RE: cdi_talk digest: September 08, 2011

sbeattysbeatty
in CDI Talk Archive
We work to get nursing to obtain diagnoses when they take telephone orders. Our coders want it in the record as well, but it supports the query opportunity and over time some of the docs have figured out that if they sign off the order the next day, they should include the diagnosis to avoid the query. At times I think they ARE trainable

Sandy Beatty, RN, BSN, CCDS
Clinical Quality Management
Columbus Regional Hospital
2400 E. 17th Street
Columbus, IN 47201
sbeatty@crh.org



-----Original Message-----
From: CDI Talk digest [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, September 09, 2011 12:00 AM
To: cdi_talk digest recipients
Subject: cdi_talk digest: September 08, 2011

CDI_TALK Digest for Thursday, September 08, 2011.

1. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 2. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 3. RE: hemoptysis as a cc 4. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 5. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 6. re: What do CDS want/need to know about ICD-10?
7. RE: What do CDS want/need to know about ICD-10?
8. re: CHF
9. RE: CHF
10. RE: CHF

----------------------------------------------------------------------

Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
From: "Barnes, Charlene"
Date: Thu, 8 Sep 2011 08:42:46 -0400
X-Message-Number: 1

Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, September 07, 2011 3:21 PM
To: Barnes, Charlene
Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009


Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

Thanks in advance.

Angela Susott, CCS, CCDS, CPC







Stress synergy and collaboration to make your CDI program work

March 5, 2009

CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

“Everyone has a role in this (CDI process),” he says. “Expand the concept of documentation and make it everyone’s responsibility.”

CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

“It’s not more work—the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two,” Krauss says. “They’ve already asked the question.”

Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: “Patient saturation 72% upon arrival in ED, put oxygen on.” The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

“Everyone has a vested interest in producing documentation, not just the quality control people at the end,” he says. “It (good documentation) promotes the value of what all these groups are doing.”

---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

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----------------------------------------------------------------------

Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
From: "Bates, Judith"
Date: Thu, 8 Sep 2011 09:07:14 -0400
X-Message-Number: 2

I may be wrong but I thought that a diagnosis documented in the physicians orders was not acceptable. Needs to be documented in the H&P and progress notes.

Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 08, 2011 8:43 AM
To: Bates, Judith
Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, September 07, 2011 3:21 PM
To: Barnes, Charlene
Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009


Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

Thanks in advance.

Angela Susott, CCS, CCDS, CPC







Stress synergy and collaboration to make your CDI program work

March 5, 2009

CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

"Everyone has a role in this (CDI process)," he says. "Expand the concept of documentation and make it everyone's responsibility."

CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

"It's not more work-the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two," Krauss says. "They've already asked the question."

Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: "Patient saturation 72% upon arrival in ED, put oxygen on." The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

"Everyone has a vested interest in producing documentation, not just the quality control people at the end," he says. "It (good documentation) promotes the value of what all these groups are doing."

---
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---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

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Copyright 2010
HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945 Confidentiality Notice:
This e-mail, including any attachments is the property of Catholic Health East and is intended for the sole use of the intended recipient(s).
It may contain information that is privileged and confidential. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please delete this message, and reply to the sender regarding the error in a separate email.



----------------------------------------------------------------------

Subject: RE: hemoptysis as a cc
From: Kelley Walrath
Date: Thu, 8 Sep 2011 09:24:30 -0400
X-Message-Number: 3

thank you. it sounds like it is an adjective type thing - makes sense.

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, September 07, 2011 4:33 PM
To: Kelley Walrath
Subject: [MARKETING]RE: [cdi_talk] hhemoptysis as a cc

Hemorrhagic is a non-essential modifier for pneumonia codes, therefore, hempotysis should not be coded separately.

Pneumonia (acute) (Alpenstich) (benign) (bilateral) (brain) (cerebral) (circumscribed) (congestive) (creeping) (delayed resolution) (double) (epidemic) (fever) (flash) (fulminant) (fungoid) (granulomatous) (hemorrhagic) (incipient) (infantile) (infectious) (infiltration) (insular) (intermittent) (latent) (lobe) (migratory) (newborn) (organized) (overwhelming) (primary) (progressive) (pseudolobar) (purulent) (resolved) (secondary) (senile) (septic) (suppurative) (terminal) (true) (unresolved) (vesicular) 486


-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, September 07, 2011 1:09 PM
To: Salinas, Sharon
Subject: [cdi_talk] hhemoptysis as a cc

I do not have an encoder so we rely on our icd 9 books. When my pt had hemoptysis and was found to be 2 pneumonia, i thought I could use it as a cc because 486 pneumonia was not on excludes list. but coder did not code it. Coder said 'hemooptysis is a sign and symptom so should not be coded if you know the etiology". most timees, the cause is identified and it is an inherent part of some diseases like tb. I would have expected all of these to appear on the excludes list.

Am i the only one in the dark on this?
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

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----------------------------------------------------------------------

Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
From: Angela McKee
Date: Thu, 8 Sep 2011 10:19:30 -0400
X-Message-Number: 4

Please see the following from coding clinic; Coding from physician orders
Coding Clinic, Third Quarter 2005 Page: 19 to 20 Effective with
discharges: September 15, 2005
Related Information
Question:

A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, "DX: Anxiety." Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order?

Answer:

It would be appropriate to assign a code for anxiety based upon the physician documentation of the condition in the physician?s order.
This advice applies to both verbal and written orders from physicians.
As long as the physician documents a diagnosis and there is no conflicting information elsewhere in the medical record, it is appropriate to code the diagnosis. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis, it is the coder?s responsibility to query the physician to determine if this diagnosis should be included in the final diagnosis.




ﾩ Copyright 1984-2010, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

Thank you,

Angie Mckee, RHIT, CCDS, CCS, CCS-P
Clinical Documentation Specialist
Performance Improvement
University Health Care System
Augusta, Ga. 30901
706-774-7836

-----CDI Talk wrote: -----



To: angelamckee@uh.org
From: CDI Talk
Date: 09/08/2011 08:42AM
Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an
order... I included the CDI Strategy from March 2009

Our coders will not take a diagnosis from physician orders. If it's
not documented consistently throughout the progress notes they
won't use the info.

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com[1]]
Sent: Wednesday, September 07, 2011 3:21 PM
To: Barnes, Charlene
Subject: [cdi_talk] ? regarding nurses asking for a dx for an order...
I
included the CDI Strategy from March 2009


Have any of you met with your nurses and asked them to attach a dx to
an order when receiving phone orders, etc.? We sometimes have
trouble with our surgeons answering things such as anemia (abla)
when a transfusion has been ordered etc. and they clearly have
abla and we were thinking this might be a route we could go. Is
anyone doing this?

Thanks in advance.

Angela Susott, CCS, CCDS, CPC







Stress synergy and collaboration to make your CDI program work

March 5, 2009

CDI professionals should not only work with physicians to clarify
documentation, but should involve all clinical ancillary staff as
well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI,
senior coding and chargemaster consultant with QHR in Brentwood,
TN.

“Everyone has a role in this (CDI process),” he says.
“Expand the concept of documentation and make it
everyone’s responsibility.”

CDI specialists should provide presentations for groups like ED
nurses, wound therapists, nutritionists, and laboratory and
radiology staff on initiatives like the Recovery Audit Contractor
(RAC) program, and on general concepts like medical necessity. If
they understand how appropriate documentation supports these
concepts and initiatives, then clinical staff members can
themselves prompt physicians for diagnoses, Krauss says. For
example, if a physician orders a blood transfusion a nurse may
appropriately ask the physician for the appropriate diagnosis
(acute blood loss anemia, for example).

“It’s not more work—the nurse is already calling the
doctor for a plan of care change, and the bottom line is they just
need the physician to put their thought processes on paper in a
sentence or two,” Krauss says. “They’ve already
asked the question.”

Good nursing notes can also be used to combat denials, which is
another point to stress to clinical staff members to get them
involved in CDI efforts, Krauss says. For example, a nurse wrote
in a medical record: “Patient saturation 72% upon arrival in
ED, put oxygen on.” The nurse told Krauss she gave the
patient oxygen after she called the physician, who then instructed
her to do so. If the nurse wrote why the physician instructed the
use of oxygen the facility could then use this note to defend a
denial for acute respiratory failure.

CDI specialists should view documentation as a manufacturing process
from the time the patient is admitted until the time of discharge,
Krauss says, with the CDI specialist as quality control manager.

“Everyone has a vested interest in producing documentation, not
just the quality control people at the end,” he says.
“It (good documentation) promotes the value of what all
these groups are doing.”

---
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:
cbarnes@hmh.net
If you would like to be removed from CDI Talk, please send a blank
email to
leave-cdi_talk-10927768.7dc3f6d0dadb37d59475edb69e4e51c8@hcprotalk.com
---
Copyright 2010
HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945

---
CDI Talk is offered for networking purposes. For official rules and
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your regulatory source.

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angelamckee@uh.org
If you would like to be removed from CDI Talk, please send a blank
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[1] mailto:cdi_talk@hcprotalk.com
----------------------------------------------------------------------

Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
From: "Bates, Judith"
Date: Thu, 8 Sep 2011 12:32:00 -0400
X-Message-Number: 5

thanks for the info...

________________________________
From: CDI Talk [cdi_talk@hcprotalk.com]
Sent: Thursday, September 08, 2011 10:19 AM
To: Bates, Judith
Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

Please see the following from coding clinic;

Coding from physician orders
Coding Clinic, Third Quarter 2005 Page: 19 to 20 Effective with discharges: September 15, 2005
Related Information

Question:

A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, "DX: Anxiety." Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order?

Answer:

It would be appropriate to assign a code for anxiety based upon the physician documentation of the condition in the physician?s order. This advice applies to both verbal and written orders from physicians. As long as the physician documents a diagnosis and there is no conflicting information elsewhere in the medical record, it is appropriate to code the diagnosis. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis, it is the coder?s responsibility to query the physician to determine if this diagnosis should be included in the final diagnosis.




© Copyright 1984-2010, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

Thank you,

Angie Mckee, RHIT, CCDS, CCS, CCS-P
Clinical Documentation Specialist
Performance Improvement
University Health Care System
Augusta, Ga. 30901
706-774-7836

-----CDI Talk wrote: -----

To: angelamckee@uh.org
From: CDI Talk
Date: 09/08/2011 08:42AM
Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, September 07, 2011 3:21 PM
To: Barnes, Charlene
Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I
included the CDI Strategy from March 2009


Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

Thanks in advance.

Angela Susott, CCS, CCDS, CPC







Stress synergy and collaboration to make your CDI program work

March 5, 2009

CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

“Everyone has a role in this (CDI process),” he says. “Expand the concept of documentation and make it everyone’s responsibility.”

CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

“It’s not more work—the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two,” Krauss says. “They’ve already asked the question.”

Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: “Patient saturation 72% upon arrival in ED, put oxygen on.” The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

“Everyone has a vested interest in producing documentation, not just the quality control people at the end,” he says. “It (good documentation) promotes the value of what all these groups are doing.”

---
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: cbarnes@hmh.net
If you would like to be removed from CDI Talk, please send a blank email to
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---
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

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If you would like to be removed from CDI Talk, please send a blank email to
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Copyright 2010
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Confidentiality Notice:
This e-mail, including any attachments is the
property of Catholic Health East and is intended
for the sole use of the intended recipient(s).
It may contain information that is privileged and
confidential. Any unauthorized review, use,
disclosure, or distribution is prohibited. If you are
not the intended recipient, please delete this message, and
reply to the sender regarding the error in a separate email.

----------------------------------------------------------------------

Subject: re: What do CDS want/need to know about ICD-10?
From: "Debbie Smith"
Date: Thu, 08 Sep 2011 12:45:36 -0400
X-Message-Number: 6

* What is the preferred way to offer this information/class (live or electronic (or both))?

BOTH

*Which type of offering do you think would get the most support from your administration - a live course (travel to a designated class location) or remote training (audio or web-based)?

Honestly, I think at my facility "the price" is what seems to be driving decisions relative to our training. Have been turned down due to "cost" twice recently.

* What topics do you need education on the most or do you feel would be most valuable?
- differences between the ICD-9 to ICD-10 system (CM and PCS coding rules/regs)? NO

- query opportunities (things that you may not be doing now that will affect ICD-10 specificity)? YES

- educating providers (what new documentation is required)?

YES

- Other non-coding related topics

- procedure documentation? YES

* Would your facility pay for you to attend such a class?

Unless it is deemed affordable, I will probably have to pay for my own training.

* If your facility does not subsidize your attendance, do you plan on attending such a class at your own expense?

I think it is necessary to do my job. I would probably pay for it even if I'm not subsidize. I want to go to the Conference also (have been a member of ACDIS for 4 years and we have not been able to get any support with this either) I want to go to the conference this year and need ICD-10 training. I don't know that I can afford to do both will have to "weigh it out"

* How long should such a class be (1, 2, 3 or more days)?

I think it should take as long as is needed to cover the material. I think there would need to be ample "breaks" to allow for "brain Rejuvenation"--don't want to miss anything due to information overload.

* What would be the most opportune time frame to attend this class?
- 2012 (all year) If the training was offered in modules (live webinar and/or on line) and each module could be selected and priced individually then it may be more self paced and could provide practice time between learning sessions as well as more of a "cafeteria plan" based on individual needs.


- 2013 (prior to the start date of ICD-10 (10/1/13))?

* If you have other ideas/comments, please feel free to expand upon this survey.

Would still like to find a CDI--ICD-10 book that offers clinical senerios with answers and rational, to practice and gian confidence in the new system. (selecting the correct Pdx and I-10 diagnosis and procedure codes and determining query opportunity).



----------------------------------------------------------------------

Subject: RE: What do CDS want/need to know about ICD-10?
From: "Maritano, Karen M. :LPH Care Management"
Date: Thu, 8 Sep 2011 10:51:04 -0700
X-Message-Number: 7



-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, September 07, 2011 12:10 PM
To: Maritano, Karen M. :LPH Care Management
Subject: [cdi_talk] What do CDS want/need to know about ICD-10?

HCPro/ACDIS is exploring the feasibility of developing training on ICD-10 especially for CDI Specialists. In order to best meet the needs of the Clinical Documentation Specialists (you guys) it would be helpful to narrow down what, in particular, you feel would be most helpful to support your role as a CDI Specialist.

Please consider addressing the following in your responses (and we hope to get many responses as your replies will "drive" the content!).

* What is the preferred way to offer this information/class (live or electronic (or both))? electronic

*Which type of offering do you think would get the most support from your administration - a live course (travel to a designated class location) or remote training (audio or web-based)? Web based

* What topics do you need education on the most or do you feel would be most valuable? All of the below topics
- differences between the ICD-9 to ICD-10 system (CM and PCS coding rules/regs)?
- query opportunities (things that you may not be doing now that will affect ICD-10 specificity)?
- educating providers (what new documentation is required)?
- Other non-coding related topics
- procedure documentation?

* Would your facility pay for you to attend such a class? Probably not but, if web based, would use work time to attend the class.

* If your facility does not subsidize your attendance, do you plan on attending such a class at your own expense? Not sure at the moment

* How long should such a class be (1, 2, 3 or more days)? Not sure, is two days for medical and one day surgical/procedures appropriate. How long are the daily classes - 6 hrs, 8 hrs or less or possibly a day a month

* What would be the most opportune time frame to attend this class?
- 2012 (all year)
- 2013 (prior to the start date of ICD-10 (10/1/13))? This d/t information being closest to ICD-10 implementation

* If you have other ideas/comments, please feel free to expand upon this survey.

Thanks for your replies - we appreciate your insight and feedback!


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Copyright 2010
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----------------------------------------------------------------------

Subject: re: CHF
From: "April Herod Floyd"
Date: Thu, 08 Sep 2011 16:47:38 -0400
X-Message-Number: 8

We have eight Cardiologist at our facility and I can safely bet we have one that is on the money EVERY time he documents CHF, two that feebly try to document correctly and the rest have to be queried every, single time. Job security, yes! They know I am going to query every time I see it and they answer when queried but are hard pressed to VOLUNTEER anything on their own. I have 13 years of Cardiology nursing background and have worked with these guys, if anything, they know that I am persistent. I think they are just "bucking the system" and don't want to conform quitely to guidelines. At least they answer their queries.....
----------------------------------------------------------------------

Subject: RE: CHF
From: "Evans, Paul"
Date: Thu, 8 Sep 2011 13:58:32 -0700
X-Message-Number: 9

Notable that Cardiology is particularly reported as resistant so
uniformly - the same issue has been noted in my workplace, as well.

Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 08, 2011 1:48 PM
To: Evans, Paul
Subject: re:[cdi_talk] CHF

We have eight Cardiologist at our facility and I can safely bet we have
one that is on the money EVERY time he documents CHF, two that feebly
try to document correctly and the rest have to be queried every, single
time. Job security, yes! They know I am going to query every time I see
it and they answer when queried but are hard pressed to VOLUNTEER
anything on their own. I have 13 years of Cardiology nursing background
and have worked with these guys, if anything, they know that I am
persistent. I think they are just "bucking the system" and don't want
to conform quitely to guidelines. At least they answer their
queries.....
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----------------------------------------------------------------------

Subject: RE: CHF
From: "Bates, Judith"
Date: Thu, 8 Sep 2011 17:31:43 -0400
X-Message-Number: 10

I just said yesterday that when I had to educate the nephrology groups about the importance of AKI with ATN...THEY GOT IT... Not the same with the ongoing issue with CHF. I am glad to hear that you share my pain and I'm not alone!!!

Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 08, 2011 4:59 PM
To: Bates, Judith
Subject: RE: [cdi_talk] CHF

Notable that Cardiology is particularly reported as resistant so
uniformly - the same issue has been noted in my workplace, as well.

Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, September 08, 2011 1:48 PM
To: Evans, Paul
Subject: re:[cdi_talk] CHF

We have eight Cardiologist at our facility and I can safely bet we have
one that is on the money EVERY time he documents CHF, two that feebly
try to document correctly and the rest have to be queried every, single
time. Job security, yes! They know I am going to query every time I see
it and they answer when queried but are hard pressed to VOLUNTEER
anything on their own. I have 13 years of Cardiology nursing background
and have worked with these guys, if anything, they know that I am
persistent. I think they are just "bucking the system" and don't want
to conform quitely to guidelines. At least they answer their
queries.....
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END OF DIGEST

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Copyright 2011
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Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Coding from orders is complaint and allowed per a Coding Clinic already referenced...the only issue would be to ensure that the body of the record o/w supports the coding of the condition. An MD may, for instance, order a chest film indicating 'r/o PNA", and if PNA was not found, it would be correct to code the PNA solely on the basis of the order.




    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, September 09, 2011 4:51 AM
    To: Evans, Paul
    Subject: RE:[cdi_talk] cdi_talk digest: September 08, 2011

    We work to get nursing to obtain diagnoses when they take telephone orders. Our coders want it in the record as well, but it supports the query opportunity and over time some of the docs have figured out that if they sign off the order the next day, they should include the diagnosis to avoid the query. At times I think they ARE trainable

    Sandy Beatty, RN, BSN, CCDS
    Clinical Quality Management
    Columbus Regional Hospital
    2400 E. 17th Street
    Columbus, IN 47201
    sbeatty@crh.org



    -----Original Message-----
    From: CDI Talk digest [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, September 09, 2011 12:00 AM
    To: cdi_talk digest recipients
    Subject: cdi_talk digest: September 08, 2011

    CDI_TALK Digest for Thursday, September 08, 2011.

    1. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 2. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 3. RE: hemoptysis as a cc 4. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 5. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 6. re: What do CDS want/need to know about ICD-10?
    7. RE: What do CDS want/need to know about ICD-10?
    8. re: CHF
    9. RE: CHF
    10. RE: CHF

    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: "Barnes, Charlene"
    Date: Thu, 8 Sep 2011 08:42:46 -0400
    X-Message-Number: 1

    Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

    “Everyone has a role in this (CDI process),” he says. “Expand the concept of documentation and make it everyone’s responsibility.”

    CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

    “It’s not more work—the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two,” Krauss says. “They’ve already asked the question.”

    Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: “Patient saturation 72% upon arrival in ED, put oxygen on.” The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

    “Everyone has a vested interest in producing documentation, not just the quality control people at the end,” he says. “It (good documentation) promotes the value of what all these groups are doing.”

    ---
    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: cbarnes@hmh.net If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-10927768.7dc3f6d0dadb37d59475edb69e4e51c8@hcprotalk.com
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    HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945

    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: "Bates, Judith"
    Date: Thu, 8 Sep 2011 09:07:14 -0400
    X-Message-Number: 2

    I may be wrong but I thought that a diagnosis documented in the physicians orders was not acceptable. Needs to be documented in the H&P and progress notes.

    Judi Bates RN, BSN, CCDS
    CDI Specialist
    856-757-3161
    Beeper 66x2906
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 8:43 AM
    To: Bates, Judith
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

    Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

    "Everyone has a role in this (CDI process)," he says. "Expand the concept of documentation and make it everyone's responsibility."

    CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

    "It's not more work-the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two," Krauss says. "They've already asked the question."

    Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: "Patient saturation 72% upon arrival in ED, put oxygen on." The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

    "Everyone has a vested interest in producing documentation, not just the quality control people at the end," he says. "It (good documentation) promotes the value of what all these groups are doing."

    ---
    CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

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    HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945

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    You are receiving this message as a member of CDI Talk as: batesj@lourdesnet.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-11574448.a103e4a5d44ebf54e5499c03ebb6c706@hcprotalk.com
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    HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945 Confidentiality Notice:
    This e-mail, including any attachments is the property of Catholic Health East and is intended for the sole use of the intended recipient(s).
    It may contain information that is privileged and confidential. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please delete this message, and reply to the sender regarding the error in a separate email.



    ----------------------------------------------------------------------

    Subject: RE: hemoptysis as a cc
    From: Kelley Walrath
    Date: Thu, 8 Sep 2011 09:24:30 -0400
    X-Message-Number: 3

    thank you. it sounds like it is an adjective type thing - makes sense.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 4:33 PM
    To: Kelley Walrath
    Subject: [MARKETING]RE: [cdi_talk] hhemoptysis as a cc

    Hemorrhagic is a non-essential modifier for pneumonia codes, therefore, hempotysis should not be coded separately.

    Pneumonia (acute) (Alpenstich) (benign) (bilateral) (brain) (cerebral) (circumscribed) (congestive) (creeping) (delayed resolution) (double) (epidemic) (fever) (flash) (fulminant) (fungoid) (granulomatous) (hemorrhagic) (incipient) (infantile) (infectious) (infiltration) (insular) (intermittent) (latent) (lobe) (migratory) (newborn) (organized) (overwhelming) (primary) (progressive) (pseudolobar) (purulent) (resolved) (secondary) (senile) (septic) (suppurative) (terminal) (true) (unresolved) (vesicular) 486


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 1:09 PM
    To: Salinas, Sharon
    Subject: [cdi_talk] hhemoptysis as a cc

    I do not have an encoder so we rely on our icd 9 books. When my pt had hemoptysis and was found to be 2 pneumonia, i thought I could use it as a cc because 486 pneumonia was not on excludes list. but coder did not code it. Coder said 'hemooptysis is a sign and symptom so should not be coded if you know the etiology". most timees, the cause is identified and it is an inherent part of some diseases like tb. I would have expected all of these to appear on the excludes list.

    Am i the only one in the dark on this?
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    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: Angela McKee
    Date: Thu, 8 Sep 2011 10:19:30 -0400
    X-Message-Number: 4

    Please see the following from coding clinic; Coding from physician orders
    Coding Clinic, Third Quarter 2005 Page: 19 to 20 Effective with
    discharges: September 15, 2005
    Related Information
    Question:

    A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, "DX: Anxiety." Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order?

    Answer:

    It would be appropriate to assign a code for anxiety based upon the physician documentation of the condition in the physician?s order.
    This advice applies to both verbal and written orders from physicians.
    As long as the physician documents a diagnosis and there is no conflicting information elsewhere in the medical record, it is appropriate to code the diagnosis. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis, it is the coder?s responsibility to query the physician to determine if this diagnosis should be included in the final diagnosis.




    ﾩ Copyright 1984-2010, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

    Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga. 30901
    706-774-7836

    -----CDI Talk wrote: -----



    To: angelamckee@uh.org
    From: CDI Talk
    Date: 09/08/2011 08:42AM
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an
    order... I included the CDI Strategy from March 2009

    Our coders will not take a diagnosis from physician orders. If it's
    not documented consistently throughout the progress notes they
    won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com[1]]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order...
    I
    included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to
    an order when receiving phone orders, etc.? We sometimes have
    trouble with our surgeons answering things such as anemia (abla)
    when a transfusion has been ordered etc. and they clearly have
    abla and we were thinking this might be a route we could go. Is
    anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify
    documentation, but should involve all clinical ancillary staff as
    well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI,
    senior coding and chargemaster consultant with QHR in Brentwood,
    TN.

    “Everyone has a role in this (CDI process),” he says.
    “Expand the concept of documentation and make it
    everyone’s responsibility.”

    CDI specialists should provide presentations for groups like ED
    nurses, wound therapists, nutritionists, and laboratory and
    radiology staff on initiatives like the Recovery Audit Contractor
    (RAC) program, and on general concepts like medical necessity. If
    they understand how appropriate documentation supports these
    concepts and initiatives, then clinical staff members can
    themselves prompt physicians for diagnoses, Krauss says. For
    example, if a physician orders a blood transfusion a nurse may
    appropriately ask the physician for the appropriate diagnosis
    (acute blood loss anemia, for example).

    “It’s not more work—the nurse is already calling the
    doctor for a plan of care change, and the bottom line is they just
    need the physician to put their thought processes on paper in a
    sentence or two,” Krauss says. “They’ve already
    asked the question.”

    Good nursing notes can also be used to combat denials, which is
    another point to stress to clinical staff members to get them
    involved in CDI efforts, Krauss says. For example, a nurse wrote
    in a medical record: “Patient saturation 72% upon arrival in
    ED, put oxygen on.” The nurse told Krauss she gave the
    patient oxygen after she called the physician, who then instructed
    her to do so. If the nurse wrote why the physician instructed the
    use of oxygen the facility could then use this note to defend a
    denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process
    from the time the patient is admitted until the time of discharge,
    Krauss says, with the CDI specialist as quality control manager.

    “Everyone has a vested interest in producing documentation, not
    just the quality control people at the end,” he says.
    “It (good documentation) promotes the value of what all
    these groups are doing.”

    ---
    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:
    cbarnes@hmh.net
    If you would like to be removed from CDI Talk, please send a blank
    email to
    leave-cdi_talk-10927768.7dc3f6d0dadb37d59475edb69e4e51c8@hcprotalk.com
    ---
    Copyright 2010
    HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945

    ---
    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:
    angelamckee@uh.org
    If you would like to be removed from CDI Talk, please send a blank
    email to
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    [1] mailto:cdi_talk@hcprotalk.com
    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: "Bates, Judith"
    Date: Thu, 8 Sep 2011 12:32:00 -0400
    X-Message-Number: 5

    thanks for the info...

    ________________________________
    From: CDI Talk [cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 10:19 AM
    To: Bates, Judith
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

    Please see the following from coding clinic;

    Coding from physician orders
    Coding Clinic, Third Quarter 2005 Page: 19 to 20 Effective with discharges: September 15, 2005
    Related Information

    Question:

    A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, "DX: Anxiety." Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order?

    Answer:

    It would be appropriate to assign a code for anxiety based upon the physician documentation of the condition in the physician?s order. This advice applies to both verbal and written orders from physicians. As long as the physician documents a diagnosis and there is no conflicting information elsewhere in the medical record, it is appropriate to code the diagnosis. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis, it is the coder?s responsibility to query the physician to determine if this diagnosis should be included in the final diagnosis.




    © Copyright 1984-2010, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

    Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga. 30901
    706-774-7836

    -----CDI Talk wrote: -----

    To: angelamckee@uh.org
    From: CDI Talk
    Date: 09/08/2011 08:42AM
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

    Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I
    included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

    “Everyone has a role in this (CDI process),” he says. “Expand the concept of documentation and make it everyone’s responsibility.”

    CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

    “It’s not more work—the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two,” Krauss says. “They’ve already asked the question.”

    Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: “Patient saturation 72% upon arrival in ED, put oxygen on.” The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

    “Everyone has a vested interest in producing documentation, not just the quality control people at the end,” he says. “It (good documentation) promotes the value of what all these groups are doing.”

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    Subject: re: What do CDS want/need to know about ICD-10?
    From: "Debbie Smith"
    Date: Thu, 08 Sep 2011 12:45:36 -0400
    X-Message-Number: 6

    * What is the preferred way to offer this information/class (live or electronic (or both))?

    BOTH

    *Which type of offering do you think would get the most support from your administration - a live course (travel to a designated class location) or remote training (audio or web-based)?

    Honestly, I think at my facility "the price" is what seems to be driving decisions relative to our training. Have been turned down due to "cost" twice recently.

    * What topics do you need education on the most or do you feel would be most valuable?
    - differences between the ICD-9 to ICD-10 system (CM and PCS coding rules/regs)? NO

    - query opportunities (things that you may not be doing now that will affect ICD-10 specificity)? YES

    - educating providers (what new documentation is required)?

    YES

    - Other non-coding related topics

    - procedure documentation? YES

    * Would your facility pay for you to attend such a class?

    Unless it is deemed affordable, I will probably have to pay for my own training.

    * If your facility does not subsidize your attendance, do you plan on attending such a class at your own expense?

    I think it is necessary to do my job. I would probably pay for it even if I'm not subsidize. I want to go to the Conference also (have been a member of ACDIS for 4 years and we have not been able to get any support with this either) I want to go to the conference this year and need ICD-10 training. I don't know that I can afford to do both will have to "weigh it out"

    * How long should such a class be (1, 2, 3 or more days)?

    I think it should take as long as is needed to cover the material. I think there would need to be ample "breaks" to allow for "brain Rejuvenation"--don't want to miss anything due to information overload.

    * What would be the most opportune time frame to attend this class?
    - 2012 (all year) If the training was offered in modules (live webinar and/or on line) and each module could be selected and priced individually then it may be more self paced and could provide practice time between learning sessions as well as more of a "cafeteria plan" based on individual needs.


    - 2013 (prior to the start date of ICD-10 (10/1/13))?

    * If you have other ideas/comments, please feel free to expand upon this survey.

    Would still like to find a CDI--ICD-10 book that offers clinical senerios with answers and rational, to practice and gian confidence in the new system. (selecting the correct Pdx and I-10 diagnosis and procedure codes and determining query opportunity).




    ----------------------------------------------------------------------

    Subject: RE: What do CDS want/need to know about ICD-10?
    From: "Maritano, Karen M. :LPH Care Management"
    Date: Thu, 8 Sep 2011 10:51:04 -0700
    X-Message-Number: 7



    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 12:10 PM
    To: Maritano, Karen M. :LPH Care Management
    Subject: [cdi_talk] What do CDS want/need to know about ICD-10?

    HCPro/ACDIS is exploring the feasibility of developing training on ICD-10 especially for CDI Specialists. In order to best meet the needs of the Clinical Documentation Specialists (you guys) it would be helpful to narrow down what, in particular, you feel would be most helpful to support your role as a CDI Specialist.

    Please consider addressing the following in your responses (and we hope to get many responses as your replies will "drive" the content!).

    * What is the preferred way to offer this information/class (live or electronic (or both))? electronic

    *Which type of offering do you think would get the most support from your administration - a live course (travel to a designated class location) or remote training (audio or web-based)? Web based

    * What topics do you need education on the most or do you feel would be most valuable? All of the below topics
    - differences between the ICD-9 to ICD-10 system (CM and PCS coding rules/regs)?
    - query opportunities (things that you may not be doing now that will affect ICD-10 specificity)?
    - educating providers (what new documentation is required)?
    - Other non-coding related topics
    - procedure documentation?

    * Would your facility pay for you to attend such a class? Probably not but, if web based, would use work time to attend the class.

    * If your facility does not subsidize your attendance, do you plan on attending such a class at your own expense? Not sure at the moment

    * How long should such a class be (1, 2, 3 or more days)? Not sure, is two days for medical and one day surgical/procedures appropriate. How long are the daily classes - 6 hrs, 8 hrs or less or possibly a day a month

    * What would be the most opportune time frame to attend this class?
    - 2012 (all year)
    - 2013 (prior to the start date of ICD-10 (10/1/13))? This d/t information being closest to ICD-10 implementation

    * If you have other ideas/comments, please feel free to expand upon this survey.

    Thanks for your replies - we appreciate your insight and feedback!


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    ----------------------------------------------------------------------

    Subject: re: CHF
    From: "April Herod Floyd"
    Date: Thu, 08 Sep 2011 16:47:38 -0400
    X-Message-Number: 8

    We have eight Cardiologist at our facility and I can safely bet we have one that is on the money EVERY time he documents CHF, two that feebly try to document correctly and the rest have to be queried every, single time. Job security, yes! They know I am going to query every time I see it and they answer when queried but are hard pressed to VOLUNTEER anything on their own. I have 13 years of Cardiology nursing background and have worked with these guys, if anything, they know that I am persistent. I think they are just "bucking the system" and don't want to conform quitely to guidelines. At least they answer their queries.....
    ----------------------------------------------------------------------

    Subject: RE: CHF
    From: "Evans, Paul"
    Date: Thu, 8 Sep 2011 13:58:32 -0700
    X-Message-Number: 9

    Notable that Cardiology is particularly reported as resistant so
    uniformly - the same issue has been noted in my workplace, as well.

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 1:48 PM
    To: Evans, Paul
    Subject: re:[cdi_talk] CHF

    We have eight Cardiologist at our facility and I can safely bet we have
    one that is on the money EVERY time he documents CHF, two that feebly
    try to document correctly and the rest have to be queried every, single
    time. Job security, yes! They know I am going to query every time I see
    it and they answer when queried but are hard pressed to VOLUNTEER
    anything on their own. I have 13 years of Cardiology nursing background
    and have worked with these guys, if anything, they know that I am
    persistent. I think they are just "bucking the system" and don't want
    to conform quitely to guidelines. At least they answer their
    queries.....
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    ----------------------------------------------------------------------

    Subject: RE: CHF
    From: "Bates, Judith"
    Date: Thu, 8 Sep 2011 17:31:43 -0400
    X-Message-Number: 10

    I just said yesterday that when I had to educate the nephrology groups about the importance of AKI with ATN...THEY GOT IT... Not the same with the ongoing issue with CHF. I am glad to hear that you share my pain and I'm not alone!!!

    Judi Bates RN, BSN, CCDS
    CDI Specialist
    856-757-3161
    Beeper 66x2906
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 4:59 PM
    To: Bates, Judith
    Subject: RE: [cdi_talk] CHF

    Notable that Cardiology is particularly reported as resistant so
    uniformly - the same issue has been noted in my workplace, as well.

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 1:48 PM
    To: Evans, Paul
    Subject: re:[cdi_talk] CHF

    We have eight Cardiologist at our facility and I can safely bet we have
    one that is on the money EVERY time he documents CHF, two that feebly
    try to document correctly and the rest have to be queried every, single
    time. Job security, yes! They know I am going to query every time I see
    it and they answer when queried but are hard pressed to VOLUNTEER
    anything on their own. I have 13 years of Cardiology nursing background
    and have worked with these guys, if anything, they know that I am
    persistent. I think they are just "bucking the system" and don't want
    to conform quitely to guidelines. At least they answer their
    queries.....
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    END OF DIGEST

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    Copyright 2011
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  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Edit - meant to state if would "not' be correct to code the PNA if this was not supported with a clinical review of the chart. (Sorry for typo). Sometimes is pretty easy to see coding from the order is okay, but I can't state an order alone always justifies coding assignment solely.



    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, September 09, 2011 12:57 PM
    To: Evans, Paul
    Subject: RE: [cdi_talk] cdi_talk digest: September 08, 2011

    Coding from orders is complaint and allowed per a Coding Clinic already referenced...the only issue would be to ensure that the body of the record o/w supports the coding of the condition. An MD may, for instance, order a chest film indicating 'r/o PNA", and if PNA was not found, it would be correct to code the PNA solely on the basis of the order.




    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, September 09, 2011 4:51 AM
    To: Evans, Paul
    Subject: RE:[cdi_talk] cdi_talk digest: September 08, 2011

    We work to get nursing to obtain diagnoses when they take telephone orders. Our coders want it in the record as well, but it supports the query opportunity and over time some of the docs have figured out that if they sign off the order the next day, they should include the diagnosis to avoid the query. At times I think they ARE trainable

    Sandy Beatty, RN, BSN, CCDS
    Clinical Quality Management
    Columbus Regional Hospital
    2400 E. 17th Street
    Columbus, IN 47201
    sbeatty@crh.org



    -----Original Message-----
    From: CDI Talk digest [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, September 09, 2011 12:00 AM
    To: cdi_talk digest recipients
    Subject: cdi_talk digest: September 08, 2011

    CDI_TALK Digest for Thursday, September 08, 2011.

    1. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 2. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 3. RE: hemoptysis as a cc 4. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 5. RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009 6. re: What do CDS want/need to know about ICD-10?
    7. RE: What do CDS want/need to know about ICD-10?
    8. re: CHF
    9. RE: CHF
    10. RE: CHF

    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: "Barnes, Charlene"
    Date: Thu, 8 Sep 2011 08:42:46 -0400
    X-Message-Number: 1

    Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

    “Everyone has a role in this (CDI process),” he says. “Expand the concept of documentation and make it everyone’s responsibility.”

    CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

    “It’s not more work—the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two,” Krauss says. “They’ve already asked the question.”

    Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: “Patient saturation 72% upon arrival in ED, put oxygen on.” The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

    “Everyone has a vested interest in producing documentation, not just the quality control people at the end,” he says. “It (good documentation) promotes the value of what all these groups are doing.”

    ---
    CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

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    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: "Bates, Judith"
    Date: Thu, 8 Sep 2011 09:07:14 -0400
    X-Message-Number: 2

    I may be wrong but I thought that a diagnosis documented in the physicians orders was not acceptable. Needs to be documented in the H&P and progress notes.

    Judi Bates RN, BSN, CCDS
    CDI Specialist
    856-757-3161
    Beeper 66x2906
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 8:43 AM
    To: Bates, Judith
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

    Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

    "Everyone has a role in this (CDI process)," he says. "Expand the concept of documentation and make it everyone's responsibility."

    CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

    "It's not more work-the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two," Krauss says. "They've already asked the question."

    Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: "Patient saturation 72% upon arrival in ED, put oxygen on." The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

    "Everyone has a vested interest in producing documentation, not just the quality control people at the end," he says. "It (good documentation) promotes the value of what all these groups are doing."

    ---
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    ----------------------------------------------------------------------

    Subject: RE: hemoptysis as a cc
    From: Kelley Walrath
    Date: Thu, 8 Sep 2011 09:24:30 -0400
    X-Message-Number: 3

    thank you. it sounds like it is an adjective type thing - makes sense.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 4:33 PM
    To: Kelley Walrath
    Subject: [MARKETING]RE: [cdi_talk] hhemoptysis as a cc

    Hemorrhagic is a non-essential modifier for pneumonia codes, therefore, hempotysis should not be coded separately.

    Pneumonia (acute) (Alpenstich) (benign) (bilateral) (brain) (cerebral) (circumscribed) (congestive) (creeping) (delayed resolution) (double) (epidemic) (fever) (flash) (fulminant) (fungoid) (granulomatous) (hemorrhagic) (incipient) (infantile) (infectious) (infiltration) (insular) (intermittent) (latent) (lobe) (migratory) (newborn) (organized) (overwhelming) (primary) (progressive) (pseudolobar) (purulent) (resolved) (secondary) (senile) (septic) (suppurative) (terminal) (true) (unresolved) (vesicular) 486


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 1:09 PM
    To: Salinas, Sharon
    Subject: [cdi_talk] hhemoptysis as a cc

    I do not have an encoder so we rely on our icd 9 books. When my pt had hemoptysis and was found to be 2 pneumonia, i thought I could use it as a cc because 486 pneumonia was not on excludes list. but coder did not code it. Coder said 'hemooptysis is a sign and symptom so should not be coded if you know the etiology". most timees, the cause is identified and it is an inherent part of some diseases like tb. I would have expected all of these to appear on the excludes list.

    Am i the only one in the dark on this?
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    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: Angela McKee
    Date: Thu, 8 Sep 2011 10:19:30 -0400
    X-Message-Number: 4

    Please see the following from coding clinic; Coding from physician orders
    Coding Clinic, Third Quarter 2005 Page: 19 to 20 Effective with
    discharges: September 15, 2005
    Related Information
    Question:

    A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, "DX: Anxiety." Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order?

    Answer:

    It would be appropriate to assign a code for anxiety based upon the physician documentation of the condition in the physician?s order.
    This advice applies to both verbal and written orders from physicians.
    As long as the physician documents a diagnosis and there is no conflicting information elsewhere in the medical record, it is appropriate to code the diagnosis. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis, it is the coder?s responsibility to query the physician to determine if this diagnosis should be included in the final diagnosis.




    ﾩ Copyright 1984-2010, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

    Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga. 30901
    706-774-7836

    -----CDI Talk wrote: -----



    To: angelamckee@uh.org
    From: CDI Talk
    Date: 09/08/2011 08:42AM
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an
    order... I included the CDI Strategy from March 2009

    Our coders will not take a diagnosis from physician orders. If it's
    not documented consistently throughout the progress notes they
    won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com[1]]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order...
    I
    included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to
    an order when receiving phone orders, etc.? We sometimes have
    trouble with our surgeons answering things such as anemia (abla)
    when a transfusion has been ordered etc. and they clearly have
    abla and we were thinking this might be a route we could go. Is
    anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify
    documentation, but should involve all clinical ancillary staff as
    well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI,
    senior coding and chargemaster consultant with QHR in Brentwood,
    TN.

    “Everyone has a role in this (CDI process),” he says.
    “Expand the concept of documentation and make it
    everyone’s responsibility.”

    CDI specialists should provide presentations for groups like ED
    nurses, wound therapists, nutritionists, and laboratory and
    radiology staff on initiatives like the Recovery Audit Contractor
    (RAC) program, and on general concepts like medical necessity. If
    they understand how appropriate documentation supports these
    concepts and initiatives, then clinical staff members can
    themselves prompt physicians for diagnoses, Krauss says. For
    example, if a physician orders a blood transfusion a nurse may
    appropriately ask the physician for the appropriate diagnosis
    (acute blood loss anemia, for example).

    “It’s not more work—the nurse is already calling the
    doctor for a plan of care change, and the bottom line is they just
    need the physician to put their thought processes on paper in a
    sentence or two,” Krauss says. “They’ve already
    asked the question.”

    Good nursing notes can also be used to combat denials, which is
    another point to stress to clinical staff members to get them
    involved in CDI efforts, Krauss says. For example, a nurse wrote
    in a medical record: “Patient saturation 72% upon arrival in
    ED, put oxygen on.” The nurse told Krauss she gave the
    patient oxygen after she called the physician, who then instructed
    her to do so. If the nurse wrote why the physician instructed the
    use of oxygen the facility could then use this note to defend a
    denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process
    from the time the patient is admitted until the time of discharge,
    Krauss says, with the CDI specialist as quality control manager.

    “Everyone has a vested interest in producing documentation, not
    just the quality control people at the end,” he says.
    “It (good documentation) promotes the value of what all
    these groups are doing.”

    ---
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    regulations related to documentation and coding, please refer to
    your regulatory source.

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    cbarnes@hmh.net
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    ---
    CDI Talk is offered for networking purposes. For official rules and
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    [1] mailto:cdi_talk@hcprotalk.com
    ----------------------------------------------------------------------

    Subject: RE: ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009
    From: "Bates, Judith"
    Date: Thu, 8 Sep 2011 12:32:00 -0400
    X-Message-Number: 5

    thanks for the info...

    ________________________________
    From: CDI Talk [cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 10:19 AM
    To: Bates, Judith
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

    Please see the following from coding clinic;

    Coding from physician orders
    Coding Clinic, Third Quarter 2005 Page: 19 to 20 Effective with discharges: September 15, 2005
    Related Information

    Question:

    A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, "DX: Anxiety." Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order?

    Answer:

    It would be appropriate to assign a code for anxiety based upon the physician documentation of the condition in the physician?s order. This advice applies to both verbal and written orders from physicians. As long as the physician documents a diagnosis and there is no conflicting information elsewhere in the medical record, it is appropriate to code the diagnosis. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis, it is the coder?s responsibility to query the physician to determine if this diagnosis should be included in the final diagnosis.




    © Copyright 1984-2010, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

    Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga. 30901
    706-774-7836

    -----CDI Talk wrote: -----

    To: angelamckee@uh.org
    From: CDI Talk
    Date: 09/08/2011 08:42AM
    Subject: RE: [cdi_talk] ? regarding nurses asking for a dx for an order... I included the CDI Strategy from March 2009

    Our coders will not take a diagnosis from physician orders. If it's not documented consistently throughout the progress notes they won't use the info.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 3:21 PM
    To: Barnes, Charlene
    Subject: [cdi_talk] ? regarding nurses asking for a dx for an order... I
    included the CDI Strategy from March 2009


    Have any of you met with your nurses and asked them to attach a dx to an order when receiving phone orders, etc.? We sometimes have trouble with our surgeons answering things such as anemia (abla) when a transfusion has been ordered etc. and they clearly have abla and we were thinking this might be a route we could go. Is anyone doing this?

    Thanks in advance.

    Angela Susott, CCS, CCDS, CPC







    Stress synergy and collaboration to make your CDI program work

    March 5, 2009

    CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.

    “Everyone has a role in this (CDI process),” he says. “Expand the concept of documentation and make it everyone’s responsibility.”

    CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).

    “It’s not more work—the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two,” Krauss says. “They’ve already asked the question.”

    Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: “Patient saturation 72% upon arrival in ED, put oxygen on.” The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.

    CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.

    “Everyone has a vested interest in producing documentation, not just the quality control people at the end,” he says. “It (good documentation) promotes the value of what all these groups are doing.”

    ---
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    Confidentiality Notice:
    This e-mail, including any attachments is the
    property of Catholic Health East and is intended
    for the sole use of the intended recipient(s).
    It may contain information that is privileged and
    confidential. Any unauthorized review, use,
    disclosure, or distribution is prohibited. If you are
    not the intended recipient, please delete this message, and
    reply to the sender regarding the error in a separate email.

    ----------------------------------------------------------------------

    Subject: re: What do CDS want/need to know about ICD-10?
    From: "Debbie Smith"
    Date: Thu, 08 Sep 2011 12:45:36 -0400
    X-Message-Number: 6

    * What is the preferred way to offer this information/class (live or electronic (or both))?

    BOTH

    *Which type of offering do you think would get the most support from your administration - a live course (travel to a designated class location) or remote training (audio or web-based)?

    Honestly, I think at my facility "the price" is what seems to be driving decisions relative to our training. Have been turned down due to "cost" twice recently.

    * What topics do you need education on the most or do you feel would be most valuable?
    - differences between the ICD-9 to ICD-10 system (CM and PCS coding rules/regs)? NO

    - query opportunities (things that you may not be doing now that will affect ICD-10 specificity)? YES

    - educating providers (what new documentation is required)?

    YES

    - Other non-coding related topics

    - procedure documentation? YES

    * Would your facility pay for you to attend such a class?

    Unless it is deemed affordable, I will probably have to pay for my own training.

    * If your facility does not subsidize your attendance, do you plan on attending such a class at your own expense?

    I think it is necessary to do my job. I would probably pay for it even if I'm not subsidize. I want to go to the Conference also (have been a member of ACDIS for 4 years and we have not been able to get any support with this either) I want to go to the conference this year and need ICD-10 training. I don't know that I can afford to do both will have to "weigh it out"

    * How long should such a class be (1, 2, 3 or more days)?

    I think it should take as long as is needed to cover the material. I think there would need to be ample "breaks" to allow for "brain Rejuvenation"--don't want to miss anything due to information overload.

    * What would be the most opportune time frame to attend this class?
    - 2012 (all year) If the training was offered in modules (live webinar and/or on line) and each module could be selected and priced individually then it may be more self paced and could provide practice time between learning sessions as well as more of a "cafeteria plan" based on individual needs.


    - 2013 (prior to the start date of ICD-10 (10/1/13))?

    * If you have other ideas/comments, please feel free to expand upon this survey.

    Would still like to find a CDI--ICD-10 book that offers clinical senerios with answers and rational, to practice and gian confidence in the new system. (selecting the correct Pdx and I-10 diagnosis and procedure codes and determining query opportunity).





    ----------------------------------------------------------------------

    Subject: RE: What do CDS want/need to know about ICD-10?
    From: "Maritano, Karen M. :LPH Care Management"
    Date: Thu, 8 Sep 2011 10:51:04 -0700
    X-Message-Number: 7



    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, September 07, 2011 12:10 PM
    To: Maritano, Karen M. :LPH Care Management
    Subject: [cdi_talk] What do CDS want/need to know about ICD-10?

    HCPro/ACDIS is exploring the feasibility of developing training on ICD-10 especially for CDI Specialists. In order to best meet the needs of the Clinical Documentation Specialists (you guys) it would be helpful to narrow down what, in particular, you feel would be most helpful to support your role as a CDI Specialist.

    Please consider addressing the following in your responses (and we hope to get many responses as your replies will "drive" the content!).

    * What is the preferred way to offer this information/class (live or electronic (or both))? electronic

    *Which type of offering do you think would get the most support from your administration - a live course (travel to a designated class location) or remote training (audio or web-based)? Web based

    * What topics do you need education on the most or do you feel would be most valuable? All of the below topics
    - differences between the ICD-9 to ICD-10 system (CM and PCS coding rules/regs)?
    - query opportunities (things that you may not be doing now that will affect ICD-10 specificity)?
    - educating providers (what new documentation is required)?
    - Other non-coding related topics
    - procedure documentation?

    * Would your facility pay for you to attend such a class? Probably not but, if web based, would use work time to attend the class.

    * If your facility does not subsidize your attendance, do you plan on attending such a class at your own expense? Not sure at the moment

    * How long should such a class be (1, 2, 3 or more days)? Not sure, is two days for medical and one day surgical/procedures appropriate. How long are the daily classes - 6 hrs, 8 hrs or less or possibly a day a month

    * What would be the most opportune time frame to attend this class?
    - 2012 (all year)
    - 2013 (prior to the start date of ICD-10 (10/1/13))? This d/t information being closest to ICD-10 implementation

    * If you have other ideas/comments, please feel free to expand upon this survey.

    Thanks for your replies - we appreciate your insight and feedback!


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    ----------------------------------------------------------------------

    Subject: re: CHF
    From: "April Herod Floyd"
    Date: Thu, 08 Sep 2011 16:47:38 -0400
    X-Message-Number: 8

    We have eight Cardiologist at our facility and I can safely bet we have one that is on the money EVERY time he documents CHF, two that feebly try to document correctly and the rest have to be queried every, single time. Job security, yes! They know I am going to query every time I see it and they answer when queried but are hard pressed to VOLUNTEER anything on their own. I have 13 years of Cardiology nursing background and have worked with these guys, if anything, they know that I am persistent. I think they are just "bucking the system" and don't want to conform quitely to guidelines. At least they answer their queries.....
    ----------------------------------------------------------------------

    Subject: RE: CHF
    From: "Evans, Paul"
    Date: Thu, 8 Sep 2011 13:58:32 -0700
    X-Message-Number: 9

    Notable that Cardiology is particularly reported as resistant so
    uniformly - the same issue has been noted in my workplace, as well.

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 1:48 PM
    To: Evans, Paul
    Subject: re:[cdi_talk] CHF

    We have eight Cardiologist at our facility and I can safely bet we have
    one that is on the money EVERY time he documents CHF, two that feebly
    try to document correctly and the rest have to be queried every, single
    time. Job security, yes! They know I am going to query every time I see
    it and they answer when queried but are hard pressed to VOLUNTEER
    anything on their own. I have 13 years of Cardiology nursing background
    and have worked with these guys, if anything, they know that I am
    persistent. I think they are just "bucking the system" and don't want
    to conform quitely to guidelines. At least they answer their
    queries.....
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    ----------------------------------------------------------------------

    Subject: RE: CHF
    From: "Bates, Judith"
    Date: Thu, 8 Sep 2011 17:31:43 -0400
    X-Message-Number: 10

    I just said yesterday that when I had to educate the nephrology groups about the importance of AKI with ATN...THEY GOT IT... Not the same with the ongoing issue with CHF. I am glad to hear that you share my pain and I'm not alone!!!

    Judi Bates RN, BSN, CCDS
    CDI Specialist
    856-757-3161
    Beeper 66x2906
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 4:59 PM
    To: Bates, Judith
    Subject: RE: [cdi_talk] CHF

    Notable that Cardiology is particularly reported as resistant so
    uniformly - the same issue has been noted in my workplace, as well.

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, September 08, 2011 1:48 PM
    To: Evans, Paul
    Subject: re:[cdi_talk] CHF

    We have eight Cardiologist at our facility and I can safely bet we have
    one that is on the money EVERY time he documents CHF, two that feebly
    try to document correctly and the rest have to be queried every, single
    time. Job security, yes! They know I am going to query every time I see
    it and they answer when queried but are hard pressed to VOLUNTEER
    anything on their own. I have 13 years of Cardiology nursing background
    and have worked with these guys, if anything, they know that I am
    persistent. I think they are just "bucking the system" and don't want
    to conform quitely to guidelines. At least they answer their
    queries.....
    ---
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    ---

    END OF DIGEST

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    Copyright 2011
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