Querying for SOI/ROM

mannb1mannb1
in CDI Talk Archive
Hello everyone,
Our CDS/coding team met recently, and the issue of using an encoder/grouper to determine if a query will make a difference in the SOI/ROM was raised. The possibility of not placing the query if it didn't change DRG, add CC/MCC or increase SOI/ROM was discussed, as those would be considered "nuisance" queries.

I remember when I started performing CDI in 2008 that the focus was for integrity of the record, completeness, and specificity. Also, shouldn't the CDI program be compliant, and if you are only looking to increase $$, is that really totally compliant?
Yes, we all want to show the success of our CDI program & efforts, but it just feels like something is being lost here if we HAVE to use the encoder/grouper to determine possible change, and only then to place a query.

I'd really be interested in your thoughts? And am I just being "old fashioned"?

thanks very much,
Becky Mann, RN, CDS
Sutter Solano Medical Center

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Hi, Becky,


    I agree with your sentiment that our purpose should be to focus upon the integrity of the record.

    I personally will sometimes initiate a query knowing as I do so that the DRG and APR/ROM have reached the highest possible scale and a positive response to my query will impact neither the current DRG or ROM - BUT, it may impact the 'next' case, even if I don't review the chart.

    (The thought is that if I query for 'acute respiratory failure' for the patient with Sepsis due to PNA with ATN, the responding MD may better accept a query for the 'next record' or, even better, he or she may spontaneously document the more compliant and precise term of acute respiratory failure rather than insufficiency IF the patient meets criteria for acute respiratory failure

    So, it is a bit complicated - however, from the stand point of compliance and also to acknowledge our role as documentation specialist, I think we should query judiciously for 'significant' conditions and use these as teaching points. I believe we strengthen the integrity of a CDI program if we query in such circumstances. (We label such cases as "educational' in Midas - meaning we used a form citing the current definition of acute renal failure, as one example, and the MD agreed with the query and subsequently documented 'acute renal failure' rather than insufficiency").

    We each have to weigh the time this requires of the CDI team and then query judiciously while also respecting the time of the physician while keeping in mind we 'could query every chart almost every time'.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • donna.kentdonna.kent
    edited May 2016
    I don't think you're being old fashioned at all. We query at times only for SOI/ROM and yet we know it will not change reimbursement. However, not only does it give a more complete and accurate picture for patients discharged alive, but it can truly reflect the severity of illness for our mortalities. We recently did a pivot table to show increase in SOI/ROM from 2008 to 2012 because of intervention by CDI. It is quite significant and meaningful. One other thing to bear in mind though is what your staffing level allows for. In our case we are severely understaffed so we can only concentrate on Medicare. I believe the goal is to help make every record complete and accurate. So we are trying to use our data to make the case for more staff. Hope that helps.

    Donna

    Donna Kent, RN, BSN, CCDS
    Manager, Clinical Documentation Integrity Program
    Clinical Quality and Accreditation
    Torrance Memorial Medical Center
    ph.:310 784-6884  fax:310 784-6899
    donna.kent@tmmc.com
  • mdomineseymdominesey
    edited May 2016
    Wonderful comments!! I always repeat the mantra that I review for SOI, ROM and Quality, and by doing so, the reimbursement invariable follows. Last month, my data crunching showed that only 58% of my queries were financial in nature, the rest did not add financial monies because the DRG was already maxed, but to get clarity and specificity for conditions already documented, and to get an accurate SOI and ROM.

    We all have to remember that we will be called on to educate and query the physicians to ICD-10 standards in the near future, now is as good a time as any to start.

    An experienced CDI Specialist does not place "nuisance queries"; if that is a feature of the culture at your place, it really begs for adjustment through greater acceptance by the docs, having your exec team champion your program, and having the queries audited / 2nd review on a regular basis to ensure that the CDI Specialist is only querying when clinically indicated.

    It IS quality, completeness, compliance, and take-back protection as much as it is reimbursement (and I argue that the reimbursement is a DISTANT second to the reasons stated).

    Then again: if you query for severity, risk, and quality, the reimbursement WILL follow!

    Mark


    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    http://www.sibley.org
    mdominesey@sibley.org
  • donna.kentdonna.kent
    Agree, agree, agree. Can you come convince my VP of same please?

    Donna

    Donna Kent, RN, BSN,
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    Very little to add: Paul, Donna & Mark are right on target.
    ... quality ... completeness ... education ... paint the whole picture ...
    There are operational choices that may need to be made, but NOT policy choices.

    RAC is here; ICD-10 is coming; VBP is starting; Bundling is just down the road; etc....

    "nuisance" queries --
    I suspect many programs have some aspect of that perception to deal with -- culture change takes years, so as Winston Churchill is quoted:
    Never give in.
    Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense.
    Never yield to force.
    Never yield to the apparently overwhelming might of the enemy.

    Simply add my voice to the "sense of the professional community" :)

    Don
  • tpeytontpeyton
    edited May 2016
    I agree....

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    One additional comments regarding dealing with CFO:


    One point I try to make with the financial side of the house (CFO) is that it could be considered 'cherry picking' (and non-compliant) to:

    1. Audit 'only' Medicare
    2. Place a query 'only' when one expects a positive ROI

    I know a CDI program is expected (officially or unofficially) pay for its existence, but still, we risk loss of credibility if we don't query for the sake of quality.

    I don't think some of the CFOs understand the other pressures we face - it is 'good' to show a ROI, and I think any CDI program that compliantly results in more precise documentation will benefit the quality metrics as well as the CMI.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • digardskdigardsk
    edited May 2016
    Totally agree.

    Query for SOI/ROM regardless and the money follows. Don't have the physicians think they only need to be clear and specific in certain cases - they won't ever get to auto pilot!




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  • mdomineseymdominesey
    edited May 2016
    Have you folks ever thought that if we were 100% effective in education and behaviour change that we would be out of a job?

    nah, too much education and change management to do! :)

    MND



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    http://www.sibley.org
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    Have had that thought .... for maybe 30 seconds! :) :o

    As you said, the mountain is just too high...and then "THEY" would just change the rules -- AGAIN!!

    Besides, we've all seen where someone says -- "have CDI do that" (because CDI is effective, because CDI has the relationships, because CDS have such a unique knowledge, personality & skill sets...)

    Don
  • mdomineseymdominesey
    edited May 2016
    Not to mention that CDI Specialists are all a beautiful bunch inside and out with great hair, and warm, inviting, generous personalities

    :)

    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    http://www.sibley.org
  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    AMEN! YOUR GROUP MIRRORS OUR GROUP HERE IN RAPID CITY... A BUNCH OF BRIGHT SHINY PERSONALITIES, ALL BUTTERFLIES AND RAINBOWS!

    JULI BOVARD RN CCDS
    REGIONAL HEALTH
  • tpeytontpeyton
    edited May 2016
    thought about it but then I remember what my consultant taught us....you will always have a job because the docs only retain stuff for 90 days....and they are constantly changing the rules anyway.


    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • afloydafloyd
    Our program is a little over 3 years old and we started from the beginning with the thought to query for clarification on EVERYTHING that we see no matter the financial impact and that has served us well. We have recently been placed under the CFO and he tends to "talk revenue" rather then quality as we are accustomed but, it's all there already in a neat package with the quality side covered as well. We use our 3M grouper as a guide and do find many query opportunites this way but it's only to paint as clear a picture as we can of each patient we see.

    April Floyd, RN, CCDS
    Director of CDCI
    Anderson RMC, Meridian, MS
    601-553-6299
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    New conditions added to code sets every year and ever-shifting definitions coupled with exponentially increasing demand for accurate and clinically coherent code sets mandated by 3rd parties = demand for CDI.

    However, some of the NLP software to issue a query is impressive and will probably perform at least some of the standard queries automatically.




    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • vanessa.falkoffvanessa.falkoff
    Not to mention that CDI Specialists are all a beautiful bunch inside and
    out with great hair, and warm, inviting, generous personalities

    :)

    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP Clinical Documentation
    Excellence Sr. Clinical Documentation Improvement Specialist Sibley
    Memorial Hospital

    You are my FAVORITE now Mark!

    Vanessa Falkoff RN
    Clinical Documentation Coordinator
    University Medical Center
    Las Vegas, NV
    vanessa.falkoff@umcsn.com
    office 702-383-7322
    cell 702-204-0054
  • sbainesbaine
    Paul,

    I like your comment about cherry picking cases. I seem to remember information regarding this same issue as a compliance risk for RAC auditors and OIG. Do you have any informantion on that I can cite at our facility. My research has turned up nill.

    Thanks

    Sara Baine, MSN-Ed, CCDS
    Clinical Documentation Specialist
    Chairman CDMP Taskforce
    SoutheastHEALTH
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Hi, Sara - Overwhelmed at this moment today (lots of admissions) - but, If you remind me with a separate message, I can try to find something for you. Meanwhile, another on this chain may cite a reference for you.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
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