Clinical Documentation Improvement Specialist: Capturing Nutritional Issues

In the past, Clinical Documentation Specialists (CDS) would ask the provider if the patient had nutritional issues based on evidence in the history, physical exam findings and lab results. They would rely on history of weight loss, findings of emaciation and body wasting, BMI, protein, albumin to ask the provider if the patient had malnutrition and its severity. Hearsay, incorrect BMIs recorded because of faulty information, abnormal losses of protein from non-nutritional issues have led to incorrect documentation of malnutrition by providers. Medicare and RAC auditors have targeted inappropriate coding of malnutrition, in cases that it is the only CC or MCC.

Dietitians have bristled at the amount of malnutrition that has been recorded by providers inappropriately. Nutritional expertise truly resides in the dietitian’s domain. They can weed out weight loss hearsay, confirm accurate BMIs, and have more accurate determination of patients’ nutritional issues. But, they are not allowed to make the diagnosis because only the providers are licensed to make the diagnosis.

In 2012, parameters for evaluation and stratification of malnutrition by nutritionists were changed. BMI, protein and albumin parameters were taken out from the criteria in identifying malnutrition. Caloric intake, weight loss and duration, physical assessment findings of subcutaneous fat loss, muscle mass loss, fluid accumulation and reduced grip strength have become the primary parameters. Thus, making it even more difficult and confusing. Most providers are reluctant to call the diagnosis without the dietitian’s full assessment.

This leads to a catch-22 situation. The providers who are licensed to make the diagnosis do not feel they have the expertise. The dietitians who have the expertise are not allowed to make the diagnosis. The solution lies in a collaborative effort between the providers, dietitians, floor nurses, CDS, and even Wound Care RNs, PT and Pharmacy. All these folks have a stake in the capture of nutritional issues.

Since the dietitians are not able to cover all patients that are admitted to acute inpatient care, they need a good referral system from all the stakeholders. The floor nurse fills out a nutritional screening form for all patients admitted to inpatient care. CDS, Wound Care RNs, PT and Pharmacy can also refer patients directly to dietitians.

New policies and procedures for the dietitians have to be formulated to assess and make a determination of patients’ nutritional issues and their severity (mild, moderate, severe). They have to go through their own Nutrition committee and have the Medical Executive committee approve and authorize the initiative. Since physical assessments have not been traditionally part of their training, they need to be trained by Rehabilitation Medicine providers or PT to make the physical assessments (i.e., SQ fat loss, muscle mass loss, fluid accumulation, reduced grip strength).

It takes time for new policies and procedures to be approved. An interim agreement for dietitian referral needs to be established. Otherwise, some dietitians may not be willing to go outside their regular scope of work and comfort level. Gray areas can be resolved by full dietary team consultation.

All of the above can only be undertaken with the cooperation of the dietary department. A preliminary meeting with the clinical manager of the dietary department would be the first step, which leads to a discussion of the need for their cooperation in starting an initiative. Showing how nutritional issues affect clinical outcomes as well as its financial impact may help convince the need for such an undertaking. Administration support for this initiative is critical.

Reference:
cl713-reference

Cesar M. Limjoco, MD, VP of Clinical Services

This post courtesy of cditips.com

Clinical Documentation Improvement: A Word On Excessive Note Taking

CDI Review Notes – How much is too much?

Compiling a “CDI version” of the documented H & P is too much!

Inevitably, CDSs need to make notes to prompt their thoughts about the cases they review, but there is much better use of time and productivity by honing in on what lacks in documentation rather than copying what is already well stated.

In defense of a CDS “newbie”, writing down more clinical content in the review notes is understandable and certainly expected while training. However, as the CDS matures, irrelevant content will become much clearer thus resulting in less daily review notes.

The CDS must gain perspective regarding the intent of review notes. The logic behind review notes is to assist any CDS with being more efficient in their work not a burdensome process eating away excessive amounts of time. In reality, CDI review notes are intended to serve as a quick reference to the potential need for pursuing improved documentation via physician clarifications.

It is important to note that the vast majority of CDSs entering the marketplace are nurses. Nurses are trained to give and receive shift reports encompassing a thorough overview of the patient’s active medical problems as well as past medical history, treatments, labs, x-rays, diet, activity, etc. This is part of a process embedded into the standard training for nurses. As a nurse, it is difficult to embrace different methods of note taking as it relates to the world of CDI. Like any learned process, it is difficult to make changes.

Additionally, nurses are not coders. However, they need a “working knowledge” of coding to do their job well. Because of this, they sometimes feel the need to write more than what’s necessary. It helps to have a strong “working knowledge” of coding to understand how certain type notes will help compliment their work when identifying the need to obtain more specific physician documentation.

But, in the end, it would be most helpful to just keep it simple and review more cases!

Kelli Estes, RN, CCDS


This post courtesy http://cditips.com

Clinical Documentation Improvement Tip: Coding Help for Hypotension Vs. Shock

67 y.o. male was admitted with a hip fracture and it was decided to do a hip replacement. Intra-operatively the femur bled and the patient lost about 1000 ml of blood. Overnight the patient’s blood pressure, baseline 130s/90s, dropped to 80s/40’s. Heart rate, baseline high 60s & low 70s, increased to 90s & 100s. Hgb on admission was 14 which dropped to 8.2 post-op.

Treatment with vasopressors followed by 500ml/hour until vital signs improved. Placed on 10L O2 & non-rebreather initially and once vital signs stable decreased to 3-4L, Patient was continually monitored in ICU, taking 10 hours to recover.

Documentation stated hypotensive due to 1000ml blood loss.

The CDS wrote a clarification, addressing it to both the surgeon and hospitalist, asking if the event was Hypovolemic Shock, with or without Anemia due to Acute Blood Loss or was the hypotension due to some other etiology.

The surgeon documented in his next note that the patient’s episode was due to Hypovolemic Shock and the Hospitalist documented Anemia due to Acute Blood Loss.

Randy Wagner, BSN, RN, CCS

This post courtesy of http://cditips.com

Clinical Documentation Advice: Capturing Nutritional Initiatives

Capturing Nutritional Issues Initiative: A Collaborative Effort

In the past, Clinical Documentation Specialists (CDS) would ask the provider if the patient had nutritional issues based on evidence in the history, physical exam findings and lab results. They would rely on history of weight loss, findings of emaciation and body wasting, BMI, protein, albumin to ask the provider if the patient had malnutrition and its severity. Hearsay, incorrect BMIs recorded because of faulty information, abnormal losses of protein from non-nutritional issues have led to incorrect documentation of malnutrition by providers. Medicare and RAC auditors have targeted inappropriate coding of malnutrition, in cases that it is the only CC or MCC.

Dietitians have bristled at the amount of malnutrition that has been recorded by providers inappropriately. Nutritional expertise truly resides in the dietitian’s domain. They can weed out weight loss hearsay, confirm accurate BMIs, and have more accurate determination of patients’ nutritional issues. But, they are not allowed to make the diagnosis because only the providers are licensed to make the diagnosis.

In 2012, parameters for evaluation and stratification of malnutrition by nutritionists were changed. BMI, protein and albumin parameters were taken out from the criteria in identifying malnutrition. Caloric intake, weight loss and duration, physical assessment findings of subcutaneous fat loss, muscle mass loss, fluid accumulation and reduced grip strength have become the primary parameters. Thus, making it even more difficult and confusing. Most providers are reluctant to call the diagnosis without the dietitian’s full assessment.

This leads to a catch-22 situation. The providers who are licensed to make the diagnosis do not feel they have the expertise. The dietitians who have the expertise are not allowed to make the diagnosis. The solution lies in a collaborative effort between the providers, dietitians, floor nurses, CDS, and even Wound Care RNs, PT and Pharmacy. All these folks have a stake in the capture of nutritional issues.

Since the dietitians are not able to cover all patients that are admitted to acute inpatient care, they need a good referral system from all the stakeholders. The floor nurse fills out a nutritional screening form for all patients admitted to inpatient care. CDS, Wound Care RNs, PT and Pharmacy can also refer patients directly to dietitians.

New policies and procedures for the dietitians have to be formulated to assess and make a determination of patients’ nutritional issues and their severity (mild, moderate, severe). They have to go through their own Nutrition committee and have the Medical Executive committee approve and authorize the initiative. Since physical assessments have not been traditionally part of their training, they need to be trained by Rehabilitation Medicine providers or PT to make the physical assessments (i.e., SQ fat loss, muscle mass loss, fluid accumulation, reduced grip strength).

It takes time for new policies and procedures to be approved. An interim agreement for dietitian referral needs to be established. Otherwise, some dietitians may not be willing to go outside their regular scope of work and comfort level. Gray areas can be resolved by full dietary team consultation.

All of the above can only be undertaken with the cooperation of the dietary department. A preliminary meeting with the clinical manager of the dietary department would be the first step, which leads to a discussion of the need for their cooperation in starting an initiative. Showing how nutritional issues affect clinical outcomes as well as its financial impact may help convince the need for such an undertaking. Administration support for this initiative is critical.

Reference:
cl713-reference

• Cesar M. Limjoco, MD, VP of Clinical Services

http://www.dcbainc.com/clinical-documentation-improvement-program/

Clinical Documentation Insight

Working in Silos is Never a Good Idea

The hospital has an electronic medical record system.  Management of the clinical documentation team originally decided to send physician clarifications via email.  The response rate from the physicians was poor.  CDS management decided to meet with the physicians and get their opinions as to how to send clarifications.  The physicians suggested using the message center in the EMR.   This allows the physician to see the clarification in the patients medical record thus making it much more convenient to answer.

So, working with the physicians to determine the best process for clarifications will result in an improved response rate.
-Randy Wagner, BSN,RN,CCS
 http://www.dcbainc.com/clinical-documentation-improvement-program/

Clinical Documentation Improvement Tips: Acute Respiratory Failure

Appropriate use of the term “acute respiratory failure” has become a hot topic recently. Some well-meaning CDSs, billers and doctors have fallen into the trap of using the term in order to bill at a higher level. This is an especially timely topic with the advent of Value Based Purchasing. At a recent client site, the pulmonary intensivists were using the term 100% of the time in their post procedure patients on a ventilator. I met with these doctors the next morning during rounds. We saw 4 patients, three of which had no problems being weaned off the vent using standing orders. The fourth patient arrested during the night after being weaned from the ventilator and had to be re-intubated. The time the intensivists spent with the first three patients was very brief. The decision making and time spent with the fourth patient was obviously more intense. It was clear that the fourth patient had indeed had an episode of acute respiratory failure. The ventilator management of the other three patients was just an integral part of the procedure and therefore use of the term “acute respiratory failure” would be inappropriate. Rounding with these doctors was incredibly beneficial. This is a very effective way to resolve documentation issues; reviewing their patients’ charts in real time.

-Kelli Estes, RN, CCDS

http://www.dcbainc.com/clinical-documentation-improvement-program/

Clinical Documentation : How to Phrase A Good Clarification

One of the more difficult tasks for a CDS to master is how to phrase a good clarification. Throughout my career I have often been given the responsibility of evaluating those clarifications. Some have been excellent, some mediocre, and some poor. They have all been instructive and useful. I have collected some examples from each of those catgories and arranged them randomly into a list. We go through that list during training,asking the CDS “what do you think of this one?”. Good,bad or mediocre? Do you think the doctor is going to understand what you are asking?”. If not, how could it have been phrased differently? This allows each CDI to see different ways to ask the same question and at the same time develop their own unique style.

Special Thanks to Dr. Tim Shulte, MD for some CDI advice!