weathering the storm - acdis journal... · weathering the storm ... outpatient query position paper...
TRANSCRIPT
JAN/FEB 2017 Vol. 12 No. 1
an Association of Clinical Documentation Improvement Specialists publication www.acdis.org
MAR/APR 2018 Vol. 12 No. 2
an Association of Clinical Documentation Improvement Specialists publication www.acdis.org
WEATHERING THE STORM OF COMMON CDI PITFALLS
2 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
CONTENTS
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CDI Journal (ISSN: 1098-0571) is published bimonthly by HCPro, 35 Village Road, Suite 200, Middleton, MA 01949. Subscription rate: $165/year for membership to the Association of Clinical Documentation Improvement Specialists. • Copyright © 2018 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.acdis.org. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of CDI Journal. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.
MAR/APR 2018 Vol. 12 No. 2
FEATURES7 The creepy-crawlies: Avoiding CDI scope creep
CDI professionals discuss the problems and dangers of CDI scope creep and offer suggestions to halt the slide into other areas.
11 The buck stops here: CDI escalation policiesWhat’s a CDI specialist to do when queries go unanswered? Learn how an escalation policy can advance your CDI program and boost your response rates.
16 Tips from the frontlines for physician engagement
Physician engagement will always be a top complaint for CDI professionals. In this article, we pull together the best tips from ACDIS members through the years to ease the pain.
DEPARTMENTS3 Associate Director’s Note
Melissa Varnavas discusses ACDIS members’ top concerns and how to weather the storm this year.
5 Note from the ACDIS Advisory BoardLaurie Prescott talks about the difference between CDI’s work and coding and why they’re distinct.
10 Radio RecapAutumn Reiter joined ACDIS Director Brian Murphy to discuss DRG validation and how CDI and coding can work together.
19 In the NewsThe ACDIS Advisory Board discussed the outpatient query position paper during the quarterly conference call. The 2017 Salary Survey benchmarks industry standards nationwide.
22 Physician Advisor’s CornerTrey La Charité examines the current state of denials and auditing and the need to readdress the healthcare reimbursement landscape.
28 Meet-a-MemberJose M. Gonzalez O’Neill is the vice president of the Florida ACDIS chapter and HIM service line manager for medical transcription and inpatient coding at a large hospital system in the Orlando area.
OPINIONS & INSIGHTS14 Communication problems? Follow the script!
Learn how Charrington “Charlie” Morell helps her CDI team communicate effectively with troublesome physicians.
24 Case Study: A new role for CDI: Appeals and analysis
With the current denials and audit landscape what it is, Baptist Health added a new position to their CDI team specifically designed to tackle appeal letters and data reporting.
CONTINUING EDUCATION CREDITSBONUS: Obtain one (1) CEU for reading this Journal
ACDIS members are entitled to one Certified Clinical Documentation Specialist (CCDS) continuing education credit for reading the CDI Journal and taking the 20-question quiz. Visit the March/April Journal page on the ACDIS website to take the quiz.
ASSOCIATE DIRECTOR’S NOTE
EDITORIAL
Director Brian [email protected]
Associate Director, Membership and Product DevelopmentRebecca [email protected]
Associate Editorial Director Melissa [email protected]
Membership Services Specialist Penny Richards, CCDS [email protected]
EditorLinnea Archibald [email protected]
Associate Director for Education Laurie L. Prescott, MSN, RN, CCDS, CDIP [email protected]
Director of Sales and SponsorshipsCarrie Dry [email protected]
CopyeditorAdam [email protected]
DESIGN
Design Services DirectorVincent [email protected]
Graphic DesignerTyson [email protected]
3 CDI Journal | MAR/APR 2018 © 2017 HCPro, a division of BLR.®
Weather CDI storms with peer advice: Save yourself from unexpected pitfallsBy Melissa Varnavas
There’s a photo of my mom and dad from the winter of 2015, snow piles towering over them on either side. That year the Boston area received bliz-zard after blizzard. We still call it (with a nod to J.K. Rowling) the winter-that-shall-not-be-named.
This winter hasn’t been so bad. In Massachusetts, we’ve had stretches of temps below 10 degrees, but not the nine-plus feet of snow 2015 dumped on us.
The thing about New England winters, though, is that if you live here long enough, you get to know them. You build up a layer of tol-erance to them. You live through the winter-that-shall-not-be-named (second only to the 2005 winter of I-can’t-believe-we-lived-through-that) and you actually miss the Tetris-esque challenge of where to put the extra three feet of snow the forcast has coming your way.
I’m not going to say that ACDIS is a community of folks who share my affinity for shoveling. Neverthe-less, just like hearty northerners, CDI professionals don’t balk at that proverbial last-minute run for bread and milk or brandishing their
shovels to dig out a path one scoop at a time. They don their winter coats for each storm and muscle through, storing away the mem-ory of lessons learned from what the weather wrought. And the next winter, they step out to help their relatives, friends, and neighbors clear off their cars, carve steps in the snow banks, or add a little fuel stabilizer to the snow blower—sharing all the winter tricks they’ve learned from the season before.
Ahead of this edition of the CDI Journal, we asked Facebook fol-lowers for their top three CDI pro-gram pitfalls. Pitfalls, like storms, bring “hidden or not easily rec-ognized dangers or difficulties,” according to Webster. While each individual snowflake may be a uniquely shaped crystal, they can be categorized into eight distinc-tive groups (thanks Wikipedia). So, too, can these seemingly hidden CDI trouble spots be identified by sharing our collective expe-riences—and, just as we do with winter woes—we can surpass and surmount them.
Facebook responders Valerie Miller, Ginny Mastro, and Jen-nifer Johnson Garrison, among others, listed lack of physician
4 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
engagement, as their bane. For Patty Wells Harris, phy-sician engagement represented pitfall number one, two, and three. She wrote: “The one or two physicians that just don’t get it. Writing the same queries for them. Phy-sicians who just want to sit in my office and chat because I have a candy dish.”
On p. 14, Charrington “Charlie” Morell shares a tip sheet she created for her staff. It includes a script of common physician questions—featuring all–stars like “Why do I have to answer this query?” and “You’re only asking me this to make the patient look sicker and make money for the hospital!”—and not only provides sample responses, but also has links to documentation that CDI specialists can use to direct physicians to source mate-rials that support their efforts. On p. 16, we take a trip through issues of CDI Journals past to cull a collection of physician engagement tips that we hope will shed some light on this ongoing problem.
Mary Alice Dewees, Kimberly Leriger Crowhurst, and Christine Schattenfield, all named mission or scope creep in their list of top concerns. “With all the quality measures related to documentation/coding we are being asked to do more and more,” wrote Ellen Jantzer.
On p. 7, Wendy Clesi explains that CDI managers need to regularly assess new review targets within the con-text of the program’s mission and goals. She also sug-gests that some measure of transparency between man-agement and CDI staff can alleviate the discomfort of changing priorities. Similarly, sharing specific data points regarding how the program plans to assess its success with any expanded measures gives the team concrete targets they can work to achieve and a touchpoint by which they can understand how their role affects the organization’s larger goals.
Glenda Reckner Stayrook included lack of escalation policy in her top three pitfalls. “Lack of communication,” listed Cheryl Ann. Tina Drake cited querying physicians but having no concrete consequences if those physi-cians didn’t respond. So, on p. 11, we talk with Karen Frosch, Jeff Morris, Bonnie Epps, and Lee Ann Landon about creating an escalation policy and how those poli-cies help ensure efficient communication pathways.
For sure, this isn’t an exhaustive list of problems CDI programs face—particularly in this time of chang-ing focus and limited budgets. There will be always be other storms to weather, other pitfalls to avoid. For now, though, button up and grab a shovel. We can clear a path together.
ADVISORY BOARD
Sam Antonios, MD, FACP, FHM, CCDSChief Medical Officer, Medical Director Information SystemsVia Christi HealthWichita, KansasSamer.Antonios@ via-christi.org
Angie Curry, RN, BSN, CCDSCDI DirectorConifer HealthFrisco, Texas [email protected]
Paul Evans, RHIA, CCDS, CCS, CCS-PClinical Documentation Integrity LeaderSutter West Bay [email protected]
James P. Fee, MD, CCS, CCDSVice [email protected]
Katy Good, RN, BSN, CCS, CCDS CDI Training Materials Specialist Enjoin [email protected]
Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM-RN Director, Clinical Documentation ExcellenceWake Forest Baptist Health [email protected]
Robin Jones, RN, BSN, CCDS, MHA/Ed System Director CDI, West Florida Division Adventist Health Care Tampa, Florida [email protected]
Karen Newhouser, RN, BSN, CCDS, CCS, CCM Director of CDI Education MedPartners Tampa, Florida [email protected]
Laurie Prescott, RN, CCDS, CDIP, CRC CDI Education Director HCPro/ACDIS Middleton, Massachusetts [email protected]
Judy Schade, RN, MSN, CCM, CCDSCDI SpecialistMayo Clinic Hospital Mosinee, [email protected]
Susan Schmitz, JD, RN, CCS, CCDS, CDIP Regional CDI director Southern California Kaiser Permanente Pasadena, California [email protected]
Deanne Wilk, BSN, RN, CCDS, CCS Manager of CDI Penn State Health Hershey, Pennsylvania [email protected]
Anny Pang Yuen, RHIA, CCS, CCDS, CDIP Principal AP Consulting Associates LLC [email protected]
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 5
NOTE FROM THE ADVISORY BOARD
Blurred lines between coding and CDIBy Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC
One pitfall many CDI professionals face is one I faced myself in my early years. As a young CDI professional, I stressed to everyone, “I am not a coder.”
I still say that to people who ask me very specific questions related to code assignment and guide-lines—when it comes to assigning codes, I defer to the experts. That said, when I started in CDI, I made the critical error of thinking that, since I was not a coder, I did not need to learn the ways of coders.
I learned many of the guidelines by osmosis, thanks to a very patient coder friend who answered my questions and guided me by quoting the Offi-cial Guidelines for Coding and Reporting and offer-ing direction.
Nobody ever told me to actually read the guide-lines for myself. Nobody ever taught me how to use the Alphabetic Index and the Tabular List. I was given access to the encoder and told, “This is all you need.”
Because of this, I developed the not-so-rare con-dition of “encoder dependency.”
My lack of exposure to the mechanics of code assignment made an already steep learning curve even harder. I was often told, “It needs to be sequenced this way,” or “You must assign this code,” with no further explanation.
I blindly followed such instructions, but because they sometimes appeared inconsistent or illogical, I did not internalize the information or learn from what others were telling me. Instead, I continued to make the same errors and ask the same questions time after time.
As we prepped for the transition to ICD-10, I had to learn to use the code books. There was no encoder. I started reading the Official Guidelines, and my coder friends held my hand as I began to use the Alphabetic Index and Tabular List to find the appropriate codes. They laughed a bit when I marveled about how the “new” little notes in the code book were so helpful in understanding the why and how of code assignment.
I remember one of my coder friends shaking her head and saying, “Laurie, these notes were in ICD-9-CM as well; you just didn’t bother to look for them.”
She was right; I had not bothered to look. I used the encoder, and that was enough for me to get by (or so I thought). I wonder how many opportunities I missed because I didn’t adequately understand the demands of the code set and the required documentation.
Now, with hindsight, when teaching new CDI specialists, I tell them to read the Guidelines and learn how to use a code book. If you are “encoder dependent,” rid yourself of that habit. I know I would have grown my skills and effectiveness quicker had I began my CDI career with these basics.
Many of my students say they don’t want to be coders and don’t see code assignment proficiency
I developed the not-so-rare condition of “encoder dependency.” My lack of exposure to the mechanics of code assignment made an already steep learning curve even harder. Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC
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as a requirement for their job in CDI. They reflect my own early professional sentiments: “I am not a coder.”
It’s true that most CDI specialists (77% according to the most recent CDI Salary Survey) are not coders, and I agree that coding a record isn’t our specific focus. To complete our given mission, however, we must under-stand the process and the guidance related to code assignment. The focus of provider education is to assist in translating “coder speak” to “medical speak” and vice versa.
The problem with concurrent coding
Of course, some people hold the direct opposite view. I recently visited a facility where CDI specialists were expected to concurrently code a record completely. The productivity of the CDI staff was being compared to national numbers related to CDI productivity, yet they were expected to assign codes for the principal diag-nosis and all secondary diagnoses, including external cause and procedure codes. They were evaluated on accuracy and speed.
As we moved through the boot camp materials and I spoke about queries, physician education, mortality reviews, etc., many of the students questioned when they would have time to perform these tasks. They were so busy coding the records that they had little room to actually do the work of a CDI professional.
They were, of course, concerned they were missing opportunities to improve the documentation, improve the severity of illness/risk of mortality, and ensure accurate reimbursement. Yet, to meet their productivity require-ments and, more importantly, ensure the accuracy of their code assignments, they couldn’t take the time to review a record to the extent a CDI professional should.
They aren’t alone, sad to say. I have seen this pattern in a number of organizations.
The border between CDI specialists and coders is a blurred one. We share functions and support each other; it’s how we successfully work together to improve doc-umentation. But, if one interprets the function of CDI to be concurrent coding, then don’t call it clinical docu-mentation improvement—call it concurrent coding. CDI specialists and coders bring different skills to the table, and we each have a different focus in our reviews.
The CDI professional should be reviewing records, with allotted time to review ancillary documentation, diagnostics, physician orders, medication administration records, EMT documentation, etc. We’re looking to bet-ter specify vague or missing diagnoses. Our goal should be to hand the coder a record that is ready to be coded, no clarifications needed.
If the goal you’ve set for your CDI staff is related to coding productivity and code assignment accuracy, my suggestion would be to implement a concurrent coding program for your coding staff. They could work side by side with the CDI specialists. Our missions complement each other, but they are not exactly the same.
So, if my long narrative here is confusing, let me rein-force: CDI specialists are not coders, even if they started their career path in a health information management/coding profession. Someone functioning in the role of a CDI specialist shouldn’t be expected to accurately and completely code a record. This expectation does not support the overall goal of CDI.
But don’t forget: Even though CDI specialists are not coders, they do need to learn the rules and guidelines that coders follow. They need to reference code book guidance and the Official Guidelines in their daily work so that, when they hand that record over to the coder for final coding, the documentation is clear, concise, and supportive of accurate code assignment true to the patient’s story.
Together we are strong. We each bring a different focus to the game, even if the lines are blurry.
Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts, and a member of the ACDIS Advi-sory Board. Contact her at [email protected]. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.
If one interprets the function of CDI to be concurrent coding, then don’t call it clinical documentation improvement, call it concurrent coding.Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 7
The creepy-crawlies: Avoiding CDI scope creep
Scope creep is “really the whole sentiment that since we’re already in the record, we can do more
and more,” says Lara Faustino, RN, BSN, CCDS, a CDI specialist at Boston Medical Center. “It hap-pened gradually for us.”
As CDI programs mature, they move away from the easy-to-reach documentation improvement targets and expand into new areas, Faustino says. Hospital administration begins to add duties—mortality reviews, denials management, DRG recon-ciliation, clinical validation, quality, medical necessity testing—looking to capitalize on CDI capabilities.
While advanced CDI programs have a lot to offer facilities in moving
beyond CC/MCC capture, program leaders need to be mindful of staff productivity, effectiveness, query efficacy, and burnout.
“I had my hands full already and I was being asked to do more and more, which I don’t mind, but I want to do a good job,” says Jennifer Garrison, RN, BSN, CCDS, a CDI specialist at Dupont Hospital in Fort Wayne, Indiana.
“In my experience, scope creep happens pretty innocuously,” says Fran Jurcak, MSN, RN, CCDS, vice president of clinical innovations at Iodine Software in Austin, Texas. “Since the CDI specialist is ‘already in the chart,’ it becomes easy to ask them to look for things outside the typical CDI issues.”
Mission focus
A few precautions can help CDI programs avoid scope creep and safeguard their program.
First, develop a mission statement. A concrete CDI mission statement enables programs to effectively communicate goals to stakeholders and measure success based on the targets expressed. When a program starts its life with a clear goal and mission in mind, it’s much easier to say no to additional duties that do not appropriately coincide with CDI expertise and yes to ones that align well, says Jurcak.
A mission statement “outline[s] the department’s present state and defines its purpose,” according to
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the ACDIS position paper “Devel-oping effective CDI leadership: A matter of effort and attitude.” The statement should be “a short para-graph that summarizes the mission of the group as aligned with that of the organization.”
It also needs to evolve with the program, the paper states. By reevaluating the departmental mis-sion statement on a regular basis (often annually), program managers and directors can ensure duties are aligned.
A mission statement is often addi-tionally tied to the program’s met-rics and staff expectations. Early assessments of CDI successes include measures such as num-ber of records reviewed, percent of query issues, physician response and agree rates, percent of coder agree rates, shift in case-mix index, etc. If, for instance, a program began with a purely financial focus through CC/MCC capture rates, the staff may be held to a higher productivity standard than staff in CDI programs that also review for severity of illness/risk of mortality or other concerns.
Mission transparency
When the mission and scope of CDI responsibilities shift, CDI pro-fessionals can feel like they’ve lost the ability to execute their jobs well, particularly when such shifts aren’t explained properly or put into context.
In such situations, it can be difficult to see how each record review or query meets both new targets and old requirements—in other words, whether individual CDI efforts are working, says Faustino. “We’re given some metrics like query rates and
agree rates, but not any big-picture data,” she says. “I don’t really know if we’re impacting anything else—what about observed to expected mortality? Denials?”
CDI professionals need to under-stand what sort of effect their efforts are having, says Christine Schatten-field, RN, BSN, CCDS, a CDI spe-cialist at the University of Kansas Medi-cal Center in Kansas City. “You have to be able to show your value, that you’re moving the needle,” she says.
Structured programs supported by written policies and procedures that are guided by goals and met-rics, which are then monitored and reported on a regular basis, tend to manage scope creep with ease, says Wendy Clesi, RN, CCDS, CDIP, executive director of CDI ser-vices at Enjoin CDI, based in Eads, Tennessee. “These programs often do not try to swallow the ocean in one drink. The demands of health-care on CDI requires a strategic vision and plan with incremental goals to be successful.”
Without a clear mission and mea-surable goals to account for shifting focus, the effect of the CDI program becomes increasingly difficult to measure, too.
“If time is spent on tasks outside of typical CDI record review then clearly the ability to impact accuracy and consistency of documentation is limited and the accuracy of the final codes could be compromised,” according to Jurcak.
Mission match
Not only can this scope creep affect individual CDI professional’s productivity and investment in daily activities, but it may result in larger
missteps for the entire program, according to Clesi. With increased responsibilities, the staff may not be adequately prepared to handle those tasks with aplomb, she says.
“Reviewing a chart for medical necessity requires different knowl-edge, the use of different tools, and a different mindset altogether versus looking at the chart from a coding and documentation perspective,” she says. “Yes, there is a significant amount of opportunities where CDI can be impactful […], however, a mix of responsibilities is often overbur-dening on the reviewer, giving merit to the adage of being a ‘jack of all trades, but a master of none.’”
CDI managers need to match expanded mission focus with the skill set of the program staff and provide additional resources in time, training, and new staff to align with goals as needed.
Like Jurcak, Clesi has seen this problem happen time and time again. Though scope creep isn’t always a terrible, program-ending problem, the issue “stems from the lack of understanding from exec-utive leadership that CDI requires dedicated resources with a defined skillset in order to be successful,” she says.
“It’s the primary reason programs fail,” Clesi says. “Something always takes priority and trumps addi-tional focus lowering impact and essentially diminishing the focus altogether.”
Not only can the purpose and outcomes get confused, but the lines between departmental
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responsibilities can become blurry, too, Schattenfield says. At her pro-gram, the department’s electronic CDI tool includes some coding elements as well. “We want to get the data in there,” she says “but that means we have to learn how to code. Are we coders or are we CDI?”
CDI professionals often assign a working MS-DRG, and do need to understand the basic rules of cod-ing. Concurrently coding a record, though, requires a higher level of coding proficiency and could reduce CDI productivity in terms of the num-ber of records staff can review in a day. It also requires instituting recon-ciliation policies to ensure clear lines of responsibility for final coding the record [which] should likely be insti-tuted with the coding department after the chart is officially coded, according to Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI Boot Camp instructor for ACDIS.
(To read Prescott’s take on CDI and concurrent coding, see p. 5.)
“We should really be the boots on the ground, educating the physicians, instead of just stuck in the charts all day,” Schattenfield says. “That’s how I’d really like to see CDI evolve.”
Creep prevention
“A mission statement with sup-porting policies and procedures that clearly delineate responsibilities and workflow processes would prevent scope creep,” Jurcak says. “When the role is clearly articulated in these documents, it limits the ability of the CDI staff to become involved in other functions.”
Just setting up a vague and mal-leable statement, however, will not do the trick, warns Clesi. “Every mis-sion statement should have a written policy in place defining the specific scope/focus and related activities of CDI based on organizational strate-gic goals and available resources.”
For example, a mission statement of simply, “to improve the quality of physician documentation” is so broad that the CDI team will have a hard time defining any practical course for the CDI program at all.
When developing a statement, careful consideration should be given to the organization’s needs and the abilities of the CDI staff.
“Self-awareness is priceless,” says Clesi. “It’s important to set reason-able goals based on program focus and available resources, then moni-tor performance.”
It’s also important to develop this statement as early in the CDI pro-gram’s life as possible, setting the program up for success from the start, says Faustino.
Outside of a formal mission state-ment, CDI programs wary of scope creep would also do well to prepare in advance of new duties being added, says Jurcak. Part of that prepara-tion comes from reviewing any sort of mission statement your program might have on a regular basis.
“Few people regularly update [their policies] on an annual basis even though program leaders recognize it should occur annually,” she says.
When it does come time for the CDI program to branch out into other
areas—whether that be quality, mor-tality reviews, or other areas—review the policies and procedures to ensure reasonable expectations are set for the individual CDI specialists and the program as a whole.
For example, consider if, when a new task was added to CDI spe-cialist’s workload, were the produc-tivity expectations evaluated in light of that? Look at productivity shifts before and after the additional tasks are assigned and bring that concrete data back to both the team and the administration for review.
“Scope creep that is planned for and adequately staffed for can result in improved outcomes as the CDI specialist could continue record review and the querying process while supporting other activities,” says Jurcak.
Overall, whether it be through a concrete mission statement, reeval-uation of CDI expectations and pol-icies, or through increased staffing and resources, programs that plan for greater responsibilities will do better in the long run. After all, when the organization recognizes the value of the CDI program, they likely will want to take that positive effect to other areas as well. It’s a natural progression.
“Many people become uncomfort-able as soon as the words ‘scope creep’ are mentioned,” says Clesi. “Does this mean more responsibil-ity, more work, for the existing team? Not necessarily.
Scope creep related to CDI may simply be a new opportunity.”
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RADIO RECAP
DRG validation: CDI and coding collaboration “DRG validation can mean many
things in many different arenas,” Autumn Reiter, RN, BSN, CCDS, CDIP, CCS, director of CDI staff-ing services at TrustHCS, said on the January 3 episode of ACDIS Radio, “New approaches in DRG validation.” “Essentially, it’s ensur-ing a correct final code for that encounter. After everything is said and done, that DRG represents that patient encounter, the treatment they received, and basically paints the picture for that patient.”
At its core, DRG validation means developing a process to dou-ble-check that the DRG assigned is the most appropriate for the encounter and, where opinions dif-fer, creating a process for collabo-ratively assessing the coding and documentation details to come to a final determination.
While some in CDI may per-ceive DRG validation as a coding department issue, as the coders are responsible for the final DRG assigned to each case and the val-idation is typically handled via an internal coding auditing process,
Reiter advocates for a collabo-rative approach between CDI and coding. “I always like to say that two sets of eyes are better than one,” she said.
For CDI programs not currently involved in the DRG validation pro-cess, Reiter suggests starting with a solid audit identifying the areas of concern based on denials volume, EHR software reports, or publicly reported data, and then delving into concerns related with that particular DRG reported.
“Maybe there’s a higher than nor-mal volume of a certain DRG, maybe we’re taking a look at our PEPPER [Program for Evaluating Payment Patterns Electronic Report] findings and there are some outliers the facil-ity is falling into,” she said. (To read a full article about using your PEP-PER to shape CDI efforts, see the November/December 2017 edition of the CDI Journal.)
However, using publically reported data can be a slippery business. “Every hospital has a very specific patient population it serves,” Reiter said. “You may need to work on your documentation, but [data] may also be patient driven. Maybe your pop-ulation just doesn’t support those additional CCs and MCCs. So, be careful with comparing.”
In order to make a difference in the DRG validation process, CDI and coding need to work rather closely. Since DRG validation has traditionally been a coding function, Reiter sug-gests developing a process to foster
a team environment to ensure the documentation and coding are both accurate for that particular patient during that particular hospital stay.
Reiter also notes that success-ful DRG reconciliation processes include joint CDI and coding educa-tion, warding off any negative feel-ings between the two groups and avoiding turf wars.
“I think it’s a good idea to promote CDI and coding education together. Maybe you have a monthly meet-ing where CDI and coding leader-ship come together and say, ‘what are the issues you’re seeing?’” she said. “Another good way to make bonds and join the team is to have CDI-coding buddies. […] It gives them the opportunity to learn from each other.”
Once the coding and CDI teams are on the same page, they then can work together to fix any issues uncovered by the DRG validation process, Reiter said.
“None of us can be siloed any-more. For us to be effective and get the best outcome for the patient and for the facility we’re working for, we need to function as a team.”
Editor’s note: To listen to the episode from January 3, click here. To learn how to regis-ter for ACDIS Radio for free, click here.
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 11
The buck stops here: CDI escalation policies
What’s a CDI specialist to do when queries go answered? What if a physician has
a backlog of unanswered queries from three weeks prior? Or what if a physician patently refuses to answer queries and says “I don’t have time” or “it’s all about the money”?
For many CDI programs, an esca-lation policy can help answer these questions. Such policies typically outline the length of time a query is allowed to go unanswered, who should follow up with a physician on unanswered queries, and any penal-ties for physicians who don’t answer their queries.
“Without a policy, you lose that validation of why CDI is important,” says Karen Frosch, CCS, CCDS, manager of CDI at Christiana Care Health Systems in Newark, Dela-ware. “If there’s no one behind you saying why queries are important, why should they respond to them?”
Perhaps you’ve heard this from physicians before—the idea that answering queries is a waste of their valuable time that could be spent on patient care. But, CDI professionals know that proper documentation is, in fact, a vital piece of patient care. And, if the proper documen-tation isn’t present in the record, a query is needed and warranted. (To see some example language
for discussing this issue with physi-cians, turn to the related article on p. 14.)
While physician education will win at least some physicians over (read the related article on physician engagement tips on p. 16), an esca-lation policy, as Frosch says, gives the need for responses a weight that it otherwise wouldn’t have.
“You can really tell with the response rates whether we had the physician champion involved. Someone higher up requesting it gives the queries more importance,” she says.
Of course, forming an escalation policy requires many things from the CDI department and takes some
12 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
work to put into place. To help those looking for answers, ACDIS spoke to some CDI professionals about their various escalation policies and picked their brains on the best way to institute a policy for the first time.
Getting startedEscalation policies come in dif-
ferent formats with varying degrees of formality. Some programs use a formal chain-of-command process, while others leverage department heads or the chief medical officer. Ultimately, the process depends on your facility’s needs and style.
“You definitely have to do your research and get your key players involved. That’s what we’re doing now,” says Jeff Morris, RN, BSN, CCDS, CDI supervisor at the Uni-versity of Southern Alabama Health System in Mobile. “We want to get everybody to agree on one thing. Historically, we’ve included lots of people on decisions, and I think we’ll continue doing that.”
Doing so brings differing perspec-tives to the table, but it also helps ensure everyone knows their role and takes ownership of the new pol-icy. Unfortunately, sometimes bring-ing everyone to the table also means some initial discomfort, says Morris.
When the University of South-ern Alabama Health System imple-mented an EHR system recently, its query response rate dropped because the physicians no lon-ger knew where to find the queries and they didn’t see the CDI team as much on the floors. However, he says, this drop in response rate
made the CDI team realize the need for an escalation policy.
“It’s sort of a good thing that is crazy and chaotic right now, though,” says Morris. “We can use that to say we need to formalize pro-cedures and processes so everyone knows what to expect.”
But for many, gaining the leader-ship support to fully institute the new policy can seem daunting in and of itself. Bonnie Epps, MSN, RN, director of CDI at Emory Healthcare in Atlanta, suggests starting with your CDI friends and then leverag-ing those relationships to gain more support.
And sometimes, CDI teams—whether they have a codified escala-tion policy or not—need to look out-
side their traditional avenues to find a champion with an in amongst the physicians, she says.
“Figure out who you could get support from and who has the phy-sicians’ respect,” she says. “Maybe it’s the director of HIM, or finance, or maybe it’s the champion for coordi-nated care.”
As Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI educa-tion director at HCPro in Middleton,
Massachusetts, said in a recent arti-cle for CDI Strategies, the person to break through to the physicians need not exclusively be another phy-sician—it can be anyone who has gained their respect.
“We need to shatter the myth that only a doctor can teach a doc-tor,” she says. “Teach those physi-cians assertively, competently, and confidently.”
The same advice goes for an escalation policy: While you need someone with the respect of the physicians to escalate issues to, don’t limit your options to the phy-sician staff.
As Epps says, look for your allies anywhere you can, even if you find them in unexpected places. Do what works best for your facility and your CDI program.
Escalating unanswered queries
How long can a query go unan-swered before triggering the esca-lation policy? The exact number will likely involve some discussion with your physicians, says Lee Anne Landon, BSN, CCDS, the network manager of CDI for HonorHealth of Phoenix and Scottsdale, Arizona.
“We give 48 hours before we con-tact [a physician] about a query,” Landon says. “The physicians felt that that 48 hours gave them time to do more of a work up on the case and gather the necessary informa-tion to answer the query.” (To see Landon’s full escalation policy, visit the ACDIS Resource Library.)
While 48 hours may work well for some facilities, others may find it a
Figure out who you could get support from and who has the physicians’ respect. Maybe it’s the director of HIM, or finance, or maybe it’s the champion for coordinated care.Bonnie Epps, MSN, RN
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 13
bit too short. That’s what happened at Christiana Care Health Systems, according to Frosch. “We decided to use 72 hours. We wanted to give the providers enough time before we followed up,” she says. “We do tell them we’d like them to answer within 48 hours ideally, though.”
The initial waiting time period also ensures that the CDI specialists have made a concerted effort to contact the physician before esca-lating the matter up the chain, says Landon.
“Our CMOs wanted to make sure we had made efforts to contact the doctor before coming to them,” she says.
Contacting wayward physicians
The format for reaching out to non-compliant physicians may also vary. Emory Healthcare started with a let-ter from the hospital CEO to depart-ment leaders as an initial push to improve response rates before the organization had even instituted an escalation policy proper.
“In that letter, we put how many queries we had sent, what their response rate was, what the target was, and instructions to contact me with questions,” says Epps. “And I did get calls, and that was just fab-ulous. It took us about a year to get up to the target, but then we exceeded it.”
After that initial push, Emory insti-tuted a full-blown escalation policy to maintain the high query response rates.
“The CDI specialist has to try to reach the physician three times, and
then they send it to me,” she says. From there, Epps can follow-up with the physician or with the head of the department to see that the query receives an answer.
Christiana Care Health Systems lets physicians know how many outstanding queries they have on a weekly basis, Frosch says. This way, the CDI team can track which phy-sicians are repeat offenders when it comes to unanswered queries.
“Our HIM department sends out a physician notification on Wednes-day with how many are 72 hours old, 72 to 30 days old, or anything that’s
over 30 days old,” she says. “Our CDI department calls the physicians on anything that’s at the 72-hour mark. Anything over that gets sent to the champion.”
An escalation policy represents a cornerstone of CDI programmat-ics, Morris says. “Not only does not getting answers [to queries] hold up coding and the revenue, but it also holds up the quality side of things,” he says.
Having such policies in place, Frosch says, backs up the CDI process and lets physicians know its value for the hospital and for themselves.
“You’re really losing a lot by not having one.”
If there’s no one behind you saying why queries are important, why should [providers] respond to them?Karen Frosch, CCS, CCDS
SAMPLE QUERY ESCALATION POLICY
1. If the query is unanswered on the electronic query form, in the prog-ress note, or in discharge summary after 48 business hours since its posting, the CDI specialist will send a notification to the appropriate phy-sician through either the CDI review section of the EHR messaging sys-tem, and/or through the preferred method for the facility.
2. If the query is not answered after the notification has been sent, the CDI specialist will continue attempt-ing to follow up with the physician via phone calls, secure texting sys-tems, or face-to-face contact. All attempts to contact the physician, including date and type of contact, will be documented in the current CDI data system.
3. If after several attempts the query remains unanswered, the CDI spe-cialist will forward the case to the CDI manager who will determine if the case needs to be escalated to the facility’s chief medical officer (CMO).
4. If the query is not answered at the time of discharge, the CDI special-ist will review the medical record, including the discharge summary to determine if the query has been answered and/or if there is a con-tinued need for the clarification. If there is a continued need for the query, the CDI will follow the steps outlined above.
5. When a pattern of a physician doc-umenting unsupported diagnoses exists, the CDI specialist will forward that information to the CDI manager for review after issuing clinical val-idation queries. The CDI manager will determine if the physician’s cases need to be forwarded to the CMO or physician advisor for evalu-ation and appropriate follow up.
Editor’s note: This sample query escalation policy was donated to the ACDIS Resource Library by Lee Ann Landon, BSN, CCMC, CCDS, the network manager of CDI for Hon-orHealth of Phoenix and Scottsdale, Arizona.
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HELPFUL HINTS
Communication problems? Follow the script!
Every CDI program needs to respond to certain common physician criticisms and questions: everything from
physician complaints about their lack of time to answer queries, to the accusation that CDI is only about the money.
Veteran CDI professionals often develop rote responses to these types of interactions—anecdotes coupled with knowledge, data, and skills—that help resolve on-the-spot conflicts and provide physicians with the information needed to better understand CDI program goals.
“I drank the Kool-Aid a long time ago, so I eat, drink, and sleep CDI,” says Charrington “Charlie” Morell, RN, CCDS, director of CDI at HCA West Florida Division Office in Tampa, Florida. But some staff members “get tongue tied when a physician starts questioning them,” she says. “Our providers sometimes seem to think that we’re just making this stuff up and that we’re just doing these queries to irritate them.”
So Morell, charged with educat-ing and supporting her staff across the facilities, created a tip-sheet of sorts that scripts common discus-sion points with concrete, succinct answers including a sentence or two related to each of the most common physician push-back sentiments.
“These were really the most com-mon questions and problems my CDI teams were calling me about,” says Morell. “Sometimes they would have a situation and it wouldn’t go as well as planned and they would say ‘what would Charlie say?’ So, this was my answer.”
The entire team has access to the tool on the organization’s Share-Point server (along with many other resources), but Morell works with newer staff, too, leveraging the script to help them anticipate the physicians’ complaints and come prepared with easy-to-understand answers that help them explain why queries were issued and why each query requires a timely, meaningful response.
“It’s really helpful for new or inse-cure CDI specialists who aren’t comfortable with the providers, as a document for role-playing. It gives them consistency and some confi-dence,” she says.
To go along with the scripting document, Morell has developed resources that include links to the applicable Official Guidelines for Coding and Reporting, the CMS inpatient prospective payment system final rule, and a document titled “Responsibilities of the Attend-ing Provider,” which cites the 2004 International Federation of Health Records Organizations Congress and the AHIMA Convention Pro-ceedings (October 2004) outlining the official duties of the attending physician when it comes to doc-umentation. When a CDI team member is having trouble with a physician or a group of physicians who ask why they in particular are receiving a query, the CDI specialist can easily provide these resources, including the links, so the physicians
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understand that queries are an industrywide standard practice.
“The CDI specialists need the website links so they have some-thing to back up what they’re say-ing,” Morell says. “That way, when they use one of the stock answers provided in the scripting document, they can immediately provide the supportive materials to avoid further pushback.”
The script also helps keep Morell’s staff aligned in their dialogues with physicians, ensuring that physicians receive the same important informa-tion regardless of her staff’s experi-ence level or physical location within the hospital system. It establishes a consistency of message that unifies the CDI team and the medical staff they serve.
“It helps us make sure all the infor-mation relayed to the physicians is the same systemwide,” she says. “The physicians really play up the differences if they can find them.”
Responding to inquiries and phy-sician skepticism isn’t easy, regard-less of skill level, but Morell hopes her scripting tip sheet helps.
Dealing with difficult physicians is never easy, but Morell speaks from experience and builds her team’s confidence in ways she knows will work.
“It’s been a big advantage having been a staff CDI specialist myself. I’m not asking them to do anything I couldn’t do myself,” she says. “What I’m really trying to do is help them be the local subject matter experts.”
SCRIPTING FOR CDI PROFESSIONALS
Charrington “Charlie” Morrell, RN, CCDS, director of CDI at HCA West Florida Division Office in Tampa, Florida, developed several scripted scenarios to help her CDI team members gain confi-dence and approach physicians with a solid knowledge base.
Here are a few of her role playing exercises.
Scenario 1:
Physician: “You’re only issuing queries to make the patient look sicker and make money for the hospital.”
CDI specialist: “Our goal is a complete and accurate medical record that withstands scrutiny. Many times, the queries we issue don’t make the patient look sicker at all and in fact, end up in removal of diagnoses that aren’t clinically supported. As an example of this might be when an ED physician documents pneumonia but there is no other physician documentation that confirms or negates it. According to the coding rules, the diagnosis would be coded. If the CDI specialist reviewing the record didn’t find clinical support such as vital signs, chest x-rays, labs, or IV antibiotics, we would query you (the attending) to ask if pneumonia was ruled in or ruled out, unable to clinically determine, or other more appropriate diagnosis.”
Scenario 2:
Physician: “I don’t understand what the query is asking.”
CDI specialist: “Here’s my business card. I’m available to assist you with queries even if I’m not the one who authored the query in the first place. I can explain what documentation triggered the query, what information is needed, and how to avoid queries in the future. A query is simply asking you for more information. On the form, the query will cite clinical indicators from the medical record that may help you provide more detail and offer clinical support for the diagnosis in question. We hope you see the CDI team as a physician resource, so you contact us anytime you need assistance even if it has nothing to do with queries. We’ll make sure to have the proper person contact you to address your concerns.”
Scenario 3:
Physician: “Why is the query addressed to me?”
CDI specialist: “The query can be addressed to a consultant on the case if the subject is in his or her specialization, to the author of the documentation, or to the attending physician. In the case of conflicting information, the attending physician is captain of the ship and therefore receives the query so he or she can weigh in. The attending physician is responsible for reviewing all consultant notes, labs, and tests, and that is why he or she is the one to receive queries for conflicting information.”
Scenario 4:
Physician: “I don’t know why I received the query. The answer is in my note.”
CDI specialist: “The query was issued because there was missing or incomplete information in the note. Code assignment is based on physician documentation and if it’s unclear or incomplete, a query is required. CMS and other payers require specificity with diagnoses whenever possible. This specificity helps reflect the appropriateness of acute inpatient hospitalization and length of stay.”
Scenario 5:
Physician: “I’m not going to answer the query.”
CDI specialist: “Respectfully, I understand you’re busy, but our query follow-up process requires me to remind you that you have an unanswered query and more information is needed. If physicians don’t answer queries, medical records can be very inaccurate. Did you know one facility had a record that said that the patient received a carotid stent at Wal-Mart? Really! Apparently, the physician dictated the report and the computerized transcription program picked up Wal-Mart. Physicians are supposed to read their notes before they sign, but sometimes that doesn’t happen. Luckily, the CDI specialist brought it to the attention of the physician who was able to correct the medical record. The patient had received a carotid stent in Vermont. So, as you can see, CDI specialists want to help ensure a complete and accurate medical record.”
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Tips from the front lines for physician engagement
Everyone working in CDI knows that the job would be much easier without physi-cian pushback—but that’s
an unrealistic pipe dream, it seems. Year after year, ACDIS’ surveys turn up the same results: The number one challenge for CDI programs is always physician engagement.
While 22.84% of respondents to the 2017 Physician Queries Bench-marking Survey said they reached a 96%–98% query response rate, 11.62% said their response rate was 80% or less.
Though this was significantly bet-ter than the 2013 survey’s results, the annual ACDIS membership sur-vey continues to show physician
engagement as the biggest chal-lenge for CDI professionals.
Even if a program has stellar suc-cess when it comes to this area, one or two problem physicians can still rear their heads from time to time.
While no one can fully escape the issue of physician engagement, CDI professionals have become adept at developing creative ways to reach physicians and educate them on the CDI process. Over the years, ACDIS has spoken to many CDI profession-als about this topic.
So, in order to help you stand on the proverbial shoulders of giants, ACDIS has searched through the archives and compiled some of the
best physician engagement tips from our members.
Tactic 1: Start ‘em young
If you’re part of a CDI team at a teaching facility, you are uniquely positioned to change the course of physician documentation. Accord-ing to a survey conducted by Lisa Dias, MD, and P. Roger DeVersa, MD, MBA, FHM, CPE, CDIP, CHDA, CCS, 40% of the medical students responding said they had never heard the team “CDI.” (To read all of Dias’ and DeVersa’s findings, see the article in the July/August 2017 edition of CDI Journal.)
If physicians in training don’t know what CDI is and how documenta-tion affects their quality scores,
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 17
reimbursement, and patient care, they’re far less likely to be receptive to the CDI process when they’ve graduated from their training.
“The residents are the ones doing the actual documentation, so we spend a lot of time communicating with them,” says Tamara Hicks, RN, BSN, MHA, CCS, CCDS, ACM, director of clinical documen-tation excellence at Wake Forest Baptist Health in Winston-Salem, North Carolina,
Whether or not this means the CDI team directly queries residents, CDI education geared toward this popu-lation has a greater reach than you might think, says Joseph A. Cris-tiano, MD, an assistant professor of internal medicine at Wake Forest Baptist Health.
As the residents rotate between service lines, they bring that aware-ness of CDI with them and “teach the attendings what we’re teaching them,” he says. This turns the resi-dents into unofficial CDI champions from a young age.
Of course, CDI teams need to work with hospital leadership to determine the best times and places to reach residents without interrupt-ing their schedules.
“Before we did anything, we asked [the director of each department] if we could talk directly to the resi-dents,” says Karen Carr, MS, RN, CCDS, CDIP, the CDI supervisor at Grand Strand Medical Center in Myrtle Beach, North Carolina. This also helps ingratiate the CDI team in the hearts of the department heads.
Tactic 2: Talk data to me
Gone are the days of people bas-ing their choice of physician solely on the recommendation of a friend or relative. While that recommenda-tion may still come into play in the decision-making process, people also now have access to publically reported data on each physician.
Because of the availability of qual-ity data to prospective patients, it’s much easier for CDI professionals to show physicians that “they have a
dog in the fight now,” says Cheryl Ericson, MS, RN, CCDS, CDIP, manager of CDI at DHG Healthcare.
While one patient opting to go to a physician down the street won’t hurt your facility or the individual physi-cian, hundreds doing so certainly will.
Physicians often say they care for extremely ill patients, but their documentation for these patients is sometimes lackluster. CDI staff can leverage the publically reported data and show physicians the effects of their poor documentation habits, says Sherri Clark, BSN, RN-BC, CCDS, CCS, clinical documentation
nurse specialist at University of Ten-nessee Medical Center in Knoxville. “If it’s not written down, it appears that you didn’t do it,” she says.
“Physicians will be engaged if they understand how documentation and coding impacts their personal profile,” says Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at Mayo Clinic Hospital in Phoenix. “Physicians are by nature compet-itive, and so they aim to be high achievers.”
As your metrics improve with phy-sician education, CDI professionals can also use those improving data points to congratulate the physicians and thank them for their help, says Michelle McCormack, RN, BSN, CCDS, CRCR, director of CDI at Stanford (California) Health Care.
“You want to select metrics that will allow you to see progress as well as areas of opportunity,” McCor-mack says.
Tactic 3: Call for backup
Though it’s likely a myth that physi-cians only listen to other physicians, certain situations warrant calling for reinforcements. CDI professionals should be ready to look for help from a variety of other departments when the going gets tough, even if that help comes from unconventional places.
“Really, it’s about bringing every-one in on the team. It’s a big group effort,” says Tressi Wicker, BSN, CDS, CDI specialist at SRMC in Lima, Ohio.
While engaging a physician advi-sor may be beyond the reach of
Physicians will be engaged if they understand how documentation and coding impacts their personal profile. Physicians are by nature competitive, so they aim to be high achievers.– Judy Schade, RN, MSN, CCM, CCDS
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some CDI programs, there’s likely at least one or two physicians at the facility who could be unofficial program champions. These indi-viduals can carry the CDI gospel forward and help explain to the other physicians what’s required of them.
“A physician advisor is typically someone who holds a formal posi-tion for which he/she has inter-viewed and receives compensa-tion. On the other hand, a physi-cian champion can be a provider who understands and supports the mission of CDI, serves as an informal resource for the CDI staff, and promotes the efforts of the CDI staff among their colleagues,” Ericson explains in a Q&A on the topic.
Enlisting those in authority at your facility—such as the chief medical officer—can also help. If the CDI team can win over the physician leaders, that support will trickle down to the rest of the medical staff and provide a larger sphere of influence than a single champion might.
(To read more about how hos-pital leadership can assist in CDI escalation policies, read the article starting on p. 11.)
“Physician investment in CDI at the highest levels encourages the involvement of the entire medical staff in day-to-day documentation improvement activities,” writes Laurie L. Prescott, MSN, RN, CCDS, CDIP, CDI education director at HCPro in Middleton, Massachusetts, in the Clinical
Documentation Improvement Specialist’s Complete Training Guide.
Tactic 4: Get creative
CDI professionals need to think outside the box too. If there’s one thing that CDI professionals are adept at, though, it’s creativity.
Everyone’s heard the oft-quoted phrase, “the way to a man’s heart is through his stomach.” Well, the same is often true for physicians. “If you corner physicians and feed them, then you’ll have them,” says Janet M. Gentle, RN, BSN, MSN, CDI specialist at North-ern Michigan Regional hospital in Petoskey. (Please note that Gentle has since retired.)
In 2017, the CDI Week Planning Committee suggested that CDI specialists print stickers with doc-umentation tips on them and place them on fun-sized candy bars to hand out to the physicians. This way, the physicians associate that tip with a kind act from the CDI team.
“Everyone needs a little pick-me-up from time to time,” says Valerie Bica, RN, CPN, CDI specialist at Nemours/A.I. DuPont Hospital for Children in Wilmington, Delaware. “Just a spoonful of sugar helps the education go down.”
Bica also tapes documentation tips to the computer she brings with her on rounds, calling it her “mobile bulletin board.” While these
tips aren’t directly divvied out to individual physicians, they’re visi-ble for all to see. While she rounds (and hands out candy), she can refer to the “bulletin board” during conversations with providers.
Physicians should also be able to recognize the CDI specialists and see them as a resource, says Carr. In order to make themselves more identifiable, Carr and her team have added a visual hint for physi-cians: Purple scrubs.
“We wear purple scrubs because it matched the original paper que-ries,” she says. Now, purple is so synonymous with the CDI team at Grand Strand Medical Center that one of the physicians calls them the “purple paper people.”
Outside of chocolate and visual cues, sometimes a simple “thank you” to the physicians goes a long way. Whether it be a hand-written note, a quick email, or a nice com-ment in the hallway, physicians will respond better to CDI profession-als who appreciate their efforts.
“Anything to make them feel good and to make them smile,” says Prescott. “Physicians respond to simple recognition,” just like the rest of us.
Editor’s note: Advice given in this article was adapted from previous articles in CDI Journal. For more physician engagement tips, visit the CDI Journal archives and search “engagement” or “physician edu-cation” in the custom search bar beneath the menu on the left side.
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 19
IN THE NEWS
Outpatient query guidance, salary survey releasedOutpatient has been the buzz-
word in CDI circles for some time now, leading to increased resources for the expansion (such as the first annual ACDIS Symposium: Out-patient CDI, the Outpatient CDI Pocket Guide: Focusing on HCCs, and First Steps in Outpatient CDI: Tips and Tools for Building a Pro-gram). And those resources were sorely needed, as anyone doing CDI in an outpatient setting knows.
“Outpatient CDI is a different beast than CDI performed in the inpatient hospital setting,” wrote ACDIS Direc-tor Brian Murphy in a January edi-tion of CDI Strategies. “The volume of encounters is significantly higher, as is the speed of the visit and the turnover of patients. Trying to use the same processes for clarifying documentation with physicians is doomed to failure.”
“Outpatient CDI is sort of a Pando-ra’s box because it can encompass so many areas,” said ACDIS Advi-sory Board member Anny Pang Yuen, RHIA, CCS, CCDS, CDIP, principal at AP Consulting Associ-ates LLC, on the February 15 ACDIS Quarterly Conference Call. “Many are accustomed to the inpatient set-ting where we have time to re-review charts, but in the outpatient setting,
we have to be more nimble and think outside the box.”
Because of the differences in CDI practice in outpatient settings, ACDIS took on the work of develop-ing and publishing query guidance for outpatient CDI—an area of partic-ular importance but with little appro-priate advice for fellow trailblazers. After many months of work, “Que-ries in outpatient CDI: Developing a compliant, effective process” was published in early January 2018.
The new publication is a position
paper, meaning that it is ACDIS’ offi-cial stance on this issue. While it was written by a committee of 10 indus-try experts, it was also reviewed and approved by the ACDIS Advisory Board and by external sources within the outpatient CDI community.
While the paper builds on the foundation of the jointly published ACDIS/AHIMA Guidelines for Achieving an Effective Query Prac-tice (first published in 2013, then updated in 2016), it also breaks new
ground for the CDI profession in two key ways.
First, the paper allows the use of prior medical records to query the physician (though not to support code assignment). “We recognized the guidelines saying you can’t apply codes based on past encounters, but we had to recognize that code assignment is different from the process of querying,” said Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts and a member of the ACDIS Advi-sory Board, on the Quarterly Call. “In the process of querying, looking back at those past records and pull-ing clinical indicators is likely neces-sary in the outpatient setting.”
Secondly, the paper encourages CDI intervention to help physicians manage their problem lists, though not by updating the list themselves. “We look at the records prospec-tively [meaning before the patient’s scheduled visit],” said Advisory Board member Tamara Hicks, RN, BSN, MHA, CCS, CCDS, ACM, director of clinical documentation excellence at Wake Forest Baptist Health, on the Quarterly Call. “We look back at things to see what’s been documented in the past and then what’s in the problem list and
Outpatient CDI is sort of a Pandora’s box because it can encompass so many areas.Anny Pang Yuen, RHIA, CCS, CCDS, CDIP
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query the provider to clean it up before the patient’s visit.”
“The problem list also affects the inpatient and outpatient areas,” said Deanne Wilk, BSN, RN, CCDS, CCS, manager of CDI at Penn State Health in Hershey and a member of the Advisory Board, on the call. “You’re seeing the same problem list on both sides.”
Despite breaking new ground for outpatient CDI professionals’ query-ing practices, ultimately “the efforts of CDI specialists must be organized and compliant as the profession expands its influence and reach,” according to the paper. (For a sam-ple query from the paper, see p. 21.)
Salary Survey
As CDI continues to expand beyond its traditional scope of work, CDI salaries have continued to rise, according to the 2017 Salary Sur-vey published at the beginning of February. Similarly, job titles show some diversification, though not as much as in years past.
Those earning the lowest annual salary, $59,999 or less, fell by 4% year-over-year from 10% to 6%, according to the survey. The largest number of respondents (20%) report earning $70,000–$79,999—the typ-ical salary range over the past three years.
Those earning that amount, how-ever, fell from 22% to 20%, and those earning the next highest pay-ment bracket of $80,000–$89,999 increased from 17% to 19%. Those in the $100,000–$109,999 bracket increased from 7% to 11%.
Yet, even though the survey results showed an uptick in the higher earn-ing brackets, career ladder options fell year-over-year in favor of step increases, which reward experience and education level advancements.
Step increases seem to align with traditional hospital practices for
compensating staff such as nurses and coders, so matching those ave-nues for growth within the CDI realm makes sense, according to Prescott.
Even though step-increases caused a downward shift in other job oppor-tunities, this year’s survey neverthe-less includes some positive trends for
the growth of the CDI industry, with 44% of respondents indicating their programs offer a CDI team lead posi-tion, followed by 22% who have a CDI education lead and 20% who have a CDI quality reviewer.
These new titles reflect trends in expanded CDI focus areas—such as quality, analytics, and audit defense—as well as bridging pro-gram trouble spots—such as phy-sician education and engagement, and educating and training CDI and coding staff on documentation targets.
People want to feel validated about the work they do and the role they fill within the organization.Lara Faustino, RN, BSN, CCDS
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 21
“People want to feel validated about the work they do and the role they fill within the organization,” says Lara Faustino, RN, BSN, CCDS, a CDI specialist at Boston Medical Center, in the report.
Much of the growth of CDI career ladders stems from the experience held by both CDI programs and staff. “There’s a lot of discussion about the length of the life of a CDI professional,” says Faustino, who puts that life cycle at around five to seven years before either retire-ment or a new job opportunity sunsets an individual’s CDI career.
However, for programs with less than five years’ expe-rience, implementing career ladders can be difficult.
Young CDI programs need to establish core compe-tencies, goals, policies, query audit practices, and inter-departmental relationships, says ACDIS Advisory Board member Angie Curry, RN, BSN, CCDS, CDI director at Conifer Health in Frisco, Texas, in the report.
Just as it takes six months to a year for a new staff member to get up to speed, CDI programs need to con-sider their strategic growth, and set goals for years one through five, and on into the future. Program leaders also need to consistently reassess CDI goals against facility priorities and shifts in healthcare reimbursement poli-cies. Professional growth opportunities for staff should mirror those priorities.
The Salary Survey also examined topics such as the link between salary and professional background, certi-fication, reporting structures, education, experience lev-els, and demographics, to provide a broad and in-depth look at where the CDI industry stands today in compar-ison to years past.
“These salary surveys always provide interesting insight into CDI trends, says Curry. “I think this year shows we have more work to do to help advance the profession.”
Editor’s note: To read ACDIS’ new position paper, click here. To read the Salary Survey, click here. “In the news” is a roundup of information reported in the email newsletter CDI Strategies, which is free to members and non-members alike. Click here to sign up.
SAMPLE COMPLIANT OUTPATIENT QUERY
In this example, the CDI specialist is reviewing a case for a pri-mary care clinic. The opportunity is to clarify if the DVT is acute or chronic and to have it added to the problem list as well as outpa-tient visit notes.
Clinic note: Patient presents with leg swelling. She was seen at urgent
care earlier this month with acute left knee pain and swelling. Recent x-ray done at urgent care on 7/3/17 revealed moderate medial and mild lateral and patellofemoral compartment degen-erative changes, progressed since 2006. At that time, she was prescribed Mobic, instructed on RICE therapy, and given a knee brace for comfort and support.
Patient states that she has had progressive left lower extrem-ity pain and swelling over the past two weeks. She states that initially it started in her knee but has progressed to her leg and proximal thigh. She has pain in her medial thigh. She has pain with movement that is only slightly improved with rest. She has no past history of DVT; however, she is morbidly obese, sedentary, and spends most of her day in bed.
Plan: Swelling of left lower extremity
Acute LLE edema, pain on palpitation of medial thigh sugges-tive of DVT. No past history of DVT; however, morbid obesity, sed-entary, and recent LLE injury place her at high risk for blood clots. Stat Doppler of LLE to rule out DVT.
7/22/17 Attending attestation: Patient presents with known DVT; PE includes LLE swelling and good perfusion. Treat with Xarelto.
Query:Please update the problem list and outpatient visit notes to
include the status of the DVT:
■ Acute
■ Subacute
■ Chronic
■ Resolved
■ Other (please specify)
■ Unable to determine
Thank you.
7/21/17 clinic note states: Known DVT, with progressive LLE pain and swelling over the past two weeks.
Monitoring: Doppler of LLE performed
Treatment: Xarelto
Editor’s note: This example was taken from the ACDIS position paper “Queries in outpatient CDI: Developing a compliant, effective process.”
22 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
PHYSICIAN ADVISOR’S CORNER
It’s time to rethink our relationshipsby Trey La Charité, MD, FACP, SFHM, CCS, CCDS
In 2015, I wrote 44 appeal letters challenging DRG validation/coding denials. In 2016, I wrote 88 appeal letters. Last year, I penned 159. We already received more than 40 DRG
validation denials in January of this year. Does this trend sound familiar?
Though I lack the specific numbers to quantify my claim, there is a similar yearly increase in medical neces-sity, observation versus inpatient, and 30-day readmis-sion denials for my facility. And these denials, sadly, yield a far more substantial financial impact than the DRG val-idation denials. For the first time, my hospital assessed the risk and decreased our anticipated revenue for the 2017 capital budget to reflect the increasing numbers of denials. It is unconscionable for a not-for-profit, safe-ty-net hospital to be forced into such a position.
In my opinion, health insurance companies have reached a new low. One of my institution’s largest pay-ers recently sent us a denial for an entire hospitalization because it occurred within 30 days of a previous admis-sion. “Failure to adequately coordinate the patient’s post-discharge care” from the index admission was the grounds they cited.
Across the country, this type of denial is becoming increasingly frequent. Clearly, the alliance between hos-pitals and insurance companies is no longer viable.
The state of the relationship
In the last century, health insurance companies ensured their profits by two methodologies: insuring only healthy, low-risk subscribers or withholding specific medical ser-vices to enrollees. “Too expensive,” “too experimental,” or “too risky” were the frequently heard reasons for denial of coverage for many procedures and treatments. Lifetime coverage caps were handy extensions of these policies, again keeping dollars in the pockets of the insurance companies. In my youth, little Jimmy (aka The Jimmy
Fund) relied on coin-jar campaigns and fundraisers to cover the cost of his bone marrow transplant because his parents’ health insurance would not pay.
Today, however, as healthcare reform has progressed, limitations such as these have become politically unpop-ular. In order to maintain the same profit margins, insur-ance companies have embraced ways to make up for their additional outlays. Because they are spending more on the front end, they have decided to take a compen-satory amount out on the back end. Unfortunately, those funds deemed necessary to keep the insurance com-pany investors happy come from providers’ reimburse-ments. While the refusal to increase provider reimburse-ments to account for inflation is universal, a more insidi-ous tactic is the tremendous increase in post-discharge denials. Every hospital in the country has experienced this over the last few years (a problem that your facility’s revenue cycle department will identify and lament).
Simultaneously, however, these same insurance com-panies encourage our facilities to provide more for our beneficiaries. With one hand, they lovingly cajole and encourage us to improve patient compliance metrics, to reduce costly prescribing and testing practices, to add additional clinic hours and services, and to accept new beneficiaries into our practices. With the other hand, they clench a tight fist and shake it menacingly. They assert that “this documented diagnosis was never clinically present” or that “this patient should only have been in observation status.” “You coded this case incorrectly,” they growl. “You did not prove that the procedure and/or entire hospitalization was medically necessary.”
Like a malicious pet owner, they coax their dog to “shake hands” and then reward the performance with a wallop on the head from a rolled-up newspaper. The ultimate outcome is that the faithful and dedicated com-panion becomes broken and cowed. Eventually, it disen-gages from all contact with its supposed loving owner. If the current situation continues, will hospitals simply quit out of frustration and dejection? If so, where will our patients go, and who will take care of them?
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 23
Let’s take a stand
I have three suggestions for preventing this sad out-come. First, in all future negotiations with insurance com-panies, this problem must be addressed. Not one of our facilities can afford to take these continued financial hits. In a hospital with a precariously thin operating margin, there’s no excess to slice from. It’s time to force quid pro quo: If the insurance carrier wants something from your organization, then what relief will they offer in return?
For example, if insurance company X wants your orga-nization to reduce emergency department utilization of its beneficiaries, by what volume is the company willing to reduce its predatory denial rate? In today’s climate, hos-pitals must remember that negotiating only for improved reimbursement rates will not be enough. Those higher reimbursements must be reallocated to fight the contin-uous onslaught of coding and utilization review denials. We cannot allow insurers to give us more money up front only to snatch it away later in the form of a claim denial. This offers no benefit to the hospital’s bottom line and merely represents a poorly executed loan instead of an incremental improvement to hospital resources.
Second, we need to specifically educate our state and federal legislators. If we don’t receive some assistance, relief, or protection, we may fade into obsolescence. Whether for-profit or nonprofit, a business cannot oper-ate indefinitely in the red. When expenses exceed reim-bursements, the doors will close. While few hospitals can afford an army of lobbyists, we must combine forces to relay our needs to the legislators. Perhaps raising aware-ness could force legislative action. Unfortunately, given the current morass at the federal level, I suspect we will have more success with our state legislative bodies.
A third option is direct legal action in the form of a class action suit. Lawyering up may bring unwanted scrutiny to these ill-conceived practices. While the insurance com-panies would undoubtedly deny the allegations and do everything they can to suppress a final verdict, a show of force might nonetheless get them to rethink their approach. Preserving their carefully crafted public image could be an impetus to change. Our patients simply can-not afford for us to take these new tactics lying down.
We need to fix this
With the considerations above in mind, I believe it’s time to evaluate the value that insurance companies add to our country’s healthcare system. A CEO of a world-wide healthcare services company stated that “providers spend 30 cents of every dollar they receive in reimburse-ment from an insurance company trying to extract the remaining 70 cents.” While I cannot vouch for the veracity of that claim, hearing it greatly increased my appreciation for the trials and tribulations hospitals face in receiving appropriate reimbursement. Hospitals and health insur-ance companies are simply not working together.
A single-payer system is a routinely touted remedy. The negatives and positives of this are beyond the scope of this article. But imagine, for a moment, what the health-care landscape would be like without the most problem-atic payers impeding your facility’s ability to care for its patient population. I’m not suggesting the single-payer system is the correct option; however, I would not shed a tear if one or two payers suddenly became extinct. Everyone cheers when a bully is thrown out of a game.
Please understand that my concerns do not express a desire to break ties with all insurance companies. How-ever, my hospital and I would gladly work with any party who can improve the care we provide to the people of East Tennessee. We must have a closer, more transpar-ent relationship between the insurers, the providers, and the patients to reach our stated goals. Sadly, the patients will be the ones who ultimately suffer the most if they have no facilities in which to receive their needed care.
For those interested, I recommend the following arti-cles to provide some scope on this topic:
■ “Insurance costs and health-care reform: Are health insurers making huge profits?” from the Economist
■ “Why spend $900 billion on health insurance?” from Forbes Magazine
■ “Taking insurance companies out of health care” by Wendell Potter for the Center for Public Integrity
Editor’s note: La Charité is a hospitalist at the University of Tennes-see Medical Center at Knoxville, a clinical assistant professor, and the medical director of UTMC’s CDI program. He is a past member of the ACDIS Advisory Board and the author of three books. La Charité’s comments and opinions do not reflect necessarily those of UTMC, ACDIS, or its Advisory Board. To reach La Charité, email him at [email protected].
24 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
CASE STUDY
A new role for CDI: Appeals and analysis
As the CDI profession matures, programs are instituting career ladders to create advanced posi-
tions for seasoned CDI professionals looking for a change in their respon-sibilities. Whether it be the addition of a second–level reviewer, an edu-cator, or even an informaticist, the options for CDI professionals are growing.
“Like with nursing, there are options in CDI. CDI has been limited in the past, but now [at our facility] with positions for auditors, edu-cators, and appeals nurse, it gives everyone more jobs to choose from and a potential career ladder,” says Rita Fields, BSN, RN, CCDS, previously the regional CDI man-ager at Baptist Health in Louisville, Kentucky.
While denials management and appeal writing has been an off-shoot of CDI specialists career paths for some time now, most CDI programs leverage an existing team member—someone who still reviews records concurrently and tackles the work of CDI—to help stem the tide of denials.
After trying to handle appeal writ-ing with their existing staff, though, the Baptist team realized they needed someone who would be specifically dedicated to that role. Enter the CDI analyst and appeals nurse.
Position beginnings
When the CDI team at Baptist Health first started reviewing clin-ical validation denials in 2017, they quickly realized that they didn’t have enough fulltime staff members to
handle the extra work. “The best thing for us to do was to hand these denials over to the educators to write the appeals for the whole system—eight facilities in all,” says Susanne Warford, MBA-HCM, RN, CCDS, who took on the system CDI analyst and appeals nurse position in Janu-ary 2018.
While the CDI educators at Baptist had the clinical and CDI acumen to handle the appeals, the task mud-died their focus and added another item to their already–full workload, Warford says. The educators often weren’t able to keep up with the appeal writing and subsequent data reporting required to demonstrate the outcomes of their efforts.
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 25
“We wanted to be able to show how many denials we’ve over-turned,” says Fields.
But without the proper data, there was no way to tell concretely if the appeals were effective. Perhaps more importantly, without any sort of data tracking, there was no basis for physician or CDI education. “We really had no good tracking,” says Warford. “So, we weren’t bringing that education forward to the phy-sicians and our staff. I really got the position approved by adding the analyst piece to it.”
Because the data will factor so heavily into the education and front-end denials prevention, Warford expects her role to focus on appeals writing, at least in the short term. “The first thing I’ll need to do is get in there, write the appeals, and find out where we’re not closing the loop,” she says.
Armed with information related to how Baptist previously crafted its appeals and with her CDI experi-ence, Fields expects Warford to bet-ter structure the appeal information to get the denial overturned. Since Warford will have dedicated time for the appeals, she’ll be able to stream-line and perfect the process.
CDI experience is a crucial part of the new position, says Fields. “We were looking for someone who had the clinical knowledge with a mini-mum of two years of CDI experience and a CCDS credential. If they did not currently have the CCDS, Bap-tist stipulated that the successful candidate would need to obtain it within six months of hire. They
also required the candidate to be a member of ACDIS. (To read the job description, see p. 26.)
Having already met these require-ments, and coming from within the CDI team, made Warford a perfect candidate for the job.
Role anticipation
After the appeals have been writ-ten and the data extracted and ana-lyzed, Warford plans some major physician educational efforts lever-aging existing relationships with the health system’s seven physician advisors. Ultimately, Warford hopes to bring them into the appeal writ-ing process. That level of involve-ment not only provides Warford with the clinical acumen needed to win appeals, but also provides the phy-sician advisors with firsthand expe-rience they can bring back to their peers, she says.
So far, Warford has found it rel-atively easy to loop physicians into
the appeal writing process. “They have actually been very receptive,” she says. “They don’t like to be sec-ond-guessed by an insurance com-pany who wasn’t at the bedside.”
From that physician involvement and peer-to-peer education, War-ford hopes systematic change will follow. “It’s partly already started to happen,” she says. “We noticed an uptick with sepsis-3 denials, but we’re using sepsis-2 in the system. So now, we’re looking at chang-ing to sepsis-3 with the help of the physicians.”
While Warford has just started her journey, she’s optimistic about the potential of her new position. “Ini-tially, it was hard to step down as manager, but it’s a new step and it’s exciting,” she says. “I love ana-lytics, actually. To me, it’s not a job—it’s a passion. I can’t wait to see where we are six months from now.”
26 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
SYSTEM CDI ANALYST AND APPEALS NURSE JOB DESCRIPTION
Position summary
The system CDI analyst and appeals nurse will func-tion in a fully accountable role responsible for managing medical denials by conducting a comprehensive analytic review of the clinical documentation to determine if an appeal is warranted.
The system CDI analyst and appeals nurse will write sound, compelling, factual arguments, when warranted, to the third-party payer denying the claim. The appeals specialist will also handle audit-related correspondence and other administrative duties as required. The system CDI analyst and appeals nurse will also report and per-form data analysis for the CDI program as needed.
Principal duties and responsibilities
The following is a summary of the major functions of this individual’s job. He or she may perform other duties, both major and minor, which are not mentioned below, and specific functions may change from time to time.
■ Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required
■ Utilize preexisting criteria and other resources and clinical evidence to develop sound and well-sup-ported appeal arguments, where an appeal is warranted
■ Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of references and/or regulatory arguments as necessary
■ Search for clinical evidence to support appeal arguments when existing resources are unavailable
■ Prepare feedback and education to the CDI pro-gram, to facility leadership, and to physicians as trends are identified
■ Track all denials and their outcomes and provide feedback to management as requested
■ Ensure HIPAA regulations, to include confidential-ity, as required
■ Perform data analysis and report out findings as needed
■ Perform other duties as assigned
Minimum education, training, and experience required
■ Must be a registered nurse with an active Ken-tucky nursing license
■ Bachelor’s degree in a healthcare-related field required, master’s preferred
■ Must have a minimum of two years of clinical doc-umentation experience
Certifications/licenses required
■ CCDS required, or must be obtained within six months of hire
Professional organization membership required
■ Member of ACDIS required
Skills and abilities required
■ Physical requirements:
§ Strength: Requires the ability to occasionally push/pull/lift objects less than 20 pounds
§ Manual dexterity: Requires the ability to con-stantly perform simple motor skills such as moving from area to area in the building, on campus or off campus. Requires the ability to frequently perform moderately difficult manip-ulative skills such as typing or data entry
§ Coordination: Requires the ability to con-stantly perform gross body movement such as stooping, filing, etc., and constantly per-form tasks, that require hand-eye coordina-tion, such as keyboard skills
§ Mobility: Requires the ability to frequently move from department to department and from building to building, and to sit for pro-longed periods of time
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 27
§ Visual discrimination: Requires the ability to constantly see objects closely as in reading and viewing paper records and computer screens
§ Hearing: Requires the ability to constantly hear normal sounds with some background noise as in answering the telephone
■ Mental requirements:
§ Concentration: Requires the ability to con-stantly concentrate on minimal and fine detail with some interruption
§ Attention span: Requires the ability to fre-quently attend to tasks/functions for more than 60 minutes at a time and to frequently attend to tasks/functions for less than 10 minutes at a time
§ Conceptualization: Requires the ability to frequently understands and relate to con-cepts behind specific ideas, and to frequently understand and relate to the theories behind several related concepts
§ Memory: Requires the ability to constantly remember multiple task/ functions given to self and others over long periods of time
§ Communication: Requires the ability to con-stantly communicate verbally and in writing using advanced vocabulary and writing skills
■ Working and environmental conditions:
§ Employee may be constantly exposed to electromagnetic radiation from computer terminals and occasionally may be exposed to dust
§ Some stress due to time constraints, dead-lines, and complexity of the job could exist
§ Requires some in-state travel (approximately 20%)
Editor’s note: This job description was provided by Susanne War-ford, MBA-HCM, RN, CCDS, system CDI analyst and appeals nurse at Baptist Health in Louisville, Kentucky.
28 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
MEET A MEMBER
Bridging the gap between CDI and coding Jose M. Gonzalez O’Neill, MSHIM,
RHIA, is the vice president of the Flor-ida ACDIS (FLACDIS) chapter, and HIM service line manager for medical tran-scription and inpatient coding at a large hospital system in the Orlando area.
CDI Journal: How long have you been in the CDI field?
Gonzalez: I’ve been a formal CDI specialist since 2015, but I’ve been involved in some form of documentation review since 2013.
CDI Journal: What did you do before entering CDI?
Gonzalez: I worked in the acute care system, labo-ratories, gastroenterology clinics, dental offices, and consulting.
CDI Journal: Why did you get into this line of work?
Gonzalez: I studied at the University of Puerto Rico Medical Sciences campus, and I wanted to be a health-care administrator, but I had a professor who always told me to apply to HIM. I applied and was not chosen for either of the programs, but was placed in a reserve list in case one of the 10 selected students for HIM declined. I always called to check if someone didn’t accept to enter the program.
Then, one day, they called to notify me that they had an opening and that I needed to go right away to register for classes. I was crazy with happiness and went to register that same day. I believe that it’s how hard you work to get where you want to be. Now, I am RHIA certified, I am a University of Central Florida Advisory Committee Mem-ber for the Health Information Management program, the past president of the Puerto Rico Health Information Management Association chapter, and the vice presi-dent of the FLACDIS chapter. Hard work pays off!
CDI Journal: What has been your biggest challenge?
Gonzalez: I came from Puerto Rico to Florida, which is a whole new environment. I used to work with paper medical records, and now I am working with an EHR. The CDI program at my facility was already established
when I arrived in 2015, and we started implementing the combination of coders/HIM and nurses in the role. At that time, people thought the combination was not a good idea, but now it’s a trend nationwide. Nowadays, it’s common to see HIM professionals and nurses work-ing together in the CDI field.
CDI Journal: What has been your biggest reward?
Gonzalez: My greatest reward would have to be obtain-ing my RHIA certification after all the hard work I put in. I was finally able to achieve my first main goal.
CDI Journal: How has the field changed since you began working in CDI?
Gonzalez: When I started working with CDI, there was disagreement about which professional background was the more adequate professional to perform CDI. I remember almost everyone in my first FLACDIS meet-ing was a nurse. And here I am, a new HIM manager working with CDI and telling everyone that coders and nurses could do the work of CDI together. Some peo-ple looked at me like I was going to eliminate their jobs. Others agreed with the idea. In the end, everyone found their happy place in the CDI process. Now, I see more and more coders or HIM professionals working hand in hand with RN CDI specialists and vice versa. Every day, we are evolving in the CDI field, and I know we are going in the right direction.
CDI Journal: Can you mention a few of the “gold nug-gets” of information you’ve received from colleagues on The Forum or through ACDIS?
Gonzalez: The CDI Strategies e-newsletter from ACDIS had been a key tool for me in my job. A recent CDI Strategies addressed an issue where coders were not coding the diagnoses documented in the consult notes because the admitting physician didn’t document the same diagnoses. This article helped the coding team become more confident in coding and helped our CDI team educate the attending physicians on reviewing the consultation notes to better establish a comprehensive picture about the patients’ care.
© 2018 HCPro, a division of BLR.® CDI Journal | MAR/APR 2018 29
CDI Journal: What piece of advice would you offer to a new CDI specialist or coder?
Gonzalez: Keep educating yourself—time goes fast, and changes are common in the healthcare field. Take webinars, go to conferences, and learn from other col-leagues in the CDI or HIM field.
CDI Journal: If you could have any other job, what would it be?
Gonzalez: I would love to coach volleyball at the colle-giate level, or to write policies for Medicare and Medicaid.
CDI Journal: What was your first job (what you did while in high school)?
Gonzalez: My first job was working at Toys “R” Us. I felt like a little kid again.
A few of Gonzalez’s favorite things:
Vacation spots: Puerto Rico
Hobby: My favorite hobby is playing the bongos and congas. I have been married for two years now. I don’t have children yet, but we are looking forward to having them in the future.
Non-alcoholic beverage: Virgin Pina Colada.
Foods: Latin food. I love to go to dinner with my wife and to drive around Florida.
Activity: Coaching high school and club volleyball. In 2017, my Top Select 18 Royal boys’ volleyball team got second place in the Florida Regional Tournament.
30 CDI Journal | MAR/APR 2018 © 2018 HCPro, a division of BLR.®
San Antonio, Texas | May 21–24, 2018
40015Visit hcmarketplace.com/acdis-conference for complete details, including agenda and hotel information.
Joe FlowerHealthcare Futurist
hcmarketplace.com/acdis-conference
615-724-7200
2018 ACDIS Keynote SpeakerJoin us in San Antonio for the nation’s first and
only conference dedicated to the CDI profession.
The 11th annual ACDIS Conference features unparalleled networking, the ACDIS Achievement Awards, and 50 sessions in the following tracks:
• Clinical and coding• Management and
leadership• Quality and regulatory
• Outpatient andrisk-adjusted CDI
• CDI expansion• Pediatric CDI
WHAT’S HOT IN 2018?We’ve added a sixth track dedicated to pediatrics and an optional closing night reception. Our popular interactive conference app returns, featuring Twitter notifications, conference materials, a session planner, and audience polls.
Register now at hcmarketplace.com/acdis-conferenceand save $100!
*Save $200 now if you are an ACDIS member.