Outpatient/ER CDI and ICD-10 preparedness

Comments

• lprescott

  June 2013 edited May 2016

  Katy, I love this question. Our program previously did not venture to the outpatient world and a few weeks ago I started spending time in the ED. This is purely experimental at this point. The ED doctors are "less than accepting" I think they feel I am going to slow them down.
  
  I am finding that I need to approach this environment very differently then on the floors. Visibility is important, so I try to just be around. Most of the information I gather is coming from what I hear versus what I read in the record. And the educational opportunities are fleeting in nature.
  
  I would assure the person you put in the ED is experienced and confident to "jump in" and assert oneself. A strong clinical background is really important. Also if they the person has even a little understanding of E&M coding it would be helpful.
  
  We do not have a UR presence in our ED. So when the opportunity arises or need for education- I do jump in to explain observation vs inpatient and what might be the most appropriate or if I am confused will call a CM to assist. The doctors do not have any patience they want immediate answers. I am finding the more they see me, the more I am able to provide them with quick pertinent information ...the more they trust me.
  
  There is little that I document, and I know know I need to get better at that. I am also struggling with how I measure my impact in the ED.
  
  Laurie L. Prescott RN, MSN, CCDS, CDIP
  lprescott@morehead.org
• katysuegood@gmail.com

  June 2013 edited May 2016

  Thanks Laurie,
  So are you primarily focused on the IN/OBS issue, medical necessity for admission and making sure H&P's for those that are admitted include comprehensive documentation? Or are you reviewing for outpatient cases that will stay outpatient too in the sense of denial prevention?
  
  We have a UR team and we contract with HER so that handles the IN/obs issue. But are likely going to be moving into OP eventually and I am trying to determine if ED is the logical next step or if we should be elsewhere.
  
  Thanks again!
  
  Katy Good, RN, BSN, CCDS, CCS
  Clinical Documentation Program Coordinator
  AHIMA Approved ICD-10CM/PCS Trainer
  Flagstaff Medical Center
  Kathryn.Good@nahealth.com
  Cell: 928.814.9404
  
• lprescott

  June 2013

  Our little hospital is a bit different- H&Ps usually not completed until the patient hits the floor by the attending or hospitalist. Our ED physicians document using a template and voice recognition software. When they are seeing the patients (and at this point I do not know if going to be in or outpatient)I review labs, nursing assessments etc. I will ask questions to them verbally when I can seize the chance.
  
  Most discussions with them are the real basics of CDI- using the right adjectives- acute, chronic etc. Explaining the importance of secondary diagnoses, defining diagnoses with approved clinical indicators. I encourage them to be as specific as they can versus their present documentation which is more symptoms based vs specific diagnoses. The concept of present on admission has been a key learning point for them to understand. They are learning how their documentation can support POA when we reach a diagnosis later in the patient stay.
  
  I don't usually get into specifics with patient status but explain a symptoms diagnosis with no known etiology most likely is observation. I also have worked with the nursing staff to educate them on status as well.
  
  I know this sounds unfocused. I celebrate my wins as they occur. two of them now understand syncope almost always means observation. and after one lengthey discussion and two AMA articles in his mailbox one physician now will use Acute Respiratory Failure for a patient NOT requiring intubation.
  
  Laurie
• katysuegood@gmail.com

  June 2013 edited May 2016

  No, it doesn’t sound unfocused. I am completely over my head, so any help is appreciated. What I am getting is that you are encouraging Inpatient CDI elements to the ED. I am assuming with the hopes of having stronger documentation to support inpatient admission and to get the documentation 'off on the right foot' with admissions that make it into an inpatient status. This part makes complete sense to me.
  We have a UR team that *hopefully* is already doing this so I think any initiatives in the ED would be focused on documentation needed in the outpatient area which is completely different than inpatient. I am fairly lost on how this might look so I am grasping at anything ;-)
  
  Thanks again!
  
  Katy Good, RN, BSN, CCDS, CCS
  Clinical Documentation Program Coordinator
  AHIMA Approved ICD-10CM/PCS Trainer
  Flagstaff Medical Center
  Kathryn.Good@nahealth.com
  Cell: 928.814.9404
  
• lprescott

  June 2013

  The one thing I stress and it supports both inpatient and outpatient needs is that they must explain their thought process and their decision making.
  
  Laurie L. PrescottRn, MSN, CCDS, CDIP
  lprescott@morehead.org
• robert.hodges2

  June 2013 edited May 2016

  Katy,
  
  
  
  I'll add my comments below but have to admit our facility is in the infancy of planning the ICD-10 transition. I'll just be putting down what I have planned. It’s going to be a challenge with only one of me and over a hundred of them.
  
  
  
  Robert
  
  
  
  Robert S. Hodges, BSN, MSN, RN, CCDS
  
  Clinical Documentation Improvement Specialist
  
  Aleda E. Lutz VAMC
  
  Mail Code 136
  
  1500 Weiss Street
  
  Saginaw MI 48602
  
  
  
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