HELP

lsipos@monument.healthlsipos@monument.health
edited April 2016 in CDI Talk Archive
What DRG/ code would you use for documented;


* SIRS due to infectious process of INFLUENZA A

* Influenza A

* Pneumonia
TIA

Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]

Comments

  • lsipos@monument.healthlsipos@monument.health
    edited April 2016
    Ok, so before I ask, I want you all to know its note that we don't want to do the work! We have created SEVERAL, (so many) slide shows/ presentations to educate providers-including Residents on the role of the CDI, query, impacts etc. We continue to update and revise them a few times a year. We also create monthly "posters" related to issues and trends we see that need more clearly defined or understood by providers, AND we attend monthly Hospitalist meetings with presentations related to possible alternate DRG's, cc/mcc capture rates, o/e ratio, LOS, SOI etc.

    Having said all this, we have now been asked (tasked :)) to attend the local chapter meeting of CODERS and do a one hour presentation for approximately 150 coders related to CDI role. As I said, we have many presentation geared toward providers, but nothing geared towards coders! So, I was wondering if anyone has even created a presentation geared towards this group? Coders are inpatient, outpt, new, old, seasoned, and novice! If someone has a presentation would they be willing to share it? That way we don't have to re-invent the wheel! TIA.

    I appreciate any help!

    Juli

    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    755-8426 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]

  • lsipos@monument.healthlsipos@monument.health
    edited April 2016
    Good morning and Help! Can anyone assist in helping me identify if, and how you measure query "agree and disagree" rates an responses. Currently we have a consultant group that initially suggested to us that if a the PROVIDER ANSWERED THE QUERY, it was pretty much an "agree" for the response. There was never an "intent of query" relationship (even though we all know realistically that we are asking for a specific diagnosis on our queries). If they didn't answer the query it was a "no response" and if they answered the query basically as "this is an inappropriate query or not applicable", then it was a "disagree".

    In measuring our agree rates this way, our metrics were reflecting a large % of "agree" responses to queries -98-99%. To me this reflected that we were placing appropriate queries. To our CMO it raised an eyebrow. We have an established CDI program, and perhaps now are wondering if we should change the "physician response" to reflect more specificity in the areas of agree/disagree/no response and unable to determine. We have the ability to change and amend the definitions of the responses to be more reflective of what we want to measure. (which we aren't sure about at this point! :))

    I would be VERY interested to know HOW other institutions measure or relegate responses from providers-relative to a query responses. Currently the suggestion was to change the response to disagree or agree in relationship to "the intent" of the query; meaning, query responded to as, physician agrees or disagrees with "intent of query". That really bothers me, as yes I have an intent for my query every time I place one; ie acute blood loss anemia-but if the provider then answered "pernicious anemia" why then should I give him a disagree (which is the suggestion). I am not an advanced practice RN, nor do I want to diagnose this patient for the provider. So, to me the fact he gave me the response of some kind of anemia, it was enough for an "agree". Another example is acute resp failure; if the patient has indicators for such, and I query for "acute resp failure" and instead get "acute resp distress", I would not "disagree" even though my intent was for "acute resp failure" . I am not the provider-and never laid eyes on this patient!

    PLEASE let me know if you have other suggestions on how to measure and responses you give to disagree and agree for provider query responses!

    Thank you in advance. Please feel free to email me directly to my email;
    jbovard@regionalhealth.com


    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    755-8426 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]
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