HCPro.com - CDI Strategies

News: Four states start ZPIC reviews, others begin soon

Thu, 12 Nov 2009 17:59:00 GMT

Health Integrity LLC, the zone four (Colorado, New Mexico, Oklahoma, and Texas) Zone Program Integrity Contractor (ZPIC), has begun requesting medical records for review.

The ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. According to the CMS Program Integrity Manual, ZPICs may “take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.”

During HCPro’s November 3 audio conference, “Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review”, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.

This information came as a mild surprise to Robert Wade, partner at Baker and Daniels, LLP, in South Bend, IN. Wade said ZPICs have the authority to start reviews as soon as they are awarded the contract, and Health Integrity was awarded the zone four contract in February.

Facilities should be aware that ZPICs could notify the facility via fax a mere hour before the visit. This can leave little time for the facility to prepare. Wade said in situations where ZPICs give short notice, facilities are within their rights to supplement any requested records with supporting documentation even after the visit is complete.

So far CMS has awarded only three of the seven ZPIC contracts:

Zone 4: Colorado, New Mexico, Oklahoma, and Texas—Health Integrity LLC
Zone 5: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia—AdvanceMed
Zone 7: Florida, Puerto Rico, and Virgin Islands—SafeGuard Services LLC

So what does this information mean for providers that are within one of these zones?

“They can come knocking at any time,” Wade said.

Consequences of a ZPIC review include payment denials, recoupment of overpayments, and referral to other law enforcement agencies. Because ZPICs can refer cases to the Department of Justice, Office of Inspector General, or other law enforcement agencies, a ZPIC review may only be the first step in a long legal battle.

News: ICD-9 to ICD-10 code conversion conference call slated for Nov. 19

Thu, 12 Nov 2009 17:57:00 GMT

Implementation of ICD-10-CM/PCS remains three years away. But it is not too soon to find out more about the data set. On Thursday, November 19, from 12:30-2 p.m. (EST), CMS plans to hold a National Provider Conference Call to discuss the conversion of ICD-9 to ICD-10.

The outreach call will describe the preliminary exercise CMS undertook to convert data using the General Equivalence Mappings (GEM), according to the announcement. The GEMs are a tool developed to assist CMS and other data users who need to convert ICD-9-CM data or payment systems to the relevant ICD-10-CM/PCS codes and

ICD-10-CM/PCS codes back to the relevant ICD-9-CM codes.

The following topics will be discussed during the conference call:

How ICD-9-CM based Medicare Severity-Diagnosis Related Group (MS-DRGs), version 26.0, were converted to ICD-10-CM and ICD-10-PCS codes
The best way to use the GEMs in converting data

According to a related Q&A on the CMS Web site a draft ICD-10 version of the MS-DRGs was completed in October 2009, and will be posted in January 2010 along with the 2010 updates to ICD-10 and the General Equivalence Mappings. CMS says it “welcome[s] recommendations regarding how this information should be displayed. [because it] believe[s] this exercise will provide useful information to other payers who will be converting their own payment systems.

To access the ICD-10-CM/PCS Medicare Severity-Diagnosis Related Group Conversion Project Presentation that will be discussed during this conference call, visit www.cms.hhs.gov/ICD10/06a_2009_CMS_Sponsored_Calls.asp and select the title of the presentation in the Downloads Section.

To register for the call visit www.eventsvc.com/palmettogba/111909 by 12:30 p.m., Wednesday, November 18. For those unable to attend, written and audio transcripts will be posted shortly after the conference call in the Downloads Section at www.cms.hhs.gov/ICD10/06a_2009_CMS_Sponsored_Calls.asp.

Strategy: Position your CDI role to meet the evolving world of healthcare reform

Thu, 12 Nov 2009 17:54:00 GMT

With so much attention on healthcare reform and CMS’ shift toward paying for quality, CDI specialists should seek to align their unique role in healthcare with these new trends, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant located in Madison, WI.

CDI specialists should review the medical record in its entirety, including the history and physical and the discharge summary, with an eye on ensuring proper documentation of not just reimbursement opportunities (i.e., CCs and MCCs), but medical necessity.

One neglected part of the record upon which CDI specialists can make an immediate impact is the discharge summary, Krauss says. This is often the only portion of the medical record that the next provider to whom the patient is discharged (e.g., home health or a skilled nursing facility) receives, and it often contains nonspecific diagnostic information.

So if a CDI specialist clarifies physician documentation of urosepsis or renal insufficiency elsewhere in the record, there’s no guarantee that the clarification will carry over to the discharge summary, which may cause denials for the hospital and the physician’s professional fees. “It doesn’t help in terms of reducing the supposed waste in healthcare due to readmissions if we don’t get the patient’s acuity properly documented and represented in the discharge summary,” Krauss says.

As always, Krauss advises CDI specialists against just looking for undocumented CCs and MCCs in the record. “We need to focus on all the diagnoses that impact acuity, not just buzzwords so that we can code something,” he says. “CDI program directors should seek to make their programs more business-like and carry a message of collaboration to the physicians.”

News: Three local CDI groups set to meet Friday, November 13

Thu, 12 Nov 2009 17:52:00 GMT

CDI professionals across the country understand the benefit of informal, informational networking. ACDIS has a number of “official” local chapters and a number of fledgling organizations in more than half the country. This Friday three states hold local meetings—Florida, Georgia, and North Carolina.

Georgia’s inaugural meeting takes place from 10:30 a.m. to 3 p.m. at Dobb University Center at Emory University Hospital, 1364 Clifton Rd., in Atlanta, GA. Event organizer Bonnie Epps has a full day planned with door prizes, lunch, networking, survey responses, and brainstorming sessions. Epps also organized sessions on:

new coding changes for 2010
RAC
the physician’s role in CDI programs

For information, contact Epps at Bonnie.Epps@emoryhealthcare.org.

Florida CDI specialists will meet at 8:30 a.m. through 1 p.m. at Shands Hospital at the University of Florida. The meeting features the following educational sessions:

This isn’t a Complication: Bridging the Communication Gap
Public Quality Measures and Mortality Risk Adjustment
Team Physician: CDI Keys for Success
Clinical Documentation Improvement Software Computer-Assisted Coding Demonstration with 3M

For information, contact Sylvia Hoffman at shoffman@tgh.org.

The North Carolina ACDIS group gathers at Appalachian Regional Healthcare Watauga Medical Center in Boone, NC, from 10 a.m. to 2 p.m., featuring the following topics:

ICD-9 coding changes – Effective 10/01/09
Certification of CDIS – What to expect
Study guide and work groups

The fact that CCDS certification is on the agenda comes as little surprise since the NC group challenged other CDI networks to see which group could boast the most CCDS certified professionals among its membership prior to the 2010 ACDIS conference in Chicago June 3-4.

Although RSVPs for Friday’s meeting were due October 22, for information about the NC Chapter e-mail President Leah Taylor at leah.taylor@iredellmemorial.org.

All three groups set their meeting dates with an eye to allow for travel time, professional time, and relaxation time. Epps hopes CDI professionals come to Atlanta for the meeting and stay the weekend to enjoy the city and get some early holiday shopping. Taylor plans to enjoy a fall foliage weekend in the mountains. Hoffman says there’s always something going on in Tampa.

For information about ongoing local meetings, read the ACDIS Blog and look at the Local Chapters page on the ACDIS Web site www.cdiassociation.com.

Q&A: Queries under RAC scrutiny

Thu, 12 Nov 2009 17:46:00 GMT

Q: We recently heard from our process management company that after several clients have had the Recovery Audit Contractor audits that we can no longer use a diagnosis in a query that has not been brought up in the progress notes. Is this true? This makes writing a query much more challenging!

A: The AHIMA physician query practice brief published in October 2008 listed the following nonexclusive circumstances for which physician queries are appropriate:

Clinical indicators of a diagnosis but no documentation of the condition
Clinical evidence for a higher degree of specificity or severity
A cause-and-effect relationship between two conditions or organism
An underlying cause when admitted with symptoms
Only the treatment (not the diagnosis) is documented
Present on admission (POA) indicator status

Moreover, the brief states that multiple choice questions are an acceptable practice and they even show an example that lists specific diagnoses. When using a multiple choice format they note that there must be a number of options that are clinically reasonable, along with “other” and “clinically unable to determine.”

I learned a lot from my time in New York and California during the demonstration project. One especially important thing I learned is that the RAC does not always do a good job of researching their positions. Many of their findings have been overturned at higher appeal levels.

Editor’s Note: Marion G. Kruse, MBA, RN, Director at FTI Consulting, and co-author of The Physician Queries Handbook answered this question.

On the ACDIS Web site

Thu, 12 Nov 2009 17:44:00 GMT

Editor’s note:The following items have been updated on the ACDIS Web site, www.cdiassociation.com.

On the ACDIS Blog

Thu, 12 Nov 2009 15:29:00 GMT

Editor’s note: The ACDIS Blog contains important association information as well as tips and commentary. The blog is free and open to the public. You can respond to any blog post by clicking on the comment button. Recent blog posts include:

Tip: Take the time to review the H&P and progress notes

Thu, 29 Oct 2009 20:50:00 GMT

CDI specialists often underestimate the importance of the dictated history and physical (H&P) and progress notes when reviewing the medical record, according to Kate Green, RHIT, clinical quality specialist with Webmedx in Atlanta, GA. Many times it’s because the notes are hand-written, illegible, and difficult to search.

Webmedx is currently developing a query process that takes the diagnoses from the patient’s H&P, matches them to a working MS-DRG, and estimates the patient’s length of stay based on that data. The company can then generate a report and transmit it to the CDI specialist or utilization reviewer when he or she comes in the next morning to start their work. “We’re trying to give them a place to start on day one of the admission before the hospital starts with tests and procedures,” Green says.

These reports are based on the data contained in the transcribed H&P and progress notes, and include the name of the dictating physician and patient’s location in the facility. The automation allows CDI specialist to start their day earlier and leave queries for physicians they might otherwise miss. Text searches of the transcribed reports allow CDI specialists to identify unspecified diagnoses like unspecified anemia.

This process allows CDI specialists to more readily identify patients with a current diagnosis or past history of AMI, heart failure, or pneumonia, for example. It’s also of enormous benefit to hospitals that implement quality (aka, core) measures documentation into their chart review duties

“It identifies those patients with those (core measures) diagnoses so that you can affect that documentation from day 1—for example, how long has it been since they’ve been on an antibiotic and what antibiotics they’ve been on,” Green says.

Green says using a dictated and searchable H&P for reviews allows CDI specialists to identify up to 50% more heart failure patients, particularly those who have had a past history of the diagnosis.

Even if you can’t afford an automated system, Green recommends the following best practices for reviewing the H&P/progress notes and improving physician documentation:

Embrace uncertainty. Initial dictation is often cloudy because physicians don’t always have the answers. Encourage them to document probable or suspected diagnoses early in the stay. “They can make an educated guess, and that may be good thing,” Green says. “It gets them thinking on day 1 and puts a more accurate slant on things.”
Review the H&P. Take a quick look at the H&P at the outset of the patient’s stay. Make sure the physician’s progress notes reflect any revisions since the H&P was dictated
Have physicians dictate their progress notes. Ask your hospital to invest in transcription or a speech-recognition service. Once they’re in an electronic system, the H&P and progress notes can be read and searched very easily. CDI specialists can use them to look for diagnoses, or for important elements like labs ordered, medications, and treatments.

“You get away from those progress notes that are illegible and just not up to par, and they can be reviewed more quickly easily if they’re in an electronic form,” Green says. “There’s so much information locked up in the dictated H&P.”

News: Simple mistakes cause profound costs

Thu, 29 Oct 2009 20:47:00 GMT

Sometimes documentation mistakes caught by CDI professionals are the simple ones. Like an incorrect date. A news brief from New York Injury News outlined the trials of HIV patient who lost his insurance coverage due to inaccurate documentation of a blood-test date.

CDI professionals well know the costs of seemingly simple mistakes. This particular case ended up costing the insurance company, Fortis, $10 million for inappropriate denial of healthcare coverage and added untold difficulties to a young man’s life.

Although all CDI specialists’ catches may not affect IPPS reimbursement or severity of illness, CDI specialists catch these seemingly simple yet significant mistakes all the time. So here’s a special request to ACDIS members and CDI Strategies readers: Tell us about some of the otherwise unseen documentation catches you make everyday. Send the funniest, most heart wrenching, or simply ‘best catch’ documentation stories by the mid-November.

For example, Lori Schmitz, RHIA, documentation specialist team leader for Mississippi Baptist Health Systems, in Jackson, recounted how a documentation explained that a patient presented to the hospital post a laparosopic nephrectomy due to a piece of chicken pot pie getting lodged in his throat, which resulted in some hypoxia that could not be treated conservatively. Initially, says Schmitz, the report said "chicken potassium pie".

Send us your ‘catches’ and we will run them by our editorial staff and pick the best to publish. E-mail Associate Director Melissa Varnavas at mvarnavas@cdiassociation.com.

Q&A: Maintaining CDI productivity under the SOI/ROM system

Thu, 29 Oct 2009 20:41:00 GMT

Q: How has switching to a severity of illness (SOI)/ risk of mortality (ROM) system affected your CDI specialist productivity?

A: It does require more review. We have not been able to add additional staff members but our current employees are working very diligently within their services. Basically, they have realigned how they look at things.

We may not see the patient the very first day they’re in, for example. It may be the second day now. And, maybe we don’t perform follow-up queries as frequently as we would like to, although we are working to improve that and we do continue to follow our patients throughout their entire stay.

If a patient has a trach and they are at a SOI level 4 and a ROM level 4, then we will not look at them as frequently as we would otherwise. That decision is left to each individual CDI specialist. While we are unit-based, we also maintain some semblance of service-base; we do cohort our patients. Our CDI specialists have learned their services and have learned how to manage their cases and when they need to do reviews. Because I have a very mature staff they’ve taken it upon themselves to make this work. It has increased our work load.

Unfortunately, we only review our DRG payers. We would like to do 100% review but of course we can’t with our existing staffing numbers. That's probably not the greatest answer but that’s reality and it’s probably reality at some other institutions.

Editor’s Note: Shelia Bullock, RN, BSN, MBA, CCM, CCDS, manager of clinical documentation services University of Mississippi Medical Center, answered this question during the Severity of Illness and Risk of Mortality: Sharpen Your CDI Focus with New Measures of Success audio conference on September 18, 2009.

Tip: Take time for a sepsis refresher

Thu, 29 Oct 2009 20:38:00 GMT

Sepsis. Severe sepsis. SIRS. Septicemia. Unfortunately, this isn’t a case of “tomato, tomahto.” Coders and physicians need to know how to use these terms accurately, or inaccurate billing and coding is a real possibility.

It is interesting to note that “septicemia” does not exist in the ICD-10 codes. When you reference it in ICD-10, it leads you to R78.81 (bacteremia NOS). Sepsis codes have become more defined in ICD-10 and documentation will be critical. For example, the term sepsis alone takes you to code A41.9 (other sepsis). However, depending on the modifying term, the code may change as in this example: When the physician documents the causative organism, such as group B strep, the code changes to A40.1. Also, when the physician documents severe sepsis in ICD-10, it takes you to code R65.20 (severe sepsis without septic shock).

As a refresher, sepsis refers to the “systemic inflammatory response to the infection” and is manifested by three or more of the following SIRS conditions in a patient:

Body temperature > 38.3°C (101°F) or < 36°C (96.8°F)
Pulse > 90/min.
Respirations > 20/min
White blood cell (WBC) count > 12,000 or < 4,000
Altered mental status
Significant edema or positive fluid balance
Hyperglycemia (without diabetes)

Severe sepsis refers to sepsis associated with organ dysfunction or failure,

hypoperfusion (i.e., decreased blood flow through an organ), or hypotension

(i.e., abnormally low blood pressure).

Editor’s note: Jennifer Avery, CCS, CPC, CPC-H CPC-I, senior regulatory specialist at HCPro, Inc., offers additional information in the Revenue Cycle Institute White Paper “Sepsis and Septicemia: Clear Up Coding and Documentation Confusion” available free following registration.

On the ACDIS Web site

Thu, 29 Oct 2009 20:22:00 GMT

Editor’s note:The following items have been updated on the ACDIS Web site, www.cdiassociation.com.

On the ACDIS Blog

Thu, 29 Oct 2009 20:19:00 GMT

Tip: Pay attention to MACs, not just RACs

Thu, 15 Oct 2009 21:00:00 GMT

With all the attention these days squarely on Recovery Audit Contractors (RAC), CDI specialists could be missing compliance initiatives of equal or greater importance issued by their local Medicare Administrative Contractor (MAC).

Case in point: NHIC Corp, A/B MAC for Jurisdiction 14, on September 24 released a document entitled “Medical Review of Inpatient PPS Claims—What did the DRG Validation Review Reveal?” The document summarizes the results of a DRG validation review of hospitals in the states of Wisconsin, Michigan, New York, and Connecticut. The DRGs included in the study were:

061, 062, and 063: Stroke-related DRGs
064, 065, and 066: Intracranial hemorrhage DRGs
067 and 068: Non-specific CVA DRGs
069: Transient ischemic attack (TIA)

The pilot project review included 396 cases from the four states. The overall error rate was 5.8%. Some specific sources of error included:

Untimely discharge summaries
Incomplete or conflicting physician documentation (i.e., stroke vs. TIA)
Failure to query the attending physician
Inaccurate coding

Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant in Madison, WI, offers the following suggestions for CDI specialists:

Stress the importance of a completed discharge summary with physicians. Under the Medicare Hospital Conditions of Participation, records must contain a “final diagnosis with completion of medical records within 30 days following discharge.”

“Work with your coding staff—they can tell you whose documentation is bad,” Krauss says. Focus your education on physicians that fail to provide completed discharge summaries.

Develop a hospital specific policy for incomplete or conflicting physician documentation. Work with your HIM/coding staff to determine what constitutes incomplete documentation. For example, many coders won’t report a diagnosis that only appears once in the medical record, whereas some CDI specialists would consider that sufficient based on the presence of clinical indicators.

“Set clear expectations, or it perpetuates adversarial relationships,” Krauss says.

Tip: Take 2010 IPPS as temporary initiative to spur CDI initiatives

Thu, 15 Oct 2009 20:57:00 GMT

Many hospitals feared a 1.9% reduction in payment for 2010, but they’ll actually see a 2.1% increase, according to the fiscal year 2010 Inpatient Prospective Payment System final rule CMS released in July. HIM directors and CDI administrators shouldn’t sit back and breathe a sigh of relief, however.

“I think that hospitals need to make the most of the 2.1% increase that we’re going to see this year,” says Debbie Mackaman, RHIA, CHCO, instructor for HCPro’s Medicare Boot Camp®–Hospital Version in Marblehead, MA.

To use the money wisely, directors must first realize what the increase could mean to their hospitals. “Look at DRGs that have the biggest bang for the buck,” says Mackaman. “These may be low volume, but they really tap into the increase in payment.”

Ensure complete documentation for all DRGs so coders can capture all relevant CC/MCCs, she explains. Furthermore, HIM directors must understand that the increase won’t last forever, says Mackaman. CMS eventually may impose a minimum 2% payment decrease across-the-board.

“Based on complete analysis of fiscal [year] 2008 and fiscal [year] 2009 data, CMS will consider phasing in future adjustments over an extended period beginning in fiscal [year] 2011,” the agency said in its press release.

Survey: Are queries a permanent part of the medical record?

Thu, 15 Oct 2009 20:48:00 GMT

An HCPro Inc. poll posted this week asked healthcare compliance professionals if their CDI programs keep queries permanently in the medical record. A 5% margin separated query keepers (45%) from non-keepers (50%), as of this writing. A similar ACDIS Weekly Poll found 77% of respondents said they remove the query from the record after the physician clarifies his or her documentation in the medical record and 20% said they keep queries as a permanent part of the medical record.

In a more detailed survey of ACDIS members regarding physician query best practices in April only 28% of respondents said they kept queries as a permanent part of the medical record.

“I’m actually surprised by how many [people] do not keep the queries in the chart,” Gloryanne Bryant, BA, RHIA, RHIT, CCS, CCDS, regional managing director HIM (Revenue Cycle N. California) for Kaiser Permanente in Oakland, CA, said in the survey analysis White Paper Use CDI Best Practices to Query Physicians.

There could be a potential compliance risk if an auditor sees a sudden change in diagnosis in the medical record without additional query information. This lack of documentation in turn could raise questions about leading queries. Some CDI programs use a central tracking database and maintain query forms within the CDI department to satisfy such documentation needs.

However you handle queries, make sure your CDI policies and procedures are clear. Define what will be kept and for how long. Also, describe how you will connect queries to medical records in the event Recovery Audit Contractors (RAC) seek additional clarification.

Related resources:

On the ACDIS Web site

Thu, 15 Oct 2009 20:45:00 GMT

Editor’s note: The following items have been updated on the ACDIS Web site, www.cdiassociation.com.

On the ACDIS Blog

Thu, 15 Oct 2009 20:36:00 GMT

On the ACDIS Blog

Thu, 01 Oct 2009 20:04:00 GMT

On the ACDIS Web site

Thu, 01 Oct 2009 20:02:00 GMT

Editor’s note: The following items have been updated on the ACDIS Web site, www.cdiassociation.com.