DOCBytes: Ambulatory CDI…Do You “SEE” Yourself?


There has been more buzz than ever about starting an ambulatory CDI (Clinical Documentation Improvement) program. First of all, let me begin with saying in some circles you’ll hear ambulatory CDI and in some outpatient CDI. Ultimately they refer to the same areas of the physician practice or clinic, the ED (emergency department), outpatient surgery, or even observation to name a few. When you think about it, observation patients may be in a bed for around 48 hours and not so ambulatory but for our benefit, we will use the terms outpatient and ambulatory CDI interchangeably. Providers are really struggling to decide; do I venture into this area, how do I go about it, and what do I need to focus on? Let’s spend a little time today discussing a few options.

Potential Focus Areas                DOCBytes - Debating Ambulatory CDI

If you are a coding professional, I am sure you can immediately identify some areas of concern within the outpatient arena. They could include problems with the type or depth of debridement for CPT (Current Procedural Terminology) code assignment, appropriate modifier usage to identify when a service is above and beyond the usual scope of a procedure like with modifier 59, or assignment of E&M (Evaluation and Management) levels, or documentation to support medical necessity, reason for the test, which has been a long-standing and problematic issue. These are certainly areas that have been thorns in our sides and always receive heightened focus when that dreaded audit internal or external such as OIG (Office of Inspector General) or MAC (Medicare Administrative Contractor) comes out of nowhere and coding or billing gets in the administrative hot seat. Suddenly this is about real big dollars and all eyes are on you or your department. Totally not fun, right? These are all areas that are potential low hanging fruit for CDI dependent on staff abilities (Wait…staffing is for another DOCBytes (smile)).

As quality is becoming of increased focus due to MACRA (Medicare The Medicare Access & Chip Reauthorization Act) and providers are taking on more risk by partnering (wanted or not) with CMS (Centers for Medicare and Medicaid Services) and other payers in more aggressive contract arrangements, understanding and reflecting the severity of the patient becomes more and more important. Remember the well in many cases help cover payments for the sick, each individual member should have dollars to cover their payment needs, and managing severity with good outcomes shows the quality and value of the provider. Understanding HCCs (Hierarchical Condition Categories) are an important part of this and is built into programs such as Medicare Advantage and many of the quality programs such as ACOs (Accountable Care Organizations), PQRS (Physician Quality Reporting System), and VBM (Value-Based Payment Modifier). As we move to participating in these initiatives, focusing on coding for HCCs may be a good place to start. In case you are not are aware, OUR PHYSICIANS ARE CODING in the clinic and this data is being reported for patients Risk Adjustment Factor (RAF) scores. In most cases, these claims sail right out the door. Tackling this area could benefit you for Physician Compare Reporting, future contract negotiations, and provider incentive payments for PQRS, VPM, and MACRA.

CDI SEE (Self-Evaluation)

This is all a lot to take in right? Well I would say take a breath and CDI SEE. Take a look at where you stand with some of the areas outlined above. Identify your band-width and what you have the ability to do fully and well. Utilize the info below to take some beginning steps and move forward to achieve Holistic Documentation!
Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA


CPT® by American Medical Association

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Refueling the Passion for your Profession

DOCBytes – Special edition

creative three-dimensional model of real human brain and scan on

I received a call today from a very passionate and well-informed HIM professional. At first, we were discussing where our profession is going and what credentials would be suitable for her going forward. As we continued to talk I realized the conversation was not so much about getting more credentials but more about feeling gratification and satisfaction in your job and refueling from the day to day, month to month, and year to year drain we can feel from continually giving our all. Keep in mind she has a number of credentials and no desire to attain another or leave her job. This was kinda like, you absolutely loved that coding audit you just completed but gee whiz; you feel like something is missing. Don’t get me wrong, credentials and education are wonderful and necessary but sometimes, it’s more than that. Let’s spend some time discussing this and refuel in the process.

First of all let me say there are many types of people and we all have different needs. Times have certainly changed and now we have employees and coworkers that work remotely. The impact of this change can be an adjustment for the employee and leadership. It is okay to have the need to feel gratified in what you do from day to day. Unfortunately, you may not get that feeling as quickly as you would like or at all. It is important as managers that we give that feedback but as individuals if we are not sharing that with our leadership, we should seek out how to share this with our leaders if possible or seek other areas and opportunities for this.

We did continue the conversation and of course we talked about coworkers that have seemed to “check-out” of their profession. “What? We have folks checking out!” you may ask. Well yes somewhat.  If you are not being satisfied and just going through the motions, you have checked-out. The healthcare industry is moving at a tremendous pace. Technology is coming at us, people are coming at us, and change in policy, regulation, process is coming at us, and this can make for a challenging work environment. All those things can give you a tendency to want to check-out. After you finish that meeting, hang up that phone or walk out of the office, IT’S A WRAP and this seems so unlike you, right? Those that can preserve some element of gratification or can refocus on why you are there in the first place can stay in sync.

Some of us have a job, some a career, and some have a calling. Many healthcare professionals I speak with especially feel they have a career that is a calling; especially clinical staff and I would add HIM professionals. There is also those that just see their shift as a job. The excerpt below is from Mayo Clinic and speaks to going sour in your job but I believe it applies to those missing something and needing to refuel.

“If you’ve gone sour on your job, think about what motivates and inspires you — and how you approach your work. For example:

  • It’s a job. If you approach work as a job, you focus primarily on the financial rewards. The nature of the work might hold little interest for you. What’s important is the money. If a job with more pay comes your way, you’ll likely move on.
  • It’s a career. If you approach work as a career, you’re likely interested in advancement. Your current job might be a steppingstone to your ultimate goal. What’s important is to be regarded as a success in your field.
  • It’s a calling. If you approach your job as a calling, you focus on the work itself. You’re less interested in financial gain or career advancement, preferring instead to find a sense of fulfillment from the work itself.”

Job satisfaction: How to make work more rewarding

So I can say disconnect when needed (a tropical getaway sounds good right now with this COLD weather) but remember if you have checked out of your job/profession it is visible. Try to find your gratification and refuel. It could be as simple as, getting involved in your associations, mentoring, writing an article, volunteering for that project, or maybe you do need that beach or a job change. With the right approach, this could be great reinforcement and a positive way to continually build your body of work for personal and professional advancement.



Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA


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Making Your EHR Documentation More Audit-Proof: The Era of the Trojan Horse


I’m back continuing simple Documentation Bytes; DOCBytes, for you to apply to your everyday world. The last post was so popular I thought it may be beneficial to provide a little more on EHR (electronic health record).

We have discussed key things to remember when documenting and learned that the quest for ease and simplicity through technology sometimes gets in the way.  What we have longed for and wished for has become our “Trojan Horse” so to speak. Beautiful and powerful and yet, filled with surprise. Kind of like those new set of wheels; whether brand new or on its last leg; much awaited for and full of surprises; good or bad. Ultimately it is the goal of interoperability and lack thereof that can be the hindrance. The structured data we utilize isn’t quite good enough and the nonstructured data is even more difficult to decipher, extract, compile, share, and utilize in a meaningful way. Let’s just say, “You’re darned if you do and you’re darned if I don’t!!” Let’s go on to say, “You’re double-dog darned if you don’t focus on how we document and input data!!” Not only can you not extract the data you need for analytics but you also are potentially at increased risk for reduced payment and denial of payment with a poor story.

I often speak of free-text which can be limited in an EHR and also problematic when it comes to extracting and analyzing data. Many physicians I speak with choose to utilize dictation to further describe details they cannot record directly within the EHR such as when completing a daily progress note. As SOAP (Subjective, Objective, Assessment, and Plan) notes have gone to the wayside, for the most part, the 5Ws can help justify your outpatient visit or your 2 midnights to justify Inpatient. If you can speak to the bullets below you can create a better picture of the patient.  Practice with a colleague; nurse, coder, clinical documentation specialist, or physician, you’ll see. As my colleague Bill Malm says; “If they don’t understand, the auditor probably won’t!” I will add we are seeing a revival of SOAP. Providers are realizing its relevance and importance in the overall revenue cycle.  Isn’t it strange how we sometimes go back to the old after the new loses its luster? I frankly still love my husband and the 80’s. They never lost it.

Remember to:

  • Be included in developing and updating EHR templates
  • Give a complete picture of the patient stay utilizing SOAP or the 5 Ws
  • Work with IT regarding what your data looks like when extracted/downloaded
  • Utilize HIM professionals, CDI, and other colleagues to see how your documentation holds up or could improve


Keep the 5Ws of documentation in mind for documentation and medical necessity support.


  • What are we treating?
    • Diagnosis
    • Procedure (if relevant)
  • Where is treatment needed?
    • Inpatient
    • Outpatient
      • Observation
      • Surgery
  • Why is treatment needed?
    • Why is this diagnosis acutely requiring attention?
    • Relationship to chronicity; is this a chronic condition acutely requiring intervention?
    • References to requiring testing, drugs, or other interventions
    • References in variation from baseline to current state
    • Potential for adverse outcome
  • HoW are we treating it?
    • What are we actively doing requiring the designated level of care or E&M services
    • Implications if not performed
  • When do you think they’ll get better?
    • Expectation for stay/care plan
    • Plan  for discharge

5Ws of Documentation and Coding

These are helpful “DocBytes” to keep in mind to assist you in Excellent Documentation.

5Ws for Documentation and Auditing

This work is licensed under



Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA


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“The EHR Is and Isn’t your friend?”

Utilizing the EHR (Electronic Health Record) offers the providers, greater access to patient information, improved patient care, care coordination, and potential for cost savings.  There are also challenges this documentation tool can bring to the provider in terms of documentation. Templates can be beneficial but should offer flexibility to the provider for ease in updates or the benefit of free text if allowable.


  1. Ensure documentation is patient specific and age appropriate. The EHR at times may set the provider up for clicking inaccurate information. For example, a patient who is bed-ridden should not have documentation that states gait normal.
  2. What goes in may or may not be what comes out. Ensure you or someone is reviewing your pdf, tiff, and paper printed documents to ensure your intent is there. A depression screen should print negative and positive components of the screen and documentation should support treatment for drug therapies administered.
  3. Understanding the patient is important to other caregivers as well as other entities reviewing the record. Documentation should reflect the current state of the patient as well as alternatives, risks and benefits of evaluations and treatments. This goes as far as including a review of likely outcomes if a treatment is withheld or refused. If the patient leaves AMA state potential patient risk. The 5Ws for Documentation and Auditing offers good tips.
  4. Be careful with copy and paste functionality. This can certainly save time but can bring forth inaccurate information that may require updating. Editing information pasted over potentially could not be updated or edited as appropriate. An example is, Ms. Notme who has had the same vital signs and normal physical findings every day; all day of her 2 day visit. Small things similar to this can turn into compliance and risk issues as well as hinder coding and billing processes and impact audit defense.
  5. Develop some policies and guidance around utilization of the problem list. Many facilities and areas within facilities utilize this list differently. Ensure you are all on the same page with is uses and limitations. Keep in mind that something that seems irrelevant to you may be beneficial to another provider. Instituting a quality review process around this area could be beneficial.

Physicians can struggle with translating the art of treating the patient into fluid documentation to justify coding and fully reflect what is happening with the patient. Having the visual on the patient certainly lends a different view if the visual can be documented appropriately; such as the patient  is septic looking or further describing the COPD (chronic obstructive pulmonary disease) patient carries their oxygen usually because they are O2 dependent and describing the COPD as acute on chronic if presenting  symptomatology describes this.



Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA

888-474-8023 (O)

704-826-7497 (O)

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“Okay Doc, Take A Seat…May I Help You?”

I have worked with many physicians over the years and have developed great relationships with quite a few. As I share information through work engagements, presentations or just chatting, we both often leave the conversation with a new perspective on documentation. Not only do we gain valuable tools to put to use in our day to day but more often than not, we glean a better understanding of the challenge of being a physician in the world of revenue and documentation integrity. Physicians have been undergoing a dramatic transformation and the rate of intensity is somewhat profound. Absolutely, physicians have always had to stay abreast of new treatment methodologies, regimes, and diseases but this is much different. The shift for physicians is not only within how they operate but also how they focus on the center of their life commitment; you and me (the patient). The physician has to provide exceptional, quality care, interact and engage with colleagues, customers, patients, all while leaving a trail of information that is secure, valid, reliable, understandable, and billable. Going forward we will focus on physicians and other healthcare professionals offering “DocBytes”.  It’s all about documentation and this is a conversation we must have in all aspects of healthcare. Physicians will be an initial focus but the goal is to help all our healthcare protégé’s in their work to allow time for physician-centric and patient-centric clinical activities. After all, that’s what we’re here for right…stay tuned, I think we’ll start with the EHR.



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Fitting Coding and CDI into MACRA

Back in 2014, I wrote an article called “Holistic Collaborative Documentation,” published in RACMonitor.  The thought behind that article was about not only how important physician documentation is within any setting but also about the need for coders and CDI (Clinical Documentation Improvement) professionals to assist in the appropriate reporting and capture of this information. Providers have had a long-standing history of minimizing diagnosis coding in the Part B revenue cycle. A key difference in Part A and Part B coding is the laissez faire approach providers take for reporting Part B diagnoses. The only times these diagnoses become of concern is when the need to justify the test for medical necessity arises and payment becomes of utmost importance due to denial or non-coverage. As I stated in that article 2 years ago, the need has come for us to better reflect what is occurring within the clinic setting and providers need to take a “holistic” approach to documentation. Medicare Access and CHIP Reauthorization Act (MACRA) is here and providers are yet another step closer to reaching the (Centers for Medicare and Medicaid Services (CMS), “Triple Aim”.

You may ask, “What does MACRA have to do with coding and CDI…MACRA is only a Quality Payment Program (QPP) that replaces the current Sustainable Growth Rate (SGR) methodology? It is only financial and is another way to measure quality of care, incentivize providers, and profile clinicians.” Well, all those things are true but it goes a step further. Programs within the QPP are risk-adjusted for severity. This means that a patient’s diagnosis is utilized to categorize the patient based on how sick they are; diagnoses. This measure of diagnoses adequately shows you and the payer the true costs of treating the patient.

Here is an example. Many providers have been participating in Accountable Care Organizations (ACOs) for years. ACOs provide care to a population of patients. Primary care physicians, specialists and hospitals manage patients as a group. The participating physicians and hospitals jointly take responsibility for the cost and quality of patient care, and they function under a various risk-sharing arrangements. There are many types of ACOs which are Alternate Payment Models (APMs) and now, in some cases, under MACRA Advanced Alternate Payment Models. Historically ACOs have had many challenges. There have been some successes and some failures. One potential problem could be the inability to adequately project benchmarks for cost of caring for the patient due to an inadequate picture of the patient from a diagnosis perspective. However, keep in mind, there are other factors that also come into play such as age, sex, socioeconomic status, and geographic location.

“The benchmark is a surrogate measure of what the Medicare Fee-For-Service Parts A and B expenditures would otherwise have been in the absence of the ACO. The initial benchmark is risk adjusted using the CMS Hierarchical Condition Categories (HCC) risk adjustment model that was originally developed in conjunction with the Medicare managed care (Medicare Advantage) program, also known as Medicare Part C. The HCC risk adjustment model is used to calculate expected expenditures for a population of Medicare beneficiaries. Although costs for an individual beneficiary may be higher or lower than expected, these variations are likely to balance each other across a population of beneficiaries. To minimize variation from catastrophically large claims, CMS truncates an assigned beneficiary’s total annual Parts A and B Fee-For-Service per capita expenditures at the 99th percentile of national Medicare Fee-For-Service expenditures as determined for each benchmark year. (“Methodology for Determining Shared Savings and Losses under the Medicare Shared Savings Program Fact Sheet”.  DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS) Centers for Medicare & Medicaid Services).

“Properly implementing a risk-adjustment mechanism is critical to intelligently assigning budget responsibility to an ACO.” (American Academy of Actuaries, Risk Assessment and Risk Adjustment, May 2010 issue brief: It is important to ascertain the ACO payment with the actual budget.

This is only an example of one type of APM/Advanced APM that is risk adjusted for diagnosis. The two models of risk adjustment utilized most often is CMS HCC Model utilized widely in Medicare Advantage plans and the HHS HCC Model which is mostly utilized within patient populations that are more diverse such as with the DHHS Healthcare Market Place. It is important for providers to become accustomed to these models and how to utilize HCCs properly.

Example APMs/Advanced APMs risk-adjusted utilizing HCCs:


The payment shift to increased quality through MACRA is another step toward providers needing documentation that is “holistic” and adequately reflects the population of patients served. This concept is crucial as providers are profiled and data is made more publically available. Oh yeah, did I mention HCC also has impact on PQRS and Value Modifier? I will try my best to explain that more very soon along with what we should be doing to prepare. In the meantime, contact me for questions or next steps.

Sharon Easterling, FAHIMA, MHA, RHIA, CCS, CDIP


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Were We Asleep at the Wheel? Changes to the Official Guidelines for Coding and Reporting 2017

Yesterday was certainly like any other, in the world of healthcare coding, clinical documentation improvement (CDI) and appeals. The work is intriguing, interesting, and certainly a learning experience every day. The only thing that made this day different was taking a look at the changes to the Coding Conventions for the 2017 Official Coding Guidelines for Coding and Reporting. Oddly enough, providers would think the updates could not be that bad after surviving ICD-10 but on the other hand, could they and did providers fall asleep or lose focus as we grappled with MACRA (Medicare Access and CHIP Authorization Act), IPPS (Inpatient Prospective Payment System) Final Rule, Quality Initiatives like PQRS (Physician Quality Reporting System), Readmissions, Value Modifier, Patient Safety Indicators, just to name a few and certainly providers probably deserve a nap. It has been a long couple of years and someone’s foot is still on the gas.

Providers utilize the Official Coding Guidelines for appropriate code assignment of ICD-10 diagnosis and procedure codes which ultimately leads to payment of a DRG for inpatient and can justify medical necessity for service within the outpatient arena. These guidelines are approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS). As stated in the guidelines, “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.” The guidelines go on to say, “Only this set of guidelines, approved by the Cooperating Parties, is official”, and become effective October 1 of every year coinciding with the IPPS Final Rule effective date.

This year’s update has quite a few significant changes that could potentially have far reaching implications that certainly requires more review and conversation. Somehow many providers missed this change.  Follow along for a deep dive.

  • Providers have struggled with the Excludes1 definition as in some cases a condition could be unrelated to another. The guidelines give the opinion that the provider should be queried if it is unclear to code separately.


  • “An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.” (ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017)


  • Not too concerning as at times it is often necessary to query the provider when documentation is not clear for appropriate code assignment. This may impact the query process or require increased need for up front education for the provider.


  • Another area that has growing concern over the past year and has recently gotten the attention worthy of AHA Coding Clinic publishing is the term “with” (interpreted as “associated with” or “due to”). The premise of this word is to show linkage between conditions or diagnoses; hence establishing a relationship. Initially the focus of the use of this term was around diabetes but as it is utilized throughout the index as a common staple, the need existed to address overall. An example would be diabetes with cataract.


  • “The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.” (ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017)


  • In the past guidance was given to providers that establishing a relationship in the documentation was required in some cases with the use of this term. This will certainly impact code assignment and statistics. An example would be the 86 year old (Hi Mom!) that has had a cataract for years and is just developing diabetes on the admission or encounter. Will this be assigned to a senile cataract or a diabetic cataract? Is documentation good enough for correct code assignment, can the problem list help, no looking at the previous admission for help right?


  • One of the most significant changes to guidelines is related to clinical criteria and code assignment. Over the past few years, providers have embraced the need for clinical documentation improvement programs and quite frankly battled regulatory scrutiny in relation to the diagnosis the physician has assigned and clinical support in the chart based on clinical criteria or indicators like labs, radiology, vitals, medications, treatment, and other interventions. This disconnect between criteria and code assignment led to the “Clinical Validation” Review process. This process was initially laid out in the Recovery Audit Contractor, RAC, Statement of Work, but quickly became a tool utilized by all payers to remove principal diagnoses as well as secondary, MCCs (Major complications and comorbidities) and CCs (Complications and comorbidities). Of course it is common knowledge that the OIG and DOJ have utilized this process to some degree since the late 80’s – early 90s when it was initially seen with the noncompliant reviews for pneumonia that were really bronchitis or asthma. Is coding going a step back or should that be decades back? Or was this the dilemma and it is being rectified?


  • “Code assignment and Clinical Criteria

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”  (ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017)


  • This will certainly stir some chickens from the roost. Since noting and sharing with colleagues there has been quite the buzz and I would say for the most part not the happy kind; more like wasps than bees.

Food for thought:

  • Does this really mean only the physician documentation counts?
  • Is there no longer the need to worry about contractors appropriately and inappropriately utilizing clinical validation?
  • Is there the same need for CDI professionals or will we just perform more training?
  • Will more CDI be utilized?
  • What about the Department of Justice (DOJ) and the Office of Inspector General (OIG)? What will the stance be from these agencies?
  • Is CMS ready to increase reimbursement to hospitals when short-stay claims begin to be coded with MCC or CC diagnoses that are not clinically validated like: sepsis, acute respiratory failure, encephalopathy?
  • How will this impact our coded data?

As providers get their arms around this change, it is important to remember there are other references to follow included in the guidelines as restated in the CMS Medlearn Matters Article # – SE1121 states, “As with all codes, clinical evidence should be present in the medical record to support code assignment. The Uniform Hospital Discharge Data Set (UHDDS) Guidelines for coding and reporting secondary diagnosis allow the reporting of any condition that is clinically evaluated, diagnostically tested for, therapeutically treated, or increases nursing care or the length of stay of the patient.”

This topic will certainly get much discussion over the coming months and many are wondering how in the heck did this topic get overlooked within industry? Stay tuned as this new era unfolds.

Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM, FAHIMA

Recovery Analytics, LLC

ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017; (October 1, 2016 – September 30, 2017)

CMS Medlearn Matters Article # – SE1121

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Documentation and The “CMS Quality Strategy 2016”

“CMS Quality Strategy 2016” was released by CMS (Centers for Medicare and Medicaid Services) in November 2015. As evidenced by recent changes in the OPPS Final Rule 2016 and other quality and value-based trends, movement has been aggressive and persistent towards value versus volume. Long-term goals for value-based payments for Medicare Fee-For-Service include:
• Goal 1: 30% of Medicare payments are tied to quality or value through alternative payment models by the end of 2016, and 50% by the end of 2018.
• Goal 2: 85% of all Medicare FFS payments are tied to quality or value by the end of 2016, and 90% by the end of 2018.

At the center of these goals is the aim of “Better Care, Smarter Spending, and Healthier People, Healthier Communities”.

In looking at the above without knowing anything about changes in PQRS, fee schedules, readmissions, or other value-based/quality initiatives, it is evident that providers have to begin implementing and working toward changing how it operates, provides and delivers services, utilizes innovation, and focuses on the patient to survive the future.

CMS has gone on to develop 6 (Six) CMS Quality Strategy Goals as part of this National Quality Strategy.

• Goal 1: Make care safer by reducing harm caused in the delivery of care.
• Goal 2: Strengthen person and family engagement as partners in their care.
• Goal 3: Promote effective communication and coordination of care.
• Goal 4: Promote effective prevention and treatment of chronic disease.
• Goal 5: Work with communities to promote best practices of healthy living.
• Goal 6: Make care affordable.

There are a few areas within this strategy that warrant an increased focus on documentation however “Goal 4” related to chronic disease is very important to pay attention to. Providers must ensure they are identifying these conditions within the documentation and coding early on and treating appropriately. This is important for targeted treatment, patient management, forecasting, and possible payment implications. Ensuring you are implementing documentation integrity processes in the clinic and other ambulatory settings as well as the acute setting is something we must do now. As mentioned by CMS, chronic conditions can include MCCs (Major Complications and Comorbidities) but also include HCCs (Hierarchical Condition Categories) for risk adjustment.
Potential Ambulatory Documentation Challenges:
1. Mental and cognitive disorders: Is this a depression that is major, situational, post-schizophrenic or other?
2. Cancer: Is this a primary or secondary cancer? Has the cancer been removed, not under treatment, and no longer active?
3. Arthritis: Is this juvenile, gouty, or other cause?
Call Recovery Analytics LLC, to begin your Quality Strategy.

By: Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA
Recovery Analytics, LLC

“In the long history of humankind…those who learned to collaborate and improvise most effectively have prevailed.”
–Charles Darwin

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The “Building Blocks of Documentation”: Cornerstone I: State of Disease

As providers venture into the world of new payment models and methodologies, having the tools to do that seamlessly and knowledgably is critical for success. Understanding and implementing the “Building Blocks of Documentation” can be a crucial first step in facing and succeeding at that change.

Essentially the “Building Blocks of Documentation” are a foundation built utilizing concepts of documentation with specificity being the ultimate goal. Within the Building Blocks are 4 concepts: State of Disease, Severity of Disease, Etiology/Type, and Laterality. It is important to keep in mind, it is sometimes only possible to document to the extent of the information available. Documentation should always be taken seriously and conditions should only be documented to the extent the provider has the ability to. Also remember, documentation versus coding is two distinct processes and coding rules and guidelines also drive the assignment of a code. Documentation is needed far beyond code assignment such as with medical necessity to support services performed, level of care, and justification of treatment. Therefore, providers should document for the patient, for the services performed, and for quality, to yield accurate reimbursement.

With leading into this Cornerstone, the question of “Why talk about acuity and chronicity?” most likely comes to mind. As the discussion of documentation is entered into, bringing attention to this is important as it is oftentimes overlooked when documenting. As a provider, the acuity of the patient should be clear as the patient is newly presenting to the hospital or clinic for treatment. The real fact of the matter is ACUITY and CHRONICITY ARE NOT ALWAYS CLEAR IN THE CURRENT STATE OF THE DISEASE AND MANY TIMES IS NOT DOCUMENTED. This has to be evident through clinical indicators, treatment, and also documentation. A great example of this is:

• A patient may have the chronic condition of asthma but if that patient presents with wheezing and shortness of breath it is most likely an acute exacerbation of the patient’s chronic asthma.
• If a patient has chronic CHF and presents with short of breath, pedal edema, and not taking their Lasix for days, it is most likely acute on chronic CHF.
• Chronic conditions can become acute conditions in many forms if left untreated or due to the nature of the disease; for example, fractures in osteoporosis.

A chronic condition can have acute episodes; exacerbations or decompensations, of the illness. This is at times seen stated as acute on chronic. Clinical indicators and treatment can lead to conclusions but the documentation has to be within the record for code assignment and to justify medical necessity. This area remains a significant challenge within clinical documentation programs. Taking a look at why the problem persists gets providers a step closer to solving it. Knowing the “Building Blocks” is a significant first step.


Upcoming webinar:  Webinar: “Building Blocks of Documentation”: Cornerstone I – State of Disease

Contact Recovery Analytics, LLC to learn more about the “Building Blocks of Documentation”.

By: Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA
Recovery Analytics, LLC

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“The Building Blocks of Documentation” for ICD-10

A couple of years ago, circa 2013, when CMS (Centers for Medicare and Medicaid Services) unveiled “The 2-Midnight Rule” and the need to certify the inpatient admission, the “5 W’s for Documentation/Auditing” were born. This laid the framework for the requirements needed to certify the admission and at the same time justify the reason for the admission.
What are we treating? Diagnosis | Procedure (if relevant)
Where is treatment needed? Inpatient | Outpatient (Observation/Surgery)
Why is treatment needed?
Why is this diagnosis acutely requiring attention
Relationship to chronicity
References to requiring testing, drugs, or other interventions
References in variation from baseline to current state
Potential for adverse outcome
• HoW are we treating it?
What are we actively doing requiring our level of care
Implications if not performed
When do you think they’ll get better?
Expectation for stay
Plan for discharge

The “5 W’s” allowed providers to decipher the complexity of the certification and gave critical insight in to the needs within provider documentation (even if their EHR did not allow it so easily) to justify admission.

Fast forward to 2015, and we are in another time of rapid change and once again we are challenged with the need to adjust in the midst of smoke and frenzy. As I am one that usually doesn’t let the smoke bother me much, I started seeing once again what was needed to decipher the mystic behind documentation for ICD-10; documentation integrity.

For many years now we have been educating providers on documentation utilizing a system much more difficult than ICD-10 when it comes to making sense of a code. ICD-10 allows us the opportunity to get to the source of the code and as I experienced, puts providers at a unique advantage once they understand the “Building Blocks”.
Something most of us know is that providers, for the most part, are highly intelligent, analytical, and can meet most challenges if given the tools they need to do so. That essentially is what the “Building Blocks of Documentation” are. A foundation built with concepts of documentation with specificity being the ultimate goal.

Building Blocks of Documentation ICD-10

BB of documentation10.15



The “Building Blocks” can be used with any diagnosis and can be utilized as a teaching tool for Coding Professionals, Clinical Documentation Integrity Specialists, and Physicians to explain the mechanics behind the code. It can be used to enhance documentation across the care continuum. What an exciting time…


By: Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA. CEO

Recovery Analytics, LLC

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