According to Merriam-Webster's online dictionary, query is a transitive verb. It requires one or more objects. To "query" someone is to ask questions in order to resolve a doubt or obtain authoritative information. CDI specialists (CDIS) and clinical coders query physicians every day to clarify documentation and achieve accurate code assignments.
In fact, 38 percent of facilities have a set query quota (amount of cases CDIS's should query). And for over 50% of CDIS's, this quota is at least 15% of all the charts they review.1 Thousands of physician queries are created and answered every day.
However, the query process remains confusing, complicated and in some cases, non-compliant with clinical coding standards. Physicians are often dissatisfied and fail to respond to CDI or coder questions. Physician apathy / lack of response and interest ranks top concern by over 50% of CDISs in a recent ACDIS survey.2
Simplifying physician queries benefits everyone: CDISs, coders and physicians. Directed step queries are one way to get the job done.
What are Directed Step Queries?
The Directed Step Query is patent-pending process designed with physicians' needs in mind. The process has a provisional patent application registered with the US Patent office*. Directed Step queries provide an answer to the question, "just tell me what you want me to do".
Directed Step queries incorporate a coherent, logical series of steps and do not favor one answer over another. Physicians are asked to take "steps" to follow and respond to the query.
Electronic or paper-based, Directed Step queries incorporate the following four components:
- Query Title
- Patient Demographic Information
- Query Instructions
- CDIS/Coder Narrative
How to Build Them
The first step in building a Directed Step query is to choose the specific diagnosis. From there, CDIS would consider causation, etiology or relationships to other diagnoses. Space is provided (electronic or paper) for physician narrative, physician accepted definition or reference, additional reminder if indicated, physician signature, CDI review and re-review dates, and coder feedback. Multiple steps and additional queries can be added to the initial Directed Step query.
Boosting Physician Response
Physician response to queries is the magic indicator of your success. If your facility has a lower than 50% physician query response rate, Directed Step queries may help. However, these three factors are necessary to successfully launch a Directed Step query program.
Solicit clinical content from relevant specialist groups and use already-established clinical parameters and definitions. Obtain Medical Executive Committee approval.
Garner C-suite sponsorship of your program and agreement from the CMO, CMIO and HIM Director.
Audit your queries for accuracy, relevance and compliance. Report your findings and make program adjustments along the way. Guidelines for achieving a compliant query practice are available from AHIMA/ACDIS here: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018
Queries aren't easy. But they are necessary and can be simplified by using the Directed Step approach. And when combined with other effective strategies, such as one-on-one conversations and educational presentations at medical staff meetings, they will successfully boost your query response rates.
CDIS's and coders have a lot of new issues on their plates in the next twelve months-worrying about physician queries shouldn't be one of them.
*NOTE: For more information about the Directed Step Query patent-pending process, contact Mark Dominesey at TrustHCS: email@example.com
1. Physician Query Benchmarking Report. ACDIS. January 2011. Available online at: http://www.hcpro.com/content/265437.pdf
2. CDI Industry Overview: Emerging Topics. 2013 CDI Week. ACDIS. September 2013. Available online at: http://www.hcpro.com/content/296174.pdf
According to Ralph Waldo Emerson, society is always taken by surprise by any new example of common sense. Such is the case with the recently released survey of nearly 300 HIM professionals regarding the state of ICD-10.
The survey was conducted jointly by the American Health Information Management Association (AHIMA) and TrustHCS in the fall of 2012. For those who are in-the-know about ICD-10, the survey revealed few surprises. But for society at large, the facts are startling.
According to the report, more than 50 percent of hospitals surveyed are still in the beginning stages of ICD-10, and 25 percent haven't even formed a steering committee to drive the project. These are very scary numbers indeed! The other blatant example of common sense: There will be a 30 percent coder shortage - on top of the 30 percent nationwide coder shortage that already exists. These facts are no surprise to HIM professionals. But what was surprising for us? And what does the survey say about clinical documentation improvement (CDI)?
New Surprises for HIM
The biggest surprise is that hiring spikes for coders will occur in 2013 and early 2014, as hospitals ramp up their dual coding programs and hire for 2014. The number of hospitals already starting to use computer-assisted coding (CAC) was also higher than expected. And more than 75 percent of the hospitals surveyed expect to use CAC for ICD-10.
CAC will certainly help hospitals curb the predicted drop in coder productivity associated with ICD-10, thus easing the coder shortage. The other new surprise involves CDI.
New Surprises for CDI
According to the survey, many hospitals already have a program in place. That's the good news; however, many respondents believe their CDI programs are failing.
Hospitals that employ outside auditors to evaluate their CDI efforts overwhelmingly believe their programs are effective. Those that conduct internal reviews think otherwise. Hospitals conducting their own audits of CDI effectiveness use internal metrics. And when these internal metrics fail to show an increase in revenue, the program is perceived to be ineffective.
Yes, the use of an outside auditor to assess your CDI program is best practice; however, hospitals also should expand their audit metrics. Metrics should include such questions as:
- Are revenue take-backs by RACs, MACs, and other auditors down or up?
- Are medical necessity denials on the decline?
- Has coding accuracy and compliance improved?
Answering "yes" to these three questions also indicates a healthy CDI program.
Still Have CDI Questions?
Still have questions about your CDI program's effectiveness? I suggest that you conduct an outside audit of your CDI program at least annually. Hospitals that have invested in a CDI program must do their homework and assess their efforts.
Finally, a complete CDI assessment must be part of your 2013 ICD-10 plan. Answers will be gleaned and areas for improvement will be uncovered. The future is ICD-10 and clinical documentation is its foundation. A complete CDI audit ensures that your organization won't be caught by surprise when ICD-10 hits your door next year.
HIM's longstanding struggle with physician documentation is well understood and globally recognized. The challenges associated with securing complete, timely, and accurate documentation from physicians is fodder for HIM jokes nationwide. Yes, nine out of 10 coders around the water cooler agree ... physicians are a tough bunch.
So with ICD-10 only one year away, how can you change up the CDI game plan to better educate your physicians, obtain stronger cooperation, and ensure coders have the documentation they need? Here are six practical ways to address the challenge:
1. Focus Your Efforts
When talking to physicians about ICD-10, focus your presentations and communications on those diagnosis and procedures specific to them. Address each department/service separately, and use real, practical examples for each, comparing differences in verbiage between ICD-10 and ICD-9. The type of practice or specialty is a big factor in the intensity and duration of education. Plan accordingly.
2. Reiterate the Benefits of ICD-10 to Their Practices
Physicians are most concerned about the impact of ICD-10 on their practices and personal revenue. So tell them.
The physician side of healthcare coding and billing is retaining CPT codes, so only diagnosis coding will change in the office setting. And while physician payment is not driven by diagnosis, medical necessity for each CPT code is.
Having correct documentation and diagnosis coding to prove medical necessity under ICD-10 will be a hot issue for physicians, especially if denials spike and reimbursements are halted. Furthermore, RACs are expanding into physician practice settings. Better documentation reduces denials, audits, and take-backs. Finally, a physician's quality scores and HealthGrades are directly impacted by correct documentation and coding.
Three specific areas that affect documentation in the physician office setting are: pathologic fractures, stages of chronic kidney disease, and trimester of pregnancy. Stay tuned to this blog as we uncover more areas within physician practice settings where adherence to new, ICD-10 driven documentation will be required.
3. Educate in Small Bites
Just like the title of this blog states, physicians want HIM to "tell them what to say." Consider short briefings, factoids, info graphics, and documentation tips that are easily digestible and transportable. Attention spans are short. Keep your message simple.
4. Go Mobile
Consider applications that push ICD-10 education and documentation reminders to physicians via mobile devices and texting. Make education fun and interactive whenever possible to keep your audience engaged. For example, many of ICD-10's funny codes can be used to both entertain and demonstrate new specificity requirements.
5. Use a Peer-to-Peer Approach
No one communicates your message better than another physician. Every effort should be made to engage multiple physician champions for peer-to-peer conversations and education. No physicians around? Consider PAs and other respected clinicians to serve in these roles. And always ask your medical staff leadership to help.
6. Inspire Competition
Whether it is on the golf course or in the parking lot, physicians are a competitive bunch. Take advantage of this trait, and set up I-10 documentation challenges. Post results, and award prizes in the physician lounge. A little competition goes a long way.
The move to ICD-10 is a project where it is virtually impossible to cover everything and do a broad brush implementation. The shotgun approach will result in time wasted and disinterest in success. Use a tailored, custom approach for physicians - molding the implementation to the specific needs of physicians and their practices. Being specialty-focused takes more time but pays off in big dividends.
At the recent AHIMA ICD-10 Summit, one message was completely clear: The most important element of ICD-10 preparation process is clinical documentation assessment and improvement. And the best news from the summit? Any efforts you expend now toward better documentation for ICD-10 also will deliver improvements in ICD-9.
Here are five reasons to start now:
- improved patient safety and quality care
- more accurate public reporting
- reduced denials and audits
- fewer physician queries and coding delays
- improved case mix index.
Time and time again my firm is being called in to assess clinical documentation in preparation for ICD-10. Documentation is the first place to look for potential pitfalls and gotchas. Coding is the second. Clinical documentation and coding are like the two bookends in improving all five issues mentioned above.
But many organizations are struggling to find an effective starting point - one that will demonstrate quantifiable improvements and cost-justify ongoing efforts. In our experience, here are the five sure bets to deliver the proof your program needs:
Step One: Identify your top MDCs.
Step Two: Conduct CDI and coding audits for the top DRGs within each of these MDCs by coding cases in ICD-10 and comparing results. Also called a CDI assessment, you'll quickly see which DRGs will cause future problems should documentation and coding remain "as is."
Step Three: Bring CDI specialists and coders together for MDC-based training. Spend one day on each MDC reviewing basic anatomy and physiology, common diseases, treatments and medications.
Step Four: Team up CDI specialists with coders for specific diagnosis and procedures to strengthen the relationship and mutual understanding.
Step Five: Rotate CDI specialist and coder pairings until all top MDCs and DRGs within those MDCs are covered.
Step Six: Measure your improvements.
By taking a MDC-based approach to CDI and coder training, quick, quantifiable improvements are bound to occur. These two professional teams are different in background, mindset and "thought-flow." The sooner you bring them together at the same desk and make them a team, the better.
Many providers have clinical documentation improvement programs. The belief is that more accurate, detailed clinical documentation is better for the patient, the institution, the government, researchers, and all aspects of quality of care. So why not have an improvement program for the improvement program?
Too many CDI programs focus on the short-term goals of reduced denials and fewer queries only for those DRGs and types of cases payers are reviewing today. But a truly visionary CDI program takes a much longer-term view of both the areas for documentation improvement and the ability for programs to achieve a return on investment.
Certainly, CDI programs should focus on current areas of weakness that are impacting cash flow, but with a focus on the longer-term goals, such as successfully implementing ICD-10 and building the framework for strong documentation practices that will support future upgrades to coding systems. Quality initiatives and pay for performance seem to be gaining traction as healthcare initiatives, which also would benefit from better, more accurate documentation. Looking forward to incorporate these programs into today's CDI initiatives gives providers time for a methodical transition to any new reimbursement model - not to mention solid quality data and business intelligence to make better, long-term decisions.
Trying to jam change into the last minute is a formula for mediocrity. You get done the absolute minimum needed to meet a program's needs, but you never reap the upside benefits that these programs present.
Your CDI initiative is a living process that should be proactive to future needs, not reactive. Preventative medicine is always preferred to illness intervention. Make sure your CDI program has an oversight group charged with improving the improvement program. While ICD-10 and the many other initiatives in healthcare seem to be overwhelming, a successful CDI program can greatly smooth the road to change.
The accuracy of your reimbursement under ICD-10 is a direct result of the accuracy of your clinical documentation. As with ICD-9, the goal is to get the dollars that you are entitled to get. No more. No less. Manipulating codes to maximize reimbursement is still considered fraud.
The assignment and order of primary and secondary diagnoses must accurately reflect the patient’s condition and resources consumed by that patient as documented in the medical record. Physician documentation must reflect the situation in detail. This has also been a challenge for HIM and CDI professionals. However, the proliferation of codes under ICD-10 makes this task even more daunting.
So how do we all cope?
The first step is to fully understand the list of CCs (complication and co-morbidity) and MCCs (major complication or co-morbidity) in ICD-10 and how these codes are extrapolated over a larger expanse of principal diagnosis. A good example for CDI and HIM professionals to reference is a diagnosis of cerebral-vascular accident (CVA).
In ICD-9 coding, the diagnosis of hemiparesis following a CVA has three choices of codes. In ICD-10, the number of possible codes for the same diagnosis explodes. You now have options for right dominant, right non-dominant, left dominant, left non-dominant, unspecified, intracranial, subdural, hemorrhagic, embolic or any combination of the above. What were three choices in ICD-9 are now 28 choices in ICD-10. So physicians must say what type of CVA, which side of the brain is impacted and to what extent.
Another case is angina. If you document only angina with spasm you will get a CC. However, if you document angina with spasm with atherosclerotic heart disease (ASHD) of native coronary artery, then it is not a CC. It is just a manifestation of the underlying disease. If the angina is documented as unstable, then it goes back to being a CC. Confusing is an understatement!
For HIM and CDI professionals, the end goal is to know and understand the needs for ICD-10 and its CCs/MCCs. Once you understand the need, you can convey to the physician community the documentation protocol to accurately code the condition. Start with your high volume, high revenue diagnoses. But please get started!
The Centers for Medicare and Medicaid Services (CMS) have released its list of complications and co-morbidities for ICD-10. Armed with the list, coders and CDI professionals can get busy identifying gaps in physician documentation and educating the medical staff. Here are a few points to help get you started.
The list contains two parts. In the first part, 43 pages of CCs and MCCs are listed alphabetically. If the CC or MCC is allowed with all principal diagnosis, then the phrase Noexcl follows the CC/MCC indicator. Otherwise, a link is given to a collection of diagnosis codes which, when used as the principal diagnosis, will cause the CC or MCC to be considered as only a non-CC.
The second part lists only eight codes. These codes are assigned as a major CC only for patients discharged alive. Ironic that CMS doesn't consider "death" a major complication. Their assumption is that if a patient dies, the hospital spent less money and should be reimbursed less. I am not sure how often that is the case!
The alphabetical presentation in List No. 1 can be problematic if you do not know which ICD-10 code you are looking for-as is the case for most of us at this stage in the game. There is some help with a ‘control F' function to find codes within a particular page.
On initial review, it does not appear that CMS has added or deleted many CCs or MCCs. However, due to the specificity of ICD-10 codes and the large increase in the number of I-10 codes, the occurrence of individual codes that contain a CC or MCC has greatly increased. For example, one ICD-9 code with CCs may blossom out into 10 ICD-10 codes each having CCs.
Welcome to the world of ICD-10!
There is some speculation and anecdotal evidence suggesting that a substantial number of the more experienced, long-term coders are going to retire rather than retooling for ICD-10. While there will be some that take the early retirement route, it is my contention that these numbers will be few.
Coding is a puzzle and has always had new changes...every October 1. Furthermore, coders are inherently problem solvers. Most, I believe, will step up to the challenge that ICD-10 and the changes to CDI will bring.
Keep in mind you may still need a few top of the line ICD-9 coders for some time to come. For starters not all health plans must transition to ICD-10. Non-covered entities do not maintain HIPAA compliance can opt to remain on ICD-9 as they do not send electronic claims. There are only a few of these:
- State Workers Compensation
- Property and Casualty insurance health plans
- Disability Insurance Programs
There will also be RAC audits with three-year look back periods-another area for ICD-9 coding expertise. Finally, ICD-9 coders could be placed in the centralized business office to help with ICD-9 denials.
Given the scarcity of experienced coders, it may behoove you to incent some ICD-10 naysayers to remain on board for a few more years. It's just another staffing strategy to consider during these tumultuous times.
With all due apologies to Bob Dylan, there are many ‘times a changing' in ICD-10 that require clinical documentation improvement (CDI) intervention. Our big day starts in 24 months, but coder and physician education regarding some of these time-sensitive definitions must begin now. In this blog, I present just a few "changing times" for your consideration and group discussions.
In the pulmonary section under asthma, ICD-10 uses the phrases "intermittent" and "persistent." These new phrases will be defined by frequency and intensity in order to differentiate the two. Organizations should begin now to establish specific definitions and educate physicians.
In ICD-9 the time requirement to code a "subsequent MI" is 6 weeks. However, in ICD-10, the same time frame is shortened to only 4 weeks.
- Peri-Natal and Post-Partum
The diagnosis times for post-partum issues and peri-natal issues are also changing in ICD-10. These can be found in the obstetrics section.
In MCD11, the urinary system, ICD-9 combines intra-op and post-op complications. These are separated in ICD-10.This will force closer scrutiny of the op notes and post-op notes to determine the time of the complication.
Clinical documentation under ICD-10 requires much more detail and specificity. Coders and physician, who have been at it for years, will have to learn all about the new "times" and incorporate them into their every day vernacular. So, in may ways, the times they are a changin'!
It used to be that clinical documentation improvement (CDI) specialists were trained on the job. OJT was the only path to a CDI position. But, just like the world of coders, an evolution has occurred. Many CDI specialists now undergo formalized training. New certification testing and credentialing programs have become available, further legitimizing the need for heightened levels of documentation completeness and integrity.
- Certified in Clinical Documentation Integrity (C-CDI) from (DocuComp)
- Certified Clinical Documentation Specialist (CCDS) from (ACDIS - HCPro)
- Coming this fall...AHIMA certification in CDI, Clinical Documentation Improvement Professional (CDIP)
Obtaining one of these credentials and pursuing a CDI position is an ideal career path for any health information management (HIM) professional. Jobs are plentiful and opportunities continue to expand for several reasons. Accurate and complete documentation is necessary for quality data; which in turn supports quality outcomes and reporting. Clinical documentation is the foundation for clinical coding; and will become even more important under ICD-10. New auditing and regulatory bodies rely on CDI expertise: ARRA/HITECH, audits-RAC, MAC, MIP etc-and by technology-EHRs.
The technological language of the electronic medical record and the clinical language changes needed to accurately code under ICD-10 are a major focus for CDI professionals; and will be for many years to come. Here are a few tips for existing CDI professionals and our future recruits:
- Stay educated and be aware of what's coming up.
- Continually incorporate regulatory changes into your CDI programs.
- Remember to address the multiple requirements mentioned; they are interwoven into the changing healthcare paradigm.
- Provide high level feedback on your program results to all key stakeholders.
If you decide to pursue a CDI credential, I personally welcome you to the fold. Never before has this profession been so exciting, dynamic and full of opportunity!
Another area where clinical documentation improvement (CDI) and ICD-10 should be coming together now is that of standardized queries. Where are your queries in the transition to ICD-10? Best practice suggests that you should look at them now and update them sooner; rather than later!
Most hospitals already have a series of standard queries in commonly occurring diagnoses. These may include such areas as:
- Heart Failure
- Surgical Debridement
- Sepsis vs. Bacteremia
- COPD / Asthma
- Renal disease
- Neurological conditions
These are some common examples, but certainly not all. The point is that standardized queries are already in place and with some diligence they can be used as a catalyst for better physician documentation under ICD-10. The process is fairly straight forward:
- Collect and review all existing queries
- For each query, identify what additional documentation will be needed to code correctly in ICD-10
- Assign staff to update the queries
- Slowly start using the new queries on current cases
- Use your physician champion to get physicians up to speed
By updating and using ICD-10 ready queries now, you'll bring physicians along slowly and minimize disruption at ICD-10 go-live. The updates should be written by a CDI specialist using the same criteria that went into the initial query. For example, do not lead the physician in a particular direction. Be general and let the physician give the appropriate documentation and let the diagnosis fall where it may.
Granted the issue of complication and co-morbidity (CC) and major complication and co-morbidity (MCC) is still an open item in ICD-10 and may require further changes to your queries. However, don't let this stop your progress. Keep your query updates going forward. After all CDI is an ongoing continuous process.
One of the keys to successful weight loss is taking smaller bites over a long period of time. The same holds true for improving clinical documentation in preparation for ICD-10.
Everyone knows that on Tuesday, Oct. 1, 2013, will start coding in ICD-10, at least for Medicare. The directive to implement I-10 is fueling clinical documentation improvement (CDI).
CDI involves a variety of clinicians and hospital staff, but the biggest area of change is physician documentation. Do not wait and make this mistake of trying to implement CDI for ICD-10 using the big bang approach. Physicians do not typically do well with massive one time change. They do much better with small incremental change -- bite size.
Many of the physicians I have worked with over the years fall into the "just tell me what to say" category. That is, they are amenable to change, but they want it fed to them slowly, easily and directly. The best practice is small incremental change fed to them in short (10 - 20 minutes) timeframes. Clearly, making the changes that give the biggest bang for the buck should be first priority. So, put those changes into effect as soon as possible and make them second nature to your physicians. You can use "lunch and learns," pocket cards and other small reminders in the CDI process. Remember, this needs to come from physicians to physicians -- as peer-to-peer training has proven itself far superior to any other methodology.
This process should be interactive. Audit now, implement CDI, audit again and then tweak training -- as CDI should be a continuous process and not your final destination. A last reminder is if you are using CDI to deal with I-9 issues, you can achieve economies of scale by implementing I-10 changes at the same time. For more information on making your CDI program ICD-10 ready, visit my ICD-10 blog.
Blog titles are supposed to be catchy to get your attention and make you want to read further. At least, that is what I was told. A blog titled "unspecified" is not something most people would understand and be drawn to. But, if you work in the world of HIM coding, or clinical documentation improvement, then you know that ‘unspecified" has ramifications.
The transition to ICD-10 has the potential to greatly increase the number of unspecified codes. This could cause many problems for your institution. For starters, unspecified typically drives lower reimbursement to your facility. Lowering your revenue in a time of increased expenses driven by healthcare changes is not a formula for job security. Secondly, unspecified will decrease your severity of illness. This takes the wind out of your sails when you try to make the case that your "patients are sicker". This may drive denials at pre-authorization based on severity. Third, unspecified is an immediate red flag for conducting more internal coding and documentation audits. Bottom line...you need to try and eliminate unspecified before 2013.
Solving the problem of "unspecified" is simple in concept. That is, simply "specify." The problem, of course, is that you need to get the physicians to specify the particulars required by ICD-10. Getting to the documentation granularity required by ICD-10 is going to require clinical documentation improvement (CDI) and, in most cases, a lot of it.
How much CDI do you need? Well, the best practice would say do an audit of your high volume, high revenue cases and code them to ICD-10 and see where they fall. This will tell you how much change you need and give you a wealth of information to help drive your CDI program. The I-9 codes tell you where you are, the gap analysis will steer you organization successfully towards ICD-10. For more information on making your CDI program ICD-10 ready, visit my ICD-10 blog.