Meeting Dues question
Hello,
We are in the process of trying to coordinate the Virginia State Chapter into an official chapter with officers etc. I have noticed in the toolkit I received from ACDIS that some of the states collect Dues......
I wound enjoy any feedback from the group if you find this successful.
Thank you
Lisa Romanello, RN,BSN,FNS,CCDS
CDI Specialist
CJW Medical Center
Chippenham Campus
804-228-6527
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 1:08 PM
To: Romanello Angelisa
Subject: RE: [cdi_talk] Resp Failure and AHRQ
Thanks Paul.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 12:58 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Resp Failure and AHRQ
The term 'postoperative' is confounding - I won't go into details due to my time constraints, but suffice to say the Index of Disease and Coding Clinic (coder compelled to follow) have been consistently inconsistent regarding how to interpret and code conditions stated as 'postoperative'.
One case in point - a coder 'must' code the term postoperative ileus as a complication.
However, other conditions termed as postoperative are not defaulted as a 'complication'
I agree it would be 'best' not to encourage staff to use this term - in my mind, it applies only to a time table, rather than establishing cause & effect - but, be aware coders are 'forced' to use certain codes for complications with such terminology. Given the tremendous time crunch faced by coders, don't expect a coder to query every time this term is charted - it won't happen in the 'real world'.
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
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 9:50 AM
To: Evans, Paul
Subject: RE: [cdi_talk] Resp Failure and AHRQ
I would be wary of making a facility or system specific determination that post-op refers to "time" and not to linkage/cause. I am not so sure the RACs and others would be ok with this determination in absence of a query to clarify in each case what the physician intended to convey. (I placed a query yesterday for "post-procedure NSTEMI", I could tell that it was clearly due to the pt's CAD and severe anemia, but we know that coders are not allowed to interpret, so a query was the safest, most compliant way to get accurate documentation).
Mark
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
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 11:53
To: Dominesey, Mark N.
Subject: RE: [cdi_talk] Resp Failure and AHRQ
Oh what a topic!
We were discussing this yesterday with coders as well. Some time ago we decided as a group to code the word "post op" as an indication of time as opposed to complication. We decided the MD needs to make the link before a complication will be coded. If the CDS sees that a complication did arise from surgery but that MD is not calling it as such, we will query the MD to verify if "xxxxxx" is a complication of surgery or inherent in the surgery. However, we listened to a webinar that gave us a conflicting opinion. We would also appreciate hearing how the majority of CDI teams are addressing this.
As for resp insufficiency (ARI), I am on the fence with this and need more clarification. I read Dr. Gold's article several months ago. I presented it immediately to our Coding manager who stated that Dr. Gold does not cite coding clinic, coding guidelines, or other research based guidelines in his article. He stated it is his "opinion". So I have been looking for something definitive. In my search, I found some references in the CDI pocket guide on page 43 regarding postop resp. insufficiency. But, I did not find a good definition of when to use ARI.
Coding clinic, 1988, Third Quarter states "when the terms of pulmonary or respiratory insufficiency are used by the physician, it is usually not in a setting of impending life-threatening conditions or the need for endotracheal intubation (as with ARDS)". Is there any guidance more current?
Can any of the Coding Gurus help me out with understanding if this means ARI is a viable term in regards to resp status even regardless of post op status. It is a code-able cc.
Thank you in advance.
-Jane
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 6:55 AM
To: Hoyt, Jane RN
Subject: RE: [cdi_talk] Resp Failure and AHRQ
Thanks Juli,
Have you seen the ACDIS article "documenting the term insufficient is insufficient"? My coding manager and I were just discussing these issues yesterday (she is a part of our CDI team) and then I came across this artivle this AM. Dr. Gold suggests that we should not be encouraging the documentation of resp insufficiency under ANY circumstances. Interesting, right?
http://www.hcpro.com/acdis/details.cfm?content_id=271879
One of the things I have been struggling with in regards to respiratory failure is that there have been several recent changes and code additions, so it can be difficult to filter through and determine which guidance is relevant and/or most appropriate currently.
I would love more input from CDS' about whether they are querying for "insufficiency".
Additionally, I would appreciate input from Coders (or CDI's with this knowledge) about what their coding team requires in the documentation before they assign a post-op resp failure/insufficiency.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 8:38 AM
To: Kathryn Good
Subject: RE: [cdi_talk] Resp Failure and AHRQ
KATY
GOOD MORNING! DIFFERENT PLACE, SAME ISSUE!~
I CAN ADD THAT WHEN OUR CONSULTANT GROUP WAS HERE IN JULY THEY ADVISED TO ADD "POST OP PULMONARY INSUFFICIENCY" TO OUR "RESP FAILURE" QUERY". THEY DID NOT HOWEVER GIVE US ANY INDICATORS. IN LOOKING AT THE ACDIS SIGHT REGARDING THAT SAME ISSUE, (THERE IS A POST REGARDING POST-OP PULM INSUFF), THE DEFENITION USED IN THE POST IS "A DECREASE IN NORMAL PULM FUNCTION DUE TO TRAUMA TO THE THORACIC CAVITY AND/OR SURGICAL INTERVENTION"......
The guidelines THEY asked their physicians to consider are as follows:
Has pulmonary/critical care medicine been consulted?
Has the patient experienced increased oxygen requirements over time?
Has the patient required frequent respiratory treatments over and above incentive spirometry more than 24 hours post-op?
Are chest x-rays being frequently monitored?
Are pleural effusions being monitored or treated?
So WE TOO ARE RESEARCHING THE SAME ISSUES AS YOU KATY...WILL BE INTERESTING TO SEE WHAT COMES UP FOR THIS TOPIC!
Juli Bovard RN CCDS
Regional Health
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 5:41 AM
To: Bovard, Juli
Subject: [cdi_talk] Resp Failure and AHRQ
Hello All!
I am trying to work out some comprehensive education for our CDI and Coding team regarding Respiratory Failure. I will be including Acute Resp Failure, Chronic Resp Failure, and Post-op Resp Failure in this discussion. Of course, I am stuck on Post-op resp failure issues. I have read the coding clinics and other resources I found on ACDIS and I understand the post-op period and all that. I have two questions:
1. What kind of documentation do you (or your facility) expect in order to tie the resp failure to surgery? I understand that Resp failure should not be assigned if it is routine for the procedure. I also know that the ICD-9 index suggests that an explicit link to surgery must be made to assign a complication. Since there are discrepancies regarding use of the term “Post-op” (link or time frame?), do you expect further documentation to establish a link before coding Post-op ARF or do you code Post-op ARF if the resp failure occurs after surg (or is extended past the usual surgical window) regardless of whether the MD specifically states that the conditions are linked?
2. Am I correct in my understanding that 518.51 and 518.53 are currently included in PSI11 for AHRQ and that 518.51 and 518.84 are no longer tracked for these purposes? I am looking at the website (pg 15 of the file below) and it appears that this is what happened in March 2012, but I want to be sure I am providing the correct information.
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V44/PSI_Changes_4.4.pdf
Anything else that anyone would like to weigh in on would be greatly appreciated as well.
Thanks!!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
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Copyright 2012
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
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Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
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Copyright 2012
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923 The Denver Health email system has made the following annotations ---------------------------------------------------------------------CONFIDENTIALITY NOTICE - This e-mail transmission, and any documents, files or previous e-mail messages attached to it may contain information that is confidential or legally privileged. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that you must not read this transmission and that any disclosure, copying, printing, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify the sender by telephone or return e-mail and delete the original transmission and its attachments without reading or saving in any manner. Thank you.
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We are in the process of trying to coordinate the Virginia State Chapter into an official chapter with officers etc. I have noticed in the toolkit I received from ACDIS that some of the states collect Dues......
I wound enjoy any feedback from the group if you find this successful.
Thank you
Lisa Romanello, RN,BSN,FNS,CCDS
CDI Specialist
CJW Medical Center
Chippenham Campus
804-228-6527
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 1:08 PM
To: Romanello Angelisa
Subject: RE: [cdi_talk] Resp Failure and AHRQ
Thanks Paul.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 12:58 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Resp Failure and AHRQ
The term 'postoperative' is confounding - I won't go into details due to my time constraints, but suffice to say the Index of Disease and Coding Clinic (coder compelled to follow) have been consistently inconsistent regarding how to interpret and code conditions stated as 'postoperative'.
One case in point - a coder 'must' code the term postoperative ileus as a complication.
However, other conditions termed as postoperative are not defaulted as a 'complication'
I agree it would be 'best' not to encourage staff to use this term - in my mind, it applies only to a time table, rather than establishing cause & effect - but, be aware coders are 'forced' to use certain codes for complications with such terminology. Given the tremendous time crunch faced by coders, don't expect a coder to query every time this term is charted - it won't happen in the 'real world'.
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
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 9:50 AM
To: Evans, Paul
Subject: RE: [cdi_talk] Resp Failure and AHRQ
I would be wary of making a facility or system specific determination that post-op refers to "time" and not to linkage/cause. I am not so sure the RACs and others would be ok with this determination in absence of a query to clarify in each case what the physician intended to convey. (I placed a query yesterday for "post-procedure NSTEMI", I could tell that it was clearly due to the pt's CAD and severe anemia, but we know that coders are not allowed to interpret, so a query was the safest, most compliant way to get accurate documentation).
Mark
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
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 11:53
To: Dominesey, Mark N.
Subject: RE: [cdi_talk] Resp Failure and AHRQ
Oh what a topic!
We were discussing this yesterday with coders as well. Some time ago we decided as a group to code the word "post op" as an indication of time as opposed to complication. We decided the MD needs to make the link before a complication will be coded. If the CDS sees that a complication did arise from surgery but that MD is not calling it as such, we will query the MD to verify if "xxxxxx" is a complication of surgery or inherent in the surgery. However, we listened to a webinar that gave us a conflicting opinion. We would also appreciate hearing how the majority of CDI teams are addressing this.
As for resp insufficiency (ARI), I am on the fence with this and need more clarification. I read Dr. Gold's article several months ago. I presented it immediately to our Coding manager who stated that Dr. Gold does not cite coding clinic, coding guidelines, or other research based guidelines in his article. He stated it is his "opinion". So I have been looking for something definitive. In my search, I found some references in the CDI pocket guide on page 43 regarding postop resp. insufficiency. But, I did not find a good definition of when to use ARI.
Coding clinic, 1988, Third Quarter states "when the terms of pulmonary or respiratory insufficiency are used by the physician, it is usually not in a setting of impending life-threatening conditions or the need for endotracheal intubation (as with ARDS)". Is there any guidance more current?
Can any of the Coding Gurus help me out with understanding if this means ARI is a viable term in regards to resp status even regardless of post op status. It is a code-able cc.
Thank you in advance.
-Jane
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 6:55 AM
To: Hoyt, Jane RN
Subject: RE: [cdi_talk] Resp Failure and AHRQ
Thanks Juli,
Have you seen the ACDIS article "documenting the term insufficient is insufficient"? My coding manager and I were just discussing these issues yesterday (she is a part of our CDI team) and then I came across this artivle this AM. Dr. Gold suggests that we should not be encouraging the documentation of resp insufficiency under ANY circumstances. Interesting, right?
http://www.hcpro.com/acdis/details.cfm?content_id=271879
One of the things I have been struggling with in regards to respiratory failure is that there have been several recent changes and code additions, so it can be difficult to filter through and determine which guidance is relevant and/or most appropriate currently.
I would love more input from CDS' about whether they are querying for "insufficiency".
Additionally, I would appreciate input from Coders (or CDI's with this knowledge) about what their coding team requires in the documentation before they assign a post-op resp failure/insufficiency.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 8:38 AM
To: Kathryn Good
Subject: RE: [cdi_talk] Resp Failure and AHRQ
KATY
GOOD MORNING! DIFFERENT PLACE, SAME ISSUE!~
I CAN ADD THAT WHEN OUR CONSULTANT GROUP WAS HERE IN JULY THEY ADVISED TO ADD "POST OP PULMONARY INSUFFICIENCY" TO OUR "RESP FAILURE" QUERY". THEY DID NOT HOWEVER GIVE US ANY INDICATORS. IN LOOKING AT THE ACDIS SIGHT REGARDING THAT SAME ISSUE, (THERE IS A POST REGARDING POST-OP PULM INSUFF), THE DEFENITION USED IN THE POST IS "A DECREASE IN NORMAL PULM FUNCTION DUE TO TRAUMA TO THE THORACIC CAVITY AND/OR SURGICAL INTERVENTION"......
The guidelines THEY asked their physicians to consider are as follows:
Has pulmonary/critical care medicine been consulted?
Has the patient experienced increased oxygen requirements over time?
Has the patient required frequent respiratory treatments over and above incentive spirometry more than 24 hours post-op?
Are chest x-rays being frequently monitored?
Are pleural effusions being monitored or treated?
So WE TOO ARE RESEARCHING THE SAME ISSUES AS YOU KATY...WILL BE INTERESTING TO SEE WHAT COMES UP FOR THIS TOPIC!
Juli Bovard RN CCDS
Regional Health
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, October 10, 2012 5:41 AM
To: Bovard, Juli
Subject: [cdi_talk] Resp Failure and AHRQ
Hello All!
I am trying to work out some comprehensive education for our CDI and Coding team regarding Respiratory Failure. I will be including Acute Resp Failure, Chronic Resp Failure, and Post-op Resp Failure in this discussion. Of course, I am stuck on Post-op resp failure issues. I have read the coding clinics and other resources I found on ACDIS and I understand the post-op period and all that. I have two questions:
1. What kind of documentation do you (or your facility) expect in order to tie the resp failure to surgery? I understand that Resp failure should not be assigned if it is routine for the procedure. I also know that the ICD-9 index suggests that an explicit link to surgery must be made to assign a complication. Since there are discrepancies regarding use of the term “Post-op” (link or time frame?), do you expect further documentation to establish a link before coding Post-op ARF or do you code Post-op ARF if the resp failure occurs after surg (or is extended past the usual surgical window) regardless of whether the MD specifically states that the conditions are linked?
2. Am I correct in my understanding that 518.51 and 518.53 are currently included in PSI11 for AHRQ and that 518.51 and 518.84 are no longer tracked for these purposes? I am looking at the website (pg 15 of the file below) and it appears that this is what happened in March 2012, but I want to be sure I am providing the correct information.
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V44/PSI_Changes_4.4.pdf
Anything else that anyone would like to weigh in on would be greatly appreciated as well.
Thanks!!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
---
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Copyright 2012
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health's mission is to provide and support health care excellence in partnership with the communities we serve.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
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Copyright 2012
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Copyright 2012
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923 The Denver Health email system has made the following annotations ---------------------------------------------------------------------CONFIDENTIALITY NOTICE - This e-mail transmission, and any documents, files or previous e-mail messages attached to it may contain information that is confidential or legally privileged. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that you must not read this transmission and that any disclosure, copying, printing, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify the sender by telephone or return e-mail and delete the original transmission and its attachments without reading or saving in any manner. Thank you.
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Copyright 2012
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Comments
Judi Bates
We meet once a quarter (4 times per year.)
Charlene
(Charlie- if I have stated this information incorrectly, please feel free and correct me!)
Twenty-five is reasonable. I also pay this amount yearly for my regional HIM association which also meets quarterly. They also charge $10 for attending meetings and receiving CEU's if you are not a member.
Norma T. Brunson, RHIA, CDIP, CCDS
Deborah A Dallen,RN, CCDS
Albert Einstein Medical Center
Phila PA 19141
Clinical Documentation Coordinator
Health Information Management
215-456-8902
Lisa Romanello, RN,BSN,FNS,CCDS
CDI Specialist
CJW Medical Center
Chippenham Campus
804-228-6527
Leah Taylor, RN, CCDS
NC ACDIS President
Data Integrity Specialist/RAC Coordinator
Iredell Health System
557 Brookdale Drive
Statesville, NC 28687
704-878-7436 office
704-878-4624 fax
leah.taylor@iredellmemorial.org