2024 ACDIS Conference Poster Flipbook

16th Annual ACDIS Conference Poster Presentations

Gennifer Aidif, MSN, RN, CCDS & Dannie Greenlee MSN, RN, CCDS Solventum Health Information Systems

Even though they are not used for final coding, inpatient radiology records provide important clinical indicators for CDI specialists to form queries.

Radiology documents can be tedious to review, and their duplicative nature increases false positives in evidence, decreases accuracy, and overwhelms end users.

There is increased CDI interest in using radiology evidence as clinical validation for queries when radiology documentation is not addressed by the treating provider.

How do we understand and utilize radiology documents efficiently and optimally?

We identified key points within radiology reports that are relevant to CDI and allow meaningful data extraction and streamlined queries.

hundreds of clinical records. Contents varied by organization and exam type, but comparison revealed a general structure and sectioning. which sections needed to be included and excluded for clinical validation within CDI queries. radiologic section constraints within our natural language understanding (NLU) logic to ensure all data presented is applicable.

Demographics

Jane Doe, 38 female

Radiology study performed

Chest X-ray

Medical reason for exam

Shortness of breath

Radiologic details about procedure

Chest posteroanterior (PA) view

Observations of body systems from study

Right lower lobe consolidation

Interpretation of observations in context of indication

Focal consolidation concerning for pneumonia

Suggestions for further medical treatment

Repeat x-ray after treatment

Constraining sections increases efficiency to the CDI program by allowing for targeted review

Understanding how to optimize supplemental documentation is critical

Increased demand in radiology services = large potential for future CDI impact

NLP vs NLU: Augmentation to the CDI Workflow Josh Amrhein, MHA Sovlentum Health Information Systems Murray, Utah

Introduction Artificial Intelligence (AI) has been known to assist in the Clinical Documentation Integrity (CDI) workflow(s).

Natural Language Understanding (NLU) is a subset of Natural Language Processing (NLP) which can be found to be used in the CDI workflow(s). Many misconceptions are made between the difference of NLU vs NLP. While both bring benefit(s) to the CDI specialists, such as increased productivity, there is a difference in how the two function.

NLU capture can be through explicit documentation, clinical evidence or both whereas NLP capture is text, but doesn’t build on the “clinical” evidence within the encounter like NLU.

Bringing AI to Success Such challenges to overcome include the following: • A lack of understanding about what a particular type of AI technology can or cannot do; • A lack of clear strategies for integrating different AI technologies into the existing care systems to effectively solve the most pressing challenges that health organizations currently face; • A shortage of a well-trained workforce for AI implementation; • The incompatibility of AI technologies with legacy infrastructure; and • A lack of access to good and diverse medical data for training Machine Learning (ML) algorithms/models.

Natural Language Processing • Data science technology where “engines” are designed to “read” narrative text to identify and tag specific words with coded values • Used to convert a blob on text into computer understandable structured data • NLP engines are built for specific purposes, are not widely adaptable – changes to the encoding logic require reprogramming • Real-world examples include Computer Assisted Coding (CAC), online chatbots, and auto-generated keyword tabs

VS Natural Language Understanding • NLU = NLP + Clinical Reasoning • Designed to provide machine reading comprehension, wider adaptability • Extend NLP codes with semantic meaning • After NLP code markup, NLU engines apply reasoning and comprehension based on clinical concept rules, tested against robust gold standards data sets

Example:

The patient is a 60-year-old male with heart failure and shortness of breath. BNP is 600pg/ml. Echocardiogram shows EF 20%.

NLP Conclusion:

NLU

NLP captures the text of “heart failure” whereas NLU uses the documentation of “shortness of breath, BNP result, and EF, to be able to produce the opportunity for further clarification of heart failure. The use of NLU in the CDI workflow has been proven to aide in increased productivity of CDI specialists. NLU technology is meant to augment the CDI workflow, but not replace necessary critical thinking of a CDI specialist.

Contact: Josh Amrhein: jramrhein@solventum.com RESEARCH POSTER PRESENTATION DESIGN © 2019

www.PosterPresentations.com

TRANSFORMATIONAL CDI THE WINGS OF TRANSFORMATION TO CDI EXCELLENCE BACKGROUND

“Embrace the whispers of change for they hold the secrets of tranfsformation.”

Anonymous

CDI TEAM HEIRARCHY

BIDMC began an RN, Pipeline Program-2017-2020 21 RN’s-Interviewed, Entrance Exam and went through a rigorous CDI training program, in multiple phases.

All of the nurses went through internal CCDS training (following 2 years in the CDS role) and received their certification (CCDS).

Over the years, the CDI Team has been educated in CDI & Coding service line specialties, and training in SME teams included; Mortality, Quality, Denials and IT/CDI software.

The CDI Team has transformed from Novice to Expert, through advanced education, internally, as well, as external consultants, with multiple innovative strategies and process improvement initiatives through structural and functional changes.

“We delight in the beauty of the butterfly but rarely admit the changes it has gone through.”

Maya Angelo

STRATEGIES FOR GROWTH & TRANSFORMATION

RECOGNITION

RECOGNITION/ENGAGEMENT CDI Spotlight BIDMC Instagram Share the Love Newsletter Self-Care Initiatives

LEARNING GAMES: Trivia*Jeopardy*Kahoot*Slido*contests

Poster Presenter-2022, 2023,2024 ACDIS Virtual Conference Speaker-2024 ACDIS/MAHIMA/NYHIMA Speaker-2023 ACDIS Leadership Committee ACDIS Events Committee MAHIMA Education Committee 100% Certification - CCDS

BIDMC BIDMC is an academic medical center located in the heart of Boston, a teaching affiliate of Harvard Medical School.

BIDMC is part of Beth Israel Lahey Health, a health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, and more than 4,000 physicians and 35,000 employees.

Advances the science and practice of medicine through groundbreaking research and education

CDI PROGRAM OUTCOMES

CDI and Quality Team up to Impact PSIs Clinical Documentation Integrity teams up with Quality for Patient Safety Indicator Case Reviews

PROCESS

RESULTS

Development of PSI Team Requested one team member from each facility to become a resource person

PSI 3: Wound care has been part of the committee since the beginning. Pressure ulcer reviews involve the Director of Wound Care on all PSI 3 or potential PSI 3 cases. Wound Care nurses are responsible for documenting stages.

INTRODUCTION It was determined that a collaborative approach to PSI identification, reporting and review would be beneficial.

PSI Team includes: Quality, CDI, Coding, Wound Care and Physician Advisors. Ad Hoc members: Nursing Services PSIs being monitored: PSI 90

• • • • • • • • • •

PSI 03 Pressure Ulcer Rate PSI 06 Iatrogenic Pneumothorax Rate PSI 08 In Hospital Fall-Associated Fracture Rate PSI 09 Postoperative Hemorrhage or Hematoma Rate PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis Rate PSI 11 Postoperative Respiratory Failure Rate PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate PSI 13 Postoperative Sepsis Rate PSI 14 Postoperative Wound Dehiscence Rate PSI 15 Abdominopelvic Accidental Puncture or Laceration Rate

Developed a concurrent and retrospective chart review process.

Meet weekly to review PSI cases and outcomes

Educated the resource team member on PSI definitions, software identification and exclusions.

Utilized resource team members in the education process for the entire CDI team.

Education included:

• • • • •

PSIs/identification/resources/notification process Increased staff awareness of PSI Utilize technology in our CDI tool for PSI identification Reporting/notification process Working with other departments on documentation

PSIs flagged in our data system are reported to the CDI Lead Analyst for a second look review.

Utilize our technology reports to confirm all identified PSIs are reviewed concurrently.

Placed a hard stop on all final coded cases with identified PSIs for retrospective review, to ensure a 100% review rate.

PSI 9 has been the most avoided due to the anticoagulant contributing to bleeding query. D68.32 code addition.

Confirmed with AHRQ that coagulopathy does NOT need to be POA. PSI 11 post op respiratory was greatly affected by developing a network wide definition of respiratory failure, query clarification and physician education.

Improvement in our O/E ratio in all facilities and service lines.

This process includes consistent focused provider education from both CDI and Quality regarding PSI and clinical documentation. Resulting RESULTSin increased capture and reporting accuracy of all PSIs being monitored.

With improved documentation integrity the result is improved quality metrics, case management, patient outcomes and appropriate revenue support.

Stats through January 2024

All cases are reviewed by CDI, Quality and Coding as needed to ensure that no opportunities are missed.

Notifications: the # of PSIs flagged in our data system and reviewed.

Feedback is utilized to provide ongoing education to all departments.

Avoided: PSI which were appropriately excluded from our PSI metrics through our combined chart review process, query clarifications and coding validation reviews.

Jan- March 2023- 56 PSI notifications, 26 avoided (46%) April- Jun 2023- 54 PSI notifications, 22 avoided (41%) Jul- Sept 2023- 49 PSI notifications, 21 avoided (43%) Oct-Dec 2023- 60 PSI notifications, 34 avoided (57%) January 2024- 38 PSI notifications, 19 avoided (50%)

Optimized DRGs by Length of Stays- Collaboration between CDI and Case Management Lourdes A. Cacanindin, MD-FMG, CCDS Sutter Delta Medical Center

Introduction Length of Stay [LOS] became a critical priority and continues to be one as the need for optimization of the DRGs Length of Stay key for health care organization. Incorrectly placed patients end up at the wrong level of care and /or being treated by clinical staff who do not specialize in their condition that can lead to slower recovery times and even clinical complications. Getting the right patient to the right bed at the right time can reduce LOS and CDI Specialist can help maximize and optimized the DRG’s length of Stay by helping case management in identifying comorbid conditions which can impact DRG assignments at the time of admission up to the time of discharge.

CDI Goals

Results COLLABORATION BETWEEN THE CASE MANAGERS, OUR PROVIDERS AND THE CDI SPECIALIST IMPACT THE APPROPRIATE REDUCTION OF THE LENGTH OF STAY OF INPATIENTS

Case Manager

CDI Specialist

1. To be able to show how the collaboration between Case Managers and CDI Specialist impacted the Length of Stay- AMLOS and the GMLOS from the time of admission to the time of discharge.

2. To identify the Operators involved and their respective roles in this collaboration a.Clinical Documentation Specialists b.Case Managers c. CDI Physician Advisor and Hospitalist d.CDI Director/ Supervisor / Lead

Providers

• Helps determine the correct Level of Care and communicates with the CDI Specialist the possible initial condition that necessitates the case admission.

• Helps determine the correct placement of patients and monitors the assigned LOS that corresponds to the possible DRG assignment by the CDI specialist reviews done up until possible discharge dates.

• Helps in Optimization of the DRG’s Length of Stay by assigning Initial DRG upon admission which is communicated to the Case Managers thru EPIC • Continuously work on the Possible DRG assignment with corresponding Length of Stays by identifying all the appropriate comorbid conditions noted until the time of Discharge

• Gives the appropriate specialized care to the patients for all the identified comorbid conditions upon admission and throughout the inpatient stay • Promotes faster recovery times without clinical complications cognizant of the Length of Stay assigned to the case.

Top 12 Optimized DRGs by LOS as impacted by CDI

3. To be familiar with all the tools used to identify the Length of Stay- AMLOS and the GMLOS a.EPIC b.Clintegrity c. Optum CAC Computer Assisted Coding 4. To have further discussion and collaboration with the case management department regarding LOS by ensuring proper patient placement and with the hospitalist’s identification of the proper diagnosis that necessitated a hospital bed.

5. To educate Case Managers regarding the CDI perspective on the importance of accurate interpretation of AMLOS and GMLOS (Show the impact of identifying the appropriate Principal Diagnosis, the Principal Procedures, and other comorbid conditions such as homelessness, type of depression, drug dependence, alcohol withdrawal.)

6. CDI can provide quick educational resources to Case Management using Coding Clinics / Coding Guidelines and the use of our Sutter Health KDS [know, Do, Share] of certain diagnosis.

7. To show the harmonious collaboration of the CDI Specialist with the Senior Case Managers.

8. To finally show some sample of the cases that has Optimized DRGs by Length of Stay Impacted by the CDI Specialist

Target Audience 1. All CDI Specialists and Case Managers/ Coordinators who want to collaborate with CDI Specialist on this regard.

2. All CDI Managers and Case Manager Supervisors who actively engage in such Collaboration 3. All Providers who want to improve their proper documentation to enhance the impact of the DRG’s Length of Stays

Methodology The Top 12 Optimized DRGs by Length of Stay as Impacted by the CDI Specialist Reviews and CDI queries done were identified in this chart within the month of October 2023 as an example to show the parameters used as follows: 1. Total Days added to the GM- LOS 2. Number of Accounts Impacted 3. Average Days added per Account

Conclusion In conclusion, “Getting the right patient to the right bed at the right time” with the collaboration of the Case managers and the CDI Specialist at our Sutter Health facilities helps maximize the Length of Stay of our Inpatients with the utmost care given by our Sutter Health providers/ hospitalists and all Specialists, making sure all the patient’s comorbid conditions were appropriately addressed and treated.

Evaluation Give the audience a quick 3 question survey to access their knowledge and their awareness of their own facilities’ Average Length of Stay / Hand them some quick tips on how to perform an effective and efficient collaboration/ Engage audience with one-on-one conversation regarding the approach to this collaboration between CDI Specialist, Providers and Case Management Department.

Addressing CDI Challenges: A Guide on How to Handle The Problem List AHIMA “Well-designed problem lists provide important information for patient care and support meaningful use requirements and health information exchange. While there are many approaches to a well-designed problem list, the key is to define clear policies and procedures that support your organization's objectives in using the information in a problem list.”1 • Is editing permissible by roles other than independent licensed professionals?

• Are the roles specified?

• Is it clearly stated in the institution’s privileging policy?

• What is the authorship?

The CDI Goal as it Pertains to the Policy • • • •

Problem list accuracy Revenue protection of OIG/RADV targeted diagnoses Maximizing efficiencies in the BPA for 2024 RAF capture of re-certified conditions Identify education opportunities

The Policy Problem List Policy Additions

Problem List Policy Deletions

I.Documentation in the provider encounter note:

I.Duplication

II. ICD-10 Guidelines:

• Encounter HPI, A&P, PE (amputations) • Status code of amputation, stomas, GT in PE, in ROS • Specificity in provider encounter, in the provider’s own words, within the body of the note • Specialist note (on staff at institution), in the provider's own words, within the body of the note (i.e. secondary cancer, resolved cancer, diagnosis specificity, etc.)

• Same diagnosis multiple times

• AMI • CVA

III. Documentation in the provider encounter note negating an active event:

IV. Acute conditions moved in history:

II. ICD-10 Guidelines: • DM ‘with’ where both conditions in same DOS but not billed with a combination code • Old MI (>4 weeks) • BMI measurement • Status codes (i.e., AKA, GT, etc.)

• I.e., ‘history breast cancer s/p lumpectomy in 2008, Anastrozole completed 2013’

• • • •

Fractures Sepsis AKI PNA

V. Unsupported diagnoses: • Morbid obesity • BMI

• Stage of CKD

Real-Time Examples ADDED as a Result of the Policy:

Real-Time Example DELETED as a Result of the Policy:

• Dementia • Morbid obesity • AAA • Skin ulcers • Morbid obesity

• AMI, STEMI, NSTEMI • Thrombocytopenia • Acute Respiratory Failure • Morbid Obesity

• History of breast/ prostate cancer • CKD III, CKD IV • Secondary cancer • Dementia

• CVA with hemiparesis • DM2 with CKD, with neuropathy, with PVD, etc.

3 Month Outcome with 13 Providers

• PNA • CVA • Cancer • Sepsis • Fractures

• Morbid obesity • DM2 with CKD, with neuropathy, with PVD, etc.

The Best of Both Worlds Two Healthcare Systems Unite and One Best-in-Class CDI Program Emerges Grand Rapids/Southfield, Michigan

Elaine Koetje, BS, BSN, RN, CCDS, CRCR, CHC Manager, Clinical Assurance Program

INTRODUCTION

Jeanette Lyons, RN, BGS, CCDS, CRCR Director, Clinical Documentation Integrity and Coding Quality

INITIATIVES

• Implemented a unified AI CDI Software tool • Modified daily workflow processes • Created system-wide Provider Query Policy • Standardized query templates • Streamlined Mortality workflow processes • Expanded collaborative PSI process • Broadened CDI educational offerings • Annual CDI pocket guides distribution • Aligned CDS productivity/query dashboard • Enhanced CDI quarterly quality reviews • Established Query Focus Group

Corewell Health is the success of Beaumont Health and Spectrum Health joining together to create a $15 billion organization with nearly 65,000 team members. Corewell Health’s CDI program has flourished during this integration by utilizing shared expertise across the East and West regions of lower Michigan. 2023 was especially successful as our legacy CDI programs joined forces to produce standardized query templates and developed processes and protocols to support system alignment.

STRATEGY All 98 CDI team members contribute to the success of our program. CDI successfully established cohesive partnerships while strengthening relationships across the healthcare system. Collaboration and engagement with other healthcare teams prevailed. CDI’s journey to bestin-class system metrics included: Coding, Coding Quality, Physician Advisors, Quality Safety & Experience, HIM, Compliance, Managed Care Contracting, Patient Financial Services, Senior Leadership, and Provider Leadership.

Successful Outcomes Query Impact Type Provider Query Policy 1%4% 13% 29% 3% 2%

0%

15%

13%

1%

Query Template

Risk Conditions (24,210) POA (114) PDx (11,185) CC (15,758) Procedure (449) MCC (12,618) CC/MCC (1,399) Clinical Validation (2,084) None (10,935) HAC/PSI (451) SOI/ROM (3,673)

19%

Query Agreement Rate

Query Response Rate

7%

1%

Physician agrees (75,829)

Response (81,962) No response (676)

Physician disagrees (6,133) 93%

99%

Team Achievements Reviews by Review Date - 2023 25000 20000 9271

15000

7017

8555

9850

9183

8617

8914

8127

7934

7642

7423

9242

10000

5000

11622

10699

January

February

12967

11813

12640

12573

March

April

May

June

12618

11624

12820

12408

12173

August

September

October

November

December

10822

0

Initial Review

July

Re-review

Legend:

Optimizing Neuroscience Mortality Index: A Collaborative Approach Yasmin Aghajan MD, Cheryl Codner MPH, BSN, Patricia Martin RN, BSN, Sandhya Prakash RN, BSN, Ronald Mendoza RN, BSN, Deborah L. Jones MSN, RN, Bradley J. Molyneaux MD, PhD

Background Department performance

Aim & Hypothesis Quality of care delivered

Why does mortality matter?

Benchmarking

Physician collaboration with CDI can identify commonly missed documentation opportunities and serve as basis for ongoing improvement in documentation practices, improving accuracy of neuroscience expected mortality.

Hospital rankings

Methods

Mortality Index

O:E % Observed mortality % Expected mortality

Neuroscience Neurologist CDI specialist

Gaps in documentation→ falsely low expected mortality and high mortality index

Review neuroscience mortality Additional queries Track expected charts for additional mortality calculation undocumented diagnoses present pre- and post- review* on admission that impact Vizient risk-adjusted expected mortality* *Vizient 2022 Interactive Risk Model Calculator

Results A. Expected mortality pre- and post- review

B. Expected mortality pre- and post-review by quarter

C. Most common additional documentation opportunities

Mean expected mortality increased from 0.33 to 0.42 # Diagnoses affecting riskadjusted mortality increased from 4.3 to 7.8 per patient Significant decrease in Vizient mortality index

D. Mean number of additional diagnoses captured per patient

E. Mean number of additional diagnoses identified by physician reviewer

F. Monthly Vizient Neurology & Neurosurgery expected mortality pre- and post-intervention Interrupted times series analysis demonstrates a significant decrease in neurology and neurosurgery service-line mortality index after the implementation of the intervention at month 10 (absolute decrease of 0.067; p<0.0001) with a continued decrease over time (slope change of 0.016 relative to preintervention slope; p<0.0001

Conclusions Collaboration between neurologists and Clinical Documentation Integrity (CDI) specialists to review documentation improves specialty-specific capture in neuroscience and increases the accuracy of neuroscience expected mortality.

References

THE ADVANTAGE of TECHNOLOGY

Does your data currently reflect accurate HCC risk scores based on reported diagnoses for your patient population?

• Are all chronic conditions documented in the medical record at least once per calendar year?

• Do you capture HCC diagnoses in all care settings?

THE CDI STRATEGISTS

A Risk Score in the context of Medicare is a numerical value meant to denote the patient’s expected costs solely based on demographics and HCCs. A risk score of 1.0 is the average expected Medicare patient’s score.

With the implementation of technological support to CaroMont Medical Group’s workflow, we were able to increase our benchmark risk scores by 6% overall, a notoriously difficult metric to move.

CMS’s Risk Adjustment model needs accurate patient data to predict statistics and reimbursement for health systems. The model uses diagnoses identified in Hierarchical Condition Categories (HCCs), and there must be evidence that these conditions are evaluated and managed by providers each year. In the busy ambulatory setting where encounters can easily number in the thousands annually, this information can be difficult to track, especially using antiquated systems, such as spreadsheets and different file folders. This sort of basic electronic data capture might be slightly better than paper charts, but still can be cumbersome and inefficient.

CaroMont Medical Group implemented utilized technology in the following ways to assist with workflow:

Moving the metrics: OPTIMIZING A RISK ADJUSTMENT PROGRAM IMPROVE RAF SCORE

Streamline Process

Quality Measures

Organization Goals

• Quality Data

• Prioritization

• Identify High Risk Areas

• Data Analytics & Reporting

• Complete Documentation

• Productivity

• Increase Patient Safety

• Reduce Denials

Pre-Visit Workflow Aggregates claims by patient for the past 2 years. Displays all ICD-10-CMs codes that went out on claims. Filters all codes previously billed in past years but not yet billed for current year. Uses technology such as Natural Language Understanding (NLU) to find evidence for diagnoses not yet sent out on a current claim, and displays to the user. Alerts CDI Specialists on gaps in clinical documentation. Allows the user to filter out most relevant diagnoses based on documentation. Shows gaps in risk scores remaining for the current year.

Concurrent Reviews & Patient Encounters Functionality that allows for notifying providers Sends auto notifications to providers based on NLU output. Allows CDI specialists to request clarification from providers for certain diagnoses before a visit takes place. Nudges providers during note creation to improve the quality of documentation.

• Accurate Coding

Analysis An organization’s success with risk-adjustment depends on the ability to ensure accurate and complete documentation and coding. CDI programs are key touchpoints for closing the gaps in care by capturing compliant and accurate hierarchical condition categories (HCCs) and risk adjustment factor (RAF) scores to reflect the patient true and accurate clinical picture. Technology provides a process to improve risk-adjusted documentation and coding through patient prioritization and real time physician nudges at the point of care. Solutions like this, along with a prioritized worklist that allows for filtering patients by risk scores, risk scores gaps, visits and diagnoses, can help provider organizations track their population from year-to-year.

Results By The Numbers

Post-Visit Workflow

80% Uses NLU to suggest ICD-10-CM codes based on completed documentation for particular visits, allowing medical coding staff to accept, modify or reject the output. Shows the HCC categories the ICD-10s are a part of.

• Improve Reimbursement & Quality Metrics

Increase in Clinical Documentation Integrity RN productivity

132%

Increase in the number of individual encounters reviewed

Created and Presented by: Wayne Morris, BSN, RN, CCDS, CCDS-O, CPC, Will Morriss, CCS, CCDS-O, April Russell, MBA, CPC, CPC-P, COC, CRC, CCDS-O

I

Viral Pneumonitis in Pediatric Patients: Is it Actually Pneumonia?

Pneumonia or Pneumonitis?

Does this impact code selection?

Children will present to the hospital with increased work of breathing, some critically ill, needing respiratory support.

Chest x-rays show no evidence of pneumonia. No antibiotics are administered, just respiratory support.

The physician’s diagnosis is viral pneumonitis. There is a growing debate among coders, auditors and clinical documentation specialists. RAC auditors are denying claims coded as viral pneumonia.

As of FY 2024, the ICD-10-CM Alphabetic Index made a simple, but significant change concerning pneumonitis.

Do the official guidelines and/or coding conventions offer any direction?

Pediatric Viral Pneumonitis: What is it?

Clinical Indicators and Imaging: Pneumonia vs. Pneumonitis

Inflammation of lung tissue

Pediatric Pneumonia

• Occurs when irritant enters the lungs • Typically not contagious • Can affect breathing efficiency

Infection of the lungs

• Wheezing • Fever/chills • Productive cough • Difficulty/rapid breathing

Causes

• Bacteria • Bird feathers/feces exposure • Certain antibiotics • High doses of aspirin • Molds • Certain anti-arrhythmia medications • Radiation therapy

Pediatric Pneumonitis Can be self-limiting

Inflammation of the lungs

Pediatric Viral Pneumonitis Symptoms

• Dry cough • Decreased appetite • Fatigue • Shortness of breath • Unintentional weight loss

• Shortness of breath • Decreased appetite • Dry cough • Fatigue • Unintentional weight loss • Children often present in respiratory distress with RA saturations in the 80s, requiring NIPPV for support.

Patients are usually weaned to HFNC then room air.

No treatment with antibiotics is needed

Physician Documentation Discharge Summary

Physician Query & Response

Reason for Hospitalization Noah is a previously healthy 4-year-old M admitted due to WARI and presumed viral pneumonitis requiring supplemental oxygen and frequent albuterol treatments. At time of discharge, illness more consistent with asthma

Pending Studies (Results not Final) (Last 100 days)

Hi CDIS - My discharge summary note never mentioned “pneumonia” or implies bacterial pneumonia. I can’t control what the other notes from other providers say. This patient had an asthma exacerbation triggered most likely by a virus. The “pneumonitis” in my note means nonspecific inflammation of the lung. I don’t usually have to answer this type of compliance question for an asthma patient.

01/02/24 1119 Hold Tube Green Top – UCH MN Routine Ordered by an Unspecified provider in process

-----Message-----Subject: Coding Clarification

Please refer to H+P note for complete details of presenting illness.

Next steps for PCP -Hospital follow up visit, repeat respiratory exam -Ensure medications at home. Flovent (or Asthmanex) and albuterol

Hospital Course Discharge Summary: Noah was admitted due increased work of breathing. RPP was negative. CXR negative for pneumonia. Given DuoNebs, dexamethasone and albuterol with some improvement. WOB worsened and required up to HFNC for support. Improved and weaned to room air, passed room air while awake and while asleep. Albuterol spaced to q4h prior to discharge. Pulmonology was consulted, recommended to start Flovent BID, continue albuterol PRN And follow up in Pulmonology clinic. Benefited from airway clearance with IS and flutter -Completed 7 days of steroids -Asthma education (asthma action plan) and inhaler teaching completed -Prior to discharge, pt active and playful, appears comfortable, afebrile and eating/drinking well -Parents counseled on return precautions and understood to follow up closely with PCP

Radiology Report

X-RAY CHEST 2 VIEW CLINICAL HISTORY: Worsening respiratory status; And concern for developing pneumonia <LCI> COMPARISON: 1/2/2024 </LCI> FINDINGS There is increased perihilar, peribronchial thickening and interstitial prominence. No confluent airspace consolidation, pleural fluid, or pneumothorax. Heart size is within normal limits. test results are released to you at the same time they are released to your healthcare team. This means you may see these results before your healthcare provider has seen them. Your healthcare provider will review all of your results. If you have not heard from them or you have questions, please contact your healthcare team through MyChart or call your healthcare provider’s office during normal business hours.

IMPRESSION: Peribronchial thickening has increased without focal consolidation.

Dear Dr. Attending, A review of the medical record has identified a need for documentation clarification in order to meet compliance, accuracy of coding and severity of illness standards.

In the H&P and discharge summary, pneumo nia is documented. After study was completed, could you please clarify the type of the Noah’s pneumonia to the highest specificity known?: - Aspiration pneumonia (please specify aspiration content, if known) - Viral pneumonia (please specify virus, if known) - Bacterial pneumonia (please specify bacterial agent, if known) - Pneumonia, unspecified - Other (please specify) - Unable to determine

How is Pediatric Viral Pneumonitis Coded?

Alphabetic Index FY 2023 • Pneumonitis (acute) (primary) (see also Pneumonia) • Air-conditioner J67.7 • Allergic (due to) J67.9 • Aspiration J69.0 • Chemical (due to gases, fumes, or vapors) (inhalation) J68.0 • Cholesterol J84.89 • Crack (cocaine) J68.0 • Chronic – see Fibrosis, lung • Congenital rubella P35.0 • Due to • Eosinophilic J82.82 • Hypersensitivity J67.9 • Interstitial (chronic) J84.89 • Lymphoid, Interstitial J84.2 • Meconium P24.01 • Postanesthetic J95.4 • Postoperative J95.4 • Radiation J70.0 • Rubella, congenital P35.0 • Ventilation (air-conditioning) J67.7 • Ventilator associated J95.851 • Wood-dust J67.8

Alphabetic Index FY 2024 • Pneumonitis (acute) (primary) (see also Pneumonia) J98.4

• • • • • • • • • • • • • • • • • • • • • • •

Air-conditioner J67.7 Allergic (due to) J67.9 Aspiration J69.0 Chemical (due to gases, fumes, or vapors) (inhalation) J68.0 Cholesterol J84.89 Crack (cocaine) J68.0 Chronic – see Fibrosis, lung Congenital rubella P35.0 Due to Eosinophilic J82.82 Hypersensitivity J67.9 Interstitial (chronic) J84.89 Lymphoid, Interstitial J84.2 Meconium P24.01 Noninfectious J98.4 Postanesthetic J95.4 Postoperative J95.4 Radiation J70.0 Rubella, congenital P35.0 Specified NEC J98.4 Ventilation (air-conditioning) J67.7 Ventilator associated J95.851 Wood-dust J67.8

Coding Conventions A “see also” instruction following a main term in the Alphabetic Index instructions that there is another main there that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code.

a. Alphabetic Index abbreviations

NEC “Not elsewhere classifiable” This abbreviation in the Alphabetic Index represents the “other specified.”

When a specific code is not available for a condition, the Alphabetic Index directs the code to the “other specified” code in the Tabular List.

NOS “Not otherwise specified” This abbreviation is the equivalent of unspecified.

18. Default codes

A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code.

That default code represents that condition that is most commonly associated with the main term or is the unspecified code for the condition. If a condition is documented in a medial record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned. source: https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines-updated-02/01/2024.pdf

Presented by: Sandy Brewton RHIT, CCS, CICA, Lisa Finley, RN, CCDS, and Lindsay Porter, RHIA, CCS

It Takes Two to Make a Thing go Wrong PSI 15 Abdominopelvic Accidental Puncture or Laceration Rate v2023

LaKisha B. Richardson BSN, RN, CCDS, CCS, CRCR Understand the rules, the old and the new… https://qualityindicators.ahrq.gov/measures/PSI_TechSpec

v2023- The New

V2022- The Old Numerator ✓ Any secondary ICD-10-CM diagnosis code for accidental puncture or laceration during an abdominopelvic procedure (TECHNI15D*) ✓ AND a second abdominopelvic procedure (ABDOMI15P* ) follows one or more days after an index abdominopelvic procedure (ABDOMI15P*)

Denominator ✓ Surgical (Appendix E: SURGI2R) or medical discharges (Appendix C: MEDIC2R ), for patients ages 18 years and older, ✓ with any ICD-10-PCS procedure code for an abdominopelvic procedure (ABDOMI15P*)

Numerator ✓ Any secondary ICD-10-CM diagnosis code for accidental puncture or laceration of a specific organ or structure during an abdominopelvic procedure (~15D *) ✓ AND a potentially related procedure for evaluation or treatment (~15P *) ✓ Performed, one to 30 days after the index abdominopelvic procedure (ABDOMI15P *), on an organ or structure related to where the reported accidental puncture or laceration (~15D *) occurred ✓ AND without a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) for accidental puncture or laceration of a specific organ or structure (~15D*) that matches the organ or structure of the potentially related subsequent procedure (~15P*) described above Denominator ✓ Surgical (Appendix E: SURGI2R) or medical discharges (Appendix C: MEDIC2R), for patients ages 18 years and older, ✓ with any ICD-10-PCS procedure code for an abdominopelvic procedure (ABDOMI15P*)

Did you know....the updates from AHRQ are effective at the beginning of the coding year, NOT the month of the release? Rule updates apply retrospectively to cases discharged after Oct 1st of the year before you receive the updates.

New Inclusion Criteria ✓ Requires specific organ or site of accidental puncture or laceration diagnosis code ✓ AND a requires a RELATED procedure code to evaluate or treat that specific site.

Example: If code J9572 Accidental puncture and laceration of a respiratory system organ or structure during other procedure is coded, a RELATED procedure code within the DIAPHR15P * code set, such as 0BQR4ZZ Repair right diaphragm percutaneous endoscopic approach, would be required to qualify for a PSI 15.

New Time Frame ✓ Time frame now limited to "one to 30 days" rather than "one or more days" after the index abdominopelvic procedure

Examples: Qualifying index procedure occurs on 12/01/23 and an accidental puncture and laceration code is also captured for K9171 Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure is coded. On 12/03/2023 a subsequent procedure, 0DQ73ZZ Repair stomach, takes place to treat the A&P. This will qualify as a PSI. Same scenario, but with second procedure date of 01/04/24 changes the outcome. This will no longer qualify as a PSI 15 since > 30 days from index procedure.

What is the Impact? ✓ Fewer erroneous PSI 15s reported due to mismatching accidental puncture codes with unrelated second procedures not directed towards the treatment of an accidental puncture or laceration. ✓ Fewer erroneous PSI 15s on patients with long stay admissions.

It takes two to make a PSI!

K9171 AP&L of a digestive system organ or structure during a digestive system procedure

GI15P *

AP&L Sigmoid Colon

Repair Sigmoid Colon

DJ Index Pro HERE TO GET THE PARTY STARTED ON THE 1’S AND 2’S

DIAGNOSIS SET

PROCEDURE SET

SPLEEN15D * D7811 Accidental puncture and laceration of the spleen during a procedure on the spleen D7812 Accidental puncture and laceration of the spleen during other procedure ADRENAL15D * E3611 Accidental puncture and laceration of an endocrine system organ or structure during an endocrine system procedure E3612 Accidental puncture and laceration of an endocrine system organ or structure during other procedure VESSEL15D * I9751 Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure I9752 Accidental puncture and laceration of a circulatory system organ or structure during other procedure DIAPHR15D * J9572 Accidental puncture and laceration of a respiratory system organ or structure during other procedure GI15D * K9171 Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure K9172 Accidental puncture and laceration of a digestive system organ or structure during other procedure GU15D * N9971 Accidental puncture and laceration of a genitourinary system organ or structure during a genitourinary system procedure N9972 Accidental puncture and laceration of a genitourinary system organ or structure during other procedure

SPLEEN15P *

PSI 15 Play List

PSI 15 Hot Tips for Every CDI ➢ Use Coding Guidelines and Coding Clinics to determine the appropriateness to capture accidental puncture and laceration codes.

Note: If the AP&L is “reportable” do NOT query the provider to determine the “clinical significance” as a way out of the PSI.

➢ Use your tools to identify and “flag” PSIs with ease. If you use an Encoder such as 3M 360 Encompass ➢ Enter your diagnosis codes, assigning appropriate POA status. ➢ Enter procedure codes AND the date of each procedure (this is key).

(Other Encoders may have similar tools to assist with this as well)

Get details on your PSI under Options > AHRQ QI Reports >PSI Report

© 2024 Ensemble Health Partners | Proprietary and Confidential

1

ADRENAL15P *

VESSEL15P *

DIAPHR15P *

GI15P *

GU15P *

Discovering opportunities to improve care team documentation through the expansion of computer assisted physician documentation tooling to other healthcare disciplines.

Megan Schneider MSN, RN, CCDS, CCDS-O, TaraJo Vaught MSN, RN, CCDS Solventum Health Information Systems, Murray, UT USA

What it is & what it does

Introduction • Accurate documentation is crucial in all disciplines of healthcare to record and track patient information.

• Providers rely on accurate documentation from the care team when reviewing the record, placing orders, and determining the plan of care.

• Accurate records assist in data collection, tracking diagnosis patterns, quality outcomes, and risk management.

• Computer-assisted physician documentation (CAPD), an artificial intelligence (AI) tool, assists providers to accurately document diagnoses.

• Natural language understanding (NLU) allows technology to find meanings in different sentences.

NLU

CAPD Real-Time analysis and monitoring

Identifies relationships and meaning between concepts

Proactive in-workflow notifications based on clinical context

Detects gaps in documentation

Across the patient encounter

Surfaces evidence for CAPD to send notification

COULD OTHER DISCIPLINES BENEFIT FROM THE USE OF SIMILAR TECHNOLOGIES?

REGISTERED NURSES

BMI BMI

CARE TEAM DOCUMENTATION

Coma Coma scale scale

ASPEN ASPEN criteria criteria

Laterality Laterality

RESEARCH POSTER PRESENTATION DESIGN © 2019

www.PosterPresentations.com

Wound Type Wound Stage Wound Location Wound POA

• • • •

Intubation/Extubation time BMI COMA Scale Infusion times

SOCIAL WORKERS • • • •

Ulcer Ulcer staging Staging

Conclusion

• • • •

Social Determinants of Health Homelessness Social environment Psychosocial circumstances

REGISTERED DIETITIANS • ASPEN Criteria • Provider documentation of malnutrition • Nutritional risk factors documented

Healthcare is an ever-changing system where technology and AI are at the forefront of countless vital advances, especially clinical documentation integrity (CDI). A focus point in CDI is complete and accurate documentation, thereby expanding the use case of current technology to include additional healthcare disciplines would achieve a most complete patient record. While ongoing research evaluates the use cases with CAPD technology, CDI specialists understand the importance of documentation within a multidisciplinary team that is invaluable to patient care.

Megan Schneider: mschneider9@solventum.com

TaraJo Vaught: tgillerlain@solventum.com

Employee Satisfaction and Turnover before and after Implementation of a Mentorship Program Karen Vakkas, MA, RN, CCDS, CCRN, Alicia White-House, BSN, RN, CCDS Penn State Health, Hershey, Pennsylvania

INTRODUCTION Like many non-clinical departments, the Clinical Documentation Specialists on our team transitioned from hospital-based work to remote work in March of 2020.

During the initial 18 months of this transition, there was an average annual turnover rate of 24%.

Higher-than-usual turnover caused dissatisfaction primarily due to increased individual productivity quotas, continuous need for preceptors to orient new specialists, and decreased revenue while new team members were trained. Exit interviews exposed isolation from peers and perceived lack of team support as major factors influencing the decision to pursue new employment.

An exhaustive literature study revealed mentors, separate from orientation preceptors, can have a significant positive impact on retention rates. Using anonymous surveys, specialists hired after the transition to remote work who did not seek new employment were asked to share how they felt about their orientation process. Answers supported the hypothesis that embodying a sense of teamwork though mentorship would positively impact the experience of both the new hires and the existing team.

OBJECTIVES Overall objective: Decrease turnover and increase overall job satisfaction through expansion of the orientation process with implementation of a mentorship program.

Secondary objective: Survey CDI team in order to obtain a baseline and determine a focus for interventions and changes.

Survey questions included: Is there anything that should be changed or added to the orientation process that would positively contribute to a new hire’s experience?

Respondents answered: “Offer more shadowing experiences, specifically when the orientee is completing the bootcamp modules, have the orientee complete the cardiac module in the morning then pair the orientee to shadow a CDI to review a cardiac chart on the same day.”

“Find opportunities for new staff to interact with a variety of staff. Work relationships that are previously established can be difficult to navigate for new staff, especially during informal staff gatherings, look for opportunities to build relationships with newer staff. Mentor(s) for new staff and ensure staff awareness of who they can contact for questions/concerns if mentor is out.”

“It would have been helpful to observe experienced CDIs review several charts for several days to better understand their workflow and thought processes regarding queries.”

“A peer preceptor/mentor role to support new staff would be invaluable. This should be a leader recognized role with training on precepting and educating adults and filled by someone who is outgoing, supportive by nature and wanting to be a preceptor.”

During the first few months, how supported did you feel when you wanted or needed help from others?

Respondents answered: Very supported – 33% Somewhat supported – 50% Not very supported – 17% In the first few weeks on the job, did you have the resources you needed to perform your responsibilities to your satisfaction?

Respondents answered: “I didn’t know how to use the resources or when to use them.”

“Overall yes, but at times would feel unsure how to proceed when meetings were only scheduled once daily; felt a little overwhelming to try to ensure all questions were addressed.”

“I was provided too many written resources, it was like drinking out of a fire hose.

They were not provided or broken down in a manner and timeline that was manageable to learn the concepts needed to perform the job.”

“More resources became accessible with the rematch of the mentor, which included the support for the transition to the remote nature of the work.”

If I had more support for questions, I would have felt more positively about my orientation experience.

Respondents answered: Agree – 71% Disagree – 29% It was easy to build relationships with my new colleagues.

Respondents answered: Strongly agree - none Agree – 43% Disagree – 29% Strongly disagree – 28% On average, how quickly are you able to get an answer to a question you have?

Respondents answered: 0-5 minutes – 14% 5-15 minutes – 29% 15-30 minutes – 57% It is easy to figure out the answer to questions I have on my own.

Respondents answered: Agree - 0 Disagree – 100% RESEARCH POSTER PRESENTATION DESIGN © 2022

www.PosterPresentations.com

METHODS Prior to development of the mentorship program: The orientation process was complete at the end of approximately 6 weeks, and was structured as follows: Weeks 1-2: ACDIS Boot Camp (online) to define the role of CDI specialist and provide comprehensive training on their responsibilities.

Upon completion, the CDIS should understand: • Coding and reporting requirements related to COVID-19 and its manifestations • The ICD-10-CM Official Guidelines for Coding and Reporting, as seen from a CDI perspective • Diagnoses frequently in need of additional documentation to support accurate code assignment across all major body systems • The value of compliant provider query practice and best practices associated with the query process • Core provider education concepts such as IPPS reimbursement, documentation integrity, and quality metrics • IPPS methodology based on MS-DRG assignment and the impact of diagnosis assignment and sequencing on hospital reimbursement • CDI benchmarking basics, compliance risks, and professional ethics *In concurrence with the ACDIS Boot Camp, weekly meetings with the CDI Educator also occur.

Week 3: Daily Microsoft Team meetings with video (60 minute) with the CDI Director to review content of the ICD-10 Monitor “Essentials for Clinical Documentation Integrity: A complete resource for documentation and coding to make chart review easy”. Meetings also include case study review.

Weeks 4-6: Daily Microsoft Team meetings with video (60 minute) with the CDI Director to review cases that were coded by the CDI specialist. *Daily meetings may extend past 6 weeks depending on the quality of the chart review and/or comfort level of the new CDI specialist.

Upon completion of orientation, new employees begin independent chart review, with CDI Director support for questions as they arise and for verification of the quality, accuracy and compliance of queries.

Additionally, the CDI Director, CDI Educator and CDI Specialist meet jointly at 30, 60, and 90 days to ensure orientation benchmarks are being met.

Current process: The mentorship program is implemented after completion of the initial orientation period.

Mentor selection method: The new employee partners with a mentor after determining the two who most closely align according to their personality style and clinical background (*detailed below).

The mentorship program is structured as follows: Weeks 7-10: Daily Microsoft Team meetings with video (30-45 minute) for the first 2 weeks. After the initial two-week timeframe, partners meet to discuss the frequency and duration of the meetings for the upcoming two weeks, with options to decrease to every other day or continue with daily meetings. Primary consideration is given to the preferences of the new employee, based on his or her comfort level with independent chart review. The option to extend this process for more time is also considered prior to moving on to step 2.

Weeks 11-14: Begins at the conclusion of the daily/every other day scheduled meeting period): Touch-base meetings, on a weekly basis minimally, with on-demand access to mentor for questions via Teams texting feature. The option to extend the weekly meeting process for more time is also considered prior to moving onto step 3.

Week 15 and forward: On-demand Teams calls or texting feature for questions as they arise. *Determining personality style: Personality style was determined by having all existing staff complete the DISC assessment tool. This tool, based on psychologist William Moulton Marston's DISC emotional and behavioral theory, determines how an individual ranks in terms of four personality styles: Dominance, Influence, Conscientiousness, and Steadiness.

RESULTS

CONCLUSIONS AND NEXT STEPS

In the time period after initiation of the mentorship program (September 2022February 2024), the turnover rate in our department was reduced from 24% to 0%.

The survey used to assess how new employees who did not have a mentor felt about their orientation process was also given to new employees who had a mentor to assess effectiveness of the program.

Survey results before and after the program was initiated: How supported did you feel as a new employee?

Post-Mentorship

Pre-Mentorship

60% 50%

Somewhat supported

Not very supported

Very Supported

Somewhat Supported

Not very supported

If I had had more support for questions, I would have felt more positively about my experience as a new employee.

Pre-Mentorship

Post-Mentorship

71%

Agree

Agree

Disagree

It was easy to build relationships with my new colleagues.

Pre-Mentorship

20%

20%

60%

Disagree

Strongly disagree

Strongly agree

Agree

Disagree

Strongly disagree

On average, how quickly are you able to get an answer to a question you have?

Pre-Mentorship

57%

Marshall M. & Gordon F. (2010) Exploring the role of the interprofessional mentor. Journal of Interprofessional Care, 24(4), 362–374.

Persaud, D. (2008). Mentoring the new graduate perioperative nurse: A valuable retention strategy. AORN journal, 87(6), 1173-1179.

Post-Mentorship

Raymond, J. M., & Sheppard, K. (2018). Effects of peer mentoring on nursing students’ perceived stress, sense of belonging, self-efficacy and loneliness. Journal of nursing Education and Practice, 8(1), 16-23.

20%

Slowikowski, M.K. (2005), Using the DISC Behavioral Instrument to Guide Leadership and Communication. AORN Journal, 82, 835-843.

14%

29%

Andersen, T., & Watkins, K. (2018). The value of peer mentorship as an educational strategy in nursing. Journal of Nursing Education, 57(4), 217-224.

Chen, C.M., & Lou, M.F. (2014). The effectiveness and application of mentorship programmes for recently registered nurses: A systematic review.

Journal of Nursing Management, 22(4), 433-442.

Fox, Kathy C,R.N., M.S.N. (2010). Mentor program boosts new nurses’ satisfaction and lowers turnover rate. The Journal of Continuing Education in Nursing, 41(7), 311-316 .

43%

29%

Potential impact to employee turnover and retention before and after transition to new leadership is possible.

REFERENCES

Post-Mentorship

28%

A new CDI Director was appointed in October 2022.

In comparison with mentors who volunteered for the program, those who were chosen reported less satisfaction with the process. Further, new employees paired with mentors who did not volunteer reported less positive impact on their orientation.

Subsequently, only mentors who volunteer to participate in the program are considered for selection.

80%

Disagree

Additionally, this transition combined CDI specialists from four different teams under singular leadership.

Potential impact to employee turnover due to this change is possible.

Modifications: In the initial phase of our program, mentors could be chosen or could volunteer for the program.

20%

29%

40% 40%

CONTACT INFORMATION 0-5 minutes

5-15 minutes

15-30 minutes

0-5 minutes

5-15 minutes

15-30 minutes

It is easy to figure out the answer to questions I have on my own.

Pre-Mentorship

40%

Agree

Disagree

Karen Vakkas, MA, RN, CCDS, CCRN CDI Specialist, Clinical Documentation Integrity Penn State Health kvakkas@pennstatehealth.psu.edu

Post-Mentorship

60%

Determining clinical background: Clinical background was determined by predominant past work experience; medical vs. surgical.

Team support Experience as a new employee Ease in building relationships

Limitations: In August, 2022, hospital hierarchy was restructured. Due to the change, our CDI Department transitioned from reporting through the Quality Department to reporting to the Revenue Department.

40%

Agree

Survey responses before and after implementation of the mentorship program validated its positive impact on new employees in the following areas:

Independent problem-solving

33%

Strongly agree

Since implementation of the mentorship program, our department has added six new team members and has had no turnover.

Time to response for questions

17%

Very Supported

Conclusions: Our mentorship program was developed and initiated in September, 2022.

Agree

Disagree

Alicia White-House, BSN, RN, CCDS CDI Educator, Clinical Documentation Integrity Penn State Health awhitehouse@pennstatehealth.psu.edu