Finding All Queries — not Just the “Right” Query

By: Fran Jurcak, MSN, RN, CCDS, CCDS-O, Chief Clinical Strategist

The goal of a quality Clinical Documentation Integrity program is to support documentation that identifies ALL of the conditions being monitored and treated during a patient encounter. Clear and simple. Yet many CDI Specialists (CDIS) in our profession spend significant time “shopping” for queries that only impact financial or quality outcomes (SOI/ROM). Not only does this waste significant and valuable CDI time, but the true goal of CD work is to ensure documentation integrity of the complete medical record.

If the clinical evidence supports a condition that is not clearly and consistently documented, best practice would dictate that communication with the provider should occur to ensure accuracy of the medical record. Period. For documentation integrity, the impact of the intervention shouldn’t matter. The need to accurately capture documentation of all the conditions that were assessed, evaluated and cared for in the medical record is essential to accurate coding of the care provided and results in accurate payment and reporting of quality metrics.  

CDI Specialists spend countless precious minutes searching for queries with impact. Thinking that the only way to engage providers is to only “bother” them with queries that matter is short sighted and misses the bigger picture of the value of documentation integrity. In a world with diminishing resources and where integrity of the medical record is so important to capturing true acuity of every patients’ condition, every query opportunity to support documentation integrity is vital.  

If the documentation does not reflect the clinical evidence in the medical record, any and all queries should be communicated with the provider. Picking and choosing the “right” query creates inconsistency that is not only confusing to providers but allows for inaccurate coding and reporting, which can lead to incorrect reimbursement and poor performance in quality metrics.   

Let’s also talk about the time wasted on searching for the right query.  Knowing that resources are limited and time is short (average length of stay is typically below 5 days) there isn’t time to spare for a search-and-seek mentality. CDI Specialists need to stay focused on the job at hand and not spend upwards of twenty minutes hunting for the query that drives a particular metric. All conditions being cared for and monitored should be appropriately documented in the medical record so they can be accurately coded and reported. 

During the current COVID-19 pandemic, we discovered that across our clients, query rates on COVID-19 patients are 33-42% higher than on non-COVID-19 patients. It’s not likely that provider documentation is materially worse for these patients than others. Rather, this seems to point to the fact that due to the perceived need for greater scrutiny on these records to capture all appropriate comorbid conditions for accurate reimbursement and reporting, CDI staff are actually querying for every co-morbid condition. Why just these patient records and not all patient records?  

Many CDI professionals spend additional time concurrently coding the record thinking this will assist them in identifying a query opportunity. While there may be other good reasons to concurrently code a record, doing so to specifically identify impactful query opportunities is often wasted effort as the impact of a query may change due to additional documentation that results later in the stay.  For example, consider a CDIS that spends time searching for a condition that will impact the DRG, say a Major Comorbid Condition (MCC).   So, the CDS searches for a condition that qualifies as an MCC and queries that condition based upon the clinical evidence but does not query other conditions that are also clinically supported but do not qualify as MCC.  Then, later in the stay an additional MCC condition becomes accurately documented, which changes the impact of the query.  The end result is wasted time concurrently coding, often leading to missed query opportunities on other conditions and subsequent negative impact to  accurate documentation, coding and reporting.  If a condition is being monitored and/or treated and not clearly and consistently documented, the documentation should be clarified regardless of the potential impact.

It’s important for CDI Specialists to  utilize their clinical expertise and judgment to determine if there are documentation integrity concerns and communicate with providers to resolve those concerns. While basic knowledge of code language and coding guidelines is important to assist in accurately capturing documentation, CDI professionals should be assessing the clinical evidence in the medical record to identify missed or inaccurate documentation of conditions to support the integrity of medical record documentation. How the condition final codes should be driven by the documentation and completed by professional coders.

So the catch line is this:  While it is important for CDI Specialists to understand coding language and be able to identify appropriate codes for conditions being monitored and treated, CDI Specialists need to focus their attention on supporting documentation integrity and query all documentation concerns, not just those that have financial impact. 

Let’s focus on documentation integrity in every record, not just where we can measure impact.

 

 

Do I Really Need to Query for that Third (or Fourth or Fifth) MCC?

Written By: Rachel Mack, RN, MSN, CCDS, CDIP, CCS
Clinical Program Manager

We all tend to have a number of “firsts” we never forget when it comes to our CDI careers: 

  • First positive interaction with a physician
  • First educational session with a physician group – and it goes well
  • First coder interaction where you have a light-bulb Coding Clinic moment 
  • First time you felt as though you truly impacted patient care

My first example of impacting patient care is when I saw a patient with a slew of clinical indicators for  malnutrition diagnosis (including significant weight loss, decreased PO intake, a pressure ulcer, and a BMI of 12). I did not yet see an order for a dietitian evaluation, and the patient had been in the hospital for several days. I took a risk and sent the query anyway; the next day the physician I sent the query to put in an RD order. That dietitian went on to document that the patient met criteria for severe protein-calorie malnutrition. I thought, “wow, I helped do that.”

But another instance I’ll never forget is opening a denial email from Coding and seeing that an insurance company was denying all three MCCs for one case. 

….three MCCs. No wonder the Coding department had reached out for CDI help!

It’s commonplace for insurance companies to deny whatever they can, whether clinically sound or not. But all three MCCs? I had to dive in and take a look. After review, I discovered that they were partially correct: one diagnosis was incorrectly coded (acute respiratory failure final coded, but was part of a previous visit only), and in our defense letter I acknowledged that yes, we should remove it from the final bill. However, the other two diagnoses – metabolic encephalopathy and septic shock – were above and beyond clinically sound. The patient was confused with a GCS score of 11 that improved to 15 by discharge and was treated with a head CT, sitter, and safety restraints. And the patient was clearly in septic shock and required Levophed s/p aggressive fluid resuscitation to improve their blood pressure. 

So what can CDI specialists do to make sure records are as safe as possible from denials? 

Here at Iodine Software we have a few best-practice suggestions:

  1. Query consistently for clarification of conditions when the clinical indicators are present but there is no associated documentation (or vice versa when it comes to clinical validation).  When we do this consistently, we help teach our providers to consistently document with a higher level of specificity. 
  2. Query consistently regardless of the financial impact to the record. Only querying for a first CC or MCC is no longer acceptable practice in CDI. If we only query for conditions when they impact the DRG, we are doing our physicians and providers a disservice. This behavior has potential positive downstream effects on quality metrics beyond the scope of typical CDI programs.
  3. Query consistently to determine present-on-admission (POA) status of conditions. It’s very easy for us (as clinicians reading the record concurrently) to make assumptions and assume that the coder will realize something is POA.
  4. Query consistently if a condition or conditions are documented in such a way that they are unclear, inconsistent, vague, or non-specific. If a condition is not clear for us reviewing a record concurrently, it will likely not be clear for the coder and is at risk for not final coding or requiring a retro query.

I don’t think we should query simply out of fear of denials. That’s no way to live or to work. But we do have to be aware of the healthcare climate of today. Hospitals are depending on us to prevent denials as much as possible – and confirming accurate documentation of diagnoses irrespective of impact is our responsibility. 

I hope this spurs some critical thinking for CDI specialists. At the least, I hope next time you hear someone say “Yeah, I’m not going to query, this record is maxed out,” you might encourage them to think again.

 

The Future of Clinical Documentation Integrity: Insights from Fran Jurcak (Part II)

You can read Part I of this interview here

Fran Jurcak, MSN, RN, CCDS, CCDS-O
Chief Clinical Strategist
Iodine Software

Fran Jurcak is an accomplished senior executive with over 30 years of success in healthcare practice, education, consulting, and technology. She is currently the Chief Clinical Strategist at Iodine Software where she has worked for four years and has assisted in bringing artificial intelligence machine learning model technology to CDI and coding workflows. Jurcak currently sits on the ACDIS Advisory Board, serves on several other advisory boards, and received the 2017 ACDIS award for Professional Achievement. Prior to joining Iodine, Jurcak was a healthcare consultant, leveraging her clinical and coding knowledge to support process improvement in the mid-revenue cycle, particularly in the clinical documentation integrity space. These process improvements allowed her clients to successfully minimize mid-cycle leakage and accurately report outcomes of care. Additionally, she is the author of the CCDS Study Guide and has co-authored several papers for ACDIS and AHIMA, both organizations which recognize Jurcak as a national speaker.

Q: Some health systems have furloughed CDI staff during COVID-19. Do you think organizations can afford to have smaller CDI teams going forward?

A: In my opinion, it would be smart for programs to evaluate where they are from a staffing perspective in order to make the right decisions moving forward, and I hope they leverage strong data to make these decisions. Now is the time to identify team members’ skill sets and ensure they are aligned in the most appropriate roles. Healthcare leaders should also consider if staff can be leveraged to cross-cover the areas with lower availability or assigned to non-traditional CDI areas of review such as pediatrics, obstetrics, psychiatry, observation, and others. 

In order for CDI programs to survive in this new world where smaller teams may be the norm even as census increases, it will be key to identify the right cases that warrant review. It is more important than ever to leverage technology that creates efficiency and effectiveness in the CDI workflow. Artificial intelligence machine learning models excel at identifying cases where clinical evidence of a condition is present but documentation is lacking specificity or accuracy. Marker-based approaches, on the other hand, partition individual cases into lists based upon the rule but do not identify the likelihood that a true documentation integrity opportunity exists. This can be accomplished through use of machine learning models. It is very important that when we talk about utilizing technology we talk about leveraging the right technology to ensure the right cases are identified at the right time for CDI review.

Q: How can healthcare leaders leverage CDI as they prepare for an uncertain future?

A: There is no doubt that documentation will still be key for reimbursement and quality reporting moving forward, at least in the current world. Regardless of the EHR and the underlying case use, documentation is still vital. Whether it’s an inpatient prospective payment system or an outpatient evaluation and management system, everything is driven by what is documented in the medical record, and that relevancy is not going away, at least not in the short term. Unless there is a major change in the way we pay for healthcare in the United States, documentation of all conditions being monitored and treated is still key – whether it be capturing risk, reimbursement, or quality, it is all driven by the documentation in the medical record. How we document may change moving forward, but the importance of documentation is not going away. It will continue to be vital to identify an efficient workflow that includes technology designed to support accurate, complete and timely documentation for every patient encounter. 

Q: As a leader in the CDI space, how do you think revenue cycle leaders should be thinking about CDI given the impact COVID-19 is having on hospital revenue and reimbursement? 

A: As impactful as the past few months have been for all of us, this is the perfect time for revenue cycle leaders to re-evaluate the expected outcomes of their CDI program and ultimately identify efficiency processes for their program. I think the value of a CDI program is abundantly clear. If anything, I think its value has been heightened by this outbreak. Moving forward, there is a huge opportunity to determine the “new” workflow for CDI.  This starts with identifying the appropriate  technology, the best workflow, and the necessary staffing levels to accomplish the health system’s desired outcomes. Finances are always a key component of a health system’s goals, but I think there are additional quality metrics and concerns that need to be addressed, and this is the perfect opportunity to refocus priorities.

The current healthcare situation highlights the value of CDI programs. Now is the time for hospital executives to reassess their programs and determine which technology best creates workflow efficiency, identify the best people to utilize the technology, and realign expected program outcomes. Knowing that we are all in the midst of a financial crisis, it is truly important to ensure that we have the right tools and staff to achieve the maximum financial and quality outcomes. Now is the time!

The Impact of COVID-19 on Clinical Documentation Integrity: Insights from Fran Jurcak (Part I)

Fran Jurcak, MSN, RN, CCDS, CCDS-O

Chief Clinical Strategist

Iodine Software

Fran Jurcak is an accomplished senior executive with over 30 years of success in healthcare practice, education, consulting, and technology. She is currently the Chief Clinical Strategist at Iodine Software where she has worked for four years and has assisted in bringing artificial intelligence machine learning model technology to CDI and coding workflows. Jurcak currently sits on the ACDIS Advisory Board, serves on several other advisory boards, and received the 2017 ACDIS award for Professional Achievement. Prior to joining Iodine, Jurcak was a healthcare consultant, leveraging her clinical and coding knowledge to support process improvement in the mid-revenue cycle, particularly in the clinical documentation integrity space. These process improvements allowed her clients to successfully minimize mid-cycle leakage and accurately report outcomes of care. Additionally, she is the author of the CCDS Study Guide and has co-authored several papers for ACDIS and AHIMA, both organizations which recognize Jurcak as a national speaker.

Q: What are the greatest challenges faced by CDI teams during the COVID-19 outbreak?

A: Perhaps the biggest challenge has been census fluctuation, and in most cases, a decline in census, which means there are fewer cases for CDI teams to concurrently review. This decrease in census has often resulted in reassignment or furloughing of staff. I also believe the second greatest challenge, specifically for facilities in COVID hotspots, is the limited availability of providers to answer queries. These challenges have caused many CDI teams to change workflow processes to identify the right cases for review, identify appropriate queries, and truly get the answers they need from providers. As a result, many programs are holding records longer than usual before final coding in order to ensure accurate and complete documentation before billing. Increased time to billing increases DNFB and ultimately time before payment is received.

Q: Given the decline in patient volumes, some CDI teams are expanding and adapting their programs. What initiatives do you think should be prioritized?

A: COVID-19 is not just impacting Medicare patients. It is impacting all patients from all payer types, even self pay. Financial reimbursement and quality reporting will continue to depend on the specificity of all conditions requiring accurate and complete documentation in all medical records. This creates a huge opportunity for CDI programs to expand to all payers and ensure that all conditions being monitored and treated during a patient’s encounter are clearly and consistently documented.

Health systems also have the opportunity to expand beyond financially motivated queries to ensure documentation integrity in the entire medical record. To truly capture patient acuity and support the research needed to identify patient patterns that identify at risk populations for COVID-19 and other diseases, CDI teams need to ensure that documentation appropriately captures all of the comorbid conditions that are being monitored and treated during the patient encounter. This means that simply documenting COVID-19 or respiratory failure will not be sufficient; capturing all other comorbidities as well as the specificity of all conditions will be crucial.

At Iodine, we are seeing a mixed bag of initiatives among our clients. For example, some have pulled back on physician-based education because physicians just don’t have additional time as they are busy caring for the influx of COVID-19 patients. Others have spent more time training and educating about COVID-19 and comorbid conditions to ensure they may not have to query as frequently. Census declines have definitely opened the door for CDI programs to reallocate time for additional education and training of their staff – whether it is cross-training to review records in a specialty they are less familiar with, or opening up to other types of inpatient admissions such as pediatrics or obstetrics. Additionally, expanding, supporting, and reinforcing the knowledge base of CDI professionals keeps staff up-to-date during a time of heightened complexity and uncertainty.

Q: In your opinion, can CDI teams stay remote full-time? What do you think the impact will be if remote work continues?

A: There are portions of what has traditionally been seen as CDI workload that I think can be done remotely. Obviously, electronic health records (EHRs) and most of the technology that CDI specialists are using in their workflow can be accessed remotely. However, engaging providers and ensuring accurate, appropriate, and timely responses requires some level of face-to-face interaction. I’ve seen teams accomplish this a variety of ways. Some programs have a portion of their staff conduct record review remotely while additional staff members interact with providers onsite. Other programs have their entire staff working a few days at home and a few days onsite so they can interact with providers themselves. In person communication is important for maintaining not only interpersonal relationships with providers but also to remind them of the relevance of documentation integrity.

I think remote work will increase moving forward, but the need to monitor quality of work will also increase. The challenge is that quality of work often suffers when teams work remotely. Social distancing makes it easier to stay focused on work, but there will be many more distractions once restrictions are lifted. Leveraging additional staff for internal auditing can help ensure query opportunities are not missed, queries remain compliant, and final codes related to queries are accurately captured. Peer audits also promote shared learning and accountability.

Part II will be published later this week.