Cac Uses Which Processing Method to Review Documentation in the Ehr and Assign a Code Number?

Clinical Documentation Improvement—A Md Perspective: Insider Tips for getting Physician Participation in CDI Programs

The following is probable not a surprise to those clinical documentation improvement specialists (CDS) working day in and 24-hour interval out improving doc documentation. But for the record-clinical documentation comeback (CDI) is not taught in medical school. The truth is that about physicians have no idea what CDI ways and why information technology should be important to them. Just it is important.

CDI programs have increased significantly over the past 10 years due to changes in reimbursement and increased scrutiny by third party payers. Every bit a upshot, hospitals have invested a significant amount of time and resource to hire CDSs to review charts and identify weather condition that were evaluated, monitored, or treated during the infirmary stay simply were not documented in a way that can be coded. Physician participation and buy-in can exist difficult since some physicians experience that CDI programs exist only to benefit the infirmary and just add more work. Merely some insider tips-provided by a physician-tin exist used to promote CDI programs to members of the medical staff and engage their willing participation in the process.

Make CDI about Quality

The main message to physicians should be that CDI is a quality initiative. When request physicians why adept clinical documentation is necessary, they will most probable say that it is to certificate the care of the patient and to communicate with other providers. Physicians understand the need to make documentation legible, timely, complete, precise, and clear. They understand that the documentation is the legal health tape. They understand the common phrase "If you didn't write information technology, it did not happen."

Physicians are not taught how to consummate the documentation in order to accurately assign codes, and physician billing does not require a high degree of specificity. A diagnosis of congestive centre failure, non otherwise specified (CHF NOS), is perfectly acceptable for physician billing. However, the lack of specificity on a hospital record can affect payment. The key is to engage physicians to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided.

The bulletin to physicians should be uncomplicated-good clinical documentation will meliorate communication, increase recognition of comorbid conditions that are responsive to treatment, validate the intendance that was provided, and show compliance with quality and safety guidelines. Although the message is simple, there are some challenges when trying to present this information to physicians. Physicians are past nature independent thinkers and volition expect a very concise, articulate reason to change documentation habits.

Recommendations for how to address CDI with physicians include:

Know your audience-academic physicians, private practitioners, mid-level providers, and students should each exist approached differently
Incorporate CDI training with ICD-10-CM/PCS-this reduces the number of messages for clinicians
Tell them why CDI is of import
Make CDI part of the clinician workflow
Documentation queries need to be consequent with clinical practice
Queries must be consequent with evidence-based guidelines
Provide meaningful data and feedback to facility clinicians

Figure i

Screen shot of UPMC's EHR organization requiring a doctor to certificate a diagnosis that justifies the transfusion of packed blood-red blood cells. This additional documentation helps coders apply the proper code.

Know the Audition

Physicians who are employed by a hospital are more likely to be receptive to incorporating CDI if outcomes data are incorporated into do contracts. In addition, the Joint Commission requires that medical staff undergo ongoing professional practise evaluations (OPPE) to monitor for quality and performance.

At the University of Pittsburgh Medical Centre (UPMC), physicians receive information regarding admissions, average length of stay, readmissions, severity of illness, and hazard of bloodshed scores. It is a mutual trait among physicians that they call back they care for the sickest patients. Proper documentation can assist support or debunk that claim. Brainwash physicians that infirmary coding determines the severity of illness and risk of mortality. Thus, proficient clinical documentation benefits the physician as well as the infirmary.

Not-salaried or private physicians at UPMC also receive OPPE data and are receptive to the message that the clinical documentation directly affects quality scores. Yet they tin exist less receptive to "helping" the hospital since it is not easy to see whatsoever direct do good to their practice. If this is brought upwards or suspected past CDI staff, information technology is useful to remind these physicians of the costs of care existence provided in the hospital. An case that could be raised: Do they retrieve it is off-white that a hospital has to provide a large bed or wheelchair for a patient with morbid obesity, but non receive extra reimbursement? The physician needs to be reminded that these patients require actress care, and the way the infirmary receives that reimbursement is through the physician documentation.

Interns, residents, fellows, and mid-level providers are often ignored in the CDI attempt since they are not the attending of tape. At UPMC, the CDI staffs' philosophy is that the house-staff of today are the attendings of tomorrow, and there is a demand to educate these individuals on specific documentation at present. It is sometimes hard to influence a trainee or a mid-level provider on good documentation skills unless the attending physician also stresses the need for skillful documentation. If possible, try to have a senior attending present during house-staff or mid-level education, in lodge to set a clear expectation of the goals for documentation. Enlist the clinical chairs of the department to bear the message to faculty. In UPMC'southward case, the best advocate was the Chair of Medicine, who regularly brought up common documentation issues during the morning report with the residents.

Explain Why if Questioned

Physicians are taught to ask "why" equally role of diagnostic preparation and demand to sympathise the reason for a change in clinical documentation in order to fully comprehend the concept. And so if a physician challenges a CDI recommendation, make information technology an opportunity to explain why CDI is necessary. Explain the concepts of the MS-DRGs and how they are designed to increment reimbursement for care of complex patients. Explicate how a severity of illness and adventure of mortality score is derived from the codeable diagnoses. Have a brusk, cogent caption available either verbally, written on a carte, or as part of your md instruction.

In one case the dr. understands that documentation has to be specific, plan staff should so movement on to the most common scenarios for documentation improvement. Share the "top x" diagnoses that are nearly frequently not documented or poorly documented at the facility. Examples of frequently queried diagnoses for many facilities include:

CHF specificity
Sepsis
Acute kidney injury
BMI (low or loftier)
Astute blood loss anemia
Pressure level ulcers and debridement
Hyponatremia
Chronic kidney disease
Malnutrition specificity
Acute respiratory failure

Information technology is also important that physicians empathise the process of audits and denials and the financial impact on the infirmary. At this time, about physicians take not felt any repercussions from a recovery audit contractor (RAC) denial, just the impact on a hospital is very tangible. Non surprisingly, the pinnacle 10 RAC-denied diagnoses are often similar to the pinnacle 10 queried diagnoses. Hence, good documentation washed concurrently will only aid to meliorate the outcome of a RAC audit.

Incorporate CDI in Physician Workflow

How physicians utilize and document in the electronic health record (EHR) tin can accept a big affect on CDI. EHR technology has clearly improved the legibility and timeliness of clinician documentation. Physicians can apply structured templates to input documentation, or they can dictate into a standard progress note format. But along with all of the benefits of electronic documentation, there are besides some significant challenges with electronic documentation. These include:

Cut and pasting prior documentation into new records, which tin can obscure new information and increase audit risks
When doctors type, they don't include much information
Symptoms, not diagnoses, are ofttimes documented
Doctors can't find correct diagnosis from choice-list
Some physicians only look in the EHR for information/communication, which can cause a lack of communication in their workflow

Many of the new generation's physicians take embraced electronic documentation since it allows them to quickly complete the daily note. Some physicians similar to keep a daily log of events in their notes, so if a colleague has to cross-cover the patient they only need to read the last annotation in the nautical chart. This is great for a cross-covering colleague, but it presents a challenge to whatsoever CDS or coder who has to review the chart. Reading the same cut-and-pasted documentation can significantly subtract productivity and increase the chance for missed opportunities for coding or documentation clarification.

Physicians are not trained in coding, yet many physicians know the codes that are important to their physician billing. If the doctor chooses a nonspecific diagnosis code to include in the notation, it can potentially make it more than difficult for a infirmary to lawmaking the instance with a more than specific diagnosis. Having physicians include codes in their notes may facilitate physician billing, simply can come dorsum to haunt a hospital if the case is reviewed past an auditor. For example, a doctor will often document an unspecified code such as "CHF NOS," when the hospital needs "Acute Systolic CHF" in order to have more accurate coding and billing. It is tough to contend with an accountant who says that the dr. has mentioned CHF NOS ten times, but you queried for acute systolic heart failure and got the documentation once. This disharmonize of the diagnosis codes is hard to defend.

The EHR creates the opportunity to assistance physicians with clinical documentation and to provide a ways of communication. Whenever possible, build clinical documentation systems that brand it easy for physicians to provide the codeable diagnoses. For example, the diagnosis of "astute claret loss anemia" is not how nigh physicians were taught to document anemia from GI bleeding. If physicians are not familiar with this diagnosis, make it easy for the dr. to provide the correct diagnosis. At UPMC, whenever a medico orders a transfusion of packed red blood cells, the EHR ordering organisation requires the physician to provide a diagnosis that justifies the transfusion (see Effigy 1). The order cannot be signed unless a diagnosis is chosen from a pick-list of choices.

Of course, the pick-list must be compliant and must non lead the physician to choose just a diagnosis that volition change reimbursement. CDI tools should exist vetted through a compliance section or committee to ensure integrity. It is also important to educate clinicians on how to cull the advisable diagnosis, again with an emphasis on choosing the correct clinical diagnosis and not the diagnosis that will increase reimbursement. Incorporating documentation in the physician workflow is an easy way to assistance clinicians and also provide accurate capture of the diagnosis.

Diagnoses such as decubitus ulcers or malnutrition are frequently institute in documentation from other clinical providers such as nurses or clinical dieticians. Engage nursing staff to aid with documentation of nowadays on access (POA) condition for lines, catheters, staging of force per unit area ulcers, and initiation of a nutrition cess. The clinical dieticians can capture significant nutritional comorbidities. The challenge is how to get the documentation from these providers to the medico for review and validation. At UPMC a paper procedure was utilized then that the nurse or dietician completed an assessment on paper then placed it in the chart for the physician to review and sign. This process had nearly 100 percent compliance because signing these documents was required every bit a part of the medical tape completion policy.

With UPMC's EHR now in place, dieticians and nurses are completing clinical documentation electronically. If force per unit area ulcers or nutritional deficiencies are noted, and so these assessments are available for review in the hospital tape. Withal, unless in that location is a specific note to the physician, physicians may not exist aware of these significant findings. By accurately identifying these conditions in clinical documentation, staff can ensure physicians are enlightened of these risks and can include plans to mitigate these conditions.

UPMC plans to create a process that automatically routes assessments to the attention for their review and attestation. While some physicians go annoyed when asked to verify their clinical diagnoses, if the process is simple and clinically relevant physicians will exist more responsive.

Keep Queries Consistent with Clinical Practice

If a CDS is going to take the time to query a physician, it is important to ensure that the query is clinically consistent with the patient's intendance. For instance, never query for a diagnosis of hyponatremia if the serum sodium is 130meq/dl, only the serum glucose is 800mg/dl. The elevated serum glucose causes a "pseudo-hyponatremia" simply the corrected serum sodium is in the normal range. It is of import for the CDS to have a strong clinical background or to be a highly experienced coder in order to identify scenarios that are not clinically relevant.

I should only query for diagnoses that are clinically meaningful to the patient and the intendance delivered during the hospital stay. As office of query policy and procedures, it is of import to include the Uniform Hospital Discharge Data Set (UHDDS) guidelines for coding and reporting secondary diagnoses. UHDDS guidelines for coding and reporting secondary diagnosis allow the reporting of any condition that is clinically evaluated, diagnostically tested for, therapeutically treated, or increases nursing care or the length of stay of the patient.

Best Way to Query Physicians

Another tip to remember is that when querying a dr., endeavour to incorporate that query into the dr. workflow. It is ideal to be able to round with physicians or participate in the morning study, but not every facility has the resource to provide a CDS on the clinical floor. The key to any successful CDI plan is the ability to communicate with physicians. In-person communication is very effective, since it provides an opportunity for instruction and immediate feedback. Many CDI programs apply the doc query every bit the method of advice. Queries tin be verbal, on paper, or electronic, but the challenge is how to monitor, track, and trend the response to the query.

When using paper queries, try to include the query inside the progress note or order to ensure that it will exist seen by the physician. Electronic documentation lends itself ameliorate to tracking the information, simply getting the documentation into the electronic health record tin exist more than of a claiming. The ideal solution would be an electronic query form that could be easily accessible to the physician, preferably while they are reviewing the clinical record. The physician should be able to answer the form electronically and road it back to the CDS. Once the electronic form is completed by the dr., it should be reviewed by the CDS to ensure that the documentation is consummate. Physicians practice make mistakes, so it is prudent to review all queries earlier making them a permanent office of the health record.

Bear witness-based Guidelines Keep Queries Consequent

Evidence-based guidelines are essential to ensuring a compliant CDI process. Physicians will have a greater respect for a CDI program that cites standard clinical guidelines equally the ground for the query. Queries should be presented to the physician in the context of clarifying the clinical documentation to ensure compliance with evidence-based guidelines. While Coding Dispensary guidelines are useful from a coding perspective, most physicians will not experience comfy using Coding Clinic guidelines equally the footing for determining a clinical diagnosis. Physicians are familiar with resources from standard medical textbooks or journals, or online resources such as UpToDate. Use these resources when querying physicians, both to educate and provide justification for the query.

Sepsis is an excellent example of a diagnosis that has new guidelines to assist physicians who are caring for a patient with sepsis or severe sepsis. Physicians may be completely unaware of the Coding Clinic guidelines for the documentation of sepsis, and so presenting this data is unlikely to yield a pregnant alter in documentation exercise or identification of sepsis.

The journal Critical Intendance Medicine recently published a consensus statement from a commission of 68 international experts on the diagnosis and management of sepsis. Presenting this information to physicians is far more than likely to increase the recognition and documentation for sepsis. In this consensus statement, sepsis was defined equally "the presence (probable or documented) of infection together with systemic manifestations of infection." Astringent sepsis was defined equally "Sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion."

When formulating a query to the physician regarding sepsis, commencement confirm that the clinical scenario is consistent with sepsis and that it will meet some of the clinical variables outlined in the table. Physicians may ask if there are a strict number of diagnostic criteria which must be satisfied in order to make the diagnosis. This is an opportunity to emphasize the clinical judgment and the need for physician estimation as to when these clinical findings are truly meaningful. However, if the patient does not accept any of these clinical findings, then it is inappropriate to query for a diagnosis of sepsis. It is incommunicable to come up up with a strict definition of sepsis, then employ these criteria every bit a guideline. Physicians may not exist aware of these clinical criteria, so having them available at the time the physician is reviewing the query will assist in educating the doc and provide justification for the query.

CDI programs often use clinical guidelines to assist with identifying diagnoses that were non documented. CDI programs tin can also aid in validating diagnoses that have been documented. If a physician documents "acute renal failure," just the serum creatinine increases from 1.2 to 1.four, tin can the diagnosis be clinically justified? Given the increased scrutiny of secondary diagnoses by external auditors, it is critically important to assistance the coders and CDSs to determine if the diagnosis is truly present or whether the physician needs to be queried for clarification.

When developing the policies and procedures for a CDI program, include the bear witness-based guidelines as function of the query development process and in the training for the CDSs, coders, and physicians. Identify physician champions in the fields of communicable diseases, nephrology, neurology, cardiology, internal medicine, and surgery to assistance in collecting the evidence-based criteria to support the queries for unremarkably queried diagnoses. These physician champions are often the best resources at educating colleagues on the demand for recognition, documentation, and intervention of these diagnoses. Ensure that a regular review procedure is in place for prove-based guidelines every bit recommendations can change.

Why Clinical Documentation Improvement is a Quality Try

Better recognition of patient comorbidities and severity of illness
Improved patient outcomes
Decreased risk of conversion to an observation stay
Training for ICD-10-CM/PCS
Md quality scores and how coding defines the expected LOS, cadre measures, infirmary-caused atmospheric condition, and patient safety indicators
Performance metrics-utilization of the severity of disease and run a risk of mortality

Provide Meaningful Data and Outcomes to Clinicians

At UPMC, the following policy regarding doctor completion of queries has been proposed. If the CDSs create a physician query that is clinically relevant, consistent with evidence-based guidelines, and the query procedure is incorporated into the doc workflow, then completion of the physician query should exist mandatory and included every bit office of medical record completion. This would hold physicians answerable to complete the query or risk the punishment outlined in the infirmary medical record completion policy. The key betoken is that the physician has to consummate the query, but they do not necessarily have to agree with the query. UPMC does non mandate a specific diagnosis choice simply only requires that the physician respond.

And then far, this proposal has plant widespread credence at UPMC facilities since physicians have grown to accept and trust the CDI program. For a new CDI program, this proposal may generate significant concern among the medical staff leadership. It will exist essential for the CDI programme to demonstrate conscientious adherence to querying only for clinically relevant weather. This approach would require approving from the Medical Executive Committee and would need to be clearly spelled out in a policy for medical tape completion.

Physicians are inherently competitive and tend to be high achievers. A CDI program should provide timely feedback to physicians and hospital administration regarding the results of the process. Suggested metrics that would exist meaningful to physicians would include:

Volume of queries by dr.
Distribution of query type
Response rate to queries
Nearly common CC/MCC diagnoses
Well-nigh common DRGs
Severity of illness, risk of mortality scores
Case mix index
Denials from auditors

Physicians appreciate the opportunity to compare their operation to their colleagues, but utilize caution as non all physicians have the same practice patterns. Some physicians may accept a low frequency of queries, but that does not always mean that the physician has loftier quality documentation. If possible, try to compare physicians based on specialty type. Trending information, and not just the volume of queries, often leads to a meaningful measure of quality. A doctor may only get two or three queries a month, merely if the physician is beingness queried for the same diagnoses each time, and so there may be a documentation quality business organisation.

Practice not emphasize the financial impact of the queries, just rather focus on the touch on to the severity of disease and risk of mortality scores. Instance management frequently appreciates this arroyo as the documentation of the comorbid conditions helps to back up the demand for medical necessity. As well consider incorporating auditor denial data to the clinicians, since this provides a sense of how clinical documentation is reviewed by an external source.

Evangelize One Message that Includes ICD-10

ICD-10-CM/PCS has received a lot of publicity, and this is an opportunity to combine the need for ICD-ten-CM/PCS education with CDI. It is essential to design the ICD-10-CM/PCS didactics with a CDI perspective. Have advantage of fourth dimension spent educating physicians to drive home the top 10 CDI documentation issues. It is important to do specialty-specific assay for the most common queries in ICD-9 every bit well as the diagnoses that could potentially have an impact in ICD-10-CM/PCS. The message is that expert clinical documentation today should not be any different than when ICD-ten-CM/PCS goes into effect.

Listen: Day-to-Mean solar day for a CDS

Clinical Documentation Specialist Amy Gardner discusses her daily work and what it takes to go a CDS. http://journal.ahima.org

Reference

Dellinger, R., Levy, Mitchell et al. "Surviving Sepsis Campaign: International Guidelines for Management of Astringent Sepsis and Septic Shock: 2012." Critical Care Medicine. 41, no.two (Feb. 2013) 580-637. http://world wide web.sccm.org/Documents/SSC-Guidelines.pdf.

Adele Fifty. Towers (TowersAL@upmc.edu) is an associate professor of medicine and psychiatry at the University of Pittsburgh School of Medicine, and the medical director at UPMC Health Data Management.

Commodity citation:
Towers, Adele 50. "Clinical Documentation Improvement—A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs" Periodical of AHIMA 84, no.7 (July 2013): 34-41.

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Source: https://bok.ahima.org/doc?oid=106669