3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

Trey La Charit, MDCDI Program Physician Advisor,Hospitalist, Clinical Assistant ProfessorStrategies for achieving medical staff compliance

Objectives:Learn effective PA techniques for cultivating medical staff acceptance of and sustained participation with CDI goals Review continuous educational effortsWhats wrong with the way I write in the chart?Promotion of CDI program as team effortGeneration of effective CDI compliance tools

Physician CDI presentationsMake each presentation service-line specificOrthopods dont care about chronic systolic CHF. Make sure they understand why it is important to learn the rules of The Game that CMS creates:The pressures that each treating facility facesThe pressures that each physician will faceIntroduce more accurate methods and terminology to appropriately document each patients severity of illness in the medical recordHow to effectively play CMS game

Physician CDI presentationsEnsure that each physician understands every reason why participation in CDI efforts is so crucial for themEnsure that each physician understands that compliance with CDI goals is strictly their responsibilityCDI is not a coding issue!Ensure that each physician understands how to be compliant with CDI goals

Why implement CDI?To make YOU and their facility look better in the public perception with quality data reportingTo make YOU look better to health insurance companies & CMS for coming P4P initiativesTo improve YOUR and their facilitys L.O.S.To appropriately categorize and justify YOUR patients admission status within hospital systemTo realize all GME educational goalsTo realize all appropriate reimbursements

Medical staff follow-upPresent CDI updates at quarterly medical staff meetingsShow changes in ICD-9 terminologyGive examples of cases where physicians either listened to or ignored CDI specialist queries with consequences of their actionsGive assurances that we are not asking them to lie, cheat, steal, mislead, commit fraud, etc.Remind them why CDI is so importantGive CDI improvement tips

Promote CDI as a team effortAttend all weekly CDI core team meetingsEveryone in room has equal statusAll on first name basis with no rankAll trying to reach same goalReview problematic/denied queries with teamProvide needed clinical education to CDI teamAllows quick CDI response for acute issuesAllows for free generation of new ideasCDI specialists much more in touch with what is happening on their floors than PA

Promote CDI as a team effortGive credit where and when credit is dueSearch for ways to make CDS specialists work experience more efficient and effectiveCDS specialists should be on wards, not in the officeProvide yearly membership in ACDISSend team members to annual ACDIS conferenceAll members should have opportunity to attendReview insurance/RAC coding denials, assist in appeals, and provide medical staff education regarding changesParticipate in coder educationKeep CDI Program momentum going

Compliance toolsPA must be creative in order to develop physician friendly CDI compliance methods that garner consistent, sustainable resultsPhysicians see themselves as overworked and extremely busyPhysicians willing to comply if . . .Request does not impact their perceived time constraintsIts believed to be more than just an additional hassle of dubious reward

CDI pocket cardsEverybody has one and they all work great!Universal or service-line specific?Advantages of universal CDI card:Everyone speaks the same languagePromote house-wide team building vs. additional individual physician or group responsibilitiesEase of implementing CMS/RAC updatesCan be facility specificNo two hospitals alike!

Service-line BlitzesIdentify service-line with opportunities for documentation improvementReview every chart on that service in one dayLeave routine queries as neededSends message that they are being watchedTake CDI team to lunch in doctors loungeOccupy prominent table at entrance of loungeDisplay large CDI posterDistribute CDI pocket cards as neededAnswer questions

Inciting SHAME!Show data to medical staff that suggests to the public they are not good doctorsShow data to the medical staff that suggests their local competition is doing a better job of taking care of patients than they doPhysicians are competitive and defensive about their abilities and skillsUse physician egos to your advantage!

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Inciting SHAME!Save examples where physician(s) ignored or disagreed with query that would have resulted in substantial MS-DRG impactPresent those cases at general medical staff meeting with all pertinent ramifications . . .What diagnoses they missedLack of meeting GM-LOS goalLoss of reimbursement to hospitalPhysician report card impactShow them the error of their ways!

Example #167 yo WM w/ HTN & hyperlipidemia goes to OSH w/ chest pain & diaphoresis. EKG shows ST-segment elevations in anterior leads. Patient transferred to UTMCK & immediately taken to cath lab. Patient arrests @ end of procedure and is intubated and revived during Code 99. IABP is placed & patient taken to ICU.

Example #1What are the diagnoses in example #1?HTNHyperlipidemiaAcute Myocardial InfarctionCardiogenic Shock (MCC)IABP was placedAcute Respiratory Failure (MCC)This patient was intubated when he arrested.

Example #1Despite repeated queries and phone calls by CDS specialists, no documentation was ever made in the medical record that this patient had cardiogenic shock or acute respiratory failure.

Example #1:If Acute Respiratory Failure or Cardiogenic Shock had been documented . . . (MCCs).4.5950$31,436.0015.6

Example #266 yo WM w/ HTN, DM, & PVD goes to ER w/ 3 days of LLE pain, erythema, fever, & chills. T=101.9F, HR=113, WBCs=17K, albumin=1.9, & HbA1c=8.3. BMI=18.6. A foul smell is noted from LLE. Patient diagnosed w/ cellulitis & gangrene and undergoes BKA. Four days later, the patient unexpectedly arrests and cannot be revived.

Example #2What are the diagnoses in example #2?HTNPVDDiabetes Mellitus Type 2 & uncontrolledCellulitis and gangrene (CC)Sepsis (MCC)Elevated Temp, HR, & WBCs @ admission met criteria for SIRS. Source was patients LLE cellulitisMalnutrition severe (MCC)Admission albumin = 1.9 & BMI < 19

Example #2At the time of admission, the physician only documented Cellulitis and did not mention Sepsis or Severe Malnutrition in the medical record.

Note:The physician paid attention to the query placed on the patients chart by CDS nurse & documented both Sepsis & Severe Malnutrition.

Amputation for Circulatory Disorders w/o CC or MCC with RW = 2.99 Sepsis as principal diagnosis with Severe Malnutrition as MCC $20,852.56Example #2:GMLOS=7.3

What about quality ratings?Predicted Mortality Rates for some disease processes in this case:Cellulitis w/ gangrene = 15%Sepsis = 30%Septic shock = 80%The patient expired which is never good for any physicians report card:However, by listening to the CDS nurse, this physicians expected mortality bar is much higher than it would have been for cellulitis only.

Problematic service-lines? Concentrate CDI training efforts on consultants and residents to improve documentationBoth sources of documentation can be coded.Treat unanswered queries as incomplete chartsMay require change in medical staff by-lawsInsert CDI goals into data gathering IS toolsDo you have EHR or CPOE?Insert CDI goals into pre-operative clinicsPre-operative clinic H&P can be coded as long as done 30 days prior to surgery.

Physician interventions? Many programs use one-on-one PA interaction with medical staff to get needed results.Physicians do not like backseat driversPotentially places PA in adversarial relationship with medical staffIf query is ignored while patient in hospital, convert to post-discharge query Make medical record incomplete until answeredCarrot Approach as opposed to Sticks.

Physician advisor resultsPhysician Advisor will not be Silver Bullet for your CDI ProgramCDI program success is team effort:Must have CDI chart review specialists to reinforce medical staff education with good, consistent queriesMust have strong administrative supportMust have strong coding department supportResults will not happen overnight!

Questions?