CDI Resource LIBRARY

The numerator inpatient hospitalizations for patients with severe obstetric complications including the following:
- Severe maternal morbidity diagnoses (see list below)
- Severe maternal morbidity procedures (see list below)
- Discharge disposition of expired
Severe Maternal Morbidity Diagnoses:
- Cardiac
Acute heart failure
Acute myocardial infarction
Aortic aneurysm
Cardiac arrest/ventricular fibrillation
Heart failure/arrest during procedure or surgery
- Hemorrhage
Disseminated intravascular coagulation
Shock
- Renal
Acute renal failure
- Respiratory
Adult respiratory distress syndrome
Pulmonary edema
- Sepsis
- Other OB
Air and thrombotic embolism
Amniotic fluid embolism
Eclampsia
Severe anesthesia complications
- Other Medical
Puerperal cerebrovascular disorder
Sickle cell disease with crisis
Severe Maternal Morbidity Procedures:
- Blood transfusion
- Conversion of cardiac rhythm
- Hysterectomy
- Temporary tracheostomy
- Ventilation

The risk adjustment includes pre-existing conditions (based on ICD-10-cm codes) including:
- Anemia
- Asthma
- Autoimmune Disease
- Bariatric Surgery
- Bleeding disorder
- BMI
- Cardiac Disease
- Gastrointestinal Disease
- Gestational Diabetes
- HIV
- Housing Instability
- Hypertension
- Maternal Age
- Mental Health Disorder
- Multiple Pregnancy
- Neuromuscular Disease
- Other Pre-eclampsia
- Placenta Previa
- Placental Abruption
- Placental Accreta Spectrum
- Pre-existing Diabetes
- Preterm Birth
- Previous Cesarean
- Pulmonary Hypertension
- Renal Disease
- Severe Pre-eclampsia
- Substance Abuse
- Thyrotoxicosis
- Long-term Anticoagulant Use
- Obstetric VTE

Additional variables used for risk adjustment. Report the first resulted value 24 hours prior to start of encounter and before time of delivery in UCUM units specified:
- Heart rate: {beats}/min
- Systolic blood pressure: mm[Hg]

Additional variables used for risk adjustment. Report the first resulted value 24 hours prior to start of encounter and before time of delivery in UCUM units specified:
- White blood cell count: 10*3/uL
- Hematocrit: %
- Platelets (for future consideration): 10*3/uL

Access The Joint Commission. (2021). eCQM Specifications 2022 Reporting Period, available at: https://lnkd.in/eFt2HuRC. 

For those of you involved in inpatient MS-DRG-oriented CDI, you are likely relieved that CMS is delaying (again) its implementation of the Comprehensive CC/MCC restructuring for at least one more year (e.g., FY2024). That doesn't mean that they're not thinking about it; if fact, they want YOUR comments as to what the CC/MCC restructuring should look like.

We at CDIMD offer to you three resources:

No. 1 - A PDF of CMS's actual file demonstrating their currently working protocols of what CCs or MCCs will be added, amended, or deleted - https://lnkd.in/eZuJtUNH - may require that you log into Dropbox

No. 2 - CMS's Nine Guiding Concepts of What a CC/MCC should involve (source: CMS FY2023 IPPS Proposed Rule)
• Represents end of life/near death or has reached an advanced stage associated with systemic physiologic decompensation and debility.
• Denotes organ system instability or failure.
• Involves a chronic illness with susceptibility to exacerbations or abrupt decline.
• Serves as a marker for advanced disease states across multiple different comorbid conditions.
• Reflects systemic impact.
• Post-operative/post-procedure condition/complication impacting recovery.
• Typically requires higher level of care (that is, intensive monitoring, greater number of caregivers, additional testing, intensive care unit care, extended length of stay).
• Impedes patient cooperation or management of care or both.
• Recent (last 10 years) change in best practice, or in practice guidelines and review of the extent to which these changes have led to concomitant changes in expected resource use.

No. 3 - Access to CMS's actual Excel spreadsheets by downloading this ZIP file. I strongly recommend that you add filters as to sort this information and read ALL the tabs as to properly interpret their data. https://lnkd.in/eA-K6vmx

1) CMS's methodology for evaluating the potential (in the future) impact of ICD-10-CM codes as MS-DRG CCs and MCCs which we touched on with my LinkedIn post this week, available at https://lnkd.in/gtU2RkcF. This has the link to CMS's actual CC/MCC impact (the C1-C2-C3) file whereby you can gauge an ICD-10-CM's impact of CC/MCC-related inpatient costs.

2) A demonstration of the CDIMD Tracker (https://lnkd.in/gK3sCFt8) and how we at CDIMD use FY2021 MedPAR to benchmark CDI performance. At the audience's request, we explored larger hospitals in Georgia and California. We can do the same for you if you contact Sasha Hoppenworth or email us at https://lnkd.in/dEQGS4z.

3) A reminder involving the 5/3/2022 publication of the AHA/ACC/HFSA Heart Failure consensus statement and how it defines HFrEF, HFpEF, and the various ACC HF classes. https://lnkd.in/g3AD3jYG

The AHA/ACC/HFSA have updated their Heart Failure management consensus statement and published it on May 3, 2022. https://lnkd.in/eS63KVCs

This should be read in the context of the Universal Definition of Heart Failure, available at https://lnkd.in/eqrDhwfN

Important definitions/statements (and my comments) include:
1) Heart Failure - A complex clinical syndrome with current or previous symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of blood. Kennedy comment: Cardiac tamponade, constrictive pericarditis, and hypertensive crisis causes heart failure since these disease entities impede heart function.
2) Stage B versus Stage C Heart Failure - While Stage B HF is labeled as "Pre-HF" and has not yet developed signs or symptoms of heart failure (Stage C), Dr. Kennedy believes that the ICD-10-CM classification in the Index as listed below conflicts with these clinical designations
Failure, heart
- Note: heart failure stages A, B, C, and D are based on the American College of Cardiology and American Heart Association stages of heart failure, which complement and should not be confused with the New York Heart Association Classification of Heart Failure, into Class I, Class II, Class III, and Class IV
- - stage A Z91.89
- - stage B -see also Failure, heart, by type as diastolic or systolic I50.9
- - stage C -see also Failure, heart, by type as diastolic or systolic I50.9
- - stage D -see also Failure, heart, by type as diastolic or systolic, chronic I50.84
Since Stage C includes patients who were previously symptomatic, the conundrum will be how to properly code stage B HF in light of this guideline. (NOTE: I've already alerted David Berglund of the CDC NCHS; I hope that they can edit the Index in time for 10/1/2022.
3) Stage D heart failure is important to recognized and document when the following 4 criteria are met:
i) NYHA class 3 (advanced) or 4
ii) Severe cardiac dysfunction w/ONE or more of these: EF < 30%, isolated RV failure, nonoperable severe value disease or congenital heart disease, EF > 40% w/marked elevated BNP AND significant diastolic dysfunction
iii) Unplanned visits/hospitalizations w/in 12 months for fluid overload, ionotropic Rx, or malignant arrythmias
iv) Inability to exercise or low 6-minute walk test

In reading the CMS FY2023 IPPS Proposed Rule released on 4/18/2022, I'm struck by CMS's proposal to implement the National Quality Forum's 3592e emeasure, the Global Malnutrition Composite Score sponsored by the Academy of Nutrition and Dietetics (AND) for CY2024.

The GMCS will require that hospitals demonstrate performance with:
1. Screening for malnutrition risk at admission.
2. Completing a nutrition assessment for patients who screened for risk of malnutrition.
3. Appropriate documentation of malnutrition diagnosis in the patient’s medical record if indicated by the assessment findings.
4. Development of a nutrition care plan for malnourished patients including the recommended treatment plan

Of course, nursing, physicians/providers, CDI, coding, dieticians/nutritionists, case management/discharge planning, compliance and, most importantly, medical informatics who tie this all together, have crucial roles in defining, diagnosing, documenting, and intervening with these underdiagnosed and documented conditions.

My review of the literature estimates that malnutrition occurs in 25% of inpatients ages 70 or higher, split 50/50 for nonsevere (moderate) and severe. The CDIMDTracker shows that, on the average, only 8-9% of Medicare patient are coded to have malnutrition.

Want to get ready for this? Then:
1) Read the NQF e3592 measure, available at https://lnkd.in/ghJ4hsik and CMS's rationale for this at https://lnkd.in/eW_utfpM
2) Listen to CMS's Open Door on Tuesday, April 26 at 2:00 pm EASTERN at Dial: 1-888-455-1397 & Reference Conference Passcode: 5109694 - MARK YOUR CALENDARS!
3) Consider my review of malnutrition coding compliance issues at https://lnkd.in/gvRrjJjG - discuss with your compliance officer!
4) Master Coding Clinic, 1st Q, 2020, pages 4-7, especially the need for policies
5) Get your EMR (e.g., Epic, Cerner, Meditech) to work out the elements and workflows of nursing, dietician, and physician documentation that identifies and intervenes in light of the GMCS
6) Put this on the agendas of your Quality, Process Improvement, and P&T committees
CDIMD can analyze and trend your data plus support your work. 

In my opinion, one of the most neglected areas in CDI is the IPPS for inpatient psychiatric hospitals. In addition, CDI in this arena is relatively simple and can be done with one review 2 days after the inpatient order is written and a 2nd review after the DC summary is done right before billing. Standardized admission note templates incorporating all risk factors that are POA can be developed so that the admitting psychiatrist and medical consultant can standardize their language for this.

The following resources are suggested:
1) Addendum A that has the relative weights for the CDI-sensitive factors - https://lnkd.in/dYS2k33g

2) Addendum B that has the ICD-10-CM codes affecting the comorbidity models - https://lnkd.in/djJCqvsz

3) The usual MS-DRG Definitions manuals that govern psychiatric DRG assignment - https://lnkd.in/dFuEZ-et

4) An appreciation of how Psychiatric IPPS works and the quality models that they are accountable for. - https://lnkd.in/dTUE5vWa

If your facility has an inpatient IPPS section, then mastery of this area is a growth opportunity. The following is mandatory reading:
https://lnkd.in/d_7myKg7

https://lnkd.in/d547E2JM

In support of Brian Murphy's post regarding how to keep up with CDI-pertinent regulations (https://lnkd.in/dC8HdG28), what's hard (at least for me) is keeping up with all the updates in CDI-pertinent clinical terminology published in medical journals.

For example, last week I posted an editorial in JAMA about replacing "TIA" with "acute cerebrovascular insufficiency" or "cerebral infarction + NIHSS score". https://lnkd.in/dKsSNMdZ

So...how does one keep up? One way is to get on medical journals' alerts that come once a week. You may wish to have a separate email address for these along with the links suggested by Brian. My suggestions include:

•General
–JAMA https://lnkd.in/d_WPFs-c - look at the bottom; sign up for all specialties that interest you, especially internal medicine, surgery, and pediatrics
–Mayo Clinic Proceedings - https://lnkd.in/dBbcXbNg
•Internal Medicine
–New England Journal of Medicine https://lnkd.in/dG2PREi7
–American Journal of Medicine - https://lnkd.in/dsFSJet2
•Cardiology
–Journal of the American College of Cardiology - https://lnkd.in/dghcXBEZ
–Circulation - https://lnkd.in/d2MAfjCc - requires registration first
•Critical care
–Critical care medicine - https://lnkd.in/dbg9mcb3
–Pediatric critical care medicine - https://lnkd.in/dTDkr3hf
•Gastroenterology
–American Journal of Gastroenterology - https://lnkd.in/deZmjE6S
•Neurology
–Neurology - https://lnkd.in/dmyGja-U
–Stroke - https://lnkd.in/d2MAfjCc
•Pulmonology
–Chest - https://lnkd.in/dEp5GPwh

Coding Clinic, 1st Q, 2022's most disturbing advice is on p. 51, stating, "The advice previously published in CC 2Q 2021, p8, does not conflict with the Official Guidelines (1.B.16) for documentation of complication of care since a cause-and-effect relationship was documented between the surgery and the serosal tear. This guideline was not intended to mean that the surgeon must specifically document the term 'complication.' The surgeon’s documentation of the serosal tear and the subsequent procedure for repairing the tear is sufficient documentation to report a complication code."

In CC 2Q 2021, p8, a surgeon explicitly documented that a serosal tear resulting in a bowel excision was NOT a complication of the operation; however, Coding Clinic REQUIRED that a complication code be reported in contradiction to the surgeon's statement.

Guideline 1.B.16 states, "Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and AN INDICATION IN THE DOCUMENTATION THAT IT IS A COMPLICATION. Query the provider for clarification, if the complication is not clearly DOCUMENTED."

So, what part of the Guidelines that states, "an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented" says they did not intend "to mean that the surgeon must specifically document the term 'complication'"?

Minus well throw out CC, 1Q, 2017, p110; 4Q 2016, pp 147-149; 2Q, 2007, pp 11-12, and 1Q 2011, pp 3-4, as well!

In my opinion, Coding Clinic just nuked Section 1.B.16, now requiring any perioperative or postoperative event due to (in the setting of) surgery that "alters the course of the surgery as supported by the medical record documentation" to be reported as a complication even if the surgeon states that it is not unless the following is ABSOLUTELY CLEAR that the event is
1) ROUTINELY EXPECTED (not just expected) WITH or INTEGRAL/INHERENT TO the PLANNED procedure, i.e., hematuria s/p prostatectomy, bowel ileus for 24-48 hours s/p bowel surgery, or respiratory failure for <24-48 hours s/p CABG
2) PRIMARILY DUE TO (not just contributed by) non-medical trauma, a medical condition, or an adverse effect of a drug
3) CLINICALLY INSIGNIFICANT
Query if these are likely but not absolutely stated.

My advice: Call your compliance officer. Discuss at your next surgery committee. Rewrite your complications policies ASAP. Complain to whoever in charge will listen; sadly, I don't think they will.

Coding Clinic, 1st Quarter, 2022 will be effective 3/18/2022. Concepts include:

1) Serosal tears alone do not qualify as reportable diagnoses. If, however, the degree of a serosal tear alters the course of the surgery as supported by the medical record documentation, then the tear should be reported as a complication, even if the physician states that it is "unavoidable" or "not a complication".

2) Even though the ICD-10-CM Guidelines require physicians to declare perioperative events to be complications as to code them as such, this guideline was not intended to mean that the surgeon must specifically document the term “complication” each and every time. For example, a surgeon’s documentation of the serosal tear and the subsequent procedure for repairing the tear is sufficient documentation to report a complication code.

3) Toxic-metabolic encephalopathy due to hepatic encephalopathy is NOT integral to hepatic encephalopathy or failure and may be coded if documented. TME does NOT have to be due to an external agent; it can be internal.

4) If a diagnosis in the title of an operative report is not substantiated by the body of the report, do not code from the title.

5) To code B20, HIV Disease, in patients on long term HAART, the patient must have had at some time a symptom or disease due to HIV and be documented to have HIV Disease. + HIV alone only get Z21.

CDI effectiveness requires the pursuit of critical thinking involving two universes, physician medical decision making (MDM) (diagnosis construction) and coders' ICD-10-CM/PCS code assignment.

Both are as different as night and day, much like the differences in marriages whereby the man is from Mars and the woman is from Venus. Viva la difference!

A recent JAMA viewpoint summarized MDM at this link, available in full to those with medical library access - https://lnkd.in/duK2Hq-b.

To make MDM work, the author encourages:
1. Establish Awareness of How Cognition Works - Type 1 (intuitive) vs. Type 2 (analytical) thinking
2. Coach Critical Thinking - add to that teamwork, communication, professionalism, and attitudinal awareness.
3. Make the Work Environment More Conducive to Sound Thinking - remove distractions, sleep deprivation, etc.
4. Circumvent Type 1 (intuitive thinking) Distortion with an "executive override" with type 2 (analytic) thinking
5. Expand Individual Expertise - venturing into flexibility as to consider rarer conditions
6. Promote Team Cognition - MDM (as with CDI) is a "we", not a "me"; consult colleagues often for feedback to see what I, as an individual, cannot see.

Coding and CDI concurrent/pre-bill review, MDM, and critical thinking are the same but different since they require physicians to explicitly document their MDM with an unfamiliar administrative language, e.g., "functional quadriplegia" vs. "bedridden", "unconscious" vs. "unresponsive", "bleeding DUE TO warfarin" vs. "bleeding ON warfarin", etc., especially since the Cooperating Parties expressly prohibit (and punish) "assumption coding" whereby a code for "duck" cannot be assigned if "quacking", "waddling", "feathers", and "web feet" are clearly evident unless the physician states "duck" and what species and gender it is.

For CDI to work, all involved MUST master their own clinical MDM processes as to advocate distracted physicians (taking care of patients) to document terminology in an unfamiliar dialect essential to proper care payment and quality and cost efficiency measurement as to rectify errors of omission and commission.

CDI's unfunded costly administrative process is required by government (and the Cooperating parties) who must be in cahoots with software, consulting, and publishing companies as to create a need for their expensive technology or services, such as 3M, ACDIS, and even me, estimated in my mind to be at least $2 billion in wasteful administrative costs per year, which will grow as CMS expands the need for P4P to physician practices.

Why must coders not be allowed to clinically abstract a record using standardized criteria established by CMS? Payers deny codes based on provider documentation if they don't meet their internal criteria. Why can they interpret but coders cannot?

We can use that $2 billion/year to expand coverage and deploy CDI nurses or physician advisors back to direct patient care.

The ICD-10-CM/PCS Coordination and Maintenance committee meets virtually on March 8-9, 2022.

Set your Outlook alarms to be able to listen in using the links outlined in CMS's/CDC's documents below.

Click the following URL: https://lnkd.in/dE5xCkJM
Passcode: 864061 (DON'T FORGET THIS - REQUIRED!)

View the handouts at:
CDC's: https://lnkd.in/emfr3vM
CMS's: https://lnkd.in/dxz3gM5q

Most of the new PCS involving pharmaceuticals; almost nothing involving procedures. Those involving diagnoses include:

Anal Fistula
Appendicitis with generalized peritonitis with or without perforation
Bardet-Biedl Syndrome and Laurence-Moon syndrome
Crohn’s Disease
Coma Due to Underlying Condition
Craniosynostosis and Other Congenital Deformities of Skull, Face and Jaw
Desmoid Tumors
Encounter for Follow-up Examination after Completed Treatment for Malignant Neoplasm
Encounter for Observation for Suspected Newborn Problem
Extraocular Muscle Entrapment
Foreign Body Sensation
Gadolinium Toxicity
Immunoglobulin G4-Related Disease
Impairing Emotional Outbursts
Inappropriate Sinus Tachycardia
Insulin Resistant Syndrome
Intestinal Failure-Associated Liver Disease
Lafora Body Disease
Leukodystrophies
Lumbar Degenerative Disc Disease with and without Pain
Metabolic Acidemia in Newborn
Non-Traumatic Peritoneal Hemorrhage
Parkinson’s Disease with OFF Episodes
Problems Related to Upbringing
Resistant Hypertension
Sickle-Cell Dactylitis and Vaso-occlusive Crisis
Social Determinants of Health
Shwachman-Diamond Syndrome
Wasting Disease (Syndrome) Due to Underlying Condition

May 9, 2022 is the deadline for receipt of public comments on proposed new codes and revisions discussed at the March 8-9, 2022, ICD-10 Coordination and Maintenance Committee Meeting being considered for implementation on October 1, 2023.

In my hospital chart review, language surrounding elevated lactates is quite inconsistent.

On one hand, I see "lactic acidosis" documented with elevated lactates when there is no reduced serum bicarbonate or pH and/or no elevated anion gap. Consider this abstract on metabolic acidosis available at https://lnkd.in/dJKhGig2.

In addition, I see little if any documentation of the cause of the elevated lactate. In the Mayo Clinic Proceedings in 2013, a review article on elevated lactates states:

Approach to the Patient With an Elevated Lactate Level

In broad terms, elevated lactate levels can be divided into 2 categories: cases in which it is driven by hypoperfusion/hypoxemia and cases in which it is not. The hypoperfusion-driven cases include all forms of shock, the post–cardiac arrest state, and regional ischemia. In all of these clinical scenarios, lactate levels that remain elevated are often important prognostically, and treatment is aimed at improving perfusion to the affected tissues. In shock, treatment can involve volume resuscitation, vasopressors, or inotropes, depending on the etiology of the shock. In regional ischemia, treatment can involve surgery to restore circulation or remove damaged tissue.

The second general category includes cases not driven by hypoperfusion. This group includes drug effects, seizures, malignancy, and thiamine deficiency. In these cases, the elevated lactate levels stem from dysfunction of cellular metabolism or overproduction from increases in metabolism or muscle work. The treatments are, therefore, quite different from those used for hypoperfusion, focusing on stopping or reversing offending agents (possibly requiring dialysis in cases such as metformin or salicylate toxicity), remedying the deficit in metabolism (as in correction of DKA or thiamine replacement), or targeting the underlying organ dysfunction.

The reference for this excellent review of lactate elevation. https://lnkd.in/dRgsy8hX

I grieve for the CDI profession when coders/CDIs leadership promote documentation and coding practices that manipulates the ICD-10-CM/PCS Index/Table/Guidelines/Coding Clinic and results in ICD-10-CM/PCS codes that do not accurately represent a patient's condition or code intent.

I first saw this in 2011 when ICD-9-CM codes for kwashiorkor were reported in Medicare patients documented to have "protein malnutrition" since the ICD-9-CM Index classified unspecified "protein malnutrition" as kwashiorkor. While this practice technically applies the ICD-10-CM guidelines, by no means did any of these patients have kwashiorkor, leading to embarrassing newspaper reports and OIG audits. https://lnkd.in/eRBxdxCe.

Recently, I was made aware of an HCC CDI "strategy" whereby providers are being encouraged to documented "hyperammonemia" in patients with cirrhosis and liver failure when the serum ammonia level is elevated as to obtain ICD-10-CM code E72.20, Disorder of urea cycle metabolism, unspecified, that results in HCC 23, Other Significant Endocrine and Metabolic Disorders, RW 0.194. This, in my opinion, is wrong since the E72.xx subcategory is intended to report the RARE disorders of urea cycle metabolism that, in my mind, are primary inborn errors of metabolism, not secondary causes like cirrhosis. https://lnkd.in/enwH9rQ6.

Other pet peeves include:
1) "Hypercoaguable states" due to atrial fibrillation. While I understand that Coding Clinic appears to allow this when documented, I am not personally aware of any paper whereby patients with atrial fibrillation develop de novo non-embolic clots elsewhere simply because of a systemic hypercoagulable state caused by atrial fibrillation. Yes, I understand that the atrium can clot due to localized factors just like my skin does when I cut it; however, to label this as a systemic hypercoagulable state is stretching it in my mind.
2) "Hyperlacticemia". Even the new FY2023 ICD-10-CM Index equate any elevated lactate as acidosis, even when there is no clinically elevated anion gap, low pH, or low HCO3. Grrrrr.

There are many others.

Coding Clinic states that "The basic rule of coding is that further research is required if the title of the code suggested by the Index does not identify the condition correctly." They, of course, never tell us how to do this research which, in my mind, requires physician query AND/OR coding policies that refuse to report codes that do not accurately represent the patient's clinical circumstances. Failure to do so, in my opinion, leads to OIG/DOJ scrutiny and disheartens those who pursue ethical coding.

The AHIMA Coding Ethics, available at https://lnkd.in/ecvX7ajT, prohibits these practices

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000092.asp

Why should physicians and facilities invest in Clinical Documentation (and Coding) Integrity as to do it correctly? I offer the CDIMD "5 Rs of CDI" for your consideration.

1) Results - Accurate diagnostic/therapeutic decision-making and its medical record documentation advocates patients and their care, improving outcomes. If I accurately label my patients with diagnoses that fit their clinical indicators, such as "myocardial injury" instead of "demand ischemia" when there's no myocardial ischemia, "acute cor pulmonale" instead of "right heart strain", "delirium", "psychosis", "coma", or other specific psychiatric or neurological terms PLUS its underlying cause(s), such as specified encephalopathies, cerebral edema, encephalitis instead of "altered mental status" and the like, I will likely implement the proper interventions. While no one likes labels like "obese" or "drug/alcohol use disorder", when accurate and compassionately portrayed, they promote healing.

2) Respect - Who does not esteem a physician/provider who accurately diagnoses patient conditions and cogently documents these in the medical record to everyone's benefit?

3) Reputation - Accurate and clinically valid documentation (which sadly, at times, must use ICD-10-CM administrative language forced on us by government that does not necessarily correspond with clinical language) and coding favorably impacts mortality, readmission, complication, and other scores reported by CMS, US News and World Reports, and other entities. Just look at the ads touting hospitals' US News Rankings or CMS Star Ratings. https://lnkd.in/gkFDs28j.

4) Referrals - With strong results, respect, and reputations comes referrals that bring patient volume essential to maintaining cost-effective and efficient operations

5) Revenue - Payers want high quality physicians and facilities in their networks and are willing to pay for them. Governments are less likely to recoup penalties when complete, consistent, and clinically valid clinical documentation promotes coding integrity.
Doing the right thing is always the right thing to do.
Words matter.
Bridging the gap between providers and coders is the rising tide that lifts all boats.
Effective CDI that's a process, not a person or department, leveraging medical informatics, ancillary services, clinical workflows, nursing, and the entire patient care teams into one cohesive unit enhances everyone.
https://health.usnews.com/best-hospitals/rankings

Yesterday, the AMA (finally) announced the new changes for inpatient physician and inpatient/outpatient ED evaluation and management (E&M) services that will revolutionize how physicians bill their professional services in these settings.
https://lnkd.in/gY597Fu7

According to the AMA, their concept of "medical decision making", which involves QUANTITY of diagnoses and LEVEL OF PATIENT RISK will determine what level (Levels 1-2-3 for IP physicians; Levels 1-2-3-4-5 for ED physicians) these providers can bill for.

Read more details at https://lnkd.in/gsttPa-8
In my estimation, physicians will now more than ever document the higher severity their patients have to justify their higher levels of E/M billing, using words like "shock" instead of "lacticemia", "acute tubular necrosis" instead of azotemia, "severe sepsis" instead of sepsis, etc.

Antibiotic stewardship professionals, usually clinical pharmacists, have an integral role in CDI for assuring clinically accurate ICD-10-CM applicable documentation within their area of expertise, much like dieticians have with malnutrition, preprocedural assessment teams have with surgical risk adjustment (regular OR, endoscopy, cath lab), and wound care nurses with wound staging and excisional/nonexcisional debridements.

Areas of influence include:
1) Suspected organisms involved in pneumonia when the cultures are negative that justify extended spectrum (e.g., Zosyn, carbapenems for gram negative rods) or targeted (e.g., vancomycin for MRSA) definitive antibiotic use

2) Identifying of antibiotic resistance that justifies broader spectrum or more expensive agents, such as multi-resistant gram-negative rods, since MS-DRGs considers any documented antibiotic resistance meeting the definition of an additional diagnosis in ICD-10-CM to serve as a CC

3) Identification of the immunocompromised state that influences antibiotic selection which, if documented along with its underlying cause, adds weight to most risk-adjustment methodologies if coded.

4) Differentiating between non-invasive and invasive pulmonary aspergillosis that requires differing antifungal agents

5) Other aspects of definitions, diagnoses, and documentation essential to justifying or withholding certain or any antibiotics.

6) Differentiated asymptomatic bacteriuria from symptomatic UTIs

Ask yourself this: Would a physician prefer to hear these questions or requests for documentation from a clinical pharmacist who, under the direction of an ID specialist, has specialized knowledge in this area and is part of the direct patient care team or from a CDI specialist or coder who has no direct role in patient assessment or provider medical decision making?

Please consider IDSA's 2016 on the role of antibiotic stewardship and consider how they can facilitate proactive CDI that captures the correct documentation involving antibiotic use influencing all risk models, relieving coders and CDI specialists from reactively obtaining this on the back end as to focus their energies in other areas. Ping me on LinkedIn or at https://lnkd.in/dEQGS4z if you would like to process this concept.

https://lnkd.in/gUsmwY6P

Update: Participate in Field Testing of Cost Measures - Deadline Extended to March 25th

CMS and its contractor, Acumen, LLC, are conducting field testing of 5 episode-based cost measures. CMS has determined that the field-testing period will be extended by 30 days and will now end on March 25, 2022. We encourage stakeholders (which means you, Doctor) submit comments as soon as feasible.

The following episode-based cost measures are currently being field tested before consideration of their potential use in the cost performance category of the Merit-based Incentive Payment System (MIPS) of the Quality Payment Program (QPP):

Emergency Medicine
Heart Failure
Low Back Pain
Major Depressive Disorder
Psychoses/Related Conditions

Clinicians and clinician groups who meet the attribution requirements for at least one of the measures will receive a Field Test Report. All stakeholders are invited to provide feedback on the draft measure specifications through an online survey (https://lnkd.in/d68Pa4vR) which now closes on March 25, 2022. Participation is voluntary.

You or your clinician group can download your Field Test Report(s) via https://qpp.cms.gov/login if you or your clinician group have at least of 20 episodes for at least one of the measures.

Field Test Reports contain information about your cost performance based on draft measure specifications. This information will be for field testing purposes only. The measurement period for these Field Test Reports is January 1 to December 31, 2019. Please refer to the Field Test Report Access User Guide available on the MACRA Feedback Page for guidance on accessing your Field Test Report.

You may provide feedback through the online survey now through 11:59 p.m. ET on March 25, 2022. Additionally, all stakeholders—regardless of whether they receive a report—are invited to provide feedback on the draft measure specifications through the online survey.

You can reference resources on the MACRA Feedback Page to help inform your feedback, such as:
Draft measure specifications documentation
Excerpted measure-specific questions from the online survey for stakeholder input

https://lnkd.in/den59aXr

Watch the Cost Measures Field Testing Presentation to Learn More
The 2022 MACRA Cost Measure Field Testing presentation recording is available at https://lnkd.in/dgQhXACZ.

The presentation provides:
Information about the 5 episode-based cost measures undergoing field testing
Project background, measure development process, and field testing activities
Discussion of the content of the Field Test Report how to access and interpret these reports, and information on the supplemental documentation posted on the MACRA Feedback Page.

Just reminding everyone that physicians participating in CMS's Merit-based Incentive Payment System (https://lnkd.in/dgeTXW3G) are having their cost efficiency of sepsis care graded since 1/1/2022 using a methodology sanctioned by CMS. View a description of this episode model at this website; click on the sepsis PDF - https://lnkd.in/dU6CKQha

Of particular interest is that patients with neutropenia or pancytopenia are excluded from this model. In addition, patients with any type of shock are placed in a different risk category.

All the more reason that physicians and CDI specialists work with facility SEP-1 core measure staff to assure that all neutropenia, pancytopenia, severe sepsis, and shock of any type (e.g., septic, cardiogenic) is properly defined, diagnosed, and documented.

One's familiarity with the SEP-1 Core Measure data specifications will aid the discussion. https://lnkd.in/dwkG_bEm

In my experience, physician engagement in the proper interpretation of lactate levels is a fertile ground for CDI. One of the best articles on this came from the Mayo Clinic in 2013 and is available at https://lnkd.in/eNk7-ks. Print this up and take to your docs as to facilitate the great discussion you are to have with them. A checklist includes:

➢ Evaluate for tissue hypoperfusion and restore adequate perfusion: 
ο Shock (distributive, cardiogenic, hypovolemic and obstructive), post-cardiac arrest syndrome
ο Tissue hypoperfusion should be initially assumed/considered until proven otherwise
➢ Evaluate for local tissue ischemia and treat accordingly:
ο Mesenteric ischemia, limb ischemia, burns, trauma, compartment syndrome, necrotizing soft tissue infections
➢ Stop/reverse potential offending agents:
ο Pharmacological agents: linezolid, nucleoside reverse transcriptase inhibitors, metformin, valproate, theophylline, epinephrine, propofol, isoniazid and salicylates 
ο Drugs and toxins: cocaine, alcohols, carbon monoxide and cyanide poisoning
➢ Consider thiamine deficiency and treat if suspected: 
ο Patient with malnutrition of any cause often (but not exclusively) alcoholics 
ο Intravenous thiamine 100–500 mg should be considered
➢ Consider current or recent anaerobic muscle activity as etiology:
ο Heavy exercise, seizures, excessive work of breathing
ο Consider other etiologies especially if rapid clearance not seen when inciting problem treated (i.e., should rapidly clear after cessation of seizure activity)
➢ Consider other metabolic derangements:
ο Diabetic ketoacidosis
ο Mitochondrial disease
ο Liver dysfunction

Let us know what works in your world.