Journal of AHIMA July 15 / 47
Practice Brief
most important of all, improved patient care. CDI has the potential
to enhance a hospital’s compliance efforts, as better documentation reduces future exposure to external audits and reduces risk.
A recent Healthcare Financial Management Association (HFMA)
executive study identified improved clinical documentation accuracy as the greatest opportunity for financial improvement.
Healthcare organizations are moving aggressively to implement
CDI programs and technology solutions. The need for clinical documentation accuracy is driving these CDI initiatives toward their
goals of widespread clinician adoption, improved quality of care,
enhanced financial results, optimizing an organization’s EHR investment, and improvement and accuracy in case mix index (CMI).
One of the initial motivators for adopting CDI solutions is the
proven, demonstrable, and sustainable improvement in CMI,
resulting in increased revenues and the best possible utilization of high-value specialists. CDI solutions are instrumental
in ensuring full and timely reimbursement from payers, while
avoiding the costly penalties of non-compliance. The appropriate capture of severity of illness and risk of mortality indicators
contributes to the development of risk-adjusted outcome profiles, improved performance in provider and facility quality profiles, and appropriate payments for hospitals and physicians.
The CDI manager must regularly review and utilize data from
internal (i.e., discharge data) and external sources (i.e., Medicare Provider Analysis and Review (MEDPAR), and Program for
Evaluating Payment Patterns Electronic Report (PEPPER)). By
applying this data, the following metrics should be tracked on
a monthly basis and measured at least quarterly to understand
the financial impact of the CDI program:
1. Case Mix Index (CMI). A measure of the relative complexity and severity of patients treated in a hospital. CMI serves
as the basis for payment methodologies administered by
CMS as well as other third-party payers. A number of factors
can affect a hospital’s CMI, including volume changes in
certain DRGs and documentation/coding improvements.
CDI leadership should understand CMI fluctuations and
declines in CMI. Through proper measurement and analysis, providers can identify ways to improve a stagnant or
declining CMI. To understand a hospital’s total CMI, the
following five metrics are calculated as follows:
Overall CMI. Add the relative weights of all DRGs and
divide by the total inpatient population, excluding psychiatric and rehabilitation patients.
Medical CMI. Add the relative weights of all medical
DRGs and divide by the total medical inpatient population, excluding psychiatric and rehabilitation patients.
Surgical CMI. Add the relative weights of all surgical
DRGs and divide by the total surgical inpatient population, excluding psychiatric and rehabilitation patients.
Adjusted CMI. Remove all high-weighted DRGs that are
not typically influenced by coding and/or clinical documentation improvements from the inpatient population, such as tracheotomies and transplants (MS-DRGs
1-17 and 652), excluding psychiatric and rehabilitation
patients. Remove this volume from the overall population before repeating the calculation for total CMI
48 / Journal of AHIMA July 15
2.
3.
4.
5.
outlined above. Some facilities may also eliminate lowweighted, high-volume DRGs (i.e., normal newborns).
Medical/surgical mix and volume-adjusted CMI.
This calculation can help you determine the percentage by which CMI has changed over two equal quarterly periods (i.e., the first quarter of 2014 to the first quarter of 2015) and the resulting change in reimbursement
for the designated time period.
-- Calculate medical/surgical mix and compare
volumes from the two equal time periods
-- Adjust the CMI to equalize these two components by freezing one period and adjusting
the mix distribution and volume of the other
period to match the frozen period
-- Compare medical/surgical mix of the periods
Overall CMI, Medical CMI, and Surgical CMI. Separately
determining the medical CMI and the surgical CMI will identify underlying problems masked in the overall CMI. Average
medical CMI weights range from 1.0 to 1.15. A low end overall
medical CMI may indicate symptom DRGs and the need for
a more specific principal diagnosis or missing complications
and comorbidities (CCs) that should have been captured. Low
medical CMIs may be heavily influenced by incorrectly documented and/or sequenced principal diagnoses.
Adjusted CMI. Remove all tracheotomies/transplants (MSDRGs 1-17 and 652), which are very high-weighted DRGs
and have geometric mean length of stay (GMLOS) and average length of stay (ALOS) impact, without documentation improvement potential. This allows focus on DRGs that
will most likely be influenced by CDI efforts. Analysis of the
adjusted CMI enables you to target underlying coding or
documentation issues that need to be addressed.
Comparative Medical and Surgical Case Mix. Compare
the volume of all inpatient cases in two comparable time
periods, as well as the percentage of cases that are medical versus surgical, by calculating the medical/surgical mix
and volume-adjusted CMI. Be sure to note losses and gains
that may indicate the need for further investigation:
Look at volume loss or medical/surgical mix change to
determine if you are losing market share to competitors.
Review the case types to see if they are moving to a different level of service (inpatient to ambulatory surgery
or to observation).
Review the CMI by service line to identify focus areas and
break it down further by DRGs to see if CC capture rates
or key DRG pairs are in the optimal DRG assignments.
Track and trend the following calculations:
Percentage of one- to two-day length of stays in both
periods. An increase in short-stay cases may be causing
a decline in CMI. Consider benchmarking your length of
stay against other hospitals to uncover any major differences. Understand the impact of CMS’ Final Rule 1599,
known as the Two Midnight Rule, which affects patient
level of care while in the hospital.
CMI by each service line or by major diagnostic category. Perform this calculation for comparable time
Practice Brief
periods, such as six-month periods in different years, to
determine if CMI has increased or decreased. This will
help narrow down the root cause(s) of a declining overall CMI to a particular set of DRGs or service lines. Further investigation may indicate less complex cases than
anticipated or possible documentation/coding deficiencies or inaccuracies, such as lower CC capture rates.
Overall CC capture rate, and then by individual DRG
level. Compare the CC capture rate between two periods to determine focus areas. Providers with access to
industry benchmarks for CC capture rates should use
these as points of comparison in addition to their organizations’ past performance. A CC capture rate may
be measured against a previous year, but it still may be
significantly behind industry performance if a provider
compares it to others outside its facility.
Present on Admission (POA). Track and trend POA indicator assignments of No (N). Conditions with a POA
indicator of N indicate that the condition was not present
on admission and occurred during the hospital stay. This
may affect facility reimbursement and data reporting.
6. Compare the volume of distribution in key DRG pairs.
For example, calculate the volume of complex versus simple pneumonia, chronic obstructive pulmonary disease
(COPD) versus respiratory failure, and gastroenteritis versus
dehydration. Review the distribution of cases in the higherweighted DRGs compared to peers or industry benchmarks.
7. CDI coding DRG reconciliation. Review and monitor
final coded DRG and assigned codes to concurrently assigned codes and DRGs. Identify CDI impacts and opportunities for CDI, coding, and physician education.
Case mix index is a constant concern for healthcare financial leaders because of its impact on the revenue stream and
should be consistently monitored and distributed to appropriate stakeholders.
Measuring the Quality Impact
The impact of complete and precise clinical documentation for
quality and outcomes reporting is an essential focus for CDI programs. Clinical documentation improvement efforts that include
a focus on the “holistic aspects” of care are crucial in the current
state of reliance on healthcare data and outcomes reporting.
Metrics for measuring the quality impact of the CDI program
include, but are not limited to, the following:
Severity of illness (SOI)
Risk of mortality (ROM)
Hospital-acquired conditions (HACs)
Core measure conditions
Patient safety indicators (PSIs)
Hierarchical condition categories (HCCs)
For these elements, it is important to capture and report the
impact that is achieved through CDI review and clarification of
physician documentation. Based on chart review, specific questions include:
W
ere there any conditions or procedures added that impact
the complexity or severity of the case (SOI and ROM levels)?
Were any conditions clarified or averted based on lack
of supporting or clarifying documentation (HACs, Core
Measure conditions, PSIs, HCCs)?
A critical focus of a CDI program is to identify deficiencies in
clinical documentation and develop processes to ensure the
complete and accurate picture of a patient’s clinical encounter.
Outcomes reporting should be monitored to measure the overall impact of the CDI program and track areas of opportunity
and success. A CDI program goal is to develop specific case examples as education for physicians, clinicians, and administrators, highlighting impacts as applicable.
Obtaining Physician Engagement
CDI is a quality initiative and this message should be clearly relayed to providers during both initial and ongoing engagement.
The key is to engage providers to appreciate how clinical documentation is an opportunity for them to demonstrate the quality
of care they are providing by way of exhibiting complete and accurate documentation in a consistent and prescribed manner,
which results in appropriate and accurate outcomes reporting.
Documentation must be complete, accurate, timely, and in
a prescribed syntax (with nothing left to interpretation) that
conveys the story of what transpired between the patient and
provider. Without this “story” other providers may not have a
complete health picture of what is going on with the patient.
Providers see many patients, so good documentation easily recalls the events of the previous visits. Documentation plays a
vital role in continuity of care.
Incomplete documentation makes it difficult for patients to receive appropriate follow up care as the current provider may not
have a clear-cut picture of the patient’s illness or what steps have
been previously taken to address the patient’s healthcare concerns. How can quality care be delivered if the provider does not
have all the information necessary to make a sound medical decision? Remember, if it wasn’t documented, then it wasn’t done.
Clinical documentation improvement specialists remind providers that their documentation is the evidence that demonstrates the
care provided to the patient. Clinical documentation substantiates
patient treatment and also patient responses to that treatment.
Providers have certainly heard of “quality measures,” but they
may not realize those quality measures are derived from their
documentation. It is essential for providers to recognize their documentation impacts data. Using data to measure performance is
a crucial component in improving the quality of healthcare. Data
aids in determining where improvements can be made, such as
inpatient outcomes or improving care processes.
CDI of the Future
Accurately reflected patient care and severity of illness capture
true resource consumption, and complete and correct quality
reporting are the overarching aspects that CDI programs impact. As the understanding of improved documentation and the
direct impact it has on quality metrics is realized, the CDI conJournal of AHIMA July 15 / 49
Practice Brief
cept continues to expand.
The benefit of CDI is being discovered in the outpatient setting.
Implementing an outpatient CDI program may be challenging,
but that doesn’t mean it cannot be done. Prior to implementation, a facility should define what is to be accomplished so that a
starting point can be identified. Understanding the facility baseline performance regarding quality metrics and denials management will provide valuable information that can be utilized
to prioritize focus areas for documentation improvement.
Many providers assign codes in the outpatient setting. Within
the outpatient clinic and physician practice, unless there is an
edit that stops the claim, in most cases the account will bill based
on the physician code selection. CDI has a tremendous opportunity within this venue to educate physicians on outpatient coding
guidelines and documentation requirements. One area of this is
hierarchical condition categories (HCC) coding, which adjusts
Medicare capitation payments to Medicare Advantage healthcare
plans for the health expenditure risk of their enrollees. Population health management and pay for performance is predicated
on how practices are measured from a quality and risk adjustment standpoint. This is important to payer contract structures
for negotiation and implementation of plan coverage, such as
health insurance exchanges and accountable care organizations.
Clinical documentation specialists will be instrumental to a
successful ICD-10-CM/PCS transition. ICD-10-PCS is much
more detailed than the current ICD-9-CM procedure coding
system, requiring very thorough documentation from the surgeon. The CDS should be knowledgeable of both ICD-10-CM
and ICD-10-PCS. An outpatient CDS must understand how
coding guidelines differ between the inpatient and outpatient
setting. Continuing education is paramount for the CDS. ¢
www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-PageItems/FY-2014-IPPS-Final-Rule-CMS-1599-F-Regulations.html.
Centers for Medicare and Medicaid Services. “Evaluation of the
CMS-HCC Risk Adjustment Model.” March 2011. www.cms.
gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/
Downloads/Evaluation_Risk_Adj_Model_2011.pdf.
Garrison, Garri. “Understanding a Declining CMI: A Step-byStep Analysis.” HFMA’s Revenue Cycle Forum. July/August
2013.
http://multimedia.3m.com/mws/media/902718O/
hfma-reprint-understanding-a-declining-cmi-09-13.pdf.
Haas, Dianne L. “Clinical Documentation Improvement:
What Executives Need to Know and the Financial Impact
of Neglect.” Becker’s Hospital Review. February 12, 2013.
w w w.beckershospita l rev iew.com/f i na nce/cl i n ica ldocumentation-improvement-what-executives-need-toknow-and-the-financial-impact-of-neglect.html.
Healthcare Financial Management Association. “HFMA’s
Executive Survey: Clinical Documentation Meets Financial
Performance.” HFMA’s Executive Survey and Education Report.
November 2013. http://engage.nuance.com/hfmasite.
Orr, Jeremy and Allen Kamer. “Accurate coding: the foundation
of accountable care.” Optum white paper. https://
w w w.optum.com/content/dam/optum/CMOSpark%20
Hub%20Resources/White%20Papers/Optum%20One%20
WhitePaper_Accurate-Coding%20FINAL.pdf.
Prepared By
Appendix A: Career Pathway to CDI is available in the online
version of this Practice Brief, located in AHIMA’s HIM Body of
Knowledge at www.ahima.org.
Danita Arrowood, RHIT, CCDS, CCS
Linda Bailey-Woods, RHIA, CPHIMS
Sharon Easterling, MHA, RHIA, CDIP, CCS, CPHM
Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
Tammy Love, RHIA, CDIP, CCS
Lori McDonald, RHIT, CCS-P
Ebenetta Rhinehart, MBA, RHIA, CCS, CTR
Michelle Wieczorek, RN, RHIT, CPHQ
References
Acknowledgements
AHIMA. “Clinical Documentation Guidance for ICD-10-CM/
PCS.” Journal of AHIMA 85, no. 7 (July 2014): 52-55. http://
librar y.ahima.org/xpedio/groups/public/documents/
ahima/bok1_050701.hcsp?dDocName=bok1_050701.
AHIMA. Clinical Documentation Improvement Toolkit. Chicago,
IL: AHIMA Press, 2014. http://library.ahima.org/xpedio/
groups/secure/documents/ahima/bok1_050585.pdf.
AHIMA. “Measuring the Value of the Clinical Documentation
Improvement Practitioner (CDIP) Credential.” Journal
of AHIMA 86, no. 1 (January 2015): 52-55. http://library.
ahima.org/xpedio/groups/public/documents/ahima/
bok1_050822.hcsp?dDocName=bok1_050822.
AHIMA Foundation. “Clinical Documentation Improvement Job
Description Summative Report.” 2014. www.ahimafoundation.
org/downloads/pdfs/CDI_SummativeReportFinal_.pdf.
Centers for Medicare and Medicaid Services. “Details for title: CMS1599-F and other associated rules and notices.” June 17, 2014.
Sheila Bowlds, MBA, RHIA
Julie Brucker, RHIA, CCS
Patty Buttner, RHIA, CDIP, CHDA, CCS
Marlisa Coloso, RHIA, CCS
Angie Comfort, RHIA, CDIP, CCS
Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA
Katherine Downing, MA, RHIA, CHPS, PMP
Jeanne M. Fernandes, RHIA, CHDA
Walter Houlihan, MBA, RHIA, FAHIMA
Lesley Kadlec, MA, RHIA
Laurie Miller, RHIT, CCS-P
Renee Petron, RHIA
Andrea Romero, RHIT, CCS, CPC
Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, FAHIMA
Vicki Willcut, RHIA
Donna Wilson, RHIA, CCS, CCDS, CPHM
Appendix
50 / Journal of AHIMA July 15
CDI Summit:
Leading the
Documentation
Journey
August 6–7, 2015
Alexandria, VA
Clinical documentation improvement (CDI) is a vital component of patient care, physician
satisfaction, and revenue cycle strategies in today’s complex healthcare environment.
CDI specialists, clinical care providers, and senior management must contribute to
organizational success and ensure the right information is available at the right time.
The AHIMA CDI Summit leads the documentation journey and explores the challenges
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• A range of presentations on CDI best practices, innovation, implementation, and ICD-10-CM/PCS
• Interactive sessions, showcasing real world examples, advancing networking opportunities
Prepare for the future, gain an edge on the latest documentation strategies, and move
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the CDI Summit August 6–7, and AHDI’s 2015 Healthcare
Documentation Integrity Conference August 7–8
Go to ahima.org/events for more information and registration!
MX11259
Coding Notes
Clinical Documentation
Improvement in the
Outpatient Setting
By Danita Arrowood, RHIT, CCDS, CCS; Laurie M. Johnson, MS, RHIA, FAHIMA; and Michelle Wieczorek, RN, RHIT, CPHQ
C
CLINICAL DOCUMENTATION IMPROVEMENT (CDI) programs have proven their worth with over a decade of success
and continued role expansion in the inpatient setting. As the
healthcare industry prepares for new initiatives such as value-based purchasing, electronic health records (EHRs), and
ICD-10-CM/PCS implementation, clinical documentation
improvement has become a focus for organizations that do
not yet have a well established program in place.
Facility-based outpatient services and physician practices acknowledge there are benefits to a CDI program in
the outpatient setting. Outpatient needs for clinical documentation improvement are much different than inpatient
needs. As outpatient federal incentive programs grow,
so too does the need for accurate, concise, and reliable
documentation. A widely-accepted pathway to analyze,
develop, implement, and monitor an outpatient-focused
CDI program has not been defined. The question becomes,
“Where do we begin?”
The physician office setting has a different approach and focus than the facility-based setting. Whether facility-based or
physician practice-based, it’s best to begin by determining the
scope and focus of the program. If claim denials are an area of
focus, drill down into the denials to conduct an analysis of audit findings and medical necessity reviews. Are denials due to
misleading, inadequate, and/or poor clinical documentation?
Many problem-prone areas have well defined expectations on
how to minimize denial risk and avoid intensified reviews,
such as National Coverage Determinations (NCDs) and Local
Coverage Determinations (LCDs).
52 / Journal of AHIMA July 15
Are claims denied repeatedly for similar documentation issues, such as inadequate documentation to support medical
necessity or previously treated conditions from the problem
list being reported as current conditions? Is nursing documentation falling short on logging infusion times? In addition
to identifying areas with recurring issues, CDI professionals
should also investigate whether the provider documentation
is capturing all the acute and chronic conditions that are being evaluated and treated.
A successful outpatient CDI program begins by developing
tools to analyze where clinical documentation in the outpatient arena falls short in providing the necessary documentation to establish medical decision making, justify services
rendered, promote continuity of care, and support proper reimbursement. Establishing procedures to address identified
issues and monitor outcomes will help ensure the success of
an outpatient CDI program.
Start With an Outpatient Data Assessment
Conduct an outpatient assessment to investigate the quality
and thoroughness of outpatient claims data. This assessment
will identify issues and determine if improved documentation will resolve the issues. Analysis of the needs assessment
will help to determine where to begin the process. The facility
should clearly state the goals of the program and create policies and procedures for outpatient CDI.
Baseline dashboards for the outpatient setting should be established. The outpatient dashboards could be developed for
the quality indicators, rejected claims, appealed claims, and
Coding Notes
additional documentation requests. The dashboards can also
be displayed by clinical specialties and/or departments. The
outpatient data should be evaluated for potential lost charges
as well as accurate pricing. A chargemaster review may be another method for evaluating charge and pricing information.
These tasks will ensure the accuracy of the data before the creation of the outpatient CDI program.
The approach of an outpatient CDI program may differ
depending on the focus. If the goal is to accurately capture
outpatient quality indicators, then the process would be
to review the quality indicators to ensure the documentation is comprehensive and accurate and easily captures the
required data. The emergency department may be an area
where opportunities abound for improvement in the capture
of the true clinical picture of the patient and use of resources
required to treat patients.
Challenges the facilities could face when setting up an outpatient CDI program include:
Short length of stay for outpatient cases
Outpatient case volumes
Lack of focus
move forward and address specific issues. Increased attention occurs by limiting the focus to a specific procedure(s). For
example, a focus could be the resolution of claim denials for
orthopedic procedures. This approach will also remediate the
volume issue.
After determining the focus and completing the data review, the next step is to evaluate a claim sample with clinical
documentation and a detailed bill. The clarity, completeness,
and reliability of documentation should be considered for the
sample. Processes may be evaluated for the data capture. Electronic health record (EHR) templates may be revised to promote data accuracy.
The facility benefits of an outpatient CDI program include:
1. Increased documentation specificity
2. Decreased additional documentation requests
3. Decreased claim denials/rejections
4. Reduced barriers to reimbursement
5. Increased quality of care
6. Increased compliance to billing and coding regulations/
principals
The program should have a clear hypothesis in order to
An emerging trend in outpatient CDI is the implementa-
CDI in the Physician Practice Setting
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Journal of AHIMA July 15 / 53
Coding Notes
tion of a physician practice-based model, which focuses on
three goals:
1. Ensure the capture of all diagnoses that the provider is currently assessing, treating, or monitoring.
2. Ensure that the Evaluation and Management (E&M) code
assigned for the encounter is correct based upon the available documentation in the EHR.
3. Identify opportunities for remediation of the EHR software
to improve the provider workflow in support of efficiency
and clarity of documentation.
In some of the first research
of its kind, a link has been
established between patient
outcomes and uncoded
diagnoses in the patient record.
The CDI program can be implemented in a concurrent workflow, which is synchronous to the patient encounter, or in a retrospective workflow, which occurs after the patient encounter. Concurrent CDI programs allow for a CDI specialist to observe the
clinical encounter from patient intake to discharge and to observe
for opportunities to improve the documentation before final coding—and thus have the greatest potential for immediate impact.
In the concurrent workf low model, a CDI specialist is assigned to “room” with a provider, and follows their patient
schedule. While observing the clinical encounter directly,
the CDI specialist takes note of the review of the patient
history, the patient assessment (review of systems), and
any diagnosis and ongoing treatment the provider discusses and makes note of. If the documentation is concurrent to the clinical encounter, the CDI specialist has the
opportunity to directly observe the documentation templates used by the provider and make recommendations
about how the templates can be improved to strengthen
the clinical documentation.
In the case of an EHR that utilizes pick lists, it is important
that the list contains selections with all required specificity
and that the most frequently selected items appear at the top
of the list to avoid scrolling and typing by the provider. A concurrent review also easily creates an opportunity to verbally
query the physician for missing diagnoses and other gaps in
documentation that may improve the final coding for both the
diagnosis and E&M level. The ability to observe the patient encounter is key to discerning documentation gaps such as diagnoses that were discussed during the visit but were not documented by the provider.
The focus on diagnosis coding is very important in the physician practice setting. In some of the first research of its kind,
54 / Journal of AHIMA July 15
a link has been established between patient outcomes and
uncoded diagnoses in the patient record. Patients that have
uncoded diagnoses account for higher utilization of inpatient
and emergency services, and experience less than optimal patient outcomes for chronic diseases such as congestive heart
failure, hypertension, diabetes, and dyslipidemia.1
Beyond the impact that diagnosis coding has on patient
outcomes, missing diagnoses can also account for medical necessity denials for referred services such as diagnostic testing, poor continuity of care between specialists, and
decreased reimbursement in risk-adjusted reimbursement
programs such as Hierarchical Condition Categories (HCCs)
used in Medicare Advantage programs.
In today’s world of quality reporting, audits, and incentive
programs, the need for accurate, concise, timely, reliable, and
complete documentation is greater than ever. Facilities and
physician offices alike should be evaluating their investment
in CDI efforts in the outpatient setting. Determining weaknesses and identifying vulnerabilities in current documentation practices will provide a starting point to create workflows,
policies, and procedures for outpatient clinical documentation improvement. ¢
Note
1. Orr, Jeremy and Allen Kamer. “Accurate coding: the foundation of accountable care.” Optum white paper. December 1, 2014. www.optum.com/content/dam/optum/
CMOSpark%20Hub%20Resources/White%20Papers/
Optum%20One%20WhitePaper_Accurate-Coding%20
FINAL.pdf.
References
Collins, Corliss. “How to Fast Track Your Outpatient
Clinical Documentation Program.” Hayes Management
Consulting Blog. December 17, 2014. http://meetings.
hayesmanagement.com/blog/fast-track-your-outpatientclinical-documentation-program.
Johnson, Laurine. “The Implementation of an Outpatient
Clinical Documentation Program.” Ingenix white paper.
2008. https://etg.optum.com/~/media/Ingenix/Resources/
White%20Papers/Ingenix_OutpatientCDI_WP_1001055.pdf.
Linnander, Robert. “CDI in outpatient settings: Are
you ready for the challenge?” The Advisory Board
Company’s At the Margins Blog. October 14, 2014. www.
advisor y.com/research/financial-leadership-council/
at-the-margins/2014/10/how-to-create-outpatient-cdiprogram.
Danita Arrowood (
[email protected]) is healthcare education
developer at Precyse. Laurie M. Johnson (
[email protected]) is
director of HIM consulting services at Panacea Healthcare Solutions. Michelle Wieczorek (
[email protected]) is general manager, coding and CDI practice at e4 Services.
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Coding Notes
DRG Grouping and ICD-10-CM/PCS
By Margaret M. Foley, PhD, RHIA, CCS
P
PRIOR TO THE October 1, 2015 implementation of ICD-10CM/PCS, every hospital must examine how the new code
set will impact MS-DRG reimbursement. A recent Centers
for Medicare and Medicaid Services (CMS) analysis indicates the overall effect of the transition to ICD-10 on hospital reimbursement will be negligible. However, the effect on
any individual hospital may vary due to that facility’s case
mix or coding accuracy.1 In order to assess the impact on
their facility, coding managers need to be familiar with how
the ICD-9 and ICD-10 classification systems differ and how
these differences are addressed in the MS-DRG grouper
logic for ICD-10.
MS-DRG Grouper Logic Addresses ICD-10 Transition
The MS-DRG grouper logic for ICD-10 has been designed
so that for almost all cases, the DRG assigned for a case
coded in ICD-10 is the same as in ICD-9. 2 The basic concepts of the DRG system have also remained stable: the
number, title, and structure of the DRGs have remained
the same; there are still pre-Major Diagnostic Category
(MDC) DRGs; the principal diagnosis still determines the
MDC to which a case is assigned; and groupings of DRGs
still exist where the presence or absence of a major complication or comorbidity (MCC) or a complication or comorbidity (CC) as a secondary diagnosis changes the DRG.
Some modifications have been made to the grouper logic,
however, to account for inherent differences between the
ICD-9 and ICD-10 coding systems while still ensuring that
the same DRG is assigned. The grouper logic is detailed
56 / Journal of AHIMA July 15
in the Definitions Manual for Version 32 of the MS-DRG
Grouper, which is available online via the CMS website. 3
ICD-10 combination codes that incorporate a CC or MCC into
a single diagnosis code pose an issue for DRG grouping. A combination code is a single code which represents multiple clinical issues. Clinical concepts that required two or more codes in
ICD-9 only require a single combination code to be assigned
in ICD-10. For example, atherosclerotic heart disease with unstable angina is reported with two codes in ICD-9 (one code
for the atherosclerosis and one code for the unstable angina).
In ICD-10, this clinical concept is reported with a single code:
I25.110, Atherosclerotic heart disease of native coronary artery
with unstable angina pectoris. The DRG grouper issue is that in
ICD-9, cases with atherosclerosis as the principal diagnosis and
unstable angina, which is a CC, as a secondary diagnosis result
in the case being assigned to a higher paying “with CC” DRG,
when applicable. With a single combination code being reported in ICD-10, however, there is no separate secondary diagnosis
code to cause the case to group to a “with CC” option.
In response to this, the ICD-10 MS-DRG grouper logic allows
a limited number of diagnosis codes to serve as a CC or MCC for
themselves when listed as the principal diagnosis. Appendix J of
the MS-DRG Definition Manual includes a list of these diagnoses. Examples of principal diagnoses that can serve as MCCs for
themselves include:
K70.41, Alcoholic hepatic failure with coma
L89.153, Pressure ulcer of sacral region, stage 3
Examples of principal diagnoses that can serve as CCs for
Coding Notes
themselves include:
D57.21, Sickle-cell/Hb-C disease with acute chest syndrome
K50.114, Crohn’s disease of large intestine with abscess
Differences in Specificity Between ICD-9
and ICD-10
Some code options that were available in ICD-9 are not included in ICD-10 because the clinical distinctions are no longer commonly used.4 For example, ICD-9 has individual codes
to represent depressive disorder, not otherwise specified (311)
and major depression (296.20). It should be noted that code
311 is not a CC and code 296.20 is a CC. In ICD-10 both depressive disorder and major depression are reported with the
same code, F32.9, Major depressive disorder, single episode,
unspecified. This code is not a CC. Another example is seen
with coding malignant hypertension and unspecified hypertension. In ICD-9, code 401.9, which is a non-CC, is assigned
for unspecified hypertension and code 401.0, which is a CC,
is assigned for malignant hypertension. In ICD-10, the same
code, I10, is assigned for both unspecified hypertension and
malignant hypertension.
For the purpose of developing the ICD grouper logic, when the
ICD-10 system provides fewer code choices, the ICD-10 diagnosis code is treated like the most frequently occurring of the
multiple ICD-9 code options. For example, the ICD-10 hypertension code I10 is not designated as a CC, like the ICD-9-CM
hypertension code 401.9. This decision was made because code
401.9 was reported more commonly than code 401.0 in the CMS
dataset used for analysis.
These examples notwithstanding, the ICD-10 classifications typically provide greater code specificity than the ICD9-CM classification. For the purposes of DRG logic, typically,
the more specific ICD-10 code is treated in the same way as
its less specific ICD-9 counterpart for grouping purposes.
For example, in ICD-10-CM, there are three code choices for
atrial flutter:
I48.3, Typical atrial flutter
I48.4, Atypical atrial flutter
I48.92, Unspecified atrial flutter
For grouping purposes, all three of these ICD-10 codes are
designated as CCs because the single ICD-9 code option for
atrial flutter, code 427.32, is a CC. Similarly, several new codes
were added to ICD-10 which further specify asthma based on
clinical descriptors such as mild, moderate, severe, persistent,
and intermittent. All of the new codes for these more specific
types of asthma which do not include exacerbation or status
asthmaticus in the code titles are not designated as CCs because
the ICD-9-CM code 493.90, Asthma, unspecified, is a non-CC
for the purposes of DRG grouping.
These decisions and designations were made to ensure DRG
grouping would remain the same during the transition from
ICD-9 to ICD-10, regardless of the system in which a given case
was coded. However, the greater specificity provided by ICD-10
codes is one of the most salient features of the new code set. In
the future, it is anticipated that the DRG grouper logic will be
refined after CMS has analyzed claims data including the more
specific ICD-10 codes.
Differences in Procedure Coding Between ICD-9
and ICD-10
Procedure coding differs greatly between ICD-9 and ICD10. For example, some procedures that were reported with a
single code in ICD-9 require two codes in ICD-10. To handle
this reporting difference, grouper logic for ICD-10 includes
a number of procedure codes that result in a different DRG
when reported alone versus when reported along with an-
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Journal of AHIMA July 15 / 57
Coding Notes
other procedure code.
For example, when ICD-10-PCS code 0JH608Z, Insertion of
Defibrillator Generator into Chest Subcutaneous Tissue and
Fascia, Open Approach, is reported alone, DRG 245 AICD Generator Procedures is assigned. However, when code 0JH608Z
is reported along with code 0JPT0PZ, Removal of Cardiac
Rhythm Related Device from Trunk Subcutaneous Tissue and
Fascia, Open Approach, to indicate a generator replacement
(codes assigned for the removal of old device and the insertion of a new device), a DRG for Cardiac Defibrillator Implant
(DRGs 222 through 227) is assigned, resulting in a higher payment to the facility.
Differences in Coding Guidelines Could Lead to
Different DRGs
Differences in coding guidelines will result in cases grouping to different DRGs in ICD-10. Coding staff need to be
aware of differences in guidelines to recognize that some
DRG shifts noted when moving from ICD-9 to ICD-10 may in
fact be deliberate. For example, the guideline for selection
of the principal diagnosis in cases of admissions for anemia
due to an underlying malignancy is different in ICD-9 and
ICD-10. In ICD-9, the anemia is assigned as the principal diagnosis. In ICD-10, the code for the malignancy is assigned
as the principal diagnosis. This guideline difference will result in a legitimate change in DRG when the case is coded in
ICD-9 versus ICD-10.
Differences in Case Mix from ICD-9 to ICD-10
A CMS analysis in which more than 10 million claims coded in ICD-9 were converted to ICD-10 provided estimates
of the positive and negative percentage changes in reimbursement for the top 25 MS-DRGs. 5 For example, a small
increase in reimbursement is expected for cases coded in
ICD-10 assigned to MS-DRG 003, ECMO or Tracheostomy
with Mechanical Ventilation for 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major Operating
Room Procedure.
Conversely, a small decrease in reimbursement is projected for cases assigned to MS-DRG 48, Hip and Femur Procedure Except Major Joint with CC. Depending upon the DRGs
that are more commonly coded by a given hospital, the
overall impact of the shift to ICD-10 on reimbursement will
vary. Additionally, the CMS analysis of claims data did not
involve recoding records. Therefore, a facility may realize
a different overall impact on reimbursement when records
are assigned ICD-10-CM/PCS codes based upon documentation in actual records.
• Coding Compliance Audits—
MS-DRG/APR-DRG/APC
HCC, LTAC, Pro Fee, CVIR/IR
• Claim Reviews and Appeals
• ICD-9/ICD-10 Dual Coding Reviews
• PACT Validation
• Remote Coding Support
• CDI Assessment and Implementation
• HIM Interim Management
• Online ICD-10 Tutorials - FREE to all Clients
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58 / Journal of AHIMA July 15
HC S
Coding Notes
Coding Accuracy Influences ICD-10 Impact
Notes
A facility’s accuracy of ICD-10 code assignment will also
inf luence the overall impact of implementing the ICD-10
code sets. The extent to which a hospital’s coding staff assigns codes appropriately may also result in differences in
DRGs and reimbursement. These differences need to be
validated to determine if the change in DRG is correct or
the result of a coding error. For example, injury codes in
ICD-10 require a seventh character that identifies the nature of the encounter (i.e., initial, subsequent, or sequela).
The assignment of the same injury code with a different
seventh character (i.e., initial vs. subsequent) can result
in differences in MS-DRG assignment, which has a significant impact on reimbursement.
Another example is the coding for the closure of an ileostomy. These cases may be coded incorrectly due to differences in ICD-9 and ICD-10. In ICD-9, this procedure requires a single code. In ICD-10, two codes are required: one
for the repair of the intestine and another for the repair of
the abdominal wall. If both codes are not reported, an incorrect DRG is assigned.
1. Mills, Ronald E. “Estimating the impact of the transition
to ICD-10 on Medicare inpatient hospital payments.”
ICD-10 Coordination and Maintenance Committee presentation, March 15, 2015, Baltimore, MD. www.cms.
gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/
Downloads/2015-03-18-Impact-ICD10-Transition.pdf.
2. Mills, Ronald E. et al. “Impact of the Transition to ICD10 on Medicare Inpatient Hospital Payments.” Medicare
and Medicaid Research Review 2, no. 2 (2011): E1-E13.
www.cms.gov/mmrr/Downloads/MMRR2011_001_02_
A02.pdf.
3. Centers for Medicare and Medicaid Services. “ICD-10
MS-DRG Conversion Project.” April 7, 2015. www.cms.
gov/Medicare/Coding/ICD10/Downloads/ICD-10-MSDRG-v32-Definitions-Manual-Text.zip.
4. Mills, Ronald E. et al. “Impact of the Transition to ICD10 on Medicare Inpatient Hospital Payments.” Medicare
and Medicaid Research Review.
5. Mills, Ronald E. “Estimating the impact of the transition
to ICD-10 on Medicare inpatient hospital payments.”
ICD-10 Coordination and Maintenance Committee presentation.
Other Groupers Also Determine Hospital
Reimbursement
CMS is not the only game in town. For example, many state
Medicaid programs use the 3M APR-DRG Grouper to determine hospital reimbursement. Similar analyses on the impact
of ICD-10 implementation on reimbursement related to these
different payers and groupers must also be conducted.
Undoubtedly, the transition to ICD-10 presents some challenges. However, through the analysis of coding and DRG data
prior to implementation, hospitals can implement measures
to minimize the impact on both the coding staff and the facility’s bottom line. ¢
Journal of AHIMA Continuing Education Quiz
Quiz ID: Q1538607 | EXPIRATION DATE: JULY 1, 2016
HIM Domain Area: Clinical Data Management
Article—“DRG Grouping and ICD-10-CM/PCS”
Margaret M. Foley (
[email protected]) is associate professor in
the health information management department at Temple University.
Correction
An additional reference should be noted for the June 2015 Coding
Notes article “Injection and Infusion Coding Offers High Stakes:”
Rubinowitz, Andrea Clark. “Infusion Confusion What’s Your Solution!! 2008
Jokers’ Wild Edition.” Presentation at the Association for Healthcare
Internal Auditors 2008 Annual Conference. www.resourcenter.net/
images/AHIA/Files/2008/AnnMtg/Handouts/TrackF6.pdf.
TAKE THE QUIZ AT WWW.AHIMASTORE.ORG
NOTE: MAILED-IN PAPER QUIZZES WILL NO
LONGER BE ACCEPTED
REVIEW QUIZ QUESTIONS AND TAKE
THE QUIZ BASED ON THIS ARTICLE
ONLINE AT WWW.AHIMASTORE.ORG
NOTE: AHIMA CE QUIZZES HAVE
MOVED TO AN ONLINE-ONLY FORMAT.
Journal of AHIMA July 15 / 59
Calendar
SUNDAY
MONDAY
5
TUESDAY
6
WEDNESDAY
7
THURSDAY
1
2
8
9
Advanced ICD-10-PCS Skills Workshop, Chicago, IL
FRIDAY
SATURDAY
3
4
10
11
Leadership Symposium,
Chicago, IL
WEBINAR:
Physician
Engagement
for Clinical
Documentation
Improvement
12
13
14
AHIMA Data Summit: Beyond
ICD-10, Baltimore, MD
20
16
17
18
Certified Health Data Analyst
(CHDA) Exam Prep Workshop,
Austin, TX
Faculty
Development
AHIMA Academy for ICD-10-CM/PCS: Building
Institute/
Expert Trainers in Diagnosis and Procedure Coding,
Assembly on
Denver, CO
Education
Symposium,
CDI Academy, Denver, CO
Austin, TX
Advanced ICD-10-PCS Skills Workshop,
Minneapolis, MN
CSA MEETING:
FLORIDA, Orlando, FL
19
15
21
22
23
24
25
WEBINAR:
Faculty Development Institute/Assembly on Education Symposium,
Austin, TX
The PreBill Review:
Directing the
Wheels of
Change
AHIMA ICD-10 Academy: Building Expertise in
Coding, Chicago, IL
CSA MEETING:
SOUTH CAROLINA, Columbia, SC
AHIMA Academy for ICD-10-CM/PCS: Building Expert
Trainers in Diagnosis and Procedure Coding,
Austin, TX
26
27
28
29
30
31
AHIMA Academy for ICD-10-CM/PCS: Building Expert
Trainers in Diagnosis and Procedure Coding,
Atlanta, GA
AHIMA Annual Convention
2016 Baltimore, MD
October 15-20
60 / Journal of AHIMA July 15
A Look Ahead
Keep Informed
AUGUST
AHIMA CDI Academies Keep
Professionals Up to Speed
July 15–17 I Denver, CO
Upcoming AHIMA Institutes, Seminars, Workshops,
and Webinars
4-5
CDIP Exam Prep Workshop, Alexandria, VA
5-7
Advanced ICD-10-PCS Skills Workshop,
Nashville, TN
6
Webinar: Computer-Assisted Coding: A Behind
the Scenes Look at NLP: Why it Works and
Why it Doesn’t
6-7
Clinical Documentation Improvement Summit,
Alexandria, VA
12-14
Advanced ICD-10-PCS Skills Workshop,
Cleveland, OH
12-14
AHIMA Academy for ICD-10-CM/PCS: Building
Expert Trainers in Diagnosis and Procedure
Coding, Chicago, IL
13
Webinar: Verifying the Three “Rights” of ROI in
EHR Environments
16-17
CSA Meeting: Connecticut, Groton, CT
19-21
AHIMA Academy for ICD-10-CM/PCS: Building
Expert Trainers in Diagnosis and Procedure
Coding, Orange County, CA
26-28
AHIMA Academy for ICD-10-CM/PCS: Building
Expert Trainers in Diagnosis and Procedure
Coding, Philadelphia, PA
26-28
Advanced ICD-10-PCS Skills Workshop,
Chicago, IL
31-Sept. 2
AHIMA ICD-10 Academy: Building Expertise in
Coding, Chicago, IL
UPCOMING INSTITUTES, SEMINARS,
WORKSHOPS, AND WEBINARS
September
2-4
CSA Meeting: Georgia, Jekyll Island, GA
September
9-11
AHIMA Academy for ICD-10-CM/PCS: Building
Expert Trainers in Diagnosis and Procedure
Coding, Orlando, FL
September
9-11
CSA Meeting: North Dakota, West Fargo, ND
September
10
Webinar: Improving Outpatient Coding
Workflow—5 Things to Do Now
September
14-15
CSA Meeting: Maine, Northport, ME
September
16-18
Advanced ICD-10-PCS Skills Workshop,
Phoenix, AZ
September
26-27
Certified Health Data Analyst (CHDA) Exam Prep
Workshop, New Orleans, LA
Check www.ahima.org/events for the latest schedule of
institutes, seminars, and workshops.
Resources and News from AHIMA
Clinical
documentation
improvement
(CDI)
programs, along with clinical care providers and
senior management, contribute to organizational
success by ensuring the right information is
available at the right time. To keep up with the
healthcare industry’s ever-changing demands and
initiatives, clinical documentation programs and
professionals must constantly evolve and adapt.
The AHIMA CDI Academy provides participants
with the information necessary to keep up with a
complex and growing industry.
For more information and to register, visit ahima.
org/events.
Certified Documentation Improvement
Practitioner (CDIP) Exam Prep Workshop
Available
August 4-5 I Alexandria, VA
This extensive two-day face-to-face workshop is
designed to prepare healthcare professionals to sit
for the Certified Documentation Improvement
Practitioner (CDIP) examination. After successful
completion of this workshop, which will review the
knowledge and skills necessary to function in the
clinical documentation improvement profession,
attendees may apply to sit for the CDIP exam
immediately.
CDI Summit Offers Tips on Leading the
Documentation Journey
August 6–7 I Alexandria, VA
The AHIMA CDI Summit is the premier industry event
dedicated to leading the documentation journey and
exploring the challenges presented by today’s
complex healthcare environment. This year the
summit is being held in conjunction with the AHDI
Healthcare Documentation Integrity Conference.
With keynote addresses from nationally recognized
industry experts, participants in this comprehensive
conference will have access to a range of
presentations on CDI best practices, innovation,
implementation, and ICD-10-CM/PCS.
For more information and to register, visit www.
ahima.org/events.
AHIMA Volunteer Leaders
AHIMA BOARD OF DIRECTORS
President/Chair
Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA
Senior Vice President of Health Information
Management and Consulting Services,
Peak Health Solutions, Inc.
San Diego, CA
(858) 746-7298
[email protected]
President/Chair-elect
Melissa M. Martin, RHIA, CCS, CHTS-IM
Chief Privacy Officer and Director of Health
Information Management, West Virginia
University Hospitals
Morgantown, WV
(304) 598-4109
[email protected]
Past President/Chair
Angela C. Kennedy, EdD, MBA, RHIA
Head and Professor, LA Tech University
Ruston, LA
(318) 257-2854
[email protected]
Speaker of the House of Delegates
Laura W. Pait, RHIA, CDIP, CCS
Chief Operating Officer, Health Information
Management Shared Service Center, Parallon
Business Performance Group, Atlanta Shared
Service Center
Norcross, GA
(678) 421-7681
[email protected]
CEO, AHIMA
Lynne Thomas Gordon, MBA, RHIA, CAE,
FACHE, FAHIMA
Chicago, IL
(312) 233-1165
[email protected]
TERM ENDS 2015—DIRECTORS
Treasurer
Susan J. Carey, RHIT, PMP
System Director, HIM, Norton Healthcare
Louisville, KY
(502) 629-8913
[email protected]
Dana C. McWay, JD, RHIA, FAHIMA
Court Executive/Clerk of Court, US Bankruptcy
Court for the Eastern District of Missouri
(314) 244-4600
[email protected]
Cindy Zak, MS, RHIA, PMP, FAHIMA
Executive Director Corporate HIM,
Admitting and Outpatient Access,
Yale New Haven Health System
Woodbridge, CT
(203) 688-5466
[email protected]
TERM ENDS 2016—DIRECTORS
Zinethia L. Clemmons, MBA, MHA, RHIA, PMP
Senior Health Information Privacy Specialist,
Department of Health and Human Services/OCR
Washington, DC
(202) 495-0533
[email protected]
Secretary
Ginna E. Evans, MBA, RHIA, FAHIMA
Business Analyst, Revenue Cycle Development,
Emory Healthcare
Avondale Estates, GA
(404) 778-7960
[email protected]
Colleen A. Goethals, MS, RHIA, FAHIMA
HIM Consultant, Cardone Record Services, Inc.
Belvidere, IL
(815) 378-2632
[email protected]
TERM ENDS 2017—DIRECTORS
Barbara J. Manor, MA, RHIA
Vice President of HIM, SCL Health
Aurora, CO
(303) 403-7511
[email protected]
Dwan A. Thomas-Flowers, MBA, RHIA, CCS
HIM Consultant
Jacksonville, FL
(904) 220-2486
[email protected]
Susan E. White, PhD, RHIA, CHDA
Associate Professor, Clinical HRS HIM and
Systems Division, School of Health and
Rehabilitation Sciences, Ohio State University
(614) 247-2495
Columbus, OH
[email protected]
Advisor to the Board
David S. Muntz, CHCIO, FCHIME, LCHIME,
FHIMSS
Senior Vice President/CIO, GetWellNetwork
Bethesda, MD
(240) 482-3192
[email protected]
2015 CHAIRS OF AHIMA VOLUNTEER GROUPS
AHIMA Grace Awards Committee
Ann F. Chenoweth, MBA, RHIA, MBB, FAHIMA
(801) 712-4537
[email protected]
Engage Advisory Committee
Thomas J. Hunt, MBA, RHIA
(989) 725-8279
[email protected]
Nominating Committee
Jill A. Finkelstein, MBA, RHIA, CHTS-TR
(954) 418-0938
[email protected]
State Advocacy Council
Debra K. Primeau, MA, RHIA, FAHIMA
(310) 617-0042
[email protected]
AHIMA Triumph Awards Committee
Judith A. Gizinski, MPH, RHIA
(321) 757-5226
[email protected]
Exhibit Advisory Committee
Steve Sonn, MS
(312) 229-7197
[email protected]
Professional Ethics Committee
Diann H. Smith, MS, RHIA, CHP, FAHIMA
(817) 457-8911
[email protected]
Virtual Lab Strategic Advisory Committee
John Richey, MBA, RHIA
(419) 447-9352
[email protected]
Annual Convention Program Committee
Kimberly D. Theodos, JD, MS, RHIA
(318) 257-2854
[email protected]
Fellowship Committee
Mona Y. Calhoun, MEd, MS, RHIA, FAHIMA
(301) 352-0304
[email protected]
2015 CHAIRS OF AFFILIATE VOLUNTEER GROUPS
AHIMA Foundation
Torrey Barnhouse
(312) 233-1131
[email protected]
Commission on Accreditation for
Health Informatics and Information
Management Education
Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS
(312) 233-1548
[email protected]
Commission on Certification for Health
Informatics and Information Management
Kay Merriweather, RHIA, CHDA, CDIP, CCS,
CCS-P, CPC-H
(404) 849-0459
[email protected]
Council for Excellence in Education
Ryan H. Sandefer, MA, CPHIT
(218) 625-4931
[email protected]
Envisioning Collaborative
Laura W. Pait, RHIA, CDIP, CCS
Chief Operating Officer, Health Information
Management Shared Service Center, Parallon
Business Performance Group, Atlanta Shared
Service Center
Norcross, GA
(678) 421-7681
[email protected]
House Leadership
Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
[email protected]
2015–2016 HOUSE OF DELEGATES
Speaker of the House of Delegates
Laura W. Pait, RHIA, CDIP, CCS
Chief Operating Officer, Health Information
Management Shared Service Center, Parallon
Business Performance Group, Atlanta Shared
Service Center
Norcross, GA
(678) 421-7681
[email protected]
Speaker-elect of the House of Delegates
Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
[email protected]
2015 PRACTICE COUNCIL VOLUNTEER CONTACTS
Clinical Terminology & Classification
Cheryl Gregg Fahrenholz, RHIA, CCS-P
(937) 848-6080
[email protected]
Enterprise Information Management
Kathleen Addison
(403) 943-0940
[email protected]
Health Information Exchange
Neysa I. Noreen, RHIA
(507) 645-0715
[email protected]
Gail Garrett, RHIT
(615) 344-6247
[email protected]
Sharon Slivochka, RHIA
(440) 937-5532
[email protected]
Katherine Lusk, MHSM, RHIA
(214) 456-8576
[email protected]
Privacy and Security
Sharon Lewis, MBA, RHIA, CHPS, CPHQ,
FAHIMA
(805) 542-0160
[email protected]
Deanna Peterson, MHA, RHIA, CHPS
(314) 209-7800
[email protected]
AHIMA volunteers also make valuable contributions as facilitators for Engage Online Communities. To locate the facilitator(s), go to a particular community, click on the “Members” tab, then click on the
“community administrator” link.
62 / Journal of AHIMA July 15
AHIMA Volunteer Leaders
COMPONENT STATE ASSOCIATION PRESIDENTS
Alabama
Sharon Horton-Woodruff, RHIT
Cullman, AL
(256) 352-8337
[email protected]
Indiana
Deborah Grider, CDIP, CCS-P
McCordsville, IN
(317) 908-5992
[email protected]
Nevada
Gregory Schultz, RHIA
North Las Vegas, NV
(702) 526-8361
[email protected]
South Dakota
Sheila Hargens, MSHI, CMT
Parkston, SD
(605) 928-3741
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Anchorage, AK
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Rayne, LA
(337) 277-5544
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Sandra Macica, RHIA
Saratoga Springs, NY
(518) 584-0389
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Colorado
Melinda Patten, CDIP, CHPS
Aurora, CO
(720) 777-6657
[email protected]
Maine
Nora Brennen, RHIT
Topsham, ME
(207) 751-1853
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Jolene Jarrell, RHIA, CCS
Apex, NC
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Elizabeth A. Taylor, MS, RHIT
East Hartford, CT
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Maryland
Sarah Allinson, RHIA
Baltimore, MD
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Delaware
Marion Gentul, RHIA, CCS
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Walter Houlihan, MBA, RHIA, CCS
Springfield, MA
(413) 322-4309
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District of Columbia
Jeanne Mansell, RHIT, CHTS-CP, CHTS-PW,
CHTS-IM, CHTS-IS, CHTS-TS, CHTS-TR
Washington, DC
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Owosso, MI
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Jean MacDonell, RHIA
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Allyson Welsh, MHA/INF
Decatur, GA
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Phyllis Spiers, RHIT
Carriere, MS
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Wailuku, HI
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Florissant, MO
(314) 276-4180
[email protected]
Idaho
Mona P. Doan, RHIT, CCS-P
Boise, ID
(208) 484-7076
[email protected]
Montana
Vicki Willcut, RHIA
Kalispell, MT
(406) 756-4758
[email protected]
Illinois
Teresa Phillips, RHIA
Effingham, IL
(217) 347-2806
[email protected]
Nebraska
Shirley Carmichael, RHIT
Fairbury, NE
(402) 729-6854
[email protected]
Utah
Vickie Griffin, RHIT, CCS
Bountiful, UT
[email protected]
Vermont
Charmaine S. Vinton, RHIT, CCS, CPC
West Chesterfield, NH
(603) 357-0170
[email protected]
Virginia
Darcell Campbell, RHIA
Hampton, VA
(757) 788-0052
[email protected]
North Dakota
Tracey Regimbal, RHIT
Grand Forks, ND
[email protected]
Washington
Sheryl Rose, RHIT
Spokane, WA
(509) 624-4109
[email protected]
Ohio
Pamela Greenstone, MEd, RHIA
Mason, OH
(513) 403-9014
[email protected]
West Virgnia
Kathy Johnson, RHIA
Sinks Grove, WV
(304) 772-5312
[email protected]
Oklahoma
Christy Hileman, MBA, RHIA, CCS
Mustang, OK
(405) 954-2824
[email protected]
Wisconsin
Susan Casperson, RHIT
Cecil, WI
(715) 853-1370
[email protected]
Oregon
William Watkins, RHIA
Oregon City, OR
(503) 867-5173
[email protected]
Wyoming
Kimberle Johnson, RHIA
Gillette, WY
(307) 682-1251
[email protected]
Pennsylvania
Laurine Johnson, MS, RHIA, FAHIMA
Sarver, PA
(724) 295-9429
[email protected]
Puerto Rico
Brunilda Velazquez, RHIA, CCS
Guayanilla, PR
(787) 505-1433
Rhode Island
Patti Nenna, RHIT
Bristol, RI
(401) 253-1686
[email protected]
South Carolina
Karen B. Farmer, RHIT
Greenville, SC
(864) 277-1982
[email protected]
E-mail changes to your listing to
[email protected]
Journal of AHIMA July 15 / 63
QualCode provides cost-effective solutions
for all your coding, reimbursement and
educational concerns.
Coding Compliance Audits
• DRG/Coding Quality Audits
• Evaluation & Management Audits
- Emergency Room
- Professional Fee Services
Advertising Index
AHIMA................................................................. 16, 51, 55
American Medical Association.......................................39
Amphion Medical Solutions.............................. back cover
Medical Coding Services
• Inpatient & Outpatient
- Onsite & Remote
• Specialty Coding
- Wound Care
Education and Training
• ICD-10-CM/PCS
Caban Resources, LLC...................................................45
Care Communications....................................................53
Channel Publishing......................................................... 22
Elsevier Clinical Solutions............................................... 25
212.368.6200
First Class Solutions....................................................... 57
www.qualcodeinc.com
QualCode, Inc.SM
Medical Coding & Reimbursement
HCPro..................................................... inside back cover
Health Information Associates................inside front cover
AHIMA Thanks Its Loyalty Program Members
Healthcare Cost Solutions.............................................. 58
HealthPort......................................................................... 9
EXECUTIVE LEVEL
Huff DRG Review Services.............................................30
In Record Time, Inc........................................................... 7
Just Associates, Inc........................................................ 21
DIRECTOR LEVEL
Perry Johnson & Associates, Inc.................................... 41
QualCode, Inc.................................................................64
MANAGER LEVEL
Textware Solutions-Instant Text..................................... 26
Health Language
University of Phoenix........................................................ 1
VHC................................................................................. 37
LexiCode
a SourceHOV company
64 / Journal of AHIMA July 15
Vitalware.......................................................................... 29
AHIMA Career Center
For classified advertising information, call Alyssa Blackwell: 410-584-1961 | e-mail:
[email protected]
While the ads in this section are deemed to be from reputable sources, the publisher accepts no responsibility for the offers made.
All copy must conform to equal employment opportunity guidelines, and the publisher reserves the right to reject, withdraw, or modify copy.
A current rate card is available on request.
ADREIMA
The nation’s largest revenue
cycle services organization
has immediate openings for
experienced remote coders.
Adreima partners with over
600 hospitals and our benefits
include competitive pay with
full benefits.
www.adreima.com/careers/
Advertise in the
AHIMA Career
Center!
Coding Validators
Staten Island University Hospital is a 714-bed,
specialized teaching hospital located in New York
City’s 5th and fastest-growing borough. Founded in
1861, Staten Island University Hospital today is a
member of the North Shore-LIJ Health System, and
enjoys numerous academic and clinical affiliations and
accreditations. We are now seeking Coding Validators
for multiple openings within our Health Information
Management team.
In this role, you will plan, organize and manage the
Health Information Management Department in the
area of coding and DRG assignment.
Qualified candidates must have a Bachelor’s Degree
in Health Care Administration, Nursing, or a related
field; along with RHIA, RHIT or RN, CCS certification/
licensure. At least two years of inpatient coding
experience is also required.
We offer competitive salaries and excellent benefits.
To apply, please visit nslijcareers.com and search for
Requisition ID STA0000UD. You may also e-mail
your resume to:
[email protected].
We are an equal opportunity employer with a smoke
free work environment.
Call 410-584-1961
Exclusively Specializing
in HIM for
almost 25 years!
We assist both
job seekers and employers
in the following specialties:
Executive Level | Consultants
Coders | Auditors | CDI
Directors | Managers | Vendors
Contact us in confidence:
Doug Ellie or
Perry Ellie, MA, RHIA, Fellow AHIMA
[email protected]
800-248-6989
Find the perfect employee.
Advertise in the AHIMA Career Center!
Contact Alyssa Blackwell at 410-584-1961 for pricing and options,
or leave her an email at
[email protected].
Journal of
of AHIMA
AHIMA July
July 15 / 65
15 / 65
Journal
AHIMA Career Center
BESLER Consulting is a recognized market leader with over 25
years’ experience providing focused Medicare expertise to the
healthcare industry through financial management and
operational consulting services.
The nation’s largest revenue cycle
services organization has immediate openings for
experienced remote coders. Adreima
partners with over 600 hospitals and our
benefits include competitive pay with full benefits.
Reasons to Join the Adreima Team:
We are seeking a qualified Physician Coder with broad level
experience in both the hospital and multi‐physician specialties
to supplement our Coding and Compliance Services Team.
• Variety of work
• Cross training in all aspects of the revenue cycle
• Opportunity for growth, development,
expansion, and upward mobility
• Flexibility, work from home and flexible hours
Requirements for the role are:
Benefits Plan:
•
•
•
•
Auditing client engagement activities and report preparation.
Working knowledge in hospital or healthcare settings such as
revenue cycle, clinical experience, charge description master,
coding (hospital outpatient coding, physician practice
coding), reimbursement and health insurance practices.
Coding expertise with ICD‐9, CPT/HCPCS, E & M coding and
billing.
Educational reimbursement
Accreditation reimbursement
Office Setup, computer, monitor, phone
Great Benefits: 401K, medical, dental, vision, and
more
Contact Jena’ Ford, our dedicated recruiter
to learn more at
[email protected]
Strong critical thinking skills with the ability to interact with
both internal & external clients
Strong oral and written communication skills coupled with
proven organizational, auditing and detail orientation skills.
Job Title: Medical Records Technician (Coder)
Department: Department Of Veterans Affairs
Agency: Veterans Affairs, Veterans Health Administration
Salary Range: $49,045.00 to $63,987.00 / Per Year
Open Period: Monday, June 1, 2015 to Friday, July 10, 2015
Position Information: Full Time ‐ Excepted Service Permanent
Duty Location: 2 vacancies in the following location(s):
East Orange, NJ
Lyons, NJ
Duties: The Medical Record Technician/Coder is a staff
position located under the Health Information Management
section of the Business Office at the VA New Jersey Healthcare
System (VA NJHCS). This position is responsible for maintaining
the quality of patient records, assigning the appropriate
International Classification of Diseases 9th Revision Clinical
Modification (ICD‐9‐CM), and/or International Classification of
Diseases 10thRevision Clinical Modification (ICD‐10‐CM) ,
International Classification of Diseases 10th Revision Procedure
Coding System (ICD‐10‐CM), Current Procedural Terminology
(CPT‐4), and Healthcare Common Procedure Coding System
(HCPCS codes).
Minimum 3‐5+ years’ (hospital inpatient, outpatient and
physician coding/billing). Related business experience in the
healthcare field may also be substituted.
Computer proficiency with knowledge of Microsoft Office
software including Word and Excel.
Knowledge of medical and general industry terminology with
working knowledge of industry regulatory requirements.
Strong knowledge of Medicare and Medicare payors highly
desirable
Remote work flexibility with 25% travel expected.
EDUCATION:
Bachelor’s degree in healthcare, business or related field
preferred. Appropriate coding certifications highly desirable.
(CPC, CPC‐H, CCS)
Interested candidates should forward their resume, cover letter
and salary requirements to Human Resources at
[email protected].
Apply online at USAJOBS.GOV
66 / Journal
15
66
/ Journal of AHIMA July 1
5
Huf DRG Review Services is a company of excellence and I
consider it a privilege to work here. It is wonderful to work with a
team of top notch individuals that are truly dedicated to the
company, clients, and HIM industry. Dr. Huf is an exceptional
employer and always makes you feel like a valuable asset to the
company. I can't say enough great things about this company.
--Elissa Hahn, MHA, RHIA, CCS, CCS-P
AHIMA-approved ICD-10-CM/PCS Trainer
Clinical Coding Analyst
company of
excellence
top notch
individuals
dedicated to
clients and
HIM industry
Journal
Journal of
of AHIMA
AHIMA July
July 15 / 67
15 / 67
WATSON VS. BIG DATA
IT IS THE MATCHUP OF the century—the towering hulk of healthcare’s Big Data versus the super computer
known as Watson. Will Watson be able to take on this lumbering, untamed mass of information and whip it
into submission?
One year ago, the Journal of AHIMA reported on the IBM super computer Watson’s use by healthcare providers like Memorial Sloan Kettering Cancer Center and medical product supply chain vendors. Since then,
Watson has seen its interaction with the health IT realm balloon, and has now set its sights on helping
healthcare providers and researchers analyze crucial clues from the health data of millions of Americans.
In April, IBM announced that its Watson Health data analytics division is partnering with Apple (including
Apple HealthKit and ResearchKit on the Apple Watch), Johnson & Johnson, and Medtronic to collect data,
conduct analysis, and give feedback on consumer and medical device applications. IBM also announced it
was buying the healthcare startups Explorys and Phytel, both of which offer cloud computing and storage
services. A month later Watson Health entered into a partnership with the electronic health record (EHR)
vendor Epic, and the Mayo Clinic, Healthcare IT News reported.
The latest pairing offers the potential to expand EHR interoperability and enable patient data sharing.
Ideally, Watson will be able to aggregate information from a patient’s EHR, wearable fitness devices, insulin
pumps, smartphone fitness trackers, and other inputs to personalize their treatment.
A New York Times report on Watson Health’s recent activities questions how well developers and providers will do with maintaining privacy and confidentiality in Watson’s sea of data. But some are looking at the
bright side.
“If that future when all this stuff works is going to become real, then having some of the key players come
together is the only way it’s going to happen. This could be a pretty important step along the way,” said Dr.
Robert M. Wachter, a professor at the University of California, San Francisco medical school, in an interview
with the New York Times. ¢
68 / Journal of AHIMA July 15
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