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Hands On Help

The Grand Collaboration, Part 2

One of the biggest challenges of CDI is simply keeping up with changes.

LESLIE: Last month we visited with Annie Williams, RHIT, CCS, CHDA; and Patrice Pongracz, RHIT, CCS, who both have excellent hands-on experience with this topic. We talked mostly about the importance of thinking of documentation as an interprofessional team effort between physicians, nurses and coders as well as other professionals. Let's continue our CDI conversation with a focus on CDI challenges.

PATRICE: One of the biggest challenges of CDI is simply keeping up with changes -- coding, reimbursement, documentation and the practice of medicine. As documentation guidelines change as a result of ICD-10-PCS, for example, it will become more difficult to code if the coders don't understand physician documentation. For example, today I was reviewing a case where the patient had a bilateral tube removal and hysterectomy. The physician documented "complete removal of both fallopian tubes." If I hadn't understood this phrase, I would not know how to best code it.

PATTY: In your experience so far, are nurses and doctors getting the ICD-10 training required to ensure accurate documentation?  

PATRICE: Yes, I think they are. I can see the impact of that training and how important nurse and coder participation is in that training.

ANNIE: As we work with physicians, we observe that their documentation training and focus is similar to an Hierarchical Condition Categories (HCC) model of documentation. Each diagnosis carries more weight than another diagnosis. But the HCC model does not apply when selecting the principal diagnosis or in ICD-10 coding.

PATRICE: It's also common to see incomplete documentation for chronic conditions. We often will see a lot of medications documented but little documentation on diagnoses. Chronic conditions documentation is a targeted CDI area.  

LESLIE: I think physician champions are key to successful CDI programs.

SEE ALSO: The Grand Collaboration, Part 1

PATRICE: Most CDI programs have a physician champion whose role is to team up with CDI staff to train and support physicians.  

ANNIE: Physicians may think that a lot of documentation is expected of them. But that isn't the case. More documentation is not needed. What is needed is documentation that is specific and concise. For example, rather than documenting "neuropathy," document "diabetic neuropathy" or instead of documenting "lung cancer," document "upper lobe lung cancer."

PATRICE: A physician trainer that we work with has a motto he shares with physicians: "Give me five seconds now or five minutes later. Five seconds of documentation saves you five minutes of query later.

LESLIE: Are there tools created to help physicians on what they should document so they don't waste time either documenting too much or needing to clarify through a query process?

PATRICE: There are pocket tools and most facilities have something they are going to give physicians to assist them. Most of thiese pocket tools have been developed for physician office documentation but I have also seen them for inpatient documentation as well.

ANNIE: It's important to conduct ongoing in-services by specialty providing specific ICD-10 tips. I think that CDI managers should attend monthly physician meetings as well. And I also think that new physicians should meet with CDI staff as part of their orientation.

PATRICE: I also recommend that physicians and nurses provide in-services to coders and discuss their specialty. Coders also have the opportunity to share their coding experiences with coding for that particular specialty. For example, when a physician performs a PTCA, she will have to dilate the artery which includes some arterial excision. Some coders might not know that and think the excision is a result of a complication. There are two ways to look at what is being said.

PATTY: What are some common documentation problems related to electronic health records (EHR)?

ANNIE: Copy and paste is a major documentation problem. And it's a contributor to poor documentation. For example, it's common to see repetitious documentation of the problem list throughout an inpatient stay. And often these problem lists include diagnoses that are no longer relevant. The diagnoses on the problem list are being carried over from note to note making it time consuming to review and code and eroding the integrity of the patient's record. On the outpatient side, we see a lot of unspecified diagnoses such as heartburn or reflux. Physicians tend to document symptoms and carry over documentation from the inpatient setting which may not always be appropriate.

PATRICE: There continues to be challenges related to the location of documentation. Every organization is a bit different and it's important to provide training not only on how to document but where in the EHR to document. There are several places to locate documentation.

LESLIE: Would natural language processing (NLP) help?

PATRICE: I think NLP can help streamline the CDI workflow in real time and also help to identify and prioritize cases to review. 

PATTY: Let's switch gears about and talk about how organizations implement CDI programs.

PATRICE: It's time intensive to implement CDI. Aligning resources and staffing are critical as are regular in-services and daily touch points. Physician champions and CDI champions are important too and a key change management component. Unfortunately, many physicians just feel like CDI is a word game. We have to help physicians understand what's in it for them -- how CDI helps them.

LESLIE: How does CDI tie to patient care and also to quality?

PATTY: CDI is the ability to accurately represent the clinical experience. CDI also ensures complete and accurate data for core measures tracking, physician and hospital profiling, patient registries such as cancer registry, and reimbursement denial prevention, just to name a few.

ANNIE: I think at the heart of CDI Is having more accurate information so that the right treatment can be rendered in real time.

LESLIE: This discussion just keeps driving home the importance of interprofessional collaboration between physicians, nurses and coders. They are all part of a documentation team. Documentation is not a singular responsibility anymore, but a team responsibility of which coders, nurses and physicians play a leadership role. 

PATTY: There is also a role for consumers as well. Patients will be key players on the documentation team in the near future.

LESLIE: We need to get to a point where we travel beyond a CDI program. We need to transform how records are created today. The sole responsibility for documentation should not be solely on physicians shoulders.

PATTY: And maybe we are placing too much emphasis on the physician having to document so perfectly.

LESLIE: Exactly. I see the future of documentation to be very different. I see the creation of a documentation team that supports physicians -- a team composed of scribes, nurses, coders, case managers, and patients who would all contribute to documentation for clinical and administrative purposes. The physician, physician practitioner or nurse practitioner could then review the documentation team's notes and approve them.

PATTY: I like how you think!

LESLIE: We have to be open to experimenting with new ways of working, interprofessional collaboration, and leveraging EHR technology.

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