Inspiration from the 2019 ACDIS National Conference Part II

The author shares highlights from the annual conference.

I am continuing my reporting on tidbits I learned at the Association of Clinical Documentation Improvement Specialists (ACDIS) annual conference in May.

As I mentioned last week, I was honored to make closing remarks on the first day. I shared my grand unified theory of documentation, which asserts that there is no focused documentation for medical necessity and then separate documentation for compliance (and yet other disparate documentation to support the DRG assignment). Clinical documentation is aimed at clinical communication, but if you tell the story fully and truthfully, all facets of healthcare should be supported equally.

It always makes me think of the parable of the blind men and the elephant. Each touches a different part of the elephant and makes an inference. One touches the tail and imagines it is a rope; one feels the trunk and thinks it is a hose. Another disagrees when touching the flank; he infers a wall. It is all the same elephant! Likewise, it is all the same documentation, and we have to support everything concurrently.

On the final day of the conference, I participated in a panel discussion with fellow ACDIS Advisory Board members talking about CDI in the past, present, and future, referring to our soon-to-be-published position paper (which is currently out) “CDI Yesterday, Today, and Tomorrow: Staying Relevant in Changing Times.” In the session, we did a straw poll on changing the “I” in ACDIS from “improvement” to “integrity.” Spoiler alert: 80 percent support the transition, as do I. I don’t think we didn’t have integrity before, but I think we need to be sure that the focus is on ensuring integrity in the clinical documentation. CDI should not merely be for DRG improvement.

Faisal Hussein and Allen Frady did a talk titled “Navigating Documentation and Coding Regulations in Search of Clinical Accuracy.” Apparently, the coding guidance hierarchy doesn’t only confuse me. When indexing leads you one place but Coding Clinic points you elsewhere, you are left in this perpetual struggle between what is compliant and what is correct. I usually opt for the accurate code, sometimes with a query or education to prevent the issue from arising in the future.

Allen used the example of documentation of “emaciation” and the conflict between indexing instructing to use the code for “nutritional marasmus,” which is likely not accurate (it is unusual in the U.S., compared to the more common protein-calorie malnutrition). Coding Clinic gave guidance to use “cachexia,” however, which also is not telling the whole story.

I think this stems from not sorting out etiologies from manifestations from diagnoses. ICD-10-CM has codes for all of these, so if you are just looking to capture a code so you can move on to the next encounter, you may get an incomplete story. My motto is to use as many codes as it takes.

They also recommended doing something I also suggest: have providers detail the cascade. “Diagnosis …as evidenced by manifestation…due to etiology… and (for good measure), treated with…” Their example was a “patient with severe protein-calorie malnutrition, as evidenced by emaciation, requiring medical intervention of TPN and long‐term planning for insertion of G tube and ongoing tube feeding.”

They also brought up obesity and how there are conflicting instructions on whether it is a codeable diagnosis. I think the issue here arises when CDISs try to apply what Allen called the traditional “five rules: that is, clinical evaluation, therapeutic treatment, diagnostic procedures, extending length of stay, and increasing nursing care or monitoring. The Uniform Hospital Discharge Data Set (UHDDS) did not mandate these five conditions; that was commentary based on the coding bible. What the UHDDS does say is “conditions that coexist at the time of admission,” which applies to obesity.

Obesity is always clinically significant – it causes disease, it impacts and affects treatment and dosing, it may change the surgical approach or affect healing. We may need more nursing lifting help, or oversized beds or wheelchairs. But does the provider have to explicitly document these as active treatments to be able to code obesity? I don’t think so. I do think that any patient who comes to the hospital with significant obesity should get dietary counseling, similar to tobacco cessation counseling. That is just in our patients’ best interest. It may not be pertinent to the current admission, but it is important to the patient’s longitudinal care and long-term well-being.

Finally, Hussein and Frady addressed clinical validation. Remember that the clinician really does the validation, not the CDIS or coder. They cited the Coding Clinic from the fourth quarter of 2017, which states that in the case of a condition that does not meet clinical criteria, the facility should request that the clinician document their rationale, and be prepared to defend it in an audit. This would require your medical staff to understand that their documentation directly generates codes and that denials result from codes that don’t seem to tell a cogent story. Most of them have no idea how appeals are crafted or what is at stake: CDIS job security!

Programming Note:

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