How to Win Friends and Enhance Learning via a CDI Educator ... · Title: Microsoft PowerPoint -...

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How to Win Friends and Enhance Learning via a CDI Educator Role

M.E. VanGelder, RN, BSN, MREd, CCDS, RHITNetwork CDI TrainerHonorHealthScottsdale, AZ

Lee Anne Landon, BSN, CCMC, CCDSNetwork CDI ManagerHonorHealthScottsdale, AZ

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Gain an understanding and recognize the value in having a dedicated CDI educator role

– Define some unique educational needs for CDI specialists and coders and describe how a dedicated CDI educator can bridge the gaps

– Recognize how CDI and coding demonstrate effective teamwork through the DRG reconciliation process, thereby strengthening the revenue cycle

– Understand how to create a business case for a dedicated CDI educator role


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Why Is a CDI Educator Needed?

• With the expanding role, CDI needs to learn:– Quality metrics – HCCs for risk adjustment– Mortality reviews– Denial management

• CDI departments have become victims of their own success—service lines, allied departments, administration, etc. are looking for more education on clinical documentation


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• With all the new roles and responsibilities, CDI programs are expanding their staff:– Who will train them?– How do you standardize their training?– Who is going to develop the necessary training materials?– How do you keep that information updated and current?


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• With increased educational needs outside the CDI department:– Who will develop all the provider education?– How can you assure others that consistent information is being provided across your network/system?

– Who will track and trend educational needs and the impact of the education provided?

– Who will provide the educational link between coding and CDI?


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Polling Question 1

• Has your CDI program expanded to include a dedicated educator position?– Yes, our program has a CDI educator– No, our program does not have a CDI educator, but we would like one– No, our program does not have a CDI educator, and we do not need one right now– Not applicable to my organization


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ACDIS Radio Survey, September 26, 2018

520 attendees with 400 responses to survey = 77% response rate71% have either an excellent/good relationship between departments

How do we build a collaborative and nurturing team?

CDI dream team, https://acdis.org/acdis‐radio


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“Examining the Blurred Lines Between CDI/Coding”

Laurie Prescott penned this article that appeared in the CDI Journal and JustCoding (2018)• In her early years as a CDI she said, “I’m not a coder.”

– Critical error in thinking: I do not need to learn the ways of coders ‐> developed “encoder dependency”

– Coding guidelines learned via osmosis through a coder friend– No one told her to read the coding guidelines – Nor taught her to use the Alphabetic Index and Tabular List

CDI educator needed!


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What the Heck Is This???

https://www.cdc.gov/nchs/icd/data/10cmguidelines‐FY2019‐final.pdf


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A Coding What???

Uncertain Diagnosis - Concern for

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Pages: 18-19 Effective with discharges: February 18, 2018 Question:

Is "concern for" a term of uncertainty that allows the "subdural empyema" to be coded, since it was documented at the time of discharge?

Answer:

"Concern for" is a term that should be interpreted as an uncertain diagnosis and coded following the guideline for "uncertain diagnosis" in the inpatient setting.

Codes are assigned for uncertain diagnoses in the hospital inpatient setting if the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," or other similar terms indicating uncertainty.


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CDI Education Needs

Optum360, ICD‐CM Expert for Hospitals 2019, p. xiv

• Understand coding hierarchy—conventions, guidelines, coding clinics– How do you to use the coding books?– What are the steps for accurate code assignment?

1. Identify the main term

2. Locate the main term in the Alphabetic Index

3. Review any sub terms under the main term in the Alphabetic Index

4. Follow any cross‐reference instructions, such as “see” or “with” notes

5. Do not code from the Index without verifying the code in the Tabular List


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What’s a PDX/SDX or DRG?

• What’s the difference between a principal diagnosis vs. secondary diagnoses?– Principal diagnosis—“the condition established after study to be chiefly responsible for

occasioning the admission of the patient to the hospital for care”– Secondary diagnosis—additional conditions that affect patient care in terms of requiring:

• Clinical evaluation, or • Therapeutic treatment, or• Diagnostic procedures, or• Extended length of hospital stay, or• Increased nursing care/monitoring

• How do you establish a DRG? – Principal diagnosis/procedure/comorbidity establish the DRG level

• DRGs are listed by Major Diagnostic Categories (MDC)• What is an MDC?

https://www.cdc.gov/nchs/icd/data/10cmguidelines‐FY2019‐final.pdf


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CDI Education Needs

• Updates: quarterly AHA Coding Clinic, yearly ICD‐10‐CM/PCS guidelines/codes, and annual DRG changes– Why are these important resources? – Where do you find them?

• New CDI roles/tools such as concurrent query for clinical validation– Requires a different CDI focus


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Education Needed for Coders and CDI

• Why is the CDI clinical validation query process needed?– Avoids assumption coding errors– Denial prevention for high‐risk diagnoses– CMS monitors DRG validation, important for coders

• RAC audits have revealed that a significant amount of claims have an incorrect PDX

• Coding audits identify opportunities to improve code assignment and compliance with CMS guideline

• How can CDI partner with coding to improve code assignments and CMS compliance?


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Collaborative Learning


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Clinical Indicator Education:Acute Respiratory Failure

• Acute respiratory failure may be present if 2 of 3 criteria are met:– pO2 < 60 mmHg– pCO2 > 50 mmHg– Respiratory distress

• As a general rule ... pulse oximetry (SpO2) of 90% is roughly equivalent to a pO2 of 60 mmHg on an ABG (exception is COPD)

• Therefore ... SpO2 of 89% or less meets 1 of 3 criteria for the diagnosis of “acute respiratory failure”


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Documentation Elements: Respiratory Distress

• A patient does not have to be placed on a ventilator for acute respiratory failure; treatment such as BIPAP, non‐breather mask, Venti‐Mask, high‐flow O2 with signs of respiratory distress is acceptable, such as:– Dyspnea– Tachypnea– Wheezing– Nasal flaring – Grunting– Use of accessory muscles– Cyanosis– Labored breathing


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Hypoxemic Failure

• Hypoxemic: Failure of O2 exchange– Due to alveolar flooding– Hypoxemia refractory to supplemental O2– PaO2 < 60 mmHg (O2 sat < 91% RA)– P/F ratio < 300 on O2– 10–15 mmHg decrease from baseline if known

• **Note: P/F ratio and RA O2 sats are not valid for O2‐dependent chronic respiratory failure

(R.D. Pinson & C. Tang, 2018 CDI Pocket Guide, p. 148)


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Respiratory Failure or Airway Protection?

• Respiratory failure due to surgery/trauma– Is respiratory failure due to a complication of surgery, or anesthesia, or underlying condition and intervention is required to prevent and/or treat decompensation?• Example: acute respiratory failure in the postop setting primarily due to preexisting CHF, traumatic hemopneumothorax 2/2 crush injury of chest

• Are clinical indicators present in the EMR?

– OR is mechanical ventilator routine to protect the airway and customary for procedure and recovery?


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Respiratory Failure or Airway Protection?

AHA Coding Clinic, Fourth Quarter 2011, pp. 123–125

• Acute respiratory failure following trauma and surgery– Respiratory failure is a relatively common postoperative complication that often requires mechanical ventilation for more than 48 hours after surgery or reintubation with mechanical ventilation after postoperative extubation

If you’re leery, you’ve got to query!


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Appeal Letter for Respiratory Failure

We are appealing determination of acute hypoxic respiratory failure.53 y.o. female, hx heroin abuse (20 years ago) on methadone, presented to the ED with c/o cough, congestion, and SOB x 2 weeks. Medical hx: active smoker with chronic bronchitis, hepatitis C, admitted for PNA. Patient had several recorded episodes of hypoxic events of 76%, several 89% on room air, 88% on 2.5 L O2. For this hospitalization her O2 requirements were continuous at 2–4 L/min.


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Appeal Letter for Respiratory Failure

• The gold standard for this diagnosis is an arterial pO2 on room air < 60 mm Hg measured by ABG – Criteria met. Hypoxic respiratory criteria = P/F ratio < 300 on O2. The patient’s recorded SpO2 readings were 90–96 (with the average 93). The patient’s O2 recorded usage was 2–4 L (with the average 3 L).

– O2 sat 93%, O2 3 L, 68/0.32 = 212 P/F ratio.

• A CDI educator can help the denial management team by providing tools to support best‐practice clinical validated appeals


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Denials: Understanding the Industry Trend

• In 2017 $3 trillion claims submitted• $262 billion denied• Averaging almost $5 million/hospital• Typical hospital has 7%–12% of its claims denied

• 500‐bed hospital, 10% claims denied: ~$15.9M• 65% of claims denials are never re‐submitted(Stinson, 2018)


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What Is CDI Educator Role in the Denial/Appeal Process?

• CDI educator can help the denial management team by providing tools to support best‐practice clinical validated appeals

• Share common clinical coding denials with staff• Focus on lessons learned • Fine‐tune ways to improve the review process for denial prevention • Important: Claims data is used to capture facility quality measures and healthcare outcomes


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CDI Educator’s Role in Chart Audits

• Chart audits are used to:– Track trends and look for gaps in process compliance– Establish the type of provider education needed

• Has provider education been effective?– Provide feedback to CDI staff

• Identify strengths and weaknesses• Used for individual staff development

– Develop staff education based on audit results– Goal: focused reviews leads to a reduction in risk areas such as denials and reimbursement


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CDI Chart Audits

• Monitor and provide education on:– Provider queries to ensure compliance– Capture of SOI/ROM – Risk‐adjusted diagnoses, HCCs – Correct POA status– Clinical validation queries

• CDI audits identify chance for enhanced queries and missed opportunities


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CDI Chart Audit Example Provider Query

• Was there a query done? Yes, for acute CVA with LUE weakness. If so, were there indications for query? No.– There is a Coding Clinic that indicates providers may occasionally document unilateral weakness due to cerebral infarction. When unilateral weakness is clearly documented as following a stroke, it is considered synonymous with hemiparesis/hemiplegia (I69.35‐). (AHA Coding Clinic, First Quarter 2015, pp. 25–26)

• Below is additional information we would audit for:– Did the query contain relevant clinical indicators? Yes– Could the query be perceived as leading? No, appropriate choices were offered– What was the physician’s response to the query? CVA with L sided hemiparesis


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Cerebral Infarction and Occlusion CDI Tip Sheet

• Document related deficits or complications such as:– Right or left hemiparesis/hemiplegia– Right or left monoplegia or upper/lower limb– Aphasia– Ataxia– Right or left neurologic neglect syndrome– Persistent vegetative state– Quadriplegia


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CDI Chart Audit Example: HCC

• Was there clinical evidence of DX clarification opportunity that did not result in a query? Yes.– PN mentioned chronic fungal pulmonary infection, continue Vfend. PN also mentioned immunosuppressive state 2/2 IVIG dependency and chronic steroids. In hx present illness section, pulmonary and critical care consult documented aspergillosis on Vfend. Vfend was ordered and given during inpatient stay.

• Comments: This was a Medicare Advantage patient, and pulmonary aspergillosis dx is a significant HCC, +0.435 to overall RAF score. HCCs are used for proper reimbursement; they predict healthcare costs/resources for the following calendar year. Mortality and readmission rates are also risk‐adjusted.


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Coding/CDI: DRG Reconciliation Process

• With collaboration this process should be smoother– Education helps us understand each other’s role

• CDI gains a greater understanding and respect for coding rules and guidelines; therefore, the coder’s feedback during the reconciliation process is valued and appreciated

• By providing education to coders on clinical indicators for various conditions, the coder gains an enhanced appreciation into CDI’s clinical prospective during the reconciliation process


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Coding/CDI: DRG Reconciliation Process

• If an agreement cannot be reached between the coder and CDI on a regular basis:– This may reflect a lack of understanding and the need for additional focused education

– It may also indicate a breakdown in the communication process• An educator can assist in bridging these areas by:

– Providing standardized education – Communicating information throughout the network/facility


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A CDI Mission Statement

• The heart of a CDI program should contain a mission, values, and goals statement– What is our purpose?– What do we hope to achieve?– What qualities and values do we exhibit?– What are our goals?

• Once your mission is established, use it!


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Our CDI Mission Statement

CDI promotes accurate and complete documentation which reflects the severity of illness, risk of mortality, utilization of resources, and appropriate quality data. This is accomplished through the application of evidence‐based knowledge, in‐depth review and analysis of the medical record, the query

process, as well as provider education and collaboration.

Education/collaboration is bound into our mission statement.


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Values and Goals

• Establish and maintain cohesive/collaborative communication lines between our organizational partners, including but not limited to care providers, coding, quality, and utilization management

• Continually learn and develop new skills that will allow us move forward with regulatory and technological changes


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What Is Our Goal?

Goal is based on mission statement

• Getting the record right every time– Ensure accurate and complete documentation– Reflect true severity of illness and risk of mortality– Capture utilization of healthcare resources– Report appropriate quality data for public profile purposes

Education and all you do should fall in line with your mission statement, values, and goals


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What Is Our ?

• Ongoing clinical education and reciprocity with others allows us to advance and adapt to a rapidly changing healthcare environment – Monthly staff meetings with coding and CDI, quality – Provide education on clinical indicators for diagnoses, clinical validation, denials

• This requires getting out of our silos and partnering with other departments to improve our clinical and quality metrics – Strengthens the revenue cycle across the continuum

• Collaboration is key to success and survival


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“Raise Your Hand” Question

• How is the standardization of your new hire and educational processes accomplished?– Internally– Outside vendor


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How Do We Get Buy‐In?

• Now we know the value and rationale behind having a network CDI educator, how do we go about getting one?

• We need to justify the value and necessity to our administration.


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Requesting a New CDI Educator Position

• Create a financial impact analysis for adding a CDI educator– The financial impact of the current CDI specialist reducing their review time for education activities

– The cost of the initial high‐intensity orientation phase—i.e. the cost of an outside vendor or cost of removing a CDI staff member completely out of our count

– The cost of denials that could possibly be prevented with additional consistent documentation education


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• Track and trend significant variation between your facilities such as MCC/CC capture, simple vs. complex PNA, O/E mortality ratios, etc. that could be impacted by standardized education

• Determine what is not getting done while staff is individually developing provider education and meeting the orientation needs of new staff


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• Develop a job description that:– Makes the distinction between provider education done by the CDI staff and the formal standardized education that can be provided throughout your system/network

– Include the development and/or regular updating of a standardized CDI orientation– The ability to analyze data to track and trend the educational needs for both CDI and providers


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Thank you. Questions?

[email protected]@honorhealth.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


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