Christine- I am a CDI consultant at a hospital with this identical issue. The issue is multifocal:
If you pm me I would be happy to talk to you.
I don't think you can assume that all payers are unawere of the Code First requirements. I work for a payer, and we are keenly aware that ICD-10 has the force of law, and that those guidelines must be followed.
THat being said, there are times when a payer may not have yet fixed a particular edit, the day that guidelines are released. Most use vendors to supply code sets and coding edit software. Those may be delayed or (occasionally) incorrect. I think that's sometimes a bigger issue when guidelines get released off-cycle.When there are issues with a payer, the best course of action is to work through your provider services/network management representative to get them corrected. If you are not contracted, you may have to do a little digging to find the right person in the claims department.
It's an issue with the 30 day readmission. I haven't found that explaining coding logic to clinicians does any good at all - ICD coding isn't clinically logical. You can only bang your head against the wall for so long. The hospital will get penalized when there are too many patients being readmitted in certain categories – and CHF is the hot one.
I think that within about two years there will be a different direction in how to code this triad – it is totally illogical to force clinicians into stating when something is NOT due to hypertension – they just don't think that way. I am using documentation decision trees with my clients and not even discussing coding rules. The approach is working better. We have also made very carefully structured templates for H&P's and worked with our ER docs as well. Another place to work on is case management if you have them in the ER – you want to get on that documentation ASAP as the ER documentation can color the whole stay. The inhouse clinical documentation specialists identify patients within a day of admission that are going to fall into this category (or who are probably going to fall into this category) and identify appropriate clinical staff proactively. This doesn't fix overnight – but we have seen a significant improvement over the last 2-3 months.
Sent from Mail for Windows 10
Right on, Jeannette. I am finding that very specific education on what has to be documented in the medical record – without mentioning anything about coding – is the most productive approach. We use very structured documentation templates – and incent the hospitalists with "how to have less queries" (and chocolate bars and coffee cards to starbucks). Teaching nonclinicians coding rules isn't productive – it does not compute. I teach them how they have to DOCUMENT and don't mention the coding.
The information contained in this electronic mail message, including any attachment (s), is confidential information intended only for the use of the recipient (s) identified above and may be legally privileged. If you are not the intended recipient of this communication, you are hereby notified that any use, dissemination, distribution, downloading, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by e-mail or by telephone (308-537-3661) and delete the original message without copying or disclosing it. Thank you for your cooperation.