by Kim Baumgartner, RN, BSN, CCDS
Clinical Documentation Integrity (CDI) is more than just chart reviews and chasing physicians to answer queries. At my facility, CDI was a newer concept and all of those involved needed a little education and training. Between CDI, the Coding Team, and the Physicians we faced some bumpy terrain to begin with but eventually we all learned what was needed and how to explain it in a language that each discipline could understand. As we all know, Physician documentation doesn’t always fall in line with Coding Guidelines and code assignment. This is where the CDI Specialist came in. I became the bridge between the Coding Team and our Physicians. My goal of getting everyone on the same page started with me. I rounded with the hospitalists group (who admit the majority of the patients) every day. I messaged, talked face to face and discussed necessary clarifications with individuals and discussed specific cases with coding on reconciliation. I attended the monthly hospitalist meeting and provided education on some of our more challenging topics. Eventually I came up with the idea of a tip sheet and born was the “CDI Tip Sheet”. I wanted to be able to reach providers that I did not see on a daily basis. I picked educational topics and formatted the tip sheet with a concise summary and a bulleted list of helpful hints. Also, I sent the education to the Coding Team and we discussed it at our monthly meetings if needed. I sent a new tip sheet out every couple of weeks to all physicians and providers and even had it posted to our internal webpage.
The first tip sheet I created was an “Introduction to CDI”. This initial tip sheet outlined the main purpose of the CDI Specialist and the program goals. I included a bio of myself and my past experience. I explained where my office was and included all my contact information. The second tip sheet was “Coding 101”. This covered the basics of coding and how important documentation is. As Physicians get very little education on documentation and coding, this tip sheet covered the importance of the primary diagnosis, how secondary diagnoses impact the stay, what is the DRG and how it is generated, the importance of the severity of illness and risk of mortality scores, basic coding guidelines, how payors play a part and some helpful hints to meet all these requirements.
I was becoming much more involved in assisting our Coding team with DRG denials. I originally sent clinical support on a specific patient for a denied diagnosis and the Coding Team wrote and sent out the denial letter. Over time, I helped develop a denial letter format for ease and quicker turn around. Sepsis was next on my list as we had an increase in denials based on the Payors use of Sepsis-3 guidelines. I researched the topic and dug in. I provided a brief history of the transition from SIRS/Sepsis -1 to Sepsis- 2 to Sepsis -3. I listed the current accepted Sepsis-3 definitions of Sepsis and Septic Shock and included a SOFA score template. There were many “Helpful Hints” to list- from including a SOFA score and supporting clinical indicators in the documentation to being cautious with copy and paste and preformatted notes. Lastly, I included an article written by a physician on avoiding sepsis denials (read the article HERE).
The hospitalist group embraced the Sepsis education and usually include the SOFA score with their diagnosis of sepsis. I calculate all SOFA scores on patients that are admitted with an infection and SIRS/evidence of organ dysfunction or if there is a diagnosis of sepsis. I message the SOFA scores to the physician so they have the information if they wish to include it in their documentation. Sometimes they beat me to it and have already included it in their note. They also have increased their documentation of linking the organ dysfunction to the Sepsis. There have been a couple of cases where the physicians have documented Sepsis but the SOFA score was less than 2. I sent them the SOFA score and a Sepsis query as a clinical validation. Sometimes the sepsis was ruled out. The challenge is when the provider feels the patient is septic but the SOFA score is less than 2. I explain that we defer to their expertise and ask that they document why they feel the patient is septic. I feel there has been a definite decrease in the number of Sepsis denials. Also, for those denials that we do receive, the physician’s documentation has given me additional information with which to dispute the denial. I am hopeful this may increase the likelihood of the denial being overturned. As guidelines and definitions change and evolve we will continue to learn and adapt and educate. Please find included my “CDI Tip Sheet #3” Sepsis for your review.
Sources: ACDIS, Surviving Sepsis Campaign, ICD 10 Official Coding Guidelines, Coding Clinic, AHA Coding Handbook
About the Author
Kim Baumgartner, RN, BSN, CCDS is a Clinical Documentation Integrity Specialist at Wood County Hospital. Her email address is firstname.lastname@example.org. Feel free to reach out to her with any questions or comments about this article!