Farewell My Friends and Colleagues

EDITOR’S NOTE: Dr. Erica Remer was, for nearly seven years, the cohost with Chuck Buck on Talk Ten Tuesday and a member of the ICD10monitor editorial board. This is her final editorial contribution.

This is my last contribution to ICD10monitor. Taking care of my father’s and my in-laws’ medical situations and financial affairs has become overwhelming for me, and I am essentially retiring from my consulting practice and ongoing responsibilities, like Talk Ten Tuesdays. It has been my honor and privilege to spend Tuesday mornings with all of you for the past seven years, and I thank Chuck Buck and MedLearn Media for the opportunity. I’d like to single out Dr. Ronald Hirsch, who was my connector to Chuck and has been a wonderful friend and support during my career. Thank you!

I’d like to leave you, my readers, with some thoughts.

The most important word in clinical documentation integrity (CDI) is “integrity.” Documentation should be an accurate reflection of the patient encounter, and coding should be an accurate representation of the conditions that were present during the encounter. The role of the clinical documentation integrity specialist (CDIS) is to ensure that the documentation is telling the story accurately and completely.

I always had trouble defining exactly what “compliance” meant – I understood it could be translated as, “follow the rules and regulations, and don’t lie.” I guess that is good enough. If a CDIS were intentionally to encourage a provider to fudge documentation so it supported a risk-adjusting condition that was not present or seemed to support a higher level of service than was medically necessary, that action might violate the False Claims Act.

Providers often don’t know that a query is a question – they sometimes think the CDIS is trying to persuade them to change their documentation. That’s why you can’t do “yes/no” queries, in many scenarios – and why you don’t reveal reimbursement or quality implications that might sway the provider. That’s why leading them is strictly prohibited. Give the clinician the facts they need to make a good decision, and give them solid choices, consistent with the clinical indicators. If they don’t understand the question, educate them first. This is why I recommend that physician advisors not pose queries. I think physician advisors (PAs) should educate their colleagues and allow the CDIS or coder to perform the query.

Clinical validation queries are an important tool in the CDI arsenal. If the clinical indicators don’t seem to support a claimed diagnosis to the CDIS or coder, they probably won’t pass a sniff test to an auditor, either. We want the record to accurately depict the patient encounter, regardless of where the coding will fall or which DRG the patient will land in. Fighting denials is soul-sucking, and if a clinical validation query can prevent a clinical validation denial, it is highly preferable.

The same principles we hold dear for inpatients carry over into the Hierarchical Condition Categories (HCCs) world. Plopping a random diagnosis into a patient chart with no clinical relevance is not permitted. If a provider believes a diagnosis is clinically significant, they must demonstrate it in the documentation. Why is it relevant? How is it going to be evaluated, monitored, or treated? Two seconds of documentation can save a world of hurt from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) or an auditor.

Providers shouldn’t just diagnose conditions to capture risk-adjustment factors, but only if they think it is important. Job one is to take care of the patient.

There is no question that artificial intelligence (AI) is here to stay. AI is going to become more and more integral to the practice of medicine. It will be great if it offloads some of the menial tasks and improves patient care. It will be dangerous if the providers, CDISs, or coders just relegate important activities to the computer without doing any oversight.

It will be worse than not mindfully editing copied-and-pasted text. Don’t let AI try to practice medicine without a license.

Finally, I recently came across a very scary article asserting that antimicrobial resistance is one of the greatest health threats of this century, and could lead to more deaths than cancer by 2050. Vaccine hesitancy is a huge contributor.

Appropriate antimicrobials to treat a bacterial infection would be unnecessary had the individual not developed the infection in the first place, but also, we doctors often use empiric (yet ultimately inappropriate) antibiotics to treat a viral infection that could also have been prevented by vaccination. I can’t understand why anyone would want to contract an infection that could have been avoided – being sick sucks! Folks, get your flu and COVID shots!

In conclusion, thank you all for letting me try to contribute to your lives and practices. I have done my best to impart my medical knowledge and have shared my insights from my personal experience with COVID and my interaction with the medical establishment. You have all been there on my journey with my father and his diagnosis of dementia, and now, my father-in-law. Thanks for your support and compassion!

I wish you all well in the future. I think that there are going to be particularly challenging times for the medical community over the next few years. I am not sorry to miss that.

Chuck, thank you again for this amazing opportunity. Laura, Chyann, Daniel, and all of our recurring and intermittent guests on Talk Ten Tuesdays, thank you for sharing your knowledge with us and me. And with that, and I’m signing off for the last time.