In The Know

INPATIENT CODING: DEFINING ‘PRESENT ON ADMISSION’

Posted by Samantha Serfass on July 24, 2019 in Blog, News

Inpatient Coding: Defining ‘Present on Admission’

In today’s rapidly developing pay-for-performance healthcare environment, collection, quality, and interpretation of present on admission (POA) indicators continues to play a key role in the inpatient coder’s responsibilities.

What is POA?

POA is defined as a condition that is present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered to be POA.

Coding options

Providers must report one of five indicators:

  • Y = yes (present at the time of inpatient admission)
  • N = no (not present at the time of inpatient admission)
  • U = unknown (documentation is insufficient to determine if condition was present at the time of admission)
  • W = clinically undetermined (provider is unable to clinically determine whether condition was present on admission)
  • 1 (on electronic claims) or blank (for paper claims) = exempt from POA reporting

The importance of documentation

Ideally, a physician works with hospital staff and coders to determine the best way to communicate POA information. POA indicators are assigned to principal and secondary diagnoses and external cause injury codes.  One recommendation is for physicians to simply put ‘POA’ in their notes next to their diagnosis. The Centers for Medicare and Medicaid Services (CMS) has suggested that the discharging physician clearly indicate in the discharge summary which of the conditions were or were not present on admission.

The Deficit Reduction Act of 2005 mandated that providers report POA indicators for all diagnoses submitted on Medicare inpatient acute care claims for discharges beginning October 1, 2007.  One year later, CMS announced that it intended to stop paying the costs of treating what it deemed to be preventable inpatient complications (Medicare No-Pay List).  This was a controversial move since the responsibility then fell to physicians and hospitals, not up to Medicare, to resolve documentation that is inconsistent, missing, conflicting, or unclear.

Like other coded data, the POA indicator is increasingly used for multiple purposes – reimbursement, clinical research, financial planning and quality of care evaluation. Successfully implementing POA reporting requires educating physicians and hospital staff on their roles in correct POA assignment.

If the coder encounters POA documentation that is unclear, they must query the provider. The physician is responsible for resolving the insufficiency.

Cynthia Alder-Smith, RHIT CCS

Auditor/ Educator Excite Health Partners

ADVISORY SERVICES: THE IMPORTANCE OF TECHNOLOGY AND STRATEGIC PLANS

Posted by Samantha Serfass on July 11, 2019 in Blog, News

Advisory Services: The Importance of Technology and Strategic Plans

Today, Advisory Services are becoming more prominent in the healthcare industry. Outside companies with experienced consultants offer organizations assistance with strategic initiatives and plans. Hospitals across the nation are creatively leveraging technology to offer more effective patient outcomes.

For example, Sentara Healthcare is working to advance the use of 3D printing. By utilizing the 3D printing technology, Sentara’s goal is to print an organ to allow doctors to assess the issues prior to surgery. University of Maryland Medical Center also is incorporating the latest technology into their medical advances – in April, the first organ delivery by drone was made to the hospital. Likewise, Hartford Hospital is leveraging advanced technology to assist with procedures. Hartford utilized 8 surgical robots to support heart, urological and gynecological surgeries and procedures.

Selecting the right outside help is key to utilizing the latest technology or developing a strategic plan/digital road map. Advisory consultants need to not only be knowledgeable of the latest technology but understand their impact in order to increase efficiency and patient outcomes. Understanding the benefits and impacts patient engagement have in an ACO model is an example of important aspects to consider when advising clients on initiatives and priorities.

Developing a strategic plan that supports a hospitals vision requires experienced consultants and fluid communication with the leadership of a hospital system.  Once a plan is finally developed, performing the system selection and portfolio management are paramount for patient and provider satisfaction.

The focus during Portfolio Management should on the core and strategic IT services needed by the healthcare system. This will help to support the IT Strategic plan over the next 3 to 5 years. The objective should be to reduce the number of applications allowing for a decrease in cost and increase in patient and user satisfaction.  

There are several different approaches for how a healthcare system can evaluate and select a vendor solution.  However, identifying the primary and secondary requirements is an important first step.  These requirements may include integration and storage capabilities, mobile device options, as well as features and functions within the application.  It’s vital to understand the strengths, weaknesses, opportunities and threats (SWOT) of each application within the healthcare system’s environment.

Through Excite’s Advisory Services, we can help your organization utilize the latest technology and develop a strategic plan to support the system. By evaluating current state environments, digital and automation initiatives, support models, project management offices and strategic plans, Excite works with you to develop each area to perform at their optimal level and provide guidance to your organization. 

Todd Klein

CIO, VP of EHR Services & Digital Solutions

CODER KNOWLEDGE: UV AWARENESS & SKIN CANCER

Posted by Samantha Serfass on June 25, 2019 in Blog, News

Coder Knowledge: UV Awareness & Skin Cancer

Next month is designated as UV Safety Awareness Month which comes as no surprise.  July is the month of summer vacations, trips to the beach, summer sports and outdoor yard work. 

Did You Know? 

Skin cancer is more and more common.  In fact, according to the American Cancer Society it has become the most frequently diagnosed form of cancer in the U.S.  The Skin Cancer Foundation notes that every year there are “more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung and colon.”

Contributing factors

  1. Skin is the largest organ in the human body.
  2. The UV index is changing due to a diminished ozone layer.
  3. Patient awareness lags other, more publicized cancers.

Basal cell and squamous cell carcinomas are the most common forms of skin cancer, melanoma has the highest mortality rate. Skin cancer can be caused by too much exposure to ultraviolet (UV) rays from the sun and other sources, such as tanning beds and sun lamps. 

However, the good news is we can take highly preventative measures to decrease our risk.  During UV Safety Month, make it your practice to follow the index levels and associated protection recommendations. 

UV Index Recommended Protection
Extremely High (11+) Sunscreen, sunglasses, hat, shade, indoors from 10 a.m. until 4 p.m.
Very High (7-10) Sunscreen, sunglasses, hat, shade
High (6-7) Sunscreen, sunglasses, hat, shade
Medium (3-5) Sunscreen, sunglasses, hat
Low (0-2) Sunscreen, sunglasses

Coder Knowledge: Cell Type Matters

Clinical coding of skin cancers is based on two key factors: the type of cell involved and the anatomical site.  As mentioned above basal and squamous sell are the most common.  These types of skin cancers are often treated topically in the physician’s office and require minimal coding expertise.  However, melanoma is more invasive, and treatment typically includes a hospital encounter with radical wide excision, skin grafts, and lymph node excision.

Example Chapter 2 Index

        C44.11 Basal cell carcinoma of skin of eyelid

                  C44.111 Basal cell carcinoma of skin of unspecified eyelid

                   C44.112 Basal cell carcinoma of skin of right eyelid

                   C44.119 Basal cell carcinoma of skin of left eyelid

        C43.1   Malignant Melanoma skin of eyelid

                    C43.10 Malignant melanoma of unspecified eyelid

                    C43.11 Malignant melanoma of right eyelid

                    C43.12 Malignant melanoma of left eyelid

In ICD-10-CM, body sites are specific to site and type of skin cancer.  They require documentation of laterality for paired organs such as ears, eyes and upper and lower limbs. Physician documentation is key to specificity.

Denise Bell, CCS

Auditor/Educator

MANAGED SERVICES: REDUCING COST & INCREASING VALUE

Posted by Samantha Serfass on June 11, 2019 in Blog, News

Managed Services: Reducing Cost & Increasing Value

Today’s IT department is supporting so many initiatives:

  • Adapting to New Payment Models
  • Improved Provider & Patient Experience
  • Population Health
  • Clinical Integration
  • Performance Improvement

It’s difficult to staff projects to accommodate the demands, timeframe, and budget all while providing the expected quality of work from your organization. As the continued trend for IT department spend continues to reduce, finding solutions for highly qualified staff and accommodating the CFO becomes more challenging.  Staffing is typically around 50% of the IT budget or higher.  Today many hospital systems are leveraging Managed Services to reduce their spend by 30% or more depending on the hospital system.  

Managed Services allow the CIO and IT directors to assign local staff to the strategic projects while working with the user base to decrease tickets with the help of remote staff.   The entryway into the cost saving approach is to find the right partner.  Someone who is dedicated to proving better service then you currently have at lower cost.   Your partner should have no problems providing an SLA (Service Level Agreement) that will meet (or beat) your current IT response time.  Another cost saving approach is to also have your partner in Managed Services take responsibility for on-call / afterhours.  This can either make up for raises the hospital couldn’t afford or reduce the costs for on-call pay with employees.  

Eliminating on-call can be an employee satisfier, in any case employee satisfaction will increase by a allowing resources to get away from the routine tasks of working down tickets and moving to project which are more strategic.  Managed Services can increase resources at the beginning of the engagement to work all application models down to zero. Manage Service can readjust resources to maintain fresh tickets in the que.  Your partner manages the work effort and staffing based on your current and changing needs.  The beauty of Managed Services is employee and end-users are more satisfied. This can help decrease costs and the headaches of adjusting staff levels also is significantly reduced.

Excite Health Partners has the expertise and experience to assist with Managed Services. We can help you explore all the possibilities while tailoring a program that provides you with the best savings and value.

Todd Klein

CIO, VP of EHR Services & Digital Solutions

Recognizing The Symptoms: Coding NASH, The Silent Liver Disease

Posted by Samantha Serfass on May 15, 2019 in Blog, News

NASH – The Silent Liver Disease

Did you know that people can develop liver disease even if they do not drink alcohol?

A condition where fat accumulates in the liver is called nonalcoholic fatty liver disease (NAFLD).

Nonalcoholic steatohepatitis (NASH) is a type of NAFLD where the fat builds up in the liver and leads to inflammation and scarring (cirrhosis), which damages the liver and can become life-threatening.

NASH is called the silent liver disease because most people do not have or notice the signs or symptoms until they are in the more advanced stages. The more advance NASH becomes the more symptoms are noticed or develop. Sometimes the cause of NASH is never known.

 According to the American Liver Foundation, NASH is one of the leading causes of cirrhosis in adults in the United States – up to 25% of adults with NASH may have cirrhosis.

Years ago when a patient that did not use alcohol developed cirrhosis it was termed cryptogenic cirrhosis because the providers had no idea how the patient developed cirrhosis. Occasionally providers will still document it as cryptogenic cirrhosis when the cause has not been determined.

Who can develop NASH? Anyone can develop NASH. NASH is now the most common cause of liver disease in children who are obese. Yes, children are now being diagnosed with chronic liver disease which could lead to them needing a liver transplant.

Typically NASH is suspected when a provider orders routine blood work which returns with abdominal liver enzymes or an imaging test that shows a fatty liver. The only definitive way to accurately diagnosis NASH is doing a liver biopsy. The results will show if there is NASH and will also provide a grade and stage of the disease, inflammation (Grade 1 through 4) and bridging fibrosis (Stage 1 through 4). 

End stage liver disease is monitored regularly. The provider orders routine blood work and uses a Module For End Stage Liver Disease (MELD) Calculator to determine the patient’s MELD score. The MELD Score Range is 6-40 with 40 being severely ill.

SYMPTOMS (per Merck Manual):

  • Most patients do not have symptoms
  • Fatigue
  • Right upper quadrant abdominal discomfort
  • Hepatomegaly can develop
  • Splenomegaly may develop if advanced fibrosis is present
  • Patients who have cirrhosis due to NASH can be asymptomatic

RISK FACTORS (per Merck Manual):        

  • Diabetes
  • Obesity and/or metabolic syndrome
  • High cholesterol
  • High triglyceride levels
  • Hereditary
  • Certain medications

Non-alcoholic liver disease stages

  • Fatty Liver – Deposits of fat, liver can become enlarged
    • Liver Fibrosis – Scar tissue forms, cell injury
      • Cirrhosis – Liver becomes hard from scar tissue, liver unable to work properly

TREATMENT:

Until the disease progresses to end stage and requiring a liver transplant there really are not a lot of treatment options but there are somethings patients can do to manage their NASH. Below is a list of the common things that are recommended by providers. Each patient should go by the plan outlined by their own provider.

  • Weight loss
  • Exercise
  • Healthy Diet – Veggies, Fruits, Lean Protein or Plant Based Protein, Small Amount of Carbs (Best to see a Dietitian)
  • Avoid Alcohol Completely
  • See your provider regularly and stick with the program he or she outlines for you
  • Consistently high MELD score – liver transplant

ICD-10-CM:

Below are some of the ICD-10-CM Diagnosis codes that could potentially be assigned based on provider documentation.

  • Nonalcoholic steatohepatitis (NASH) – K75.81
  • Fatty liver, not elsewhere classified – K76.0
  • Other cirrhosis of liver – K74.69

The important thing to remember when assigning a code for steatohepatitis and/or cirrhosis is to not automatically assume it is alcohol related. It is important to read the record thoroughly and if in doubt query the provider for clarification of the type of steatohepatitis and/or cirrhosis.

Lorrie Strait, RHIT, CCS

Auditor/Educator

WINDOWS 10: HEALTHCARE ADVANTAGES

Posted by Samantha Serfass on May 3, 2019 in Blog, News

Windows 10: Healthcare Advantages

As mainstream support for Windows 7 will end in January 2020, soon everyone will need to move to Windows 10. There seems to be a scramble in the industry to migrate thousands of devices to the new platform—and with good reason. 

Windows 10 will be the last major upgrade for Microsoft as they shift to a Windows-as-a-Service (Waas). This allows for a more secure system and in-place predictable upgrades.  

Below are some advantages healthcare users can expect in Windows 10.

  1. Quicker access to your desktop making log-ins faster.   The new operating system (OS)supports most finger print devices currently deployed.  Windows 10 also offers a second option to log-in by facial recognitions, however, this requires a 3D infrared camera.
  2. The new browser, Edge, is much faster.  Edge is a slim down, light weight browser integrated with Cortana.  Cortana is a new voice-activated personal assistance, which comes with Windows 10…  Although the new Edge is a slim down version, it may not run some webpages, like ones which encapsulating Active X.  This is by design and that’s why IE is still included in Windows 10.  By configuring the policies correctly, You can have IE start on pages which include Activate X.
  3. One or two computer monitors can be used in the new SNAP modes. This allows for independent views on a single monitor. While this feature was somewhat available on previous versions, Windows 10 allows for a glitch-free process. Space for monitors is tight in many hospitals making the new SNAP mode an advantage for many users.

The Conversion process from 7 or 8 to Windows 10 has four major phases:

  1. Down-level Phase: Runs the source OS code
  2. SafeOS Phase: A recovery partition is created, files are expanded and rollback is prepared.
  3. First boot Phase: Initial settings are applied
  4. Second boot Phase: System is running under the target OS

While most errors occur with incompatible drivers and hardware during SafeOS and First boot Phase Windows 10 should encounter less errors than previous versions. (Here is a full list of Microsoft upgrade errors).   

If you need help with your Windows 10 conversion or any digital service offerings contact Excite Health Partners, we have the knowledge and resources to make your projects successful.

Todd Klein

VP of EHR Services & Digital Solutions

CODING SEPSIS: KNOWING THE SIGNS & SYMPTOMS

Posted by Samantha Serfass on April 16, 2019 in Blog, News

Coding Sepsis:  Knowing the Signs and Symptoms

Sepsis is the body’s extreme response to an infection. It occurs when an infection you already have in your skin, lungs, urinary tract, or somewhere else triggers a chain reaction throughout your body. Anyone can get an infection, and almost any infection can lead to sepsis including bacterial, viral or fungal infections.

Globally, an estimated 20 million to 30 million cases of sepsis occur each year. Hospitalizations for sepsis have more than doubled over the past 10 years, and the incidence of sepsis developing after surgery tripled from 1997 to 2006. Mortality from sepsis is estimated to be greater than mortality from AIDS and breast cancer combined.

Common signs and symptoms of sepsis:

  • Altered mental status, drop in urine output, and decreased capillary refill of nail beds or skin
  • Fever (temperature greater than 100.4 degrees) or hypothermia (temperature less than 96.8 degrees)
  • Leukocytosis (white blood cell count greater than 12,000) or leukopenia (white blood cell count less than 4,000 or greater than 10% bands)
  • Hypotension (systolic blood pressure < 90 mm Hg or fallen by > 40 from baseline, mean arterial blood pressure < 70 mm Hg)
  • Lactate >1 mmol/L.
  • Tachycardia (greater than 90 beats per minute)
  • Tachypnea (respiratory rate greater than 20 breaths per minute or a pCO2 of less than 32 mmHg)

Coding a patient’s record with sepsis can prove challenging for medical coders. For example, the ICD-10 Official Coding Guidelines tell us signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. If the patient is admitted with a localized infection and sepsis, the code for the systemic infection should be assigned first, followed by a code for the localized infection. If the patient is admitted with a localized infection, and develops sepsis after admission, a code for the localized infection is assigned first, followed by a code for the sepsis.

A systemic infection can occur as a complication of a procedure or due to a device, implant or graft. This includes systemic infections due to wound infections, infusions, transfusions, therapeutic injections, implanted devices, and transplants. 

When sepsis is complicating pregnancy, childbirth, or the puerperium, the obstetrical code is sequenced first, followed by a code for the specific infection.  When a newborn is diagnosed with sepsis, a code from category P36 Bacterial sepsis of the newborn is assigned.

Both the coding guidelines for sepsis as well as ambiguous provider documentation often mean coders require an extended length of time to review a record – only to place it on hold for a physician query. It is up to the physician’s clinical judgement to decide whether the patient has sepsis.  The coder cannot assume the patient has sepsis based on criteria being met – they must rely on the physician’s documentation. Coders should emphasize to physicians the importance of capturing patient severity which will be reflected in accurate coding and correct facility reimbursement.

From a patient’s perspective, there are ways to help prevent sepsis.

  • Get vaccinated. According to a recent CDC study, 35% of sepsis cases stemmed from pneumonia. Annual flu shots can also prevent respiratory infections that often turn septic.
  • Treat urinary tract infections promptly. A quarter of sepsis cases resulted from urinary tract infections. It is important to see a healthcare provider if you have warning signs of those infections including a painful burning feeling when urinating and a strong urge to ‘go’ often.
  • Clean skin wounds properly. About one in 10 sepsis cases follows a skin infection. It is essential to care for wounds and scrapes properly – washing with soap and water, cleaning out any dirt and debris, and covering wounds. 
  • Avoid infections in hospitals. Insist that everyone who comes into your hospital room, including doctors and nurses, wash their hands before they touch you.

Knowing the signs and symptoms of sepsis is a medical coder’s first step towards accurately coding what can be a life-threatening illness. Coders should take the time to thoroughly review and learn from these records rather than be overwhelmed by them. 

It is also important to review how to apply sequencing guidelines and to query the physician for any ambiguous or conflicting information present in the patient’s record.

Cynthia Alder-Smith RHIT, CCS

Auditor/Coding Educator

Epic Community Connect: Planning the Right Approach

Posted by Samantha Serfass on April 3, 2019 in Blog, News

Epic Community Connect: Planning the Right Approach

Epic Community Connect: Planning the Right Approach

The need to extend EHRs to affiliates is increasing along with the integration needs of ACOs.  Epic Community Connect is a methodology and approach to extend EHR systems to partners and clients.  Community Connect can be licensed to both clinics and hospitals typically working with smaller budgets.  It’s crucial to understand the impacts of offering Community Connect as a host so no surprises arise in the process.

UNDERSTANDING THE COSTS

Identifying the cost to license Epic and its 3rd -party applications is an important factor to consider before offering Community Connect to providers.  Cost models for Community Connect can be very complex.  In the outpatient area, the costs are typically identified per physician.  A common price might be $15,000 per physician, but what might be a surprise is the complex costs of the 3rd parties.  For each 3rd– party application, health organizations need to revisit the contract. Every contract can be priced out differently for example:

  • SureScripts may have little to no costs for outpatient, however inpatient is based on the number of beds
  • For OBIX Electronic Fetal Monitoring, the cost is based on the number of births per year along with a one-time fee and a yearly support cost
  • For Patient Education & Discharge instructions from Elsevier, it may be based on the number of AVEs (Epic’s calculation of volume licensing)

Each hospital system has a different contract with not only Epic but with the many 3rd-party supporting applications, which have to be considered again before offering Community Connect to the community.  Health systems offering Community Connect without considering all the costs could end up with budget cuts, program delays and staff layoffs.

Excite’s Community Connect cost model includes the quadratic equation to help identify an accurate per physician cost and support needed to purchase Community Connect. Once a health system has implemented the EMR and its 3rd parties, each physician moving forward will require less support.

DEVELOPING A GO TO MARKET APPROACH

The amount of effort required by the receiver of Community Connect also depends on how the host organization packages the service offering to the market.  For example, if the receiving client is going to need to increase their IT security infrastructure to meet the hosts standards, additional resources will be needed.  However, if the host packages the offering to include the security services to ensure it is completed accurately, then that will also impact the effort for the receiving party.  Security is just one example but there are many others, such as:

  • Reporting
  • Training
  • 1st Level Support
  • Informatics

Smaller hospitals and clinics often don’t have additional staff to assist with an EMR implementation.  It’s vital for the health organization to recognize the Community Connect receivers time, effort and resources needed during implementation, especially if customization to the system is required. The key questions that host health organizations need to consider are:

  • Where can customization occur, and what will it impact for the implementation and support?
  • What is the cost and how much time and effort will be required?

SETTING EXPECTATIONS

While there is no one single method in setting expectations, the most important tool is a Detailed Project Plan. The plan should identify activities for the host, as well as the foreseen activities for the recipient.  Incorporating resources and estimated times of effort for activities can help assist in identifying the overall time the client will have to spend to implement the new system.

Developing a governance structure where Community Connect clients have a voice will help support the partnership. Expectation setting also requires guiding principles that both parties can embrace during the implementation and support phase. Strong communication is key to help reduce anxiety and concerns. When issues or concerns are escalated up through governance, guiding principles will need to be looked at and leveraged regularly.

Finally, when considering being a Community Connect host, it’s important to conduct a pilot first.  Conducting a practice run (or pilot), is where a host organization can identify the challenges they may face.  As a host, the health organization will now be a vendor providing a service, which is new to many organizations.

These elements all contribute to a successful Community Connect implementation. It’s important to consider all aspects of the project before offering Community Connect.

Todd Klein

VP EHR Services & Digital Solutions

Breaking Down Denials: CC/MCC Denials

Posted by Samantha Serfass on March 19, 2019 in Blog, General, News

BREAKING DOWN DENIALS: CC/MCC DENIALS 

When someone in the healthcare industry hears the word “denial”, many things can come to mind.  There are many different types and kinds of denials; what could be said about denials could fill a book. To narrow the conversation, let’s touch on one specific type of denial that has become more prevalent for hospitals in recent years. 

A documented and coded diagnosis acting as a CC or MCC for the DRG is denied by the payer with the claim that the clinical picture does not support that it is a true and valid diagnosis.  By removing the diagnosis code, the DRG is reduced, resulting in a reduced payment to the hospital.

This type of denial has been called various things which can create confusion when assigning the appropriate person to address it.

A few examples are:

  • “clinical denials” which could also mean denial of admission to an inpatient bed stating the patient’s clinical picture does not warrant inpatient care
  • “DRG denials” which could also mean the entire admission was denied, not just a denied diagnosis changing the DRG
  • “Coding denials” which tends to sound like this is a coder issue when in fact it is not a coding issue at all

Payers have learned how to target the types of inpatient discharges that lend well to this type of challenge.  Common targets include DRGs with a single CC or MCC where the CC or MCC is acute renal failure/injury, acute respiratory failure, encephalopathy, malnutrition, or sepsis.

If this is not a coding specific issue, then where does the problem lie?  The Center for Medicare and Medicaid Services (CMS) has not stated any one criterion as the official clinical criteria for all to follow.  As a result, many payers including the RACs have created their own criteria or adapted existing criteria in the industry such as AKIN (Acute Kidney Injury Network), RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease), or KDIGO (The Kidney Disease: Improving Global Outcomes).  Providers most often do not know what individual payer criteria is being used.  Physicians have not been educated on when additional documentation is needed to support certain conditions that they diagnose and document. 

The coding teams are stuck in the middle.   Facilities can trend what different payers are targeting and the basis of their denials.  Armed with this information, coders still cannot diagnose the patient.  Even with outlined criteria to follow, conditions documented in the record and not ruled out cannot be ignored by the coder.  The coder cannot make the determination that a documented diagnosis is not valid and choose not to code it. 

What’s a hospital to do?  Hospitals should create a team to review these types of denials and fight back whenever possible.  Some hospitals have taken the extra steps to create internal clinical guidelines to give direction and promote consistency; however, payers may still deny diagnoses based on their own criteria.  Offer as much education on the issue as possible to physicians, CDI staff, and coders.

Who should review and argue the cases? The best person to review these denials and write up an appeal letter would be the very person that documented the diagnosis in question, the physician.  However, it is a rare hospital that has a medical staff member with the time and willingness to do so.  So, the task should fall to someone with strong writing skills with a clinical background that can create a strong argument in support of a documented diagnosis by outlining the patient’s clinical picture in detail.

From a different angle: Coding was initially created for the primary purpose of statistics and research.  Coded data can play a key role in value-based care and other programs based on patient care outcomes and quality of care indicators.  While Official Coding Guidelines offer clear direction on when to assign a secondary diagnosis code, the guidelines could be a part of the problem.  The guidelines state additional conditions are coded when they affect patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, they extended the length of stay, or necessitate increased nursing care and/or monitoring.  But what the guidelines neglect to include are conditions that create a patient health risk for the future.

One example includes patients with morbid obesity that decline nutritional counseling or any other type of intervention.  Because the condition is not being addressed, some payers are denying it as a secondary code/s.  As patients develop obesity related conditions in the future, there will be limited data for research of obesity related health problems because the condition of obesity is not being coded now.  This also could create a problem with quality of care analysis when patients’ conditions are uncontrolled due to unaddressed obesity such as diabetes, respiratory conditions, joint problems, and cardiac disease.

 Every denial should be reviewed and where possible and appropriate, challenged.  Payers may tend to target facilities that do not argue or fight back.  Do not accept a payer’s denial at face value.  Review the case.  If there is enough clinical support in the record to argue, do so.  The continued challenge is what constitutes “enough clinical support”?  Not even CMS answers that for us.

Lisa Marks

VP of HIM Services

The Importance of Accurately Documenting Workflows

Posted by Samantha Serfass on March 6, 2019 in Blog, News

Importance of Accurately Documenting Workflow

In the mid to late 1990’s, EHR vendors started focusing on workflows– and not just the feature function of the system.  A great example of initial focus on workflows are Flex Orders.  A flex order made it possible for a provider to make another order based on the results with little navigation to other screens.  EHR vendors expanded their solution offerings by developing specialty modules with workflow as the root of the design. The goal focused on targeting the right data, for the right patient at the right time.

As EHR vendors now target smaller hospitals, they pack their implementation services with tighter timelines, while accepting the EHR vendors tools, content and workflows.  Although the hospitals may be smaller, they still have complex requirements to collect and process the data in their unique environment. While an out of the box solution from the vendor is a great start, it may not provide enough focus on workflows.

Here’s one example from an EHR vendor:

  • Five years ago, the hospital employed trainers who would own the workflows. The vendor provided Viso diagrams of workflows so the hospital trainers could modify them as design decisions were made that required the workflow to change.
  • Now the same vendor recommends hospitals outsource training roles allowing the vendor to provide the trainers. However, now they aren’t documenting them accurately, if at all.

The same software company providing the roles that own your workflow is a self-serving offering.  Rather than the software vendor modify the workflow to accommodate a hospital, the hospital is now asked to modify their workflow to adopt the software.  This isn’t always a bad approach.  However, unless a hospital makes a specific focus to evaluate workflow design, it won’t happen on its own.  The vendor is focused on getting their software live as soon as possible.

Here’s an example of the impact on the hospital.

  • Five years ago, when a hospital went live, the Visio diagrams of the workflows would be referenced for training prior to Go-live and troubleshooting after Go-Live.
  • Now based on the out of the box implementation methodology, no one has the workflow diagrams which they have been implemented and trained on.

Many top EHR vendors have implemented their software several times –why not trust the out of the box solution?  When workflows are not properly documented and tailored for the specific health organization, loss in revenue can occur.

Excite Health Partners is currently working to correct a 27-million-dollar issue due to inaccurate workflow design and supporting documentation. During the implementation, the vendor did not document the workflows, and the revenue cycle test scripts weren’t customized to the hospital’s needs.

At Go-Live, the hospital realized the workflows hadn’t been built out (or tested) for one of the modules, pre-collections. They also discovered the Medicaid billing process actually had 2 different workflows the employees were following.  90% of the revenue cycle issues came back to workflow and building the system to support the hospitals processes. Excite is now helping our client resolve these issues. Important to remember to properly design and document workflows to void these types of issues.

Todd Klein

VP EHR Services & Digital Solutions