Thoughts on today's conference call
Long rant coming...
I noted that our discussion about medical necessity/CMI yesterday was pulled into today's presentation, so I'm just throwing out some questions/comments:
It was said during the presentation that even though there's a diagnosis, the facts of the case have to support it. I agree with this, but as a matter of practicality, I'm not sure how to make this happen. We're not supposed to question the provider's clinical judgment. I once queried a physician who documented ABLA in the presence of completely normal labs and no treatment, asking for clinical support for the dx, and was basically told "because I said so." We have sepsis documented when there are no SIRS indicators and the patient doesn't look all that sick. We have coders taking sepsis because the pt was admitted on their last day of abx for line sepsis diagnosed four weeks earlier. Our CDI program and our software doesn't understand asking for lower, but more compliant, DRGs, either. Need help here.
I did an inservice last month with our hospitalists on symptom codes and spent some time talking to them about medical necessity and how the RACs are slamming hospitals for lack thereof, and why they need to document accordingly. But at the same time, like someone posted yesterday, the company that CM uses to approve admissions is killing us by approving everything. How do we backtrack and make the silk purse out of a sow's ear? The clinical justification just isn't there...what to do? They also talked today about working w/CM on getting the documentation to support medical necessity. I am actually in the CM department and I couldn't tell you what a single CM looks like. I once sent over to CM a question where the pt was in IP status but the doctor had written in his note, "admit for 23 hour observation," and had my head bitten off by the recipient. So I don't any more. I'm just sayin'. We in CDS don't have access to IQ/Milliman and it's been years since I used them, so I don't know the criteria as well as I could. I think that's why I'm really interested in the earlier thread about putting CDS in the ER.
Another topic mentioned that is near and dear to my heart is how to do a proper evaluation of the CDI program. Right now we are measured on the # of reviews, the # of queries, the # of "impact" queries, the response rate, and how well we match the coder's final DRG, and, of course, the dollar impact. All BS, IMO. When I suggest that we dump the metrics I am told there needs to be something they can measure. I want to be able to present an alternative universe where our performance is measured in a meaningful, qualitative rather than quantitative manner. I've done lots of searches and haven't found an answer.
Sorry for the rant. Ok, not really.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
I noted that our discussion about medical necessity/CMI yesterday was pulled into today's presentation, so I'm just throwing out some questions/comments:
It was said during the presentation that even though there's a diagnosis, the facts of the case have to support it. I agree with this, but as a matter of practicality, I'm not sure how to make this happen. We're not supposed to question the provider's clinical judgment. I once queried a physician who documented ABLA in the presence of completely normal labs and no treatment, asking for clinical support for the dx, and was basically told "because I said so." We have sepsis documented when there are no SIRS indicators and the patient doesn't look all that sick. We have coders taking sepsis because the pt was admitted on their last day of abx for line sepsis diagnosed four weeks earlier. Our CDI program and our software doesn't understand asking for lower, but more compliant, DRGs, either. Need help here.
I did an inservice last month with our hospitalists on symptom codes and spent some time talking to them about medical necessity and how the RACs are slamming hospitals for lack thereof, and why they need to document accordingly. But at the same time, like someone posted yesterday, the company that CM uses to approve admissions is killing us by approving everything. How do we backtrack and make the silk purse out of a sow's ear? The clinical justification just isn't there...what to do? They also talked today about working w/CM on getting the documentation to support medical necessity. I am actually in the CM department and I couldn't tell you what a single CM looks like. I once sent over to CM a question where the pt was in IP status but the doctor had written in his note, "admit for 23 hour observation," and had my head bitten off by the recipient. So I don't any more. I'm just sayin'. We in CDS don't have access to IQ/Milliman and it's been years since I used them, so I don't know the criteria as well as I could. I think that's why I'm really interested in the earlier thread about putting CDS in the ER.
Another topic mentioned that is near and dear to my heart is how to do a proper evaluation of the CDI program. Right now we are measured on the # of reviews, the # of queries, the # of "impact" queries, the response rate, and how well we match the coder's final DRG, and, of course, the dollar impact. All BS, IMO. When I suggest that we dump the metrics I am told there needs to be something they can measure. I want to be able to present an alternative universe where our performance is measured in a meaningful, qualitative rather than quantitative manner. I've done lots of searches and haven't found an answer.
Sorry for the rant. Ok, not really.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Comments
Wow. We just had almost this same discussion in our office this morning. I completely agree with you!
Thank you for sharing your thoughts below...Please contact me directly if you wish to discuss your thoughts further.
Glenn
Would really like some ideas/responses re this problem.
Thanks,
*************************
We're not supposed to question the provider's clinical judgment. I once queried a physician who documented ABLA in the presence of completely normal labs and no treatment, asking for clinical support for the dx, and was basically told "because I said so." We have sepsis documented when there are no SIRS indicators and the patient doesn't look all that sick. We have coders taking sepsis because the pt was admitted on their last day of abx for line sepsis diagnosed four weeks earlier.
Sharon
--=_alternative 006768778625789C_=
Content-Type: text/plain; charset="US-ASCII"
Renee, your points here are extremely on the mark.
We are not taking care of the patients, therefore clinically cannot make a
judgement of appropriateness of diagnoses made by the physicians. My
soapbox is to take those scenarios to my physician advisor. He can then
review the chart for the diagnosis and supporting documentation. Then
decide to let the diagnosis stand or talk to the physician. We are not to
question their judgement nor are the coders. There are times when the drs
will ask me what does Medicare want me to say and what tests will I need
to support this. Sad world, but the drs are starting to understand the
game. But they still do not want to be questioned on their judgements.
Education is the key, not calling them out on particulars.
My experience with CM is they are extremely busy people. Although they
have access to physician more readily then CDI here, their business of the
patient is a priority. Strapping CDI to their backs may not particularly
be the best mechanism. It will cause the same animosity as with the
scenarios that we are trying to coders with the coding dept.
lastly, in a perfect world there would be no productivity or performance
measures, but that just doesn't exist and never will. The hospitals have
to meet certain measures by CMS, contacts, etc. So expecting this area
not too is blue cloud thinking. I know we (including me) would all like
the focus to be on documentation and not revenue, but rationalizing the
space I am taking in the hospital will be remain a priority.
Stacy Vaughn, RHIT, CCS, CCDS
Data Support Specialist/DRG Assurance
Aurora Baycare Medical Center
2845 Greenbrier Rd
Green Bay, WI 54311
Phone: (920) 288-8655
Fax: (920) 288-3052
I do leave queries for clarification if Sepsis is documented by the physician and there are no signs and symptoms of sepsis in the record. Sometimes it is corrected and other times it is not. When I have time, I do approach the physician so we can discuss their documentation.
I think as RN's and CDIS we should read the chart and use our clinical knowledge to ask questions.
Tracy M Peyton RN, CCDS
Case Management
814-558-0406
I think we should meet for drinks...Lots of them:) Actually, I hear you loud and clear. I think the most frustrating part of CDI is that there is a segment of the hospital "powers that be" that give us lip service or just feel that we are just out to get that MCC. I take my job very seriously, and whatever I can do to help "the cause", I will do.
All that being said. I would really like to have the quarterly conference call be about actual clinical issues and less about the value of CDI. I know my value...Can we have more of the clinical focus? Please?
I have submitted those queries with mixed results. But hopefully they are at least a teaching tool. Speaking one on one with the physician and explaining the situation (mentioning RAC) can be helpful in curtailing those diagnoses without clinical evidence.
As for CM, my CM is overwhelmed with the amount of discharge planning on myb floor as we have some of the worst placement problems. I wouldn't dream of dumping something else in her lap.
NBrunson RHIA, CCDS
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 26, 2011 12:56 PM
To: Salinas, Sharon
Subject: re:[cdi_talk] Thoughts on today's conference call
Renee,
I think we should meet for drinks...Lots of them:) Actually, I hear you loud and clear. I think the most frustrating part of CDI is that there is a segment of the hospital "powers that be" that give us lip service or just feel that we are just out to get that MCC. I take my job very seriously, and whatever I can do to help "the cause", I will do.
All that being said. I would really like to have the quarterly conference call be about actual clinical issues and less about the value of CDI. I know my value...Can we have more of the clinical focus? Please?
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: ssalinas@barlow2000.org
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12538092.1a48df689a710d0d4e067dc4c85563ef@hcprotalk.com
---
Copyright 2010
HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
We have lost money due to lack of medical necessity and clinical indicators not supporting the diagnosis MD documented.
We do not question a diagnosis once it is documented by our MD (even if it does not make sound clinical sense).
These charts, in my opinion, should be handled MD to MD. We have not been very successful with this issue. Perhaps when the RACs come administration will pay more attention to all of those lost healthcare dollars and become more involved with this issue.
Renee's "rant" is all too familiar.
Each query begins with-
"In an effort to obtain documentation that will clarify conflicting, ambiguous, or incomplete information contained in the medical record and to bridge the gap between clinical language and reportable terms, we pose the following question to you. Please document your response in the progress notes and continue through to the Discharge Summary".
If the final DRG goes to a lower weighted DRG after it is coded, we capture the potential loss that would have been recouped by a RAC audit denial.
Very nice!
Sharon Cole, RN, CCDS
CDI Specialist
Case Management Dept
Providence Health Center
254.751.4256
srcole@phn-waco.org