the importance of cdi - arkansas hfma · the importance of cdi: inpatient and outpatient michele...
TRANSCRIPT
2/18/2019
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The Importance of CDI:Inpatient and Outpatient
Michele Hand, Senior Clinical and HIM Consultant
CDI
• A collaborative process between coding, CDI professionals and
providers to ensure that documentation accurately reflects the condition
and acuity of the patient during the episode of care.
• CDI reconciles inconsistent, incomplete, and conflicting documentation
prior to the final coding
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Characteristics of Good, Quality Documentation
• Complete
– Complete clinical picture of the patient encounter
– Includes chief complaint; physician orders and reason for the
orders; diagnostic test results; procedure, therapy and nursing
notes; physician and consultant notes
• Reliable
– Content is trustworthy and safe and everyone reading the record
has the same understanding
• Precise
– Accurate and well defined
– Detail supports clinical picture from diagnostic and treatment
positions.
– Clinical details include vitals, test results and other clinical
indicators needed for the diagnostic process
Characteristics of Good, Quality Documentation
• Consistent
– No contradictory statements from providers
– If diagnosis changes, indicate reasons for further specificity or new
diagnosis.
• Legible
– Documentation must be able to be understood by everyone
reviewing it.
– Illegible documentation compromises the quality of documentation
• Clear
– Comprehensible and distinct
– Vague documentation can be ambiguous and unclear
• Timely
– Available when it is needed for patient care delivery.
– Cannot be corrected after the fact
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Complete Medical Record Entries
• Support the diagnosis/condition
• Justify the care, treatment, and services
• Document the course and results of care, treatment, and services; and
promote continuity of care among providers
Evolution of Clinical Documentation Improvement
• Initial endeavors started in the inpatient setting
– These are still important, but with time, providers need less
assistance
– Capture comorbid conditions and major comorbid conditions
• MS-DRG Assignment
– Assign APR-DRGs which use SOI (severity of illness) and ROM
(risk of mortality)
– Document Present on Admission
– Ensure patients meet medical necessity and are placed in the
correct level of care
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DRG and Comorbid Condition Example
Scope of Focus is Expanding
• Inpatient Setting
– Hospital Value Based Purchasing
• Quality
• PSIs
– Clinical Validation
– Hierarchical Condition Category (HCC)
– Denial Management
• Outpatient Setting
– Hierarchical Condition Category (HCC) and Risk Adjustment
Scores
– E/M Levels
– Medical Necessity
– Denial Management
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Inpatient CDI
Hospital Value Based Purchasing
• Designed to improve the quality, efficiency, and safety of care during
acute care inpatient stays and to improve experience of care during
hospital stays
– Reduce or eliminate adverse events
– Adopt evidence-based standards and protocols that improve patient
outcomes
– Improve the transparency of care quality
– Improve patient experience
– Recognize hospitals providing high quality of care at lower costs
based on achievement and improvement
• Performance period for 2019 was 2017
• 2019 performance will affect future reporting
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2019 Performance Based on Four Quality Domains
CMS: Understanding the Fiscal Year 2019 Hospital Value-Based Purchasing Program, July 2018
Four Quality Domains
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CMS PSI 90 Measures
Hospital Acquired Conditions Reduction Program
• Hospitals that are not above the 75th percentile of reporting hospitals will
receive a 1% reduction in payment of claims for FY 2019
• Retrospective, so documentation this year will be used for future
reporting
• These are publicly reported on Hospital Compare
• 2 Domains are reviewed
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Hospital Acquired Conditions Reduction Program
– Domain 1: 10 PSI 90 Measures
• Reporting period 10/1/15 – 6/30/17
• 15% of total score
– Domain 2: 5 Healthcare Associated Infections
• Reporting period 1/1/16 – 12/31/17
• 85% of total score
Hospital Readmission Reduction Program
• Readmission is defined as an admission within 30 days of a discharge
from the same or another IPPS acute care hospital.
• Looks at 3 years of discharge data
– 2019 looks at 7/1/14 – 6/30/17
• Do not know what future readmissions will be measured, so
documentation must be complete for all conditions treated.
• Must have 25 discharges for the condition that is being measured
• Compared with hospitals in same “Peer Group”
• Reported on Hospital Compare
• This is a penalty program
– Maximum penalties of 3% reduction in payment
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Hospital Readmission Reduction Program
• Looks at readmissions in 6 areas
– Acute Myocardial Infarction (AMI)
– Chronic Obstructive Pulmonary Disease (COPD)
– Heart Failure (HF)
– Pneumonia
– Coronary Artery Bypass Graft (CABG) Surgery
– Elective Primary Total Hip Arthroplasty and/or Total Knee
Arthroplasty (THA/TKA)
Clinical Validation
• Diagnoses documented in a patient's record must be substantiated by
clinical criteria generally accepted by the medical community
– Professional guidelines and consensus
– Evidence-based sources
• Should not have conflicting documentation between providers
• Focus of RAC and MIC Audits
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Clinical Validation
• Separate function from DRG Validation
• Separate function from routine coding process
• Facilities should have a process in place to validate clinical conditions
prior to completing the coding process
• Ensure not only accurate coding but to also reflect the accurate clinical
scenario
• Examples
– Pneumonia with a negative chest x-ray
– Acute respiratory failure with normal ABGs
– Severe malnutrition with a normal BMI
Clinical Validation Queries
• Is there conflicting documentation between providers?
• Would the provider come to the same conclusion based on the same
information?
• Is the diagnosis a reasonable conclusion based on the totality of the
health record?
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Clinical Validation for Difficult Diagnoses
• Create list of vulnerable diagnoses and agree on standard clinical
indicators for diagnosis
– Criteria should be provider driven
– Many diagnoses lack a standardized definition
– Evidence based
– Goal to promote consistency in diagnoses criteria
– Internal policy helps with RAC Audits
• Providers should always be ready to defend their diagnoses to auditors
• Collaborative CDI/coding/provider meetings
• Second-level reviews to validate an accurate and complete clinical
picture
Outpatient CDI
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Outpatient CDI
• Multiple Outpatient Settings
– Hospital
• Emergency departments
• Infusion departments
• Other outpatient services
– Physician offices
– Outpatient surgery centers
Outpatient CDI Focus
• Select a focus of high volume, high risk review areas
– Risk - Reimbursement and Quality Score Impact
– Volume -Top 10 diagnoses and procedures
– Review
• Claims data
• Frequency of claims edits
• Coding audit report
• Denial information
• Chargemaster
• E and M
• HCCs and Risk Adjustment Scores
– Look at specific payors
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Chargemaster Review
• Prevents
– Overpayment or overcharging
– Underpayment or undercharging
– Claims rejections
– Fines
– Penalties
• Looks at supplies, devices, medical services and procedures
• Implement changes
• Schedule regular reviews, at least annually
Chargemaster Review Process
• Assemble team
– CFO or finance department billing department representative
– Representative from each charging department
– Coding representatives
– information systems department representative
• Run reports of chargemaster for review
• Chargemaster should be Current, Comprehensive, Compliant
• Research chargemaster issues, including new codes
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Evaluate and Manage
• May 2014 Report from OIG
– Over 40% of claims for E&M services were incorrectly coded and/or
lacking documentation
– E&M Claims are 50% more likely to be paid in error than any other
Part B services
– Target for audit
– Providers who bill for high level E&M codes are heavily scrutinized
by OIG and CMS Contractors
– Large percentages of errors identified were downcoding
Level of E/M Service Performed
• Selection of code depends on
– Patient type
– Setting of service
– Level of E/M services performed
• Code sets organized into various categories and levels.
– More complex the visit, the higher the level of code
• Provider is responsible the select a code that reflects the services
furnished.
• 3 key components
– History
– Examination
– Medical Decision making
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Medical Necessity
• Health care services or procedures that are necessary for the purpose
of preventing, diagnosing or treating an illness, injury, disease or its
symptoms in a manner that is
– In accordance with generally accepted standards
– Clinically appropriate in terms of type, frequency, extent, site
– Not primarily for the economic benefit of the health plans, providers
or beneficiaries
• Understand NCDs and LCDs and benefits of specific plans
Hierarchical Condition Categories
• Chronic health conditions or diagnoses that require a higher level of
resources to treat
– Given a weight
• Used by payors, including Medicare and Medicaid, to predict future
healthcare costs for beneficiaries
• CMS has 83 HCC categories for 2019 and HHS has more, with close to
10,000 ICD-10 codes within the categories
• Must be documented and coded every year
• Used to predict the healthcare costs of beneficiaries
– RAF Score
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Hierarchical Condition Categories
• Review Quality Measure, MACRA and MIPS reports to see gaps
• Review 1-2 years of HCC Reports from MA payors
• HCC documentation affects Risk Adjustment Factor Scores
• Documentation criteria should follow MEAT standards
–Monitor
–Evaluate
–Assess
–Treat
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Risk Adjustment Factor
• Two parts
– Patient Demographics
• 20 -15% of the score
– Claims Data (ICD-10 HCC codes)
• 75 – 80% of the score
RAF Example
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Top Ten Risk Adjustment Coding Errors
• Health record does not have a legible signature with credentials.
• Electronic health record was not authenticated and electronically signed.
• Highest degree of specificity was not assigned to diagnosis.
• A discrepancy exists between billed diagnosis and actual description of the
condition noted in documentation.
• Documentation does not indicate a condition as being monitored,
evaluated, assessed, or treated.
• Cancer status is unclear and treatment is not documented.
• Chronic conditions such as hepatitis are not documented as chronic.
• Lack of specificity is an issue, such as unspecified arrhythmia versus a
specific type of arrhythmia.
• Chronic conditions and status codes are not documented on an annual
basis.
• Required linking language, causal relationship, or manifestation codes are
missing.
Outpatient Chart Review and Queries
• Prospective
– Pre-visit assessment of the patient’s problem list prior to encounter
– Use this information to monitor documentation after the encounter
to ensure the problem list was updated
– Develop a reminder to providers to review and update the problem
list
– Query would not be warranted prior to an encounter
• Concurrent
– Can be difficult to achieve in a busy physician practice
• Retrospective
– To ensure that all areas of focus have been addressed
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Chart Review
• Minimize claim edits from Scrubbers
– Hold up claim submission
– Can decrease reimbursement
– Require manual review
• Look at denial trends and reports for areas of focus
– Denial categories
– Denial volumes
• Coding audit reports (by coder)
– Internal and external
– Can show documentation gaps
• Increase specificity
• Support medical necessity
• CPT/HCPCS code assignment, including E/M level
Denials and Appeals
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Denial Management
• Denials are expensive
– No payment received
– Response to and defense of denials is time consuming
• Overturning the decisions made by RAC auditors is difficult
• Biggest area of denials
– Clinical Validation
– Medical Necessity
– Missing Documentation
– Inaccurate Code Assignment
Types of CMS Audits
• Audits can be done pre-payment or post-payment
• Types of Audits
– Automated: Electronic information used to detect improper claims
• Medical Code Editor (MCE)
– Non-medical record review: Identify improper coding that can
lead to improper payments
• National Correct Coding Initiatives Edits (NCCI)
– Medical record (Complex) review: Manual record review
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Types of CMS Audit Contractors
• CERT: Monitor the accuracy of MAC payments
– Findings are the road map for future audits by all types of Medicare
auditors, including MACs and recovery auditors
– Publicly reported
– Error Categories
• No Documentation
• Insufficient Documentation
• Medical Necessity
• Incorrect Coding
• Other
Types of CMS Audit Contractors
• MAC: Regional contractors with ability to compare Part A and Part B
claims for the same services to look for discrepancies to make sure the
hospital doesn't have a high payment error rate,
– Prepayment review can affect cash flow, which potentially can have
a much greater impact on a hospital than a RAC.
• RAC: Coding validations, medical necessity reviews, and clinical
validation reviews in both the inpatient and outpatient setting
• MIC: Ensure that paid claims were for services provided, properly
documented, billed properly, using correct and appropriate procedure
codes;
– 5 jurisdictions
– Audit, Review and Educate
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Types of CMS Audit Contractors
• SMRC: Focus on decreasing improper payments and increasing the
proficiencies of the medical review process for Medicare Part A and B
and durable medical equipment (DME) providers.
– May include liabilities identified by CMS’s CERT program, internal
databases, professional organization, and federal oversight
agencies
• ZPIC/UPIC: Goal is to recognize cases of suspected fraud and to then
perform an investigation to recoup inappropriate Medicare payments
using
– Investigations and Interviews
– Medical reviews
– Data analysis
– Administrative actions (e.g., payment suspension, auto-denial edits)
– Refer cases to law enforcement and licensing boards
Overview of Audit Scope
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DRG Validation Reviews
• Medicare Severity-DRG (MS-DRG) system indicates the severity of
illness that is used to represent the appropriate acuity level and the
resources utilized
• Determine if the appropriate DRG has been assigned based upon the
supplied clinical documentation and ICD-10-CM/PCS
• Ensure the diagnostic, procedural, and discharge information has been
assigned appropriately
• Evaluate all procedures that affect the DRG assignment and validate
they were reasonable and medically necessary
Medical Necessity Review
• Called “Patient Status Reviews”
• Performed by licensed medical professional
• Look at
– Admission criteria
– Invasive procedure criteria
– Inpatient-only procedures
– Coverage guidelines
– Published CMS criteria
– DRG validation guidelines
– Coding guidelines
– Other criteria such as practice guidelines
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Medical Necessity Review
• Looks at 2 Midnight Rule to make sure claims are suitable to pay under
Medicare Part A
• Documentation should support the provider’s judgment (patient history
and comorbidities, the severity of signs and symptoms of a diagnosis,
the current medical needs of the patient, and the risk of an adverse
event)
• Diagnosis sequencing can impact the likelihood of claim selection for
validation
– Principal Diagnosis definition is “the condition, after study, which
occasioned the admission”
– Comorbidities can increase the severity of illness of the patient
• Also review of diagnostic testing ordered to ensure they were necessary
to determine diagnosis
Clinical Validation Review
• Goal is to ensure accurate data was reported which represents the
patient’s condition and services provided to prevent fraudulent practices
(intentional or unintentional)
• Can identify underpayments as well as overpayments
• Requires a comprehensive record review performed by clinicians
• Clinical indicators and the patient’s overall condition are reviewed to
confirm diagnosis criteria were met
• Looks at the medical record (including physician queries), medical
literature, evidence‐based medicine
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Clinical Validation Review
• Common findings by auditors
– Acute code when the clinical information indicates a chronic
condition
– Diagnosis that is only supported by one lab test
– Diagnosis for a condition that is inherent in another condition
– Conflicting documentation between providers
– Improper queries
Queries
• Acceptable Query types
• Queries should not lead provider
• Create neutral queries
– Clinical presentation
• Signs and symptoms
• HPI/progress notes/consults
– Diagnostic workup/lab values
– Multiple‐choice options
• Either/or
• Yes/no
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Denial Management Prevention
• Prevention is best practice
– Standard, physician approved diagnosis criteria to define difficult
diagnoses
– CDI reviews to ensure complete, consistent, accurate medical
records
• Present on Admission
• Correct DRG
• Clinical Validation
– Coders cannot omit a diagnosis that isn’t supported by
clinical indicators
• Specificity (Goal is < 20% of unspecified or NOS)
– Compliant query processes
– Tip Sheet development
– Education, education, education
Education
• Ongoing
• Pertinent
• Process improvement
• Formal and informal
• Educate
– Providers
– CDI professionals
– Coders
– Billers
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Standardized Evidence Based Criteria for Diagnoses
• For problematic diagnoses
• Providers must agree to use these guidelines or be prepared to defend
why they are not using this if audited
• Can assist in appeal process
• Gather diagnostic criteria that should be met from payors
– Some payors use Sepsis 2 and some use Sepsis 3
• Medicare definition is a hybrid of the two
Perform Audits Prior to Claim Submission
• Internal or external audits
• Documentation audits
– Specificity
– Clinical Validation
– Medical Necessity
– E/M level
• Coding quality audits
– Principal and secondary diagnoses and procedures
– Secondary diagnoses impacting SOI/ROM
– MS-DRG or APR-DRG assignment
– Present on admission (POA)
– Discharge disposition
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Management Strategies
• Document and track denials
– Reason for Denial (Coding error, Billing error, Documentation, etc)
– Changes and monetary differences (eg DRG change)
– Timelines
– Physician, CDI specialist and coder who were involved
– Whether it was appealed and appeal stage
– Action plan
– Final resolution
• Create Denial Management Team
– Defined responsibility for each member
• Physician should document clinical rationale for diagnoses and be
prepared to defend their diagnosis in an audit
Appeal Process
• Evaluate whether an appeal is warranted
• Understand different payors appeals process
• ADR (Additional Development Request)
– Reason your claim was selected
– What actions you need to take
– When you need to reply
– Consequences of not replying
– Instructions for replying
– Contractor contact information
• Create template library
– Subject matter experts (SMEs) information
– Case outlines
– Appeal letters (Must be customized for each appeal)
– Standardized clinical indicators for diagnosis
– Prior similar favorable decisions
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Appeal Letter Content
• Date of the denial letter in the heading
• Patient identifiers and Insurance information
• Restatement of the reason for denial
• A concise and factual statement explaining why the organization
believes the payer decision is inaccurate
• Physician Statement
• Supporting documentation, including where to find it
– Synopsis of the history of presenting illness
– Diagnostic results
– Clinical findings, including vital signs at time of admit decision
– Medications and their routes of administration, noting differences
from home medication regimens
– Nursing and additional clinical team member documentation
– Physician orders (admission level of care)
Appeal Letter Content
• Admission level of care review and level of care criteria screening tool
• Documentation of unexpected recovery
• Other documentation that supports the appeal (eg reference material)
• Corrective information taken
• Compliance or regulatory guidance
• Reference the CMS Conditions of Participation, AHA Coding Clinic®,
Official Guidelines for Coding and Reporting, local coverage rules,
hospital policies, etc.
• Requested outcome
• Organize information clearly
– Table of Content
– Exhibits
– Regulations
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Medicare Appeal Process
• Level 1: Redetermination of claim by MAC
– 120 days to file
– Second look at claim by someone not associated with denial
• Level 2: Reconsideration by a Qualified Independent Contractor
(QIC)
– 180 days to file
– May be panel of physicians or healthcare personnel
• Level 3: Hearing by an Administrative Law Judge (ALJ)
– 90 days to file
– ALJs operate under HHS Office of Medicare Hearings and Appeals,
is independent of CMS
– Appeals can be done
• By video teleconference, telephone, in person
• Face-to-face may be waived and answer sent by mail with an
appeal letter
Medicare Appeal Process
• Level 4: (Peer-to-peer) Review by the Medicare Appeals Council
– 90 days to file
– Facility disagrees with the ALJ decision or wants to escalate your
appeal
– Can overturn a previous denial in whole or in part
• Level 5: Judicial Review in Federal District Court
– 60 days to file
– Facility feels the Appeals Council decision is not favorable
– US District Court
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Denial Examples
• Pdx of sepsis, secondary to pneumonia (WBC 10.2, RR 32, HR
– 110, B/P 88/50), Patient is currently being treated with
chemotherapy for colorectal cancer and treated with dopamine, IV
fluids, and vancomycin.
– Denied due to not having enough clinical evidence to support the
diagnosis of sepsis.
• Pdx of aspiration pneumonia. Documentation indicates a stroke patient
with a failed swallow study
– Denied due to not having documentation to support the Pdx
• A 65 yo female, admitted to observation with dx of TIA. On day 2 she
developed hemiparesis and slurred speech and changed to an inpatient,
but no dx change made
– Denied for payment as an inpatient because TIA did not meet
medical necessity for IP care
Denial Examples
• Patient with breast cancer is admitted with anemia secondary to breast
cancer and dehydration. Treatment is directed toward anemia and
dehydration. The principal diagnosis is coded to breast cancer
– Denied due to incorrect coding, but payer agreed to pay for a
principal diagnosis of dehydration.
• Diagnosis of acute respiratory failure, with respiratory rate of 24, pulse
ox is 89% on RA, 1L of oxygen via nasal canula. Pulse ox is 97% on 1L
of oxygen. Lungs are clear and non‐labored breathing is documented.
– Denied due to not having enough clinical evidence to support the
diagnosis of acute respiratory failure
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Denial Analysis
Remember
• Document all conditions being treated for all episodes of care
• Determine facility wide standardized criteria for highly audited
diagnoses
• All Queries should be neutral and compliant with guidelines
• Perform clinical validation reviews
• Providers should be prepared to defend their diagnoses if audited
• Continue to educate
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Questions?
References
• Fernandez, Valerie. "Ins and Outs of HCCs" Journal of AHIMA 88, no.6 (June 2017): 54-56
• CMS Hospital-Acquired Condition Reduction Program Fiscal Year 2019 Fact
Sheet, July 2018
• CMS FY 2019 HACRP Matrix of Key Dates, July 2018
• Understanding the Hospital Readmissions Reduction Program, Lake Superior Quality Innovation Network, July 2018
• CMS Quality Payment Program Website (https://qpp.cms.gov/)
• CMS Hospital-Acquired Condition Reduction Program (HACRP) Website
(https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/hac-reduction-program.html)
• CMS Hospital Readmissions Reduction Program (HRRP) Website
(https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html)
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References
• CMS MLS Booklet Hospital Value-Based Purchasing, September 2017
• CMS Understanding the Fiscal Year 2019 Hospital Value-Based Purchasing
Program, July 2018
• Optimizing Revenue through Comprehensive CDI and Coding Practices, Joy
King Ewing, CCS AHIMA, September 2018
• Data Analytics for Outpatient CDI Programs, Pamela C. Hess, MA, RHIA, CDIP,
CPC; Vanessa Griggley-Owens, MGA, RHIA, CHC, AHIMA, 2018
• AHIMA 2016 Clinical Documentation Improvement Toolkit, 2016
• AHIMA Inpatient Query Toolkit, 2018
• AHIMA Clinical Validation Practice Brief, Melanie Endicott, MBA/HCM, RHIA, CHDA, CDIP, CCS, CCS-P, FAHIMA; Tammy Combs, RN, MSN, CDIP, CCS, CCDS
• AHIMA Clinical Validation: The Next Level of CDI, Journal of AHIMA 87, no.7 (July 2016): extended web version. Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne
References
• ACDIS Q&A: Querying for clinical validation of a diagnosis, CDI Strategies, August 29, 2013; Cheryl Erickson, MS, RN, CCDS, CDIP
• AHIMA CDI and Coding Collaboration in Denials Management TOOLKIT,
2018
• A Primer on Audits by RACs MACs, ZPICs and CERTs, Michael Taylor, M.D., May 24, 2011
• Medicaid Integrity Program: Medicaid Integrity Contractors
(https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/Provider-Audits/Downloads/MIP-Contractors-Presentation.pdf)
• Denials and CDI: A Recovery Auditor’s Perspective, Tim Garrett, MD;
Barb Brant, RN, CCDS, CDIP, CCS, 2017 ACDIS Conference
• Denials Management/Appeals, Alicia Kutzer, Esq., 2017 ACDIS
Conference
• CDI in Denials Management, Blog, Tammy Combs, RN, MSN, CDIP,
CCS, CCDS, Oct 30, 2017
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References
• ACDIS How to Mitigate and Manage Denials, Patricia Buttner,
MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, Tammy Combs, RN, MSN,
CDIP, CCS, CCDS, ACDIS Conference 2018
• AHIMA Ten Steps to Successful Chargemaster Reviews, Maureen
Drach, Althea Davis, Carmen Sagrati, Journal of AHIMA 72 2001
• AHIMA Care and Maintenance of Chargemasters, Journal of AHIMA
March 2010
• HHS, OIG Improper Payments for Evaluation and Management
Services Cost Medicare Billions in 2010, Daniel R. Levinson Inspector
General May 2014
• AHIMA Auditing Across the Continuum: One Size Doesn’t Fit All,
Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, Natalie Sartori,
MEd, RHIA
• AHIMA You Got Proof? Payers, Auditors Increase Clinical Validation
Checks, Mary Butler Journal of AHIMA 89, no. 7, July-August 2018
References
• AHIMA Guidelines for Achieving a Compliant Query Practice (2016
Update), AHIMA Practice Brief, January 2016
• ACDIS Ultimate Test for Queries, Cesar M. Limjoco, MD, Kelli A. Estes,
RN, CCDS, 2017
• Excellent Documentation is Necessary to Meet Medical Necessity, Erica
Remer, MD, FACEP, CCDS, ICD-10 Monitor
• AHIMA Medical Necessity for Outpatient Services, Rose T Dunn, RHIA,
CPA, CHPS, FACE, Shelley S. Safian, MAOM/HSM, CCS-P, CPC-H,
CHA, Audio Seminar Series, 2008
• A Refresher on Medical Necessity, Peter R. Jensen, MD, CPC,Family
Practice Management July/August 2006
• AHIMA Outpatient Clinical Documentation Improvement (CDI)
TOOLKIT, 2018