G2 Provider Solutions

02/27/2024

09/01/2020

Spread the word IDocDX

Q: How can we help providers understand that clinical validation queries aren’t meant to question their medical decision making?

A: To avoid physicians feeling like the CDI team is questioning their medical decision making, the CDI specialists should introduce the concept and purpose of clinical validation to the medical staff. The education should stress that we not challenging their medical judgement but are challenging the quality of the documentation, meaning we are only reviewing the documentation (not assessing the patient) and support for the documented diagnosis is not clearly evident.

The provider should understand the purpose of a clinical validation query is to point out that the documentation does not offer clinical support and allows the provider to further clarify the patient’s diagnoses. This further clarification allows for accurate code assignment and accurate reporting of the conditions present.

Read the rest of Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O's expert advice here: http://ow.ly/5AkJ30qpnSS

09/01/2020

IDocDX

Q: Our dietitians send cases needing a query for malnutrition to our CDI staff. Previously, they were notifying providers of the need for the documentation of the diagnosis directly, but from a compliance perspective, they were more comfortable with us owning the formal query process.

Now, however, my hospitalists are wondering if there is a better way to leverage technology to feed (no pun intended) the dietitians’ assessment and diagnosis back to the providers to minimize the query burden. Do you have any recommendations for processes that work well to ensure the dietitians’ assessment is followed up with documentation by the provider? Can the provider cosign the dietitian’s note?

A: At my organization, when the dietician completes their American Society for Parenteral and Enteral Nutrition (ASPEN) assessment for malnutrition (which may be in a consult note or a progress note), they send that note to the provider for them to cosign. The note appears in our system as usual, but it will say “waiting for cosign” until it is attested.

Continue reading this expert advice here: http://ow.ly/cpa230qTsMZ

06/27/2020

06/22/2020

03/21/2020

Q: How can we help providers understand that clinical validation queries aren’t meant to question their medical decision making?

A: To avoid physicians feeling like the CDI team is questioning their medical decision making, the CDI specialists should introduce the concept and purpose of clinical validation to the medical staff. The education should stress that we not challenging their medical judgement but are challenging the quality of the documentation, meaning we are only reviewing the documentation (not assessing the patient) and support for the documented diagnosis is not clearly evident.

The provider should understand the purpose of a clinical validation query is to point out that the documentation does not offer clinical support and allows the provider to further clarify the patient’s diagnoses. This further clarification allows for accurate code assignment and accurate reporting of the conditions present.

Read the rest of Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O's expert advice here: http://ow.ly/5AkJ30qpnSS

03/13/2020

Q: I’ve always thought that, as long as the clinical indicators support the condition you’re querying for, providing all the options for the specific type/specificity of that condition allows the provider to use their clinical judgement. Is this correct?

A: The direction within the ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” brief clearly states that we shouldn’t offer choices that are not clinically supported. For example, if you are querying for the type of heart failure and the ejection fraction is 50%, I would not offer systolic heart failure as an option as it does not fit the clinical indicators.

Offering choices that are clearly incorrect can also be frustrating to physicians and hurt your provider engagement in the long run.

Read the rest of Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O's expert advice here: http://ow.ly/QMzD30qnqcg

02/22/2020

Q: If a patient is admitted with both gram-negative pneumonia and acute respiratory failure, which should be sequenced as the principal diagnosis?

A: This question often causes friction between both coders and CDI professionals. The confusion lies in the instructions found within American Hospital Association’s (AHA) Coding Clinic over the last 15-20 years as well as the use of the Official Guidelines of Coding and Reporting to “optimize” payment.

Years ago, the ICD system viewed acute respiratory failure as a symptom more so than a definitive diagnosis. As you are likely aware, Section 1.C.18.b in the Guidelines instruct us:

Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Read the rest of Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O's expert advice here: http://ow.ly/uNfQ30qhy5h

02/20/2020

02/20/2020

02/20/2020

It is that time of year! The 2019 ACDIS salary survey is here, showing that CDI salaries are on the rise.

Ten years after the first-ever ACDIS CDI Salary Survey, respondents have consistently, incrementally reported higher annual salaries. According to that very first salary survey, more than half of all respondents earned $69,999 or less. In 2019, only 13.23% fell into that bracket, down from 17% in 2018. The next earnings bracket, and usually the largest group—those who earned $70,000–$79,999—also fell year-over-year from 21.17% in 2018 to 16.34% in 2019.

This year, for the first time in the history of the survey, the largest earning bracket was those who made $80,000–$89,999 (18.61%), followed closely by those who made $90,000–$99,999 (17.48%). Additionally, those earning the highest salaries (combining earning brackets of $100,000 or more per year) rose by more than four percentage points from 28.15% in 2018 to 32.99% in 2019.

Continue reading the salary survey here: http://ow.ly/PtCy30qhy6Q

02/06/2020

Cerner Corp. is preparing to sell part of its software portfolio in Germany and Spain as part of an effort to increase its adjusted operating margin to 22.5% by the end of 2020.