New Year’s resolutions for readers of ICD10monitor.

For providers, resolve to provide excellent clinical care to your patients, and invest the time needed to document it well. Improved documentation improves both the quality and others’ perception of quality of medical care. I have a few concrete suggestions:

  • I know it is a hassle, but include acuity, severity, specificity, and linkage in your diagnoses.
  • Consider doing a documentation timeout. Spend a few moments prior to dictating or typing or clicking, and cogitate about what the reader needs to know. Think about what advances the story of the patient encounter. Put mentation into your documentation. Make the medical decision-making the star of the entry.
  • Copy and paste less; always mindfully edit. Input novel documentation more.

For clinical documentation improvement specialists (CDISs):

  • Read the record for the story, not as a hunt for potential complications and comorbidities (CCs) and major CCs (MCCs). If the story isn’t making sense, something may be awry. Clinical indicators may need translation into diagnoses, or documented diagnoses may not fit the picture of the clinical encounter. If the length of stay exceeds the expected, make sure you are in the right tier.
  • Generate worthy queries. Don’t query for key performance indicators (KPI) metrics’ sake. Query to clarify and ensure accuracy.
  • Make your queries clear and concise. As the clinician’s ally, you do not want to be impeding them taking care of patients by bombarding or confounding them.

For CDI analysts:

  • When you are assessing your CDISs’ performance, be honest and give good constructive feedback. Telling someone they are doing something wrong without giving them specific instructions on how to do it better is not helpful.

For coders:

  • Resolve to read the encounter for the story, and be sure the codes detail that same story.
  • Don’t just accept computer-assisted suggestions; thoughtfully consider whether the codes they are offering are valid and accurate.
  • Let your people know what they really need to do to give you permission to pick up codes. There is more going on in their heads than they elect to put down in the record. They think they are giving you what you need.

For physician advisors:

  • Be present. Resolve to spend regular time with the medical staff, even if it is short aliquots, and give them actionable information. Just-in-time education works well with adult learners. They need feedback to improve future performance, whether it is CDI or utilization management (UM).
  • Set up education for your CDISs and coders or your case managers. Getting everyone knowledgeable and on the same page will serve your organization well.

For pro fee coders:

  • Make sure you and your colleagues approach assignment of evaluation and management (E&M) levels of service similarly. It is very confusing to a provider to see the same type of patient, document the encounter the same way, but have two different levels of service assigned.
  • Provide clinicians with feedback regularly. If you do annual reviews, increase it to quarterly. If you do quarterly audits, consider monthly. They can’t fix it if they don’t know it is broken.

Along those lines, if you do denials management, loop in your providers. They don’t know that there is a denial unless you tell them. Explain how it could have been prevented to avert the next one.

For quality, utilization management, case management, and compliance folks:

  • You are all touching the same record as the CDI team. Resolve to work together – teach each other about what you do so you can identify the responsible individual to be recruited to fix a detected issue. Making the patient look sick from the get-go demonstrates medical necessity, establishes present-on-admission status, and supports quality metrics.
  • Have open lines of communication and cross-representation on committees. It’s not threatening, it’s collectively strengthening.

For administrators:

  • Recognize that everyone is feeling significantly stressed these days. Productivity is important, but so is retention. Resolve to be gentler, kinder, and empowering toward your employees.
  • Support them. Consider paying for some CEUs. If it can be safely accomplished, bring everyone together to remind them they are not alone and that you care.

For external auditors:

  • Your job is important too. No one wants fraud, waste, and abuse in the system. But it’s wrong and wasteful to make people fight denials gratuitously. Deny righteously and overturn on appeal when that is the right thing to do.

To all our readers – thank you for sharing your time with us. Please have a safe, healthy, and happy holiday season and New Year! Get your booster shot and see you next year! May 2022 be a good year for us all.

Programming Note: Listen to Dr. Erica Remer live today when she co-hosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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