3M’s Quality Webinar Series

(DESCRIPTION) A slideshow. Title slide, 3 M Quality Webinar Series. Respiratory syncytial virus - what you need to know now. December 16, 2022. Copyright 3 M, 2022. All Rights Reserved. (SPEECH) Hello, everyone. And thank you for joining us for this special edition of the 3M Quality Webinar Series. Today, we're going to be talking about respiratory syncytial virus-- what you need to know now. (DESCRIPTION) Slide, Presenters, pictures, names, and titles of four people. (SPEECH) I'd like to first introduce our presenters. My name is Susan Belley, and I'm the manager of compliance and audit services for consulting services. Next, we have Dr. Melissa Clarke. She's our physician clinical transformation consultant in the 3M HIS division. Third, we have Teresa Brown and RN in our CDI section of consulting services. She's a pediatric nurse by specialty. And lastly, we have Audrey Howard, a senior auditor in our compliance and audit services. (DESCRIPTION) Slide, Learning Objectives, a bullet point list and a disclaimer. (SPEECH) The objectives of our presentation today are to learn about RSV symptoms, manifestations, and treatments, identify potential query opportunities in RSV documentation, and understand coding and sequencing for RSV and related conditions. (DESCRIPTION) Slide, Clinical aspects of R S V. (SPEECH) So we'll start out today by talking about the clinical aspects of RSV with Dr. Clarke. (DESCRIPTION) Slide, a question in a speech bubble next to a picture of Dr. Clarke. (SPEECH) So, Dr. Clarke, tell us about respiratory syncytial virus infection that seems to be so prevalent in the population at the present time. (DESCRIPTION) Slide, Respiratory syncytial virus (R S V), an illustration of microorganisms, and a bullet point list. (SPEECH) Great question, Sue. Well, RSV or Respiratory Syncytial Virus is one of the many viruses that cause respiratory illness of the nose, lung, and-- nose, throat, and lungs. The virus usually occurs yearly in the late fall through early spring months. But that can vary actually based on different parts of the country. Typically, RSV just causes cold symptoms. But in those who are at higher risk, it can actually progress to bronchiolitis. Of course, that's disease of the small airways or pneumonia. Bronchiolitis specifically is particularly dangerous in former preemies and infants under 12 weeks because of their small immature airways that can get easily obstructed due to edema and mucus and their difficulty with clearing those secretions. RSV is very contagious. And it's spread via respiratory secretions, coming into contact with mucous membranes of the eyes, mouth, nose, or inhalation of droplets via direct person-to-person contact, unclean hands. RSV can actually survive for 30 minutes or more on unwashed hands. And it can also survive on surfaces up to six hours. So touching unclean surfaces and then touching your face is another common way of spread. And then talking about the symptoms, those can come two to 10 days after contact with RSV. According to the CDC, most people are contagious for about three to eight days. However, if you are an infant or have a weakened immune system, you can be contagious for as long as four weeks, even if you're not showing symptoms. And then the immune compromised symptoms can last up to three weeks. Although in healthier people, they only last up to about five days. And so you see on the slide some of the symptoms that can be a problem at any age-- fever, severe cough, wheezing, tachypnea, hypoxia, and cyanosis, and then particularly to infants, poor feeding, apnea, and chest wall retractions. (DESCRIPTION) Slide, a new question in the speech bubble. (SPEECH) OK. Well, thank you for all that information. Why are we seeing this tremendous surge now? I know you said that it can run from the fall into the spring. But by all accounts, it's much worse this year. (DESCRIPTION) Slide, Reasons for the R S V surge, pictures of a restaurant, a classroom, and a baby in a hospital. (SPEECH) Absolutely. So we're right in the middle of RSV season now. And the reason we're seeing it more severely are due to those masking and social distancing measures that we've been doing over the past couple of years due to COVID, as more people are vaccinated and those mitigation strategies are going away, we're now exposed to the RSV that we weren't exposed to because of those mitigation strategies over the past couple of years. And then as many people are returning to daycare and school and other places without masks, as a result of the relaxation of those mitigation strategies, viruses are doing their thing. They're spreading as normal. However, the children who are more vulnerable than usual never got to establish immunity and get their circulating antibodies and antibody memory cell-- and memory cells, immune system memory cells, that they would have had had they been exposed to RSV over the past couple of years. In addition, the spread of RSV and other seasonal respiratory illnesses seem to start earlier this year or this season. And then people can catch RSV more than once. But the first time you get RSV as a child, you're going to be generally sicker than the next time. So we're seeing those cohorts of infants who are born after 2020 who are now one and two now just having their first RSV infection. So they're getting more severe symptoms now. All that's leading to the overwhelming of hospitals and emergency departments and urgent cares. Thank you. (DESCRIPTION) Slide, a new question in the speech bubble. (SPEECH) So when we think about RSV, we know that children are treated in the outpatient setting. But what about the disease requires hospitalization for some? (DESCRIPTION) Slide, R S V hospitalization, a picture of a baby in an incubator, and a bullet point list. (SPEECH) Yeah, so the hospitalization occurs in individuals who are at risk, the elderly who have underlying disease or problems mounting our immune response. And then infants who are 12 weeks old or younger at the start of RSV season, again, anatomical factors lead them to be more at risk, same with premature or low birth weight infants, those infants who have underlying chronic disease, like chronic lung disease of prematurity, certain types of heart defects, neurologic conditions that make it more difficult for them to clear their secretions, those who are undergoing treatments that lower their immune system. And then there are also some additional risks, such as having siblings or your mom smoking during pregnancy, being exposed to secondhand smoke in the house, not breastfeeding because breastfeeding actually transfers antibodies to the young child. So these individuals are at higher risk for hospitalization. They have more difficulty with secretions, getting oxygen into the body. So poor oxygenation is a reason for hospitalization. Because they're working so hard to breathe, they're unable to feed, they become dehydrated, so they may have to be admitted for IV fluid hydration and supplemental nutrition via tube feeding. They may also need nasal suctioning, frequent nasal suctioning. And then there's the chance, because your immune system is now lowered and busy fighting RSV, that you have a chance for secondary bacterial infection. All those reasons are ones to come into the hospital. (DESCRIPTION) Slide, a new question. (SPEECH) Thank you. So we're hearing a lot in news reports about the twindemic and the triple-demic. Can you tell us about that? (DESCRIPTION) Slide, Influenza-like illness surveillance map, December 10, 2022 week, a map of the United States with a color-coded I L I Activity Level, and a bullet point list. (SPEECH) Sure. That's basically the combination of surging influenza, RSV, and COVID-19 cases. That's what the triple-demic is. Millions of Americans are getting sick, as I mentioned, putting pressure on hospital systems. And they're all respiratory viruses. And so what's complicated is that the initial phases of each or mild cases of each all look the same. So sometimes it's hard to distinguish at home unless testing is done. This map from the CDC shows that the mapping of influenza-like illnesses, which we've been doing for years prior to COVID. For this most recent map actually shows that these influenza-like illnesses are just about high to very high activity all over the United States with just a few exceptions here and there. The most marked rise in cases, hospitalization, and death in the most recent weeks have actually been from influenza. CDC estimates that the reported flu cases, hospitalization, and death just one week after the Thanksgiving weekend were higher than during some entire flu seasons. Nationwide, just over 35% of children aged six months to 17 years have gotten their flu vaccine. So that's definitely room for improvement there. And then when it comes to RSV, more adults have been ill this year. The rate for adult hospitalizations for RSV is actually 10 times that of prior years. One piece of positive news is that it looks like the RSV hospitalization rate for children has peaked, so we're at its peak. So we're hoping that it will come down. And as a result of all of this, many jurisdictions are actually calling for a return to masking, although, most have stopped short of reimposing mask mandates. (DESCRIPTION) Slide, a new question. (SPEECH) OK. We've been hearing a lot in the news about the shortage of amoxicillin due to RSV. Why is this? (DESCRIPTION) Slide, Amoxicillin suspension shortage, a picture of a bottle of pills, and a bullet point list. (SPEECH) Amoxicillin is commonly used to treat ear infections and other problems, infectious problems in children. It's in short supply related to the surge in respiratory infections, including RSV, that can then lead to complicating and secondary ear infections and sometimes the overtreatment of viral diseases as bacterial diseases. Only a few countries produce the active ingredient for amoxicillin. And so the national shortage of amoxicillin is specifically though with amoxicillin suspensions, which is the formulation that's given to children. And it's expected to last for several months. The good news, though, is not all forms of amoxicillin are affected. So there are some workarounds that are being done, so prescribing the tablets, the capsules, or the chews for children. And if they're too young to take that, crushing them or opening the capsules, which can be done by the pharmacist to make sure that the right dose is given for ones that are too young to take those formulations. And then, of course, there are alternatives, like Augmentin, cephalosporins like Keflex or ceftriaxone or IM or oral penicillin, all of which could be used. Well, that's encouraging that we have some workarounds. (DESCRIPTION) Slide, a new question. (SPEECH) What are the measures that can help prevent or mitigate the tripledemic? (DESCRIPTION) Slide, "Tripledemic" mitigation, pictures of a mask, a vaccination station, and a child with a bandage on their arm. (SPEECH) So the good old tried and true, masking, indoors, hand-washing, and of course, staying home if you have symptoms, all these are effective ways to slow the spread of all three viruses. For little ones under 12 weeks, the best treatment is avoidance, keeping them away from lots of individuals who might unknowingly pass the virus on to them. For COVID, keeping up to date on COVID vaccinations clearly reduces complications of infections. The newest bivalent COVID booster is available to anyone five years and up. The influenza vaccine, all people over age six months should receive an annual flu vaccine. And a special focus on pregnant women, we've already seen a rise in maternal deaths due to the COVID pandemic, actually up to 40% increase in maternal deaths due to COVID. So getting the flu vaccine and the updated COVID booster is especially critical for pregnant women because protection from these viruses actually extends to the newborn in the baby's first six months of lives before they're eligible to be vaccinated themselves. And then when it comes to RSV, no vaccine exists. Although, pharma companies are working on it. The highest risk infants are eligible to receive RSV prophylaxis with a drug called palivizumab or Synagis. This is a monoclonal antibody therapy that binds the fusion region of the RSV virus and prevents it from binding to enter the cell. It's offered to specific groups of infants at high risk during RSV season. It's a monthly injection that you get. And actually this year, because of the severity of RSV season, the American Academy of Pediatrics has actually expanded eligibility. So talking with your doctor about that is a way to go if you have little ones. (DESCRIPTION) Slide, C D I in the pediatric R S V population. (SPEECH) Well, thank you so much, Dr. Clarke. I think you've given us a nice broad spectrum of things to think about from a clinical perspective on RSV. So-- Thank you. Yes, thank you so much. So we'll move to Teresa Brown, who will talk about CDI in the pediatric RSV population. Teresa. (DESCRIPTION) Slide, What is R S V? A picture of a person working in a lab, and a bullet point list. (SPEECH) Thank you, Sue and Dr. Clarke. So as Dr. Clarke just explained what RSV is, what I wanted to really emphasize from a clinical documentation standpoint is one of the most common causes of bronchiolitis and pneumonia in our infants is RSV. So as we saw, oftentimes they come in with multiple conditions. The other thing I wanted to really point out is once-- RSV in infancy is thought to be related to a development of asthma later on in childhood as well. And as Dr. Clarke explained, these infants and certainly our children with chronic lung disease, all have an increased risk of developing RSV. (DESCRIPTION) Slide, R S V - symptoms and treatment, two bullet point lists. (SPEECH) So some of the symptoms here and treatment. So as was mentioned earlier, they may start with a runny nose. And certainly if they can't breathe, they're not going to feed. But I know in our younger patients, we oftentimes may see periods of apnoea. We may see in that assessment, in that physical assessment, tachypnea, chest wall retractions. And so from a CDI standpoint, oftentimes if we've got the assessment descriptions of retractions, look at how they're treating them because that's going to give us some clues into do we have a query opportunity? So certainly, as Dr. Clarke mentioned, dehydration. So are they on continuous IV fluids? And looking to see how much oxygen do they need. And certainly by the time we get into if we have tube feeding, do we have a query opportunity there for a nutritional diagnosis? But also what our medications tell us, what the provider's thinking. Certainly, as was mentioned, we have the respiratory syncytial virus immunoglobulin. So that's going to-- when you see that on the [INAUDIBLE], we know that they're treating RSV and also with palivizumab, the antibody against RSV. So hopefully, this is going to lessen the severity of illness and really shorten that length of stay. (DESCRIPTION) Slide, Bronchiolitis, a picture of a man in a lab coat, and a bullet point list. (SPEECH) So in documenting, as we've built up today, a lot of this population is not coming in with only RSV. RSV might be the trigger. But one of the things I do want you to know is that bronchiolitis again is an infection of the lower respiratory tract that it usually affects infants. But the most common cause of bronchiolitis is a virus. And that's what we're seeing with RSV. So they're not-- so a lot of these children are not coming in with only RSV. So look to see, as Dr. Clarke mentioned, we are seeing now if-- are they testing for influenza? So make sure you're looking to see, OK, did we do-- what were the results? So look at your labs and see what that is to get specificity to the type of flu is it? And also, bronchiolitis can have a bacterial component as well. So look to see. Again, that treatment's going to guide you. We know we don't give antibiotics for viruses. So that's going to give us a clue that they may have a bacterial type infection. (DESCRIPTION) Slide, Bronchiolitis, continued, an illustration of the lungs, and a list. (SPEECH) So initially, this virus causes just an upper respiratory infection. But it can go on and extend down into that lower respiratory tract, and that's where we see because it causes that overall inflammation within the respiratory tract. Oftentimes bronchiolitis it occurs where in that we're seeing that now most commonly within the fall and winter. And typically, this impacts infants three to six months of age. The data tells us that there's a little higher incidence in our males, and about 75% of the bronchiolitis is occurring within that first year of life. (DESCRIPTION) Slide, Pediatric pneumonias, a picture of a child in a hospital bed, and a bullet point list. (SPEECH) The next condition that we really should be looking for is, do we have clinical indicators of a pneumonia? And when we think of really with childhood pneumonias, oftentimes there's outpatient treatment. And that really covers the mild to moderate pneumonia types in children. And the medication is typically the same used for acute otitis media. So I think of what is causing this child to be admitted? So the other piece is that RSV is a major cause of pneumonia during infancy and early child-- up to the two years of age. So most of childhood pneumonias are a viral nature. But what really is going to guide you is, how are they treating them? So oftentimes when we see that there's maybe a possible bacterial etiology, look at your chest X-ray results. Are we seeing infiltrates? And that may be an indicator. But sometimes I know sputum cultures are a little difficult to get. And sometimes even if they're negative and we've got an infiltrate, but also look at how they're treating because again, that's going to give us-- oftentimes, as Dr. Clarke mentioned, amoxicillin we're using and we're seeing shortages now. But typically, they began at that amoxicillin level. So oftentimes infants between one and three months of age when they do acquire a pneumonia, these typically tend to be bacterial in origin. And they're usually gram positive or staph aureus is the culprit. So again, the treatment, your diagnostics, make sure that you're looking at all of those elements. (DESCRIPTION) Slide, Pediatric pneumonias, continued, a bullet point list. (SPEECH) What we've seen is with the Haemophilus influenza type B, this one has been less common since the introduction of the Hib vaccine. But we do see children less than two years of age still can be at a higher risk for this type because the immune response has not been developed. But again, typical regimen is outpatient therapy. And there are second and third-generation cephalosporin that they're using to treat. And so always look at that. Why wasn't this child able to be treated in the outpatient or at home? So typically, again, children younger than five years, we're really going to see that initial treatment of IV ampicillin. But you may also see gentamicin and certainly the cefotaxime for neonates. And sometimes these can be a single dose, especially for children greater than 28 days or up to five years of age as well. (DESCRIPTION) Slide, Neonatal pneumonias, a bullet point list. (SPEECH) Another category is our neonates, and we know that those include from birth to 28 days of life. So when we see pneumonia in this population, the most common, it tends to be a bacterial infection. And we often see this with sepsis. But again, there's a later onset that usually occurs about seven days of age, and again, a lot of these babies are going to be in ICU. Some of the organisms we see there are going to be a gram positive but even some gram negative. And they often will treat them with broad spectrum antibiotics as well because, again, they are often infected with pseudomonas, the citrobacter, bacillus, and Serratia. But the other cause of this are viruses. And so RSV comes back into this population as well, really RSV and CMV, and even some fungal causes in this neonatal population. (DESCRIPTION) Slide, Pediatric anatomy, a bullet point list. (SPEECH) So when we look at why the need for hospitalization or the need if you are having your children and they're in PICU, in the Pediatric ICU, and you think, OK, we've talked about a lot of these pneumonias are treated in the outpatient arena. So we really want to accurately make sure that we're reporting why they're at this ICU level of care. So one of the things that really puts our pediatric population at risk are just anatomical differences in the respiratory system and some of those. And they contribute to that higher frequency of respiratory compromise. So they don't need much to really push them into maybe a possible respiratory failure. And so some of those are going to be, they have a large head. They have a very small mandible, small neck, but they also have a large posteriorly placed tongue. They're obligate nasal breathers, but they also have a less rigid upper airway. Their epiglottis is larger and sloppier, but again they have immature musculature. So this really puts them at a higher risk of muscle fatigue, where they just wear out. But the other is they have an increased metabolic rate, which therefore it results in an increased oxygen consumption. But a little more on the physiological level is they have smaller and fewer alveoli. So there's less surface area for gas exchange. (DESCRIPTION) Slide, Pediatric respiratory failure - common causes, two bullet point lists. (SPEECH) So when we look at respiratory failure, we can-- I've seen it cause-- I've seen it referred to as extra-thoracic, meaning upper airway. So something outside of the lung is causing an impaired, is impairing their airway. And this might be due to airway malformations, vascular malformations but foreign bodies. But it may also be infections. Epiglottis is one of those or croup. But when we think of respiratory failure and it's inner thoracic, what we're saying is something within the lung is now impairing their ability to oxygenate. So that's when we started to see is, as I mentioned just a little bit ago, bronchiolitis. One of the leading causes of that is RSV. Pneumonias, have we-- maybe we started out with a viral component but have gone on to develop because we can have a viral and a bacterial component. And that infection it may be contributing to just again their airways are smaller. They may develop pulmonary edema, and even we may see respiratory distress. (DESCRIPTION) Slide, Pediatric respiratory failure signs and symptoms, a picture of a woman in a white coat talking to a woman and child, and a bullet point list. (SPEECH) So when you look at, I think, from a CDI standpoint, we really want to look at what are our-- how are providers documenting? How are they giving us those descriptors of what they're seeing the patient look like? Because again, I think this is a great example. Children, so if we see that they're lethargic we know that that's always a flag. We know our kids they're very resilient, and not much keeps them down. So when they're lethargic, when they're irritable, that's a sign of-- and certainly all the way to anxiety, anxious or unable to concentrate. But oftentimes they will sit up. They'll lean forward and look to see, do they have-- are they using-- are they documenting accessory muscle use? Because again, this allows for that diaphragmatic movement. And so one of the things with epiglottis, they sit upright and they extend-- you'll see that neck extended and head forward. But they may be drooling and mouth breathing as well. So look at how your providers are documenting the description of the patient because that's going to give us clues as well. (DESCRIPTION) Slide, Pediatric respiratory failure signs and symptoms, continued, a bullet point list. (SPEECH) The other is when our providers facilitate, what do they hear? Are they hearing stridor? Do we have wheezing and crackles? Those Rice Krispie sounds are more indicative of pneumonia, a bronchiolitis. Or are they saying severe work of breathing? And oftentimes they'll be tachypneic until they start to wear out. And if we see bradypnea, that's never a good sign. But again, oftentimes they're breathing fast, but they were out quickly. The other is, is there a description of cyanosis, even though we've put them on 1 liter or 2 liters of oxygen? And certainly, if we see decreased breath sounds, oftentimes that's indicative of severe-- we know that we're not getting airway-- the bronchioles are so inflamed. They're not able to move any air. So you look for, is this-- they may come in with RSV, but do they have underlying asthma as well? So looking for-- that may be an opportunity to query for the severity and type of an asthma exacerbation. If we're seeing pleural effusion, do we have an underlying congenital heart defect that is maybe now causing some heart failure? If we see the documentation of paradoxical movement, that just means the chest wall moves in during inspiration and out. Oftentimes we see this movement with foreign objects, but it can also be from severe electrolyte imbalances. And so when we think of viruses and they're not able-- oftentimes those come along with vomiting, diarrhea, and dehydration, which then causes those electrolyte imbalances as well. (DESCRIPTION) Slide, Pediatric respiratory failure, a table and a bullet point list. (SPEECH) As we've talked about respiratory failure, look back in your medical record and see, oftentimes, there'll be a pediatric assessment triangle of some sort. It's a bedside tool that's used. So again, it's a rapid identification for children that are in respiratory distress. We know that if we don't intervene when they're in distress, they will move on to failure. And so this is called a PAT. So you can-- again, this is going to give you a clue that wait a minute that our providers are thinking-- they're thinking about respiratory distress or failure. But this is a quick tool that they'll look to see what do they look like? Level of alertness, interaction. Are they responding to stimuli? What is their work of breathing? Are they grunting? Is that abdominal breathing, nasal flaring? So these are all going to be clues for STDIs. And then again, what's the color? Cyanosis, when we get those-- when we have nail bed cyanosis or around the mouth, that's telling us that this child is not being oxygenated, all the way down to pallor and even mottling. But it's really about that early recognition. And because we know that respiratory failure doesn't happen on its own, it's looking at now, what is the underlying etiology? What's the cause? And oftentimes it may be RSV that has triggered these cascade of events. (DESCRIPTION) Slide, Respiratory failure - query example, a sample of a request for a diagnosis. (SPEECH) This is just a quick query example of if you see-- if we've got ABGs or even VBGs, you can use those. I know sometimes we don't always have ABGs. But if we've got those, it's always good to note when if you do have an ABG, also make sure you note how much oxygen they were on when they were drawn. Because sometimes they may look really good, but then you look to see, oh, well, they're on a 100% FiO2. So take note of that. But also look at what your nurses are documenting. Sometimes they'll give us maybe a little bit more. In this example, this came from a nursing assessment. And she documented that the patient was lethargic, that they now had decreased interaction, accessory muscle use with grunting and tripoding. The treatment, it looked like they had placed them on BiPAP for five hours. They were then placed on a 50% non-rebreather. So that really demonstrates that high flow oxygenation. And this is an easy example, whether you do something like this or you give them appropriate choices. But I felt like this was just a quick. It doesn't have to be complicated. Based on the above clinical picture, please clarify a corresponding respiratory diagnosis. So we don't-- I know sometimes the multiple choice can be a little intimidating, but this is just a quick, easy query for you to write. (DESCRIPTION) Slide, Secondary diagnosis to capture the clinical picture, a list. (SPEECH) So as we've talked through today, from a CDI standpoint, I think it's very important for us, whether it's CDI encoding for us to really capture that clinical picture for the accuracy for all-- for these patients. And the way that we do that is through our secondary diagnoses. So really as we've talked about, did they do-- did they swab for pneumonia-- oh, I'm sorry, influenza? If they did, what was the type? So we want to make sure that we're accurately reporting that. And as Dr. Clarke had mentioned with COVID-19, look to see at those results. The other is dehydration. As a secondary diagnosis, if we've got-- it's certainly with these children that require IV fluids. Do we have a diagnosis with that? The other is along with dehydration, again, we often see electrolyte disturbances. In those, we've always got to replace. So if you're seeing that we're replacing the potassium, the magnesium, those are great secondary diagnoses that really impact the severity of illness. But also look, especially with our ICU patients or even the step down, if they're on telemetry, are they experiencing any arrhythmias? And making sure we get this in the documentation along with hypoglycemia, even apnea, bradycardia. Or acidosis and alkalosis, we may see that especially with these respiratory conditions and even nutritional deficiencies. And I know poor feeding in our neonates is a good severity driver. All the way, do have we now, because of their inability to take in nutrition, have they now passed over into malnutrition? Also, don't forget to report the mode of oxygenation. That can also be-- again, these are going to give us those severity drivers. And again, if we've got underlying conditions, such as asthma, we want to know the type and the severity. And also, does this baby-- as Dr. Clarke mentioned, our preemies are really at a high risk for this. And are they coming in with other chronic respiratory diseases that originated in the perinatal period but are now impacting this episode of care? And again, we can query for these. Well, thank you so much, Teresa, for all that good information. Thank you. (DESCRIPTION) Slide, Coding for R S V and related conditions. (SPEECH) We will switch to Audrey to finish up talking about coding for RSV and related conditions that we've discussed today. Audrey. (DESCRIPTION) Slide, Coding for R S V, two bullet point lists. (SPEECH) Thank you so much, Sue. We will start talking about coding for RSV first. There are several combination codes that identify both the condition and the RSV virus so that if they are documenting RSV pneumonia or RSV bronchopneumonia, you see on screen here that it goes to a specific code that captures both the, J12.1. The same is true for acute bronchitis and also acute bronchiolitis as well. That has a combination code. Now, there are some times that RSV will be in a condition or be the underlying organism involved in a condition that does not have a combination code. And in those instances, we would put the B97.4 as a secondary diagnosis with the actual condition sequenced as the principal diagnosis. Some examples of that could be croup. It could be upper respiratory infection. It could be otitis media. So your condition in those instances would be sequenced first, followed by the RSV as the cause of disease is classified elsewhere as a secondary diagnosis. Now what's also important to note on these types of situations is picking up some additional secondary diagnoses to complete the entire story, if applicable, on this patient. We have heard mentioned that RSV could be more of a risk factor in patients that come from secondhand smoke. So if there's a smoker in the house, that could be triggering or being a risk factor for it. So picking up that z code as a secondary diagnosis would be important or even in the perinatal period where they were exposure to a tobacco smoke. So picking those up as secondaries are also important in those for all of the respiratory conditions. So it's not just applicable to the RSV coding. It's with all types of respiratory conditions. It's a chapter note that's available. (DESCRIPTION) Slide, Coding for influenza, two bullet point lists. (SPEECH) Now let's discuss a little bit about coding for influenza. There are three different categories that are available for influenza coding. You'll see J09, J10, and J11. J09 is for the influenza that's due to a certain identified influenza virus. And these are less common types of flu viruses but really significant that could cause severe flu in patients. And that would be your avian flu, swine flu. You may even hear something like the novel influenza A. Now, I'm pointing that one out because I don't want us to get confused with your common more everyday types of influenza A, which would be categorized to category J10. So be careful when they are swabbing for the specific type of flu and that information comes back and the provider documents it. Make sure that you are categorizing it correctly. Your more common everyday flu A would go to category J10, where your novel influenza A, which is a specific type of influenza, would go to J09. And I'm bringing this up because it can have an impact on your DRG assignment. Now, also, within each category of the-- that categories the flu conditions, they have other manifestations that are commonly associated with it. So if the patient has pneumonia or other respiratory conditions or gastrointestinal manifestations or other manifestations, which could include your encephalitis or encephalopathy, those will have specific codes to it as well. And it's also important to pick it up. Notice that it has the term with. And so it's just that it is with. Your pneumonia is with influenza. Now, you're going to have specific codes available also regarding the type of pneumonia. So is the pneumonia the same organism as your flu? So in other words, maybe it's pneumonia you have a flu, influenza type A, your common every one-- day 1. And so it's a viral pneumonia that's of the same type. If there is no additional documentation, you would just be picking up that flu with pneumonia code, the one code within the J10 category. However, if the pneumonias we have been often hearing about could be superimposed bacterial pneumonia along with your virus of the flu, then you can pick up an additional code and following all the sequencing directives that are on this because typically your flu would go first under-- the pneumonia codes there is coding directives that will tell you the sequencing, your coding directives that will imply the sequencing implications to that. But know that sometimes you can pick up a secondary code for the specific type of bacterial pneumonia, and once again, that can impact on your DRG assignment. (DESCRIPTION) Slide, Coding for COVID-19, a list. (SPEECH) Now, let's move into just briefly talking about some coding related to COVID. And I'm not going to go into the specifics of COVID with all of those guidelines that are available just to note that. Because we could be having a patient admitted with multiple viruses, the RSV, the COVID, the flu, it could be that the baby or the child or even the adult in whatever situation, may have been exposed to COVID or had COVID in the past, in the last couple of weeks, and they're coming in now with other sorts of issues that are going on. We need to really pay attention to the provider's documentation. If the patient was recently diagnosed with COVID or has COVID now, what is the documentation stating? Is the documentation stating that it is a current or active infection? Well, then that's going to code to the U07.1. However, if it was a past condition that the virus is no longer active or it's not causing an acute infection and they are saying that the patient may be having some sequelae of the COVID but that it's no longer an active infection, well, then that may be going to the U09.9 code. Or if the patient just had a previous history of the COVID, they're not having any active manifestations, they're not having any sequelae of the previous infection with COVID, it's just a personal history of the COVID, then that's going to go to the Z86.16. Once again, always really following the provider's documentation of is it a current active infection? We know that patients can continue to test positive for COVID-19, but it's no longer an active infection. Sometimes that documentation is not clear. And this is where a good query could come into play to find out if this current positive test for COVID, even though they just-- they had the active infection previously, is it a current infection? Or is it a past and no longer that they have the active virus and maybe they're just doing the viral shedding? So really looking at that documentation and querying as appropriate. (DESCRIPTION) Slide, Sequencing of principal diagnosis, a quote. (SPEECH) Now when it comes to sequencing as your first listed or your principal diagnosis, always sequencing depends upon the circumstances of admission. We have been hearing the clinical side of it from Dr. Clarke and from Teresa regarding why is the patient being admitted at this time? And so that's the question you are asking yourself when you go to list or sequence your principal diagnosis. Why was the patient coming in? They may have had the virus, and the virus of RSV or flu or COVID may not necessarily always cause the hospitalization. But it's what other condition? It could be that combination of the pneumonia due to RSV that's causing the admission. Well, absolutely, then that could be your principal diagnosis. If they've had the virus for a couple of days but all of a sudden their breathing starts getting worse and they're coming in now because of the respiratory failure, well, then you may be putting the respiratory failure as the principal diagnosis. One answer to each individual case is not going to be the way. You have to really-- in other words, it's not always going to be your RSV pneumonia or always going to be your respiratory failure is the principal diagnosis. So you really have to apply the circumstances of admission. What necessitated that inpatient status at this time as to be that condition that you're going to sequence as your principal diagnosis? So really looking at the treatment that was provided and the clinical evidence, the clinical signs and symptoms that the patient brought in with them to the hospital, is going to guide your selection. Sometimes you may have a choice as to what is sequenced as the principal diagnosis when they come in with multiple conditions but really looking at the treatment that is provided. Because if they're getting some treatment, that would not really be causing the inpatient-- and I'm speaking of inpatient stay on this one-- causing the inpatient stay at this point, then that may not be able to be your principal diagnosis. They may have been able to get, for example, fluids in the ED and go home. What caused that the kick over into the inpatient setting? So looking at the documentation, looking at the treatment that is provided, the clinical evidence that the patient has at the time of admission, and if it's not clear, query the provider for clarification to say what was the condition? Or what were the multiple conditions that required the condition? And that can help you sequence your principal diagnosis. (DESCRIPTION) Slide, Perinatal infections, a list. (SPEECH) I just want to briefly bring up about perinatal infections. And so this is going to be about infections that are happening within the first 28 days of life. There is a guideline that states that if a newborn has a condition that can be either considered due to the birth process or community-acquired and the documentation does not indicate which it is, the default is going to be due to the birth process. And the perinatal code should be used in that situation. Now, if the condition was community-acquired, then the perinatal code should not be assigned. So once again, the key point of that is that if the documentation is not telling us, then you default to the infection being due to the birth process. Now, there is an exception to this, and that there was a coding clinic granted it was a dozen years ago, and it is from ICD-9 time frame. But the clinical information on this is not changed. RSV infection is considered a community-acquired infection. So if a baby does develop an RSV infection during the first 28 days of life, well, it is considered community-acquired. So you would be using-- not, you would not be using the perinatal code in that situation. You would be putting the community-acquired condition as your principal diagnosis. Also, the guidelines related to COVID-19 and perinatal condition seemed to flip-flop the original coding guideline. And they were stating that if the documentation did not indicate the specific type of transmission for your COVID-19 that you would default it to be in community-acquired and go to the U07.1 as the principal diagnosis. But if they did say, if the provider's documentation did state that the COVID-19 was contracted in utero or during the birth process that you would put the perinatal code, that P35.8, as the principal diagnosis, followed by the U07.1. But all in all, when it comes to perinatal infections, if you don't really know for sure if it's originating during or due to the birth process or if it was community-acquired, query the provider for the clarification on this just to make sure that you get the appropriate principal diagnosis. (DESCRIPTION) Slide, R S V in preterm infants, two codes. (SPEECH) And finally, we have meant-- Dr. Clarke and Teresa have mentioned that a preemie, a premature baby may be at risk for developing the RSV infection or getting the virus. I wanted to point out here that if the provider's documentation includes that it was a premature delivery, that there was a preterm birth, and it was contributing to the patient's current condition and not just limiting to RSV infection but we are-- that's the topic of this presentation. And it was related to the RSV infection or that it's contributing condition to that that you can assign the prematurity code to this current encounter, even though it's not the birth delivery. So you can put the P07.2 for the extreme immaturity or the P07.3 for the preterm prematurity newborn on these encounters. Remember, these perinatal codes may be used throughout the patient's lifetime if it is appropriate. But you need to get that documentation, that stating that it is a contributing condition or a contributing factor to the current encounter. And, Sue, at this point, I'd like to turn it back over to you to wrap it up for us. (DESCRIPTION) Slide, 3 M educational boot camps for advanced C D I, pediatrics and quality training, a list of training sessions and a button labeled Click to learn more. (SPEECH) OK. Thank you, Audrey. And thank you to all of our presenters today. I think you have given a nice well-rounded picture of RSV and some related conditions, which is very pertinent to what's happening out there in the community today. I'd like to draw your attention to some of the upcoming educational bootcamps that 3M consulting services will be offering. Specifically on the right, we do have a boot camp for advanced CDI pediatric training. Then you can reach out to 3M or click to learn more about those upcoming webinar training programs. (DESCRIPTION) Slide, 3 M Client Experience Summit. May 22-25, 2023, Atlanta, Georgia. A description of the summit and buttons labeled 3 M C E S webpage, and Speaker submissions are open. (SPEECH) I'd also like to mention that the 3M Client Experience Summit for 2023 is coming up. It's going to be held in May of 2023, and it will be held in Atlanta. So we have information about the Client Experience Summit on the 3M web page. And we are also taking submissions for anyone who wants to speak at the summit. (DESCRIPTION) Slide, Thank you! (SPEECH) So thank you very much and wishing everyone a happy holiday season. (DESCRIPTION) Slide, Notices, a list.

(DESCRIPTION) Slide, New year, new webinar platform! A sample of the platform, showing a media player, chat box, slideshow, speaker bio, survey, and a menu bar. Text, 3 M Quality Webinar Services. Copyright 3 M, 2022. All Rights Reserved. Two women appear on a video call at the top left-hand corner of the slideshow. (SPEECH) Good afternoon and welcome to our November quality webinar. We have a great session today about the IPPS 2023 updates. (DESCRIPTION) Slide, 3M.. Science. Applied to Life. 3 M Quality Webinar Series. I P P S 2023 updates and impacts on C D I and quality. November 30, 2022. (SPEECH) Before we get started, I'm going to go ahead and do some quick housekeeping items. We have a lot to get through, so I'm going to try to get through this as quick as I can. (DESCRIPTION) Slide, Housekeeping, a bullet point list. (SPEECH) Since we do have this web-based platform, if you are experiencing any audio issues, do a quick refresh, make sure you're closed out of VPN and multiple tabs. And use Chrome, that is the recommended browser for utilizing on 24. And also check your speaker settings, in case there's any issues with your audio. We do have the ability to move engagement sections around. So you'll see that there's a Q&A box. Put in as many questions as you want to. We'll get to as many as we can at the end. There's also a Resources section where you can find the presentation handout for today, as well as the certificate of attendance. You can submit that certificate to accredited associations to get CE use. And also, there are a couple other resources to register for next month's webinar, as well as review any of our previous. Again, we do have that Q&A box, so please feel free to ask as many questions as you can. But then also at the end, we do have a survey. We appreciate your feedback. But also we did add a question for your opinion on topics. Our team is preparing for 2023. So if there is something that you'd like to hear our experts talk about, let us know in that survey. (DESCRIPTION) Slide, Meet the speakers. Cheryl Manchenton, R N, B S N, Project Manager, Quality Services Lead, 3 M Consulting. Audrey Howard, R H I A, Senior Auditor, Compliance & audit services. (SPEECH) So our speakers today are no strangers. They have been on many of our quality webinars as our experts. So if you do want to read more about Cheryl and Audrey, their bios are in the Speakers section of the Resources. But let's go ahead and turn things over, so we have enough time to get through this great topic. So Audrey, I'm going to go ahead and pass it off to you. (DESCRIPTION) Audrey appears on the video call. Slide, Learning objectives, a bullet point list. (SPEECH) Thank you so much, Lisa. And so today, we are going to be talking about, of all the changes that took place that became effective on October 1st, which were changes related to diagnosis codes, procedure codes, updates to the official coding guidelines, and also changes within the MS-DRG classification system, of all of those changes, which ones impacted quality? And how did they impact quality? So that's really what we're going to be covering within this hour. (DESCRIPTION) Slide, F Y 2023, I C D 10 C M, updates related to quality. New slide, Summary of changes - by the numbers. (SPEECH) So let's really get into the diagnosis coding changes that took place. Overall, there were almost 1,200 new diagnosis codes. So a whole boatload of new codes that came in. And a lot of them were back in the external cause codes range. So-- but there were some that are pertinent to quality. And we're going to cover those today. There were some diagnosis codes that were deleted, but not really that the diagnosis is actually-- the code was actually deleted, it was that it was expanded at another character level. So the subcategory was deleted as they developed-- as they expanded out at the other character levels. And then there were some diagnosis code titles that were revised as well. (DESCRIPTION) Slide, Heparin induced thrombocytopenia (HIT), two bullet point lists. (SPEECH) At this time, in hitting the first subject, I'm going to turn it over to Cheryl so that she can talk about this first topic. No pun intended on hitting the first topic for HIT, heparin induced thrombocytopenia. Again, obviously, there are two types which I did not know. So this was actually interesting. I love when a new code prompts me to understand more about the disease process. There are type 1 and type 2 HITs. And you'll notice, type 1 is a non-immune mediated heparin induced thrombocytopenia, where type 2 is your immune system is also making me more susceptible, shall we say, to the effect of heparin. And it tends to take a little bit-- you have a more delayed response and it's actually a little bit harder to treat because you're also-- not only are you dealing with the result of the HIT, but also trying to get your immune system settled down. (DESCRIPTION) Slide, continued, a table of new diagnosis codes. (SPEECH) Why we're giving you that level of detail, of course, is because there are new codes that were, again, as obvious as expanded. And you'll see that we have immune mediated, non-immune mediated, or other. And you can see the inclusion terms under each of those. One of my favorite things that Audrey does every year when we get the new code is she actually goes to the coordination and maintenance committee meeting minutes and reads the information about that. How did we get here? What is the purpose of these codes, et cetera? And again, probably, you're going to see my phone up here near my mouth. But this code expansion was actually requested by AHRQ, so there is a hint to you that-- where these coats came from. And we'll talk about when and the why, but we always prompt you, go and read those meeting minutes. They're always really interesting, believe it or not. There's lots of what I call the gossip behind the codes. So you see, we have this expansion with the different types. And you'll see they're, of course, assigned to DRG 813, if that was the reason for admission. (DESCRIPTION) Slide, table continued. (SPEECH) And going forward, there is one other new code, other platelet-activating anti-PF4 disorders. And again, it's other types. Again, it's a cousin, it's not a direct HIT, it's just a different type of heparin induced thrombocytopenia. (DESCRIPTION) Slide, How do new HIT codes impact quality? A list. (SPEECH) So the question, of course, and we're going to do this similarly as we go through is, how does this impact quality? Again, broadly, does it impact HACs? Does it have impact PSIs or is it a general risk adjustment impact? The question is, nope, it's not on the HAC list. As far as, again, as we know, there are no exclusions for hospital-acquired conditions anyway. So there's no direct impact to that, but there is definitely going to be an impact directly to the PSI, and probably to the risk adjustment. (DESCRIPTION) Slide, Impact of new HIT codes, a bullet point list. (SPEECH) So currently, there is the-- the HIT codes are not an exclusion for PSI 12. So in other words, having the presence of immune mediated HIT does not provide an exclusion for the patient who develops DVT or PE in a surgical patient. AHRQ, as we said, after the code expansion to say, you know what? These are not preventable. This is when your immune system is already primed, shall we say, to cause this interaction with the heparin, this is not a truly avoidable event. Now, it is not effective right now, right? Because that version was released last July, this previous July, prior to our new fiscal code changes. But when AHRQ releases their next version, which would be probably in July of 2023, we expect that this will be one of the excluded criteria, meaning, they're immune mediated. So do stay tuned. Do watch. But understand that because it's always affected back to October 1st of the current fiscal year, meaning, October of 2022, we can start clearing today and getting that level of specificity on the HIT, so that when that new version is released from AHRQ that you're prepared. But you also see the HIT codes or HIT codes are all currently on your Elixhauser commodity list already, in that coagulopathy category. So we have no reason to think that AHRQ would not-- Elixhauser would not use expanded codes. I have no reason to expect that it would be any different. So definitely, two categories or areas of risk adjustment, if you will, that they will be influencing. Audrey, I'm going to turn it over to you. (DESCRIPTION) Slide, Acidosis, a table of new diagnosis codes. (SPEECH) So the next subject that we're going to talk about are the expansion of the acidosis. Prior to October 1st, we just had one code for acidosis, and that included metabolic, lactic, respiratory acidosis. Now with the expansion of this, we have different codes that are available. And they have separated out the lactic acidosis with-- and what's included with that is the metabolic acidosis. But they have created new codes for acute or chronic metabolic acidosis, which, once again, the lactic acidosis will be included with that. They put the respiratory acidosis down into the other acidosis. So once again, expanding out, there's different codes that are available. We'll want to know, is it lactic, metabolic, respiratory acidosis, what is the acuity or chronicity of that, and-- to be able to assign the right code. All of the codes, you'll notice, are considered CCs. So just as the predecessor code was, they are still considered CCs. (DESCRIPTION) Slide, Acute slash chronic respiratory acidosis, a table. (SPEECH) You'll notice also that for the respiratory acidosis, if it was unspecified, it went to that other acidosis. So not otherwise specified. But if it's considered acute or chronic respiratory acidosis, that is now included under the codes for acute respiratory failure with hypercapnia, or chronic respiratory failure with hypercapnia respectively if it's acute or chronic respiratory acidosis. So it's interesting that they have put this-- the respiratory acidosis, if it's specified as acute or chronic under the same code for the respiratory failure with hypercapnia. (DESCRIPTION) Slide, How do new acidosis codes impact quality? A list. (SPEECH) So Cheryl, tell me how it's going to impact quality on these new acidosis codes. Certainly. So again, you'll see a theme that it is not really going to affect those hospital-acquired conditions. And again, as best as we can tell, it's not going to affect our PFI proper, but it will definitely affect risk adjustment. (DESCRIPTION) Slide, Impact of new acidosis codes on quality, a bullet point list. (SPEECH) So again, to summarize, acidosis is not an exclusion diagnosis for any quality metric. So it doesn't provide an automatic exclusion. It does not mean it's not part of risk adjustment, but it doesn't provide a-- if I developed this complication, if I were asked about it can be an exclusion. Also note that respiratory failure, meaning, workload going, more charts being assigned to gustatory failure by that acute respiratory acidosis as an example. It's also not an exclusion for any quality metrics. However, gustatory failure is utilized for risk adjustment in most of our methodologies. And of course, it seems obvious to us that the more that we just get a doctor to call it acute respiratory acidosis, that would be a sign to acute hypercapnic respiratory failure, we're probably going to get more patients with that, and that's more risk adjustment. Please remember, though, for risk adjustment, typically, that diagnosis does need to be present on admission. So it's not just enough to get that diagnosis on there, we do need to review and ensure it was present on admission. Of course, our respiratory failure codes are already HCC, so we'll have more report at HCC. It is also utilized for risk adjustment in CMS's 30-day mortality and the admissions program. And again, for your knowledge in version 24, they're included under category 84. And then finally, when respiratory-- acute respiratory failure is the principal diagnosis with a secondary diagnosis of emphysema or bronchiectasis, that's not part of CMS's 30-day mortality or readmissions program. So again, an increase in reporting can actually help us in terms of risk adjustment and possibly, avoidance of a 30-day mortality or readmission. (DESCRIPTION) Slide, Dementia, a table. (SPEECH) Miss Audrey, dementia. So the next topic is dementia. And they expanded out the three categories that were currently available regarding dementia, the vascular dementia, dementia and diseases classified elsewhere, and then the unspecified dementia. So they expanded that out, creating a lot of new codes. In fact, 69 new codes related to the dementia. And what the new codes are capturing now are the severity. Is it unspecified severity, mild, moderate, or severe in the severity level of it? In addition, before, we are able only to pick up with behavioral disturbance or without behavioral disturbance. Well, they've expanded that out to capture different types of behavioral disturbance or types of behavior from these patients with dementia. And you'll see that it's with agitation, with other behavioral disturbance, with psychotic disturbance, mood disturbance, and with anxiety. You'll notice that off to the side here, each of the new codes that have a type of behavioral disturbance with it are classified as CCs. And therefore, it doesn't matter what is the severity level of the patient, mild, moderate, severe, it's really that, did they have a behavioral disturbance of some sort? Without behavioral disturbance are the only ones that are considered non CCs. (DESCRIPTION) Slide, Behavioral and psychological symptoms of dementia, 5 bullet point lists. (SPEECH) On this next slide, you'll see that there's-- it's broken out. Of all those different types of behavioral or psychological types of dementia, what's included under each one? And what's listed here are the inclusion terms that are in ICD-10-CM. So it's what is already included in there. So you'll see, under agitation, it will have aberrant motor behavior such as exit-seeking, pacing, restlessness, blocking, or other types of verbal or physical behaviors. And you'll see those what are listed-- what's considered one of those types of behaviors. And then the other types of what is considered other behavioral disturbances, you'll see what those listed are. And then as well as the psychotic and the mood disturbance. Anxiety is just anxiety on this. And once again, all of these types of behavioral or psychological disturbances are considered CCs. The only one that's not considered a CC or non CC are those without a behavioral disturbance. (DESCRIPTION) Slide, Mild neurocognitive disorder, a table. (SPEECH) Also, I didn't mention that they-- on all of those new dementia codes, they had even listed a new inclusion term, and the major neurocognitive disorder was listed with all of that. So if they have a major neurocognitive disorder, then they're also going to develop codes for the mild neurocognitive disorder. So F06.7 was a new code that was-- subcategory that was created for this. And then they broke this out even to say with or without behavioral disturbance. So just know that there is another set of codes that are available for mild neurocognitive disorder. It seems to be the new terminology that providers may be using instead of dementia. (DESCRIPTION) Slide, Chapter 5: Mental, behavioral and neurodevelopmental disorders (F01 to F99), a bullet point list. (SPEECH) Now we are going to talk about other updates to the official coding guidelines later. But because we're talking about dementia, we went ahead and took it out of sequence and put the dementia updated coding guideline here. Just so you know that there was some updated guidelines on this. And basically, it is just saying that severity is available. And it's going to be up to the provider to document the severity of the dementia. And then that's how it's going to be coded. So we may need to query. There are some definitions that are available out there for what is mild, moderate, and severe type of dementia. But it is going to be up to the provider to document that severity. It is also nice to see that if the patient is admitted in one type of severity and they progress to a higher severity level, then we are going to only assign one code for the highest severity level reported during that stay. So that's a nice update to the coding guidelines there. (DESCRIPTION) Slide, How do new dementia and neurocognitive disorder codes impact quality? A list. (SPEECH) So Cheryl, how does it impact-- how does this impact quality? So before we do that, as we're watching the chat, I want to make sure-- I want to make sure everybody's clear, because there was a good question that came up. And I thought we could address it quickly. Those behaviors are assumed related unless the provider is back in another cause. They're indexed under the with terminology so the provider does not have to specifically say the anxiety is due to dementia, unless he had said she has primary anxiety, she's had anxiety for 50 years, or she has anxiety related to surgery, shall we say, or something like that. But they are assumed related in the codebook. And Audrey, did you need to say anything different on that before I move on to the quality impact? No. That is a very good point that the with guideline here-- and I do like how you distinguish that if they had anxiety for 50 years, then you know that anxiety is not related to the dementia. Yeah. Possibly just exacerbated, but certainly not the primary cause. So let's talk about these new codes, how they do impact quality. But again, we appreciate the great questions. And sometimes, when we cut them quickly, we will leave them in because we'd like that term is as close to the subject matter. Obviously then, we do think that this will impact our PSIs and it will certainly impact risk adjustment. (DESCRIPTION) Slide, Impact of new dementia and neurocognitive disorder codes on quality, a bullet point list. (SPEECH) Dementia as a diagnosis is included in most of your risk adjusted methodologies. So again, we have no reason to think that they would not use the expanded code to be included in the existing methodology. OK? And of course, for the Elixhauser methodology in particular. That does not require the diagnosis to be POA. So we know sometimes, Mrs. Smith comes in with dementia that is quite mild on presentation. She's doing quite well. And she gets in the hospital for a few days. And she starts having behavioral disturbances. So we would assign that with a POA of no. But that would still be giving us credit in that Elixhauser methodology because the dementia itself is a-- we'll call it a chronic condition. As Audrey alluded to, I hadn't seen this in the documentation as well. The providers are using that phrase "Neurocognitive disorder" more frequently. And when you try to clear the providers, we were getting some pushback. They're saying, I'm not comfortable taking the mini mental status exam. So it was just a terminology they might not have been comfortable with. Know that if they had described it as major, as Audrey alluded to, it would be assigned to the dementia category. In other words, we are going to have more patients that will get an increase in the Elixhauser score with documentation of major neurocognitive disorder. We don't know if they will include the mild on that risk adjusted list, stay tuned. And for those asking, no, the Elixhauser version that normally comes out in October of this year did not come out yet. I have been watching. I even looked just last week. So I can't tell you if it is on there. Certainly, the dementia with or without behavioral disturbances is an exclusion for AHRQ-- PSI 11 for a post-procedural respiratory failure. But again, starting with this current version, it has to be present on admission to provide an exclusion. And again, for those in the chat who are asking the question, if that behavioral disturbance itself was not present on admission, you would find that combination code with a POA of no. And so it would not provide that exclusion. Now, again, progression of severity, mild, moderate is different than having an acute behavior. So again, we have to follow the guidelines that talked about progression, but it did not talk about the POA assignment of the behavioral disturbance. All we have is a reference. And I know Audrey, you'll agree, it's our POA guidelines about combination codes and POA assignment. That's correct. OK. (DESCRIPTION) Slide, Malignant pericardial effusion, a table. (SPEECH) So go ahead and take our next topic. The next one is malignant pericardial effusion that they created a specific code to be able to capture a malignant pericardial effusion. And you'll see that there is a code first note under there that says code first underlying neoplasm. So the underlying neoplasm will have to be sequenced first, followed by the malignant pericardial effusion so that this code would not be sequenced as the principal diagnosis. (DESCRIPTION) Slide, How does malignant pericardial effusion impact quality? A list. (SPEECH) So Cheryl, how does this impact quality? Really, it's unclear. So you'll notice, we have a different emblem. We have a question mark, meaning, there's nothing obvious, we really don't know one way or the other. And here's why. (DESCRIPTION) Slide, Impact of malignant pericardial effusion on quality, a bullet point list. (SPEECH) Metastatic cancer, so our metastatic site, there are some metastatic cancers in your Elixhauser category for metastatic cancer. I don't know if they're going to add this code. But what I will tell you on their previous version, it's cousins, if you will, the malignant ascites and the malignant pleural effusion are currently not in the metastatic category. So I don't think they would add the malignant effusion to this category. If it is, it's a very heavily weighted category in the Elixhauser weight. As you can see, 11.4 mortality or 23.4 readmissions. So I don't think it's going to be on that list. Selected metastatic cancers are HCCs. And again, its companion cousins, those are also not HCC, so I don't know if that will be added. Your cancer codes are an exemption for PSI 7, right? PSI 2 and 7. But again, I sincerely don't think those codes will be added as the only comparative code that we have as your effusion, your ascites are not on those cancer list from AHRQ. There are only the C codes and a couple of codes in the D code range. Your traditional cancer codes are the only ones included there. So don't anticipate this impacting. But again, we are not certain that for world models such as Vizient, Premier, Healthgrades, et cetera, they might be using this as risk adjustment in their other models. We obviously don't have insight to that at 3M, but I would expect if the-- again, the ascites and the effusions are already used for risk adjustment in those models. I would expect those same models would expand to the effusion. But we don't know for certain. (DESCRIPTION) Slide, Hepatic encephalopathy, a table. (SPEECH) For the next topic, we have hepatic encephalopathy, which it has its own unique specific code now. In ICD-9, there was a specific code for hepatic encephalopathy. And early on in ICD-10, the hepatic encephalopathy was basically a part of hepatic failure. So now, it has been chiseled out. And we have a brand new code specifically for hepatic encephalopathy. And you'll see what all is included under here. It is hepatic encephalopathy without coma. So if it is with coma, it will go to a different code. And you'll see that it is not considered a CC based on this, but it's not classified as a CC at this point. (DESCRIPTION) Slide, How does hepatic encephalopathy impact quality? A list. (SPEECH) So Cheryl, how does this impact quality? This is going to be interesting. Again, from a risk adjustment perspective, I think we're going to see some changes. So let's talk through these. (DESCRIPTION) Slide, Impact of hepatic encephalopathy on quality, a bullet point list. (SPEECH) So previously, as Audrey said, it was previously classified as hepatic failure. And the hepatic failure itself is included in your AH-- sorry, the Elixhauser comorbidity list. But note, the only ones that were there was your alcoholic hepatic failure and your chronic hepatic failure. So it did not include the unspecified, for example, hepatic failure that the encephalopathy would have gone to. So I don't really believe, again, that there's going to be a change to those Elixhauser rates because it wasn't very often that we had these codes being represented for a patient with hepatic encephalopathy. And again, you're alcoholic and your chronic liver failure HCCs in category 27. They're currently-- the diagnosis itself is not currently used for an exclusion for any PSI. But again, as we said, it might be included in other risk adjustment models. And again, know that there is no distinction on acute or chronic hepatic encephalopathy. We have one code now for the questions that are coming in on this. It's not an MCC. We get basically nothing for this diagnosis. You still might have the ability to query on the chronicity of the hepatic failure if the patient has that, but in this code, and I'm trying to think how to say this the right way, they basically mimicks the way it was being represented in ICD-9. And again, do I say that correctly, Audrey? Yeah. Yes. (DESCRIPTION) Slide, Fracture of ribs slash sternum associated with C P R, a table. (SPEECH) OK. The next set of new codes that we're going to discuss are related to fractures of the ribs or sternum associated with CPR. So it's always-- based on some recent advice, we were told to assign a non-traumatic fracture code as if there is fractures related to CPR or chest compressions. So now they've created unique codes specifically for this. So you'll see how it ranges down. It fracture the sternum, fracture of one rib, fracture of multiple ribs, even if you have a flail chest related to CPR, or other types of fractures associated with CPR. So just specific codes, it's in the M category, the M chapter, M96, so that it can be able to distinguish this type. And I have always heard, and I'm a coder by background, I play a doctor on TV, that you're not doing CPR right unless you are breaking a couple of ribs in there. So I see Cheryl nodding your head, so I haven't said anything silly yet. Most of these codes are CCs. There is one MCC in here, and that is if it's flail chest associated with the chest compressions. So that will be classified as an MCC. And even that flail chest will go to if it's the principal diagnosis, it will go to MDC 4, which is the respiratory MDC. So good set of new codes that are created. And let's see how it impacts quality. (DESCRIPTION) Slide, How do chest injuries from C P R impact quality? A list. (SPEECH) And I'll make that statement. You haven't done good CPR on an elderly patient without breaking a few ribs. Some of our younger people might sustain. The other thing that I'll add is the doctor actually has to say those ribs are due to the CPR and not due to something else. We can't make that assumption. That's not a whip thing in our codebook. So do know that you're looking for that appropriate documentation. But again, it's not really affecting our HAC or our PSIs. And again, we'll talk about why on the next slide. And Audrey already alluded to it. (DESCRIPTION) Slide, Impact of chest injuries from C P R on quality, a bullet point list. (SPEECH) We weren't supposed to be assigning traumatic injury code for injuries occurring from a procedure. And we've had that advice way back, as you can see, from 2019. And we had even more specific coding clinic advice in 2021. And there, again, officially, had been in our guidelines back since, again, about 2019, but, of course, are still incorporated in our current guidelines. And we've got those references for you here. Secondly, I do think that there will be an indirect impact because even though we weren't supposed to be assigning those codes, I have seen those codes in audits being assigned inappropriately to those traumatic injury codes starting with an F. So hopefully, this will prevent us-- protect us from ourselves, if you would, from our errors. Again, really don't know, though, on the flip side, are they going to say that any broken rib during CPR is a bad outcome? Is that going to be considered a bad outcome in the future? Don't know. I really don't know. I had one recently where many, many, many bad things happened during a code. And you could wonder, did we actually do some harm? But I think it will be several years before anybody would look at the data. They have enough data to really determine, is this a truly bad outcome? And as a reminder, these are not HACs. This is not on the HAC list. None of the-- not-- its predecessor code that it used to go to, M9896 was not on the HAC list, nor are these new codes. But like I said, very glad we have these very, very specific codes. I'm pleased that we have them because we don't know where they're going to be used on a future. Again, from my perspective, I think it would be sad if they use those as a complication because we're literally in those life saving moments, if you would. And as a kind of a note, those Elixhauser codes are not available yet, the new version. But they are available out on AHRQ's website. If you look up Elixhauser, they have a website in a file to download. But the new version is not out yet. (DESCRIPTION) Slide, Contrast-induced nephropathy, a table. (SPEECH) Audrey, how about contrast-induced nephropathy? Basically, a brand new code was created for contrast-induced nephropathy to be able to identify the nephropathy if it is related to contrast. You are allowed to code acute kidney injury, AKI, if it is present. and reportable, with this new code of N14.11, because you'll see that there's an Excludes 2 note. An Excludes 2 means that both conditions can be reported together if both are reportable and documented in the record. You'll see that it is not considered a CC. So how does it impact quality? (DESCRIPTION) Slide, How does contrast nephropathy impact quality? A list. (SPEECH) This is another one I actually really like because you can get nephropathy from vancomycin is a great example, as compared to contrast. So having a unique code, I think, is going to be really good for the future, but again, how is that going to be utilized? I don't think there was a way to really utilize it without having its own unique code. (DESCRIPTION) Slide, Impact of contrast nephropathy on quality, a bullet point list. (SPEECH) In other words, I think down the road, just might be used at some point. It's currently the contrast-induced nephropathy, its predecessor code was not included as an HCC or the Elixhauser categories because as we know, it's typically transient, right? It's usually not permanent. We give them fluid, give them the Mucinex, hold the offending medications, give them fluids, and things usually get better. Like I said, I think it could be used in the future. That might be a good thing for researchers to study that to say, how often does this occur? And did we do all the protective-- renal protective therapies that we should have done in terms of pre-hydration and Mucinex, or maybe not using contrast or using lower doses. So not sure what's going to go in the future, but I-- I'm pleased there's a unique code. (DESCRIPTION) Slide, Problems related to housing and economic circumstances, a table. (SPEECH) The next topic is on social determinants of health. Basically, these new codes are within the social determinants of health section. And so you'll see that new codes were created for transportation insecurity, financial insecurity, and material hardship. And we'll talk a little bit more from a coding guideline standpoint about social determinants of health. But just know that these are some new codes that were created. I know it's a huge topic right now, and that it was discussed to have a lot of new codes created for this. But for effective October 1st, these are the only three codes that were created for this section. (DESCRIPTION) Slide, How do new S D O H codes impact quality? A list. (SPEECH) So Cheryl, how does it impact quality? And as Audrey said, they had been releasing the codes. And just as a reminder, it's actually meant to be staged out over several years. In other words, they've had a plan not to release 800 codes at once. They were gradually doing them by category. So this is part of a major project, the Gravity Project for those that are interested and want to read up on that. Again, really unclear because where are the current SDoH codes being utilized? (DESCRIPTION) Slide, Impact of new S D O H codes on quality, a bullet point list. (SPEECH) None of those are included currently in CMSs or AHRQs risk assessment models. Now here's the thing. I'm not going to disagree with anyone saying, well, they should have been. Yeah. And I think that both CMS and AHRQ would agree with you. The problem is we don't have consistent reporting across our organizations, across our settings on these SDoH codes. There's been a huge push over the last five years, especially. But how can you utilize something when the data is not consistent? Of course, as a reminder, CMS, for the last two years, has been asking for input on, how do we include these? What should we include not just SDoH but other socioeconomic status? Should we be including race, age, living environment, et cetera? But do know that outside of the big quality picture, there are several states that have initiative to capture these and are mandating some reporting. And again, from my perspective, the more we do today, the more that we make this a standard part of our coding work, if you would, I think the better data set we have to maybe use for future models. But right now, it's really unclear. And again, some of them might be used in some of the proprietary methodologies, but nothing on a formal risk assessment that we're aware of. But that I am hope. (DESCRIPTION) Slide, F Y 2023, I C D 10 P C S, updates related to quality. (SPEECH) OK. Audrey, let's shift over to PCS. (DESCRIPTION) Slide, Summary of changes - by the numbers. (SPEECH) OK. And with PCS, which is the procedures portion of ICD-10, you will see that overall, the 331 new procedure codes were created, 64 were deleted. And this year, they did not revise any of the procedure code titles. This is a moderate number of changes for this year. Definitely, not as much as they have done in the past. But they did create a lot of good new codes that will be able to identify the new technology, to be able to identify difference in approach on how some of them are done, some qualifiers were changed. So they did make a moderate amount of changes for the PCS section. (DESCRIPTION) Slide, How do new and modified P C S codes impact quality? A list. (SPEECH) So overall, Cheryl, how did the procedural coding section impact quality? Well, again, another big question mark, because as Audrey said, the codes weren't really exciting this year. And I don't mean it in a negative way. They were good codes that need to be there, but they weren't these big, big changes in procedural coding other than maybe shifting. (DESCRIPTION) Slide, Quality impact of new P C S codes, a list. (SPEECH) But let's talk through those. I mean, it really is undetermined because most of those, as Audrey really alluded to, they're expansions of pre-existing codes, adding additional qualifiers or moving out of administration the measurement or things like that. But please know that in terms of procedural coding changes, AHRQ is always one version behind CMS. So in other words, the codes we released today, they will incorporate into their next version. And again, when we look through this code list, Audrey and I look through, and we're like, those are non OR procedures and they-- and not even in AHRQ's world, meaning, their predecessor codes, if you will, or the previous category they were assigned to, they weren't already on AHRQs operative procedure code list. So we don't think that this is going to have any direct impact. But as always, I would agree that having more specific qualifiers and having better PCS code can aid in the methodology down the year. That is another note. AHRQ doesn't do anything overnight. They usually look for about five years of coded data before they make any drastic determinations, because again, it takes time for all of us to adapt to the new codes and report them appropriately and accurately. So AHRQ, sometimes, does some things quickly, such as the HIT code. But other times, they really do wait to have a more comprehensive set of data. So we don't really think any of these new codes are going to have an impact per se. (DESCRIPTION) Slide, F Y 2023 Official Coding Guidelines, updates related to quality. (SPEECH) So how about the coding guidelines? (DESCRIPTION) Slide, Conventions for the I C D 10 C M, a bullet point list. (SPEECH) So moving into the coding guidelines, they didn't change a lot this year as compared into previous years. But they did add several statements that made us scratch our heads a little bit. And also, we're thankful for some of the clarifications. Once again, these are updates to the official coding guidelines. And so you're trying to apply your each individual record to the guidelines to make sure you're staying within that. The first update that we want to discuss is what is sometimes referred to as guideline 19, where the overall premise of the guideline is to say that your diagnosis code assignment is based on the provider's diagnostic statement, that the condition exists. So if the provider has documented it, basically, it should be quotable as long as it's reportable, that it's evaluated, monitored, treated, et cetera. So that's what this guideline is saying. Code assignment is not based on clinical criteria. This has always been in here. So what's in green is what has been updated this year or what's been changed so green usually means that it's been updated on these slides. Red does mean that something has been taken away or deleted. And blue typically means revision. So here, they added the statement, if there is conflicting medical record documentation, query the provider. Seems like a simple statement. And it is something that we should always follow. Whenever there's conflicting documentation, we need to query the provider to get that clarification in the record. But they specifically did put it under this guideline 19 that's saying, you are trying to make sure that if it's documented, is there-- is it supported in the record? And if we're unsure, then we do need to query the provider. (DESCRIPTION) Slide, How does update to clinical criteria guideline impact quality? A list. (SPEECH) So Cheryl, let's talk about the quality on that. I think we'd all agree that this could affect any of the complications methodologies. I think this is a definite-- it's a subtle change, but let's talk about the how. And again, Audrey said, clinical criteria guidelines. The guideline is not new. (DESCRIPTION) Slide, Impact of update to clinical criteria guideline on quality, a bullet point list. (SPEECH) But it's a reminder, because I think there's been a push back and forth between CDI and coding, sometimes. Coding is saying, it's documented so I'm going to go ahead and capture that. In other words, it does meet reporting criteria. The doctor said it so we have to move on. It's a reminder, we don't necessarily have to move on if there is something in the medical record that is conflicting with what the doctor is saying. And that may reduce the number of documented complications such as a PE when there is literally no diagnostic evidence, there's an MRI that's negative, or a V/Q scan that is actually negative. That might-- that-- instead of just capturing that PE, that might require-- that might warrant, I should say, a query that might remove that being a complication. But also understand that with a reminder that if a clinical picture is not consistent, because that is also conflicting documentation, not just doctor's words, if there is conflicting documentation, conflicting evidence, as we do more clinical validation, it may reduce some of those diagnoses that are utilizing risk adjustment. And again, just examples, of course, being some of those heavy hitters like sepsis or hyponatremia, acute respiratory failure, where you might see less of those reported. Again it's not limited to those. We're just giving you examples of if the patient now does not have that or an acute MI is another great example with the new nonischemic myocardial injury code. If the doctor is calling that a type II MI, but there is no evidence, a query would be warranted. So I do think, as I hate to say a very blatant reminder in the guideline to query, that this probably will have an effect. It should have always been that way, as Audrey said. We should have always been querying for conflicting documentation. But sometimes, that extra elbow will probably have an influence. (DESCRIPTION) Slide, General coding guidelines, a bullet point list. (SPEECH) Audrey, next topic. So the next one is an update to the documentation of complications of care. And what you'll see is that the top part of this guideline has not changed. We still need to have the provider's documentation establishing the relationship between the condition and the care provided. What they are doing is expanding on that cause and effect relationship between the care provided and the condition. And what they added in here was saying the documentation must support that the condition is clinically significant. And how it did say and what it said in the past is there must be a cause and effect relationship between the care provider and the condition. And that an indication in the documentation that it is a complication. So instead of that vague way of saying that there was an indication, that there was a complication, just that it's clinically significant, that it's been proven in there, and that it is not necessary-- It goes on to say, it's not necessary for the provider to explicitly document the term "Complication." So that's nice to see that in there. Going on with that, they give the example of saying that it doesn't need to explicitly document their complication, but that the condition will alter-- for example, the course of the surgery is documented in the operative report. So they're giving this information. They're putting it into the guideline. There was a coding clinic that was on this within the year related to this. So they took that information from the coding clinic advice, and actually felt like it was important enough to put this into the guideline as well. So they are trying to make it that the information from the operative report, if they're saying that there was something that happened in the operative report, it's not being explicitly needed to be documented as a complication, but they're saying it's severe enough that it may be coded as a complication without a query necessary at that point, that you would be appropriate to code it as a complication code. But they still kept in here, query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care provided. So they updated that section as well, but still saying that a query is necessary. So Cheryl, I am going to pass it over to you to talk about the impact on the quality in this case. (DESCRIPTION) Slide, How does update to complications coding guidelines impact quality? A list. (SPEECH) Did we lose you? Are you on mute? There we go. So sorry. I have home construction so I've been muting by phone, so everyone did not have to hear the banging. Apologies there. There was a question that physician doesn't have to use the exact word alters the course of surgery. I had one recently said, two enterotomies were made. Hence, I converted to open procedure to repair them. In other words, he didn't have to say it over. He told me, I altered the course to repair those lacerations. But our general note here is we really want to be a little bit broad here. And by that, we mean, this is a hot topic. And also, we're going to give you an advertisement for hopefully, February of next year. Stay tuned. Watch this web page. We are going to do a special session on this particular topic, because Audrey and I could spend four hours arguing this, debating this, discussing this, coming up with what about. So we're going to do a special session, not just with the two of us, but with some physicians as well. So we are telling you to stay tuned. (DESCRIPTION) Slide, Impact of complications coding guidelines on quality, a bullet point list. (SPEECH) But globally, quickly, chart review and code assignment of complications. It's a really complex process. It does not fully resolve whether or not you should have assign complication codes, because there are nuances in each clinical scenario. And again, I had a chart particular where the surgeon had a totally different answer. A surgeon that we reached out to for their opinion came up with something that I wasn't expecting at all. We are making a general statement that we believe your best practice in the future is really going to have a multidisciplinary committee look at this. And we have several clients that have done this in the past and continue to do this process. But we also want to make sure that you have a surgeon leader. Again, when we shared a particular note with a provider, they gave us a totally different perspective than any of us were expecting. And as always, it's going to need to be on a case by case basis. But like I said, we could talk on this for hours, so we're going to bypass this [INAUDIBLE]. So please stay tuned and come back. We're going to talk about this in a lot more detail. But we didn't want to ignore it. And people say, why didn't you discuss this new guideline? (DESCRIPTION) Slide, Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00 to T88), a bullet point list. (SPEECH) So let's shift over to underdosing. Well, and I will say one thing on that. I mean, even though we are going to discuss it later, I want to make sure-- I mean, there is no real definition of what alters the course of surgery. It really is on, like Cheryl said, on a case by case basis. Take a look at it. What did they say? What did they do in the operative report? And try to apply the guideline to it. It's just going to be on a case by case. And you're going to have to-- if you do have any questions on it, you can always reach out to us and give us that example. That would add to our arsenal, actually. But moving on to underdosing. Underdosing is underreported, if you will. So they updated the guidelines to, in my opinion, make it easier on being able to pick up the underdosing. So they added a couple of statements into the guideline. And that documentation of a change in the patient's condition is not required in order to report an underdosing code. So the fact that if the provider is documenting that the patient is taking less of a medication than is prescribed or has discontinued the prescribed medication on their own, then that's sufficient for the code assignment. So that's the additions to the underdosing guideline at this point. And so Cheryl, talk about the quality. (DESCRIPTION) Slide, How does update to underdosing coding guidelines impact quality? A list. New slide, Impact of update to underdosing coding guidelines on quality, a bullet point list. (SPEECH) And I think you're still on mute. As you take yourself off mute, you can code the underdosing and the medicine noncompliance together on the same record. Absolutely. And thank you for that. Again, these underdosing codes are not currently used by CMS or Elixhauser for risk adjustment. But it doesn't mean that it might be utilized in other models. And maybe more robust data might influence that. Because I think we'd all agree, it should be utilized in risk assessment, right? But he didn't take his Lasix. OK. I'm agreeing with you clinically. So I think the more that we apply these codes and the more robust data we have, the potential for them to be utilized, it will be higher. (DESCRIPTION) Slide, Chapter 21: Factors influencing health status and contact with health services (Z00 to Z99), a bullet point list. (SPEECH) And it's cousin, those social determinants of health. So yeah. For the social determinants of health, they are saying that code as many codes as necessary for that. But the key point in here is that there's an associated problem or risk factor. They do put in the example, not every patient individual living alone is really needing that code for problems related to living alone. You notice on the new codes, they were saying, they were out of money. Well, who's not out of money? That-- I mean-- or that, how did it state that you're low on money? We're all going to say that we're low on money, but we're all not going to have that code assigned for our situation. It's when there is a problem associated or there's a risk factor associated with that situation that that code would be assigned. So I think that's the key factor in the updated guidelines. (DESCRIPTION) Slide, How does update to S D O H coding guidelines impact quality? A list. (SPEECH) Cheryl. Yeah. And we'll quickly-- the official code and guidelines always trump any coding clinic advice. So for the person that was asking that question, you always refer to the official coding guidelines as your source of truth on the underdosing. Again, if there's not-- it doesn't matter if there's not associated condition. The fact they didn't take their medicine, they got lucky. But I just want to reiterate that really fast before we move forward. But meanwhile, back to our social determinants again, another question mark, if you can imagine, because again, they're not currently utilized. (DESCRIPTION) Slide, Impact to update to S D O H coding guidelines on quality, a bullet point list. (SPEECH) And again, as a reminder, they are utilized, for example, one of our question or comments was, it is being-- some of these codes are being used in a new ECQM or Electronic Clinical Quality Measure, the severe obstetric complications. So they are part of that model, but they're not part of some of what we'll call the bigger risk adjustment, those that affect our payment if you'll say, for example. But again, I think it's still important that we're getting these SDoH codes. The more that we're capturing, I think, the better we're representing, and the better they can be utilized for risk adjustment as needed. (DESCRIPTION) Slide, F Y 2023, M S D R G, updates related to quality. (SPEECH) And then our last little topic here, the MS-DRG update, yes, Audrey? (DESCRIPTION) Slide, Summary of changes - by the numbers. (SPEECH) Yup. We are heading into the homestretch with the last topic. And you'll see here, no new MS-DRGs, no deleted MS-DRGs, and no revised MS-DRG titles. So they didn't really change a lot of the major things, but they did shift a lot of codes around. (DESCRIPTION) Slide, Embolization of portal and hepatic veins, a table. (SPEECH) So some codes, what you'll see here, some-- these four codes that were previously classified to the unrelated DRGs were moved to MDC 7 in the other hepatobiliary or pancreas procedures because they were closely related to a diagnosis that is classified to MDC 7. So it's the occlusion or restriction of the hepatic or portal vein that were added to MDC 7. So that instead of going to unrelated, they would go to the DRG within MDC 7. (DESCRIPTION) Slide, How do M S D R G updates impact quality? A list. (SPEECH) And how does that impact quality? Well, it does probably, possibly impact PSIs or risk adjustment. And for those that are worried as we're approaching this half hour, we are going to go a little bit over. Remember, if you have to drop off, this session has been recorded if you need to hear the end. But we'd rather give this it's good view, if you would. (DESCRIPTION) Slide, Impact of M S D R G procedure update changes on quality, a bullet point list. (SPEECH) This is getting very complicated. But the point being that when you have procedures that were unrelated DRGs, the MDC exclusions that would have avoided a PSI are negated when they were in the unrelated category. So those procedures in MDC 7, moving into MDC 7, I would show you as an example. Those now coming in, we might get some actual exclusions on those. And when you think about these types of patients that are having that procedure, you can understand that some of that might be-- sorry, may not be salvageable, that patient may not be able to survive that hospitalization. So this will actually be in our benefit to you all. And let's move to our next one. (DESCRIPTION) Slide, Percutaneous excision of hip muscle, a table. (SPEECH) For the next three slides, it's moving procedures around again. And in fact, these four procedures that are related to percutaneous excision of the hip muscle are now considered non-OR procedures, therefore, it will no longer impact the MS-DRG assignment. They made them similar to a percutaneous excision of the retro peritoneum, that was not considered an OR procedure. And they say they're similar in nature, so they made these non-OR procedures as well. So these are specific to excisions of the right or left hip muscle, percutaneous approach if it's a biopsy or not. So no longer considered OR procedures. (DESCRIPTION) Slide, O.R. procedure to non-O.R. procedure, a table. (SPEECH) On these five procedure codes, they were changed from an OR procedure to a non-OR procedure. So they may still impact on some DRGs, but they did change the designation on the occlusion of the splenic artery, the-- some excision of the larynx, changing them to a non-OR procedure. (DESCRIPTION) Slide, Non-O.R. procedure to O.R. procedure, a table. (SPEECH) And then vise versa, these four procedure codes were changed from a non-OR procedure to an OR procedure. So now it will impact on the DRG, and the DRG that's involved depends on what the principal diagnosis is. So Cheryl, how does it impact quality? (DESCRIPTION) Slide, How do M S D R G updates impact quality? A list. New slide, Impact of M S D R G updates on quality, a bullet point list. (SPEECH) I think this again is probably a little bit bigger, with, again, a question mark. But understand, AHRQ use two different sets of files to determine if a patient had surgery. They're either they're OR procedure lists or the surgical MS-DRG list. When the OR procedures are being refined to non-OR procedure, you're potentially reducing your denominator and your numerator for all of those PSIs that are based on a surgical procedure. So you'll see, it's a pretty big list there. And then conversely, the non-OR procedures being assigned to OR procedures, again, when AHRQ uses that current code set, you could have potentially increased denominator candidate claims, and maybe more PSIs because of those OR procedures. Again, I always find it interesting to see what's moving backwards and forwards because remember, typically, CNS is doing that about resource consumption. What were the resources involved in caring for that patient? But there are sometimes these other downstream impacts that may apply or may happen. (DESCRIPTION) Slide, Key takeaways, a list. (SPEECH) So our key takeaways. As you saw, there are some minor code changes or again, some coding guidelines updates that can actually have a big impact on quality outcomes. Not just listening to Audrey and I, but we really encourage all of you to carefully look at all of those new codes and understand why the code change was made, or the code was deleted, expanded, et cetera. But it's not just enough to look at the codes, you need to fully really understand the risk adjustment methodology. So often, I get questions where the real problem is they did not understand AHRQ's methodology to begin with. So if you don't understand the methodology, then you don't understand how the updates may apply. So it's really being a good student, if you will. And then finally, really encourage all of you to not keep the-- your light under a bushel. Share that information with all the stakeholders. Make sure quality hear, make sure your leadership hears this information of the big changes. Not just learning that other changes happen, but when is that going to affect our metrics, when are we going to see this affect the data, to really ensure that we are making everyone aware, so that there's no surprises later. Well, why didn't you tell me this? Or, yes, that happened this year, but we're not going to see that until the data in three and four years down the road, possibly. Making sure you're sharing that detail. (DESCRIPTION) Slide, Q&A. (SPEECH) And with that, I'm going to turn it over to Lisa. All right. Well, thank you, both, so much. So much information. And for those of you that are still on, we are going to be recording this, as was mentioned. It will be available on our website in the next couple of weeks. So if you do want to listen in again, it'll definitely be there. So we're going to go to just two questions right now, just so we can get a little bit more clarity on these ones we thought it was important to go over on these ones as well. So the first one is, thoughts about the capture of chronic respiratory failure from the documentation of chronic respiratory acidosis on those patients that are not dependent on continuous oxygen. That was a mouthful. [LAUGHS] Yeah. And it's a good question. I didn't see it in the chat early enough to address it, but I want to get back to that. Remember, you have two types of chronic respiratory failure. You have hypercapnic, and you have hypoxic. So a patient can have hypercapnic respiratory failure and not be dependent on oxygen. So for me, I have no concerns from a clinical validity process or denial process because you typically have evidence of chronic respiratory acidosis by that normal pH with an elevated bicarb. So again, remember, there is two distinct types. And that's why we have the different codes that talk about hypercapnic versus hypoxic. All right. And to piggyback on that a little bit, to query for the acuity of respiratory acidosis, should the patient display additional signs and symptoms of respiratory failure since it will code to acute or chronic respiratory failure with hypercapnia. Yeah. Great question. So again, I will tell you that when no codes were assigned, an index under acute respiratory failure and chronic respiratory failure-- Audrey and I went-- it did cause a pause. But by definition-- and similar with the chronic, by definition, part of the more common definition is respiratory decompensation, not just physically but in your blood gases. So in other words, if you are acidotic, I don't care if you're not having distress, you're not doing a good job. And COVID is a perfect example of that. And I hate to pick that one in particular, but tell the patients have profound hypoxia without us knowing that, without them being symptomatic. Many times, we're much more surprised on what we get on the blood gas. If you look at the patient, they're able-- they're holding their own, if you will. They've got enough to out of the water. So I want to make sure that that acidosis is clinically deviated enough, meaning, in other words, just because your pH is 7.34-- I'm using that as an example, is that truly significant enough to warrant an acute respiratory acidosis? The same way that we would validate a hyponatremia with just a barely low sodium or a slightly low platelet count. Just because it's not in that normal range doesn't mean it is significant. So instead of rushing to query every time they say respiratory acidosis acute or chronic, we need to make sure that acuity, if you will, that actual patient presentation, overall picture of what are they doing about that pH. A thing, is it due to a nebulizer? I mean, there's so many variables, but it's just proceed with caution. But for some of those providers that don't like to answer queries, if they're documenting respiratory acidosis, and it's clinically appropriate. And they give you that level of acuity, going to the appropriate code for chronic or acute makes clinical sense based on, again, some of the more common definitions for the hypercapnic respiratory failure. But it is a great question. And I do think we need to proceed carefully with these. Fantastic. Thank you so much. Don't forget, in the Resources section, you do have the ability to register for that other-- we're calling it a special edition session for the quality webinar in December. So if you haven't registered for that one, you can get to that link there. We also have provided the certificate of attendance. And so you can download that and submit it to an accredited association of your choice to obtain CEUs. (DESCRIPTION) Slide, 3 M educational boot camps for advanced C D I, pediatrics and quality training, descriptions and dates for three training sessions. (SPEECH) And there is also a link in there as well if you'd like to learn more information about our educational bootcamps. We are already planning for next year, which is crazy. And so our first bootcamp is in January. And we also recently sent out for our customers that are joining us today, that CES is going to be taking place in May. So if you haven't seen that email for our customers that want to join us in May, make sure you check your email on that as well. And so again, Audrey and Cheryl, thank you so much for your time today. It was a great session. I'm glad we have this one recorded. And we'll get this on our website as soon as we can. (DESCRIPTION) Slide, Thank you! (SPEECH) And if anybody has any questions, please feel free to reach out to us. And we will talk to you again in December. Thank you all for joining today.

(DESCRIPTION) Diagram of platform. (SPEECH) Hello, and happy first day of fall. Welcome to our September quality webinar. We appreciate you joining us today. As we have our attendees joining, I'm going to go ahead and go over a couple of housekeeping items. And then I'll kick it over to our speakers to get started. So again, thank you for joining us for what you don't know, or audit may hurt your quality scores. Again, before we get started, this is a web based platform. For a better user experience, we do recommend using Google Chrome and to close out VPN or multiple tabs, just to help with the bandwidth and security walls. If you are having any issues with your audio, check your speakers settings. And you can do a quick refresh of your browser, and that usually clears out the cache. You do have the ability to move around the engagement section. So if you want to make the presentation larger or the media player larger, you can. Those all move around, and you can close them and minimize them, if you want to. We do encourage you to ask questions. So in the engagement tools, there is a Q&A box. So please, during the webinar, ask questions, and we'll get to as many as we can at the end. We do offer a certificate of attendance, as well as other resources, like the handout in that resources section. So before the webinar is complete, make sure you check those resources to download those prior to the end of the webinar. In our engagement tools, we do offer closed captioning. So if you do need that feature, in the media player, you can turn that on, it is in real time. And again, check the resources section. We have a lot of information there. And lastly, if you can complete the survey, once the webinar is complete, we always like to know how we did. So let us know your feedback. We really appreciate it. Our speakers, you all should know well. We have Sue Belley and Audrey Howard. If you're interested in learning more, the biographies of them both are in the engagement tools as well, that you can check out their history. And so let's go ahead and get started. I'm going to go ahead and pass it over to Sue. (DESCRIPTION) A slide is titled, Learning Objectives. (SPEECH) Yes. Good afternoon, everyone. I'm Sue Belley. And I want to thank you for joining us this afternoon. My colleague, Audrey Howard, and I are going to talk about some of the elements of an in-patient hospitalization that can impact an organization's quality metrics. Typically, we find that organizations spend a lot of time validating the clinical documentation and coding of records with diagnoses identified as patient safety indicators or PSIs, hospital acquired conditions, also known as HACs, and readmissions and mortalities. However, when we perform audits on organization's medical records from a quality perspective, we're really struck by the number of opportunities that impact quality metrics that organizations are not aware of or tend to overlook during their auditing process. Many of you know that quality metrics are extremely complex, and it takes a really deep knowledge to understand all of the intricacies of them. What we'll be focusing on today is one aspect of these metrics, which are the elements you see listed on screen, the observation outpatient surgery converted to inpatient status, point of origin, admission type, present on admission indicators, clinical validity, and discharge disposition. Some of these elements are what might be considered administrative data, such as the patient's status, the point of origin, the admission type, and discharge disposition. We're going to about each of these overlooked components and make the case for including them in quality audit workflows that organizations are doing today. So I'm going to turn the presentation over to Audrey. And we'll get started. Audrey. Thank you so much, Sue. The first topic that we're going to cover today is regarding the conversion of the patient from either observation or outpatient surgery to the inpatient status. (DESCRIPTION) Text, Impact of inpatient status on timing quality. (SPEECH) Since our focus here today is on inpatient cases, this conversion to the inpatient status is extremely important to the selection of the principal diagnosis, which impacts all quality metrics. In addition, this establishes the admit date, which will also help us to determine the point of origin and the admit type, which we will discuss in more detail late. What makes this even more challenging is that different payers may have different rules about the admit date after the time spent in observation or outpatient surgery. Therefore, it is very important to work with case management or utilization review as well as the billing department to establish the inpatient admission date, at which point, you can select the principal diagnosis following the official coding guidelines. (DESCRIPTION) Observation status, monitor, inpatient status. (SPEECH) The official coding guidelines related to a patient which originally starts in observation or goes from outpatient surgery to observation to the inpatient status are similar. These patients were expected to go home following observation. But something happened to cause them to be admitted to the inpatient status, either the condition worsened, it did not improve, or the provider wanted to continue monitoring the condition or complication. Therefore, that condition, which required the inpatient status, is sequenced as the principal diagnosis. This follows the definition of the principal diagnosis. The most common example of observation to inpatient admission is a patient admitted with pain, either a chest pain or abdominal pain, and they work the patient up. Maybe the pain did not subside in the allotted time, and needed to be admitted to the inpatient status, or maybe a more definitive diagnosis was established and required inpatient care, or maybe another condition developed during that observation status that required the admission to the inpatient status. Review of the medical record and-- is critical. And it's important to determine the intent behind the conversion to the inpatient status. And if the documentation is not clear, then always query the provider for clarification. (DESCRIPTION) Text on a green arrow reads, Admission from outpatient surgery. (SPEECH) The same premise is true of a patient being admitted to the inpatient status from outpatient surgery. When a patient receives surgery in the hospital's outpatient surgery department, and is subsequently admitted for continuing inpatient care at the same hospital, the principal diagnosis for the inpatient admission depends on the circumstances of admission. The complication code would be sequenced as the principal diagnosis if the reason for the inpatient admission is a complication. The condition necessitating the outpatient surgery will be sequenced as the principal diagnosis if no complication or other condition is documented as the reason for the inpatient admission. In other words, maybe the provider just wanted to continue monitoring the patient after the outpatient surgery, but there is no complication. If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. For example, maybe the patient developed atrial fibrillation during the post-op monitoring period and required inpatient admission. (DESCRIPTION) Before and after table. Case example. (SPEECH) This slide is showing a case example of a patient who presented to the emergency department with hematochezia. The documentation stated, admit to observation where a colonoscopy was performed and three arterial venous malformations were cauterized. During the colonoscopy, the provider noted pneumoperitoneum secondary to iatrogenic perforation of colon. The documentation then supports the patient was admitted to the inpatient status for repair of the colonic perforation. Now based on this documentation, it appears that the reason for admission to the inpatient status was the accidental perforation of the colon. In this case, we recommend querying for confirmation of the reason for conversion from observation to inpatient, and to confirm the inpatient admit date and time was after the colonoscopy. Confirming this information would change the principal diagnosis, allowing the accidental perforation of colon to be the principal diagnosis present on admission. In this case, that change would eliminate PSI 15. At this point, I'd like to turn the presentation back over to Sue to discuss the next topic. (DESCRIPTION) Text, Point of origin slash admission type. (SPEECH) Thank you, Audrey. The point of origin-- we're going to talk about point of origin and admission type. So I'll start with point of origin. The point of origin is a code that is placed on the claim form to identify where the patient came from at the time of admission to the hospital. So examples of point of origin codes include a patient who is admitted from home or a patient who comes in from a skilled nursing facility or another acute care hospital, just some examples. The point of origin may impact CMS's mortality and readmission measure, AHRQ's patient safety indicators, and other quality reporting organizations or methodologies like Healthgrades. For example, we know that PSI 4, which is the death rate among surgical inpatients with serious treatable complications, has a denominator exclusion for patients admitted from a hospice facility, which is point of origin code F, for example. (DESCRIPTION) Point of origin codes table. (SPEECH) So on screen, you see a table of the point of origin codes and their descriptions. So here, I'm circling-- you can see point of origin code of F, transfer from a hospice facility, which is the example that I just gave on the previous slide. You can see point of origin code of 1, which would be used for a patient who comes in from home. So the point of origin code is assigned at the time of admission during the registration process with the patient. The information is gleaned from a variety of sources, such as the patient, the family, the physician, nursing staff, the EMS squad that brought the patient in, or perhaps, from a facility transfer form from a skilled nursing facility. When I think about all the possible sources where the point of origin can be gleaned from, I see how easy it might be for the point of origin code to be incorrectly captured and placed on the claim form. (DESCRIPTION) Text, Quality metrics using admission type. (SPEECH) The admission type goes hand in hand with point of origin. So the admission type indicates the priority of the patient's admissions. And by this, I mean, is the admission classified as an emergency admission, an urgent admission, or an elective admission? Or a newborn admission, in the case of a newborn. Or a patient admitted as a trauma center admission for trauma facilities. Admission type may impact CMS's mortality and readmission measures, the AHRQ PSIs, and other quality reporting organizations. (DESCRIPTION) Admission type table. (SPEECH) On this slide, you'll see the definitions for the admission types I just explained, emergency, urgent, elective, newborn, and trauma center. (DESCRIPTION) Types 1-5. (SPEECH) So on screen, I have an example from one of our test systems. And it is a record for test patient Bob Smith. And you can see that his admission type is undefined here. And for that matter, his admission source-- to the left of the red arrow-- is also undefined. So perhaps, something went wrong during the registration process, and this was-- this information wasn't captured and entered into the registration system. I mentioned that admission type PSIs, we know that PSIs 10, 11, and 13 are dependent on an admission type of three or elective. And we also know that for PSI 4, which is again, death rate among surgical inpatients with serious treatable complication, the denominator inclusion criteria includes, in part, an admission type of elective, or any admission type in which the earliest ICD-10 PCS code for an operating room procedure occurs within two days of admission. So I know that sounds like a mouthful. And it's a hint at the intricacies of PSI methodology that I mentioned earlier. (DESCRIPTION) Before and after table. Case example. (SPEECH) On this example on screen, this is an example of an admission type gone wrong. So this patient was transferred to a facility due to the fact that the patients PEG tube-- the percutaneous endoscopic gastrostomy tube-- was displaced. And the patient was positive for C. diff colitis. The patient underwent a replacement of the PEG tube four days after admission. Unfortunately, the patient did expire during the hospitalization. And the patient's admission type was registered as elective. When we think about this situation, this wasn't an elective admission, but rather, either an urgent or an emergent admission type. We recommend revising or correcting the admission type for this particular patient, which would eliminate the triggering of PSI 4, that death rate among the surgical inpatients. Because urgent or emergent cases with procedure dates greater than two days after admission do not meet the denominator inclusion criteria for PSI 4. So again, I know that sounds complex and confusing, and possessing a deep understanding of the PSI or PSIs and their inclusion and the exclusion criteria is critical. And then validating that all of the information that impacts the PSI is accurately captured and reported takes really a great deal of knowledge and skill. And sometimes, you want to work with quality department, for example, or those individuals in the organization who are really expert at PSIs if your team or the individual coders don't possess that information. (DESCRIPTION) Color-coded table. (SPEECH) So I mentioned earlier that the admission type is captured during the registration process. So hospitals usually have some type of job aid, which I shared an example of on screen, for registrants to use to help them assign the correct admission type. So as you can see here, if a patient is being admitted to a rehab hospital or their pre-admission to hospice care at this particular organization, they're considered elective. If they're coming in, they're an OB patient that's coming in through the ED, being admitted, they're emergency, or they have a stroke or a heart attack. So those kinds of aides can help the registration process. So looking at how to verify that or help get the correct information in the end. So I'm going to turn the presentation over to Audrey. And she's going to continue by talking about discharge disposition-- I'm sorry, present on admission. Thank you so much, Sue. So now, we are going to discuss the present on admission and-- which became effective for inpatient discharges on October 1, 2007. So it's been around for quite a while. And this was a part of the Deficit Reduction Act of 2005. (DESCRIPTION) Present on admission. (SPEECH) It was originally created to identify certain hospital acquired conditions or HACs, resulting in a lower MS-DRG payment in those select cases. However, present on admission indicators are becoming a factor in an increasing number of quality metrics beyond the original use of the hospital acquired conditions. We have been doing some audits with patient safety indicators and present on admission indicators are critical to those, for example, with sepsis, deep vein thrombosis, and pulmonary embolism to name a few. But there are other conditions where we might-- where we find the most opportunity for change. In addition, other quality metrics such as CMS mortality and readmission measures, and the Elixhauser comorbidity index are using POAs in their measurements. For the other quality reporting organizations such as Vizient, Premier, and Healthgrades, to just name a few, the POA Indicator may impact on the risk adjustment or exclusion criteria. We don't know for sure how it impacts because this information is proprietary, but we are hearing observations from our clients that it may impact such as with the do not resuscitate. (DESCRIPTION) Alphabet blocks read, Y N U and W. (SPEECH) Here are the POA indicators that are available-- yes, no, unknown, and clinically undetermined. The next several slides are going to discuss the indicators in more detail. However, it is important to note that typically, in the quality metrics reporting, the POA indicators of Y and W are considered present on admission, and therefore, not counted against you, where the POA indicators of N and U are not considered POA, and included in the quality outcome score. So when I realized that some coding professionals and CDI specialists may inadvertently assign the POA indicator for yes to all the diagnoses after they code the entire record, and that how-- it just may become like autopilot for them to do this. So changing the practice and probably clicking on each present on admission indicator just after the code is assigned to make sure that it's-- you've gotten the correct POA indicator is probably a better practice so that you can be able to keep up the accuracy of the POA assignment and help with the inclusion or the exclusion of the case inequality metric. (DESCRIPTION) A green block reads, Y. (SPEECH) So let's quickly review through the POA indicators. The present on admission indicator of Y for yes is typically the most common POA indicator assigned. It means that the diagnosis is present at the time the order for the inpatient admission occurs. It also includes any condition that develops during the outpatient encounter, such as the emergency department, observation, and outpatient surgery prior to the inpatient admission. So building on what I said earlier, if a patient was converted to the inpatient status from the observation or outpatient surgery, the POA indicator on that diagnosis would be yes for that condition. And please notice again that I did say it was at the time the inpatient admission order occurs. So just because something happens in the emergency department, you have to look at what time was the patient admitted, because the patient may still be in the emergency department when something happens. And so you need to see, did it occur before or after that inpatient admission order happened? (DESCRIPTION) A blue block reads, N. (SPEECH) The POA indicator of N for no is assigned when the condition develops after the order to the inpatient admission. Using POA N is essentially saying the condition developed during the hospital encounter. And if that is the case, then it needs to be reported as such. However, if that is not the case, reporting it as not present on admission may have a negative impact to the facility. (DESCRIPTION) A lighter blue block reads, U. (SPEECH) Although the POA indicator of U, which stands for unknown is an available option, in my opinion, U should stand for unacceptable. In my opinion, no diagnosis code should be build with the POA indicator of U. Instead, prior to the final coding, the provider should be queried if the documentation is unclear, vague, or inconsistent. (DESCRIPTION) Text, please clarify if condition was. 3 options listed. (SPEECH) This is an example of a query for a confirmation of the POA status. The query is simply asking if the condition was present at the time of admission, developed during the inpatient stay, or if the provider is clinically unable to determine if the condition was present on admission. (DESCRIPTION) A purple block reads, W. (SPEECH) Because establishing the POA indicator is not always straightforward with some conditions, the provider may legitimately answer clinically unable to determine, which goes to the POA indicator of W. W-- the POA of W is based on the provider's clinical judgment. This POA designation should be based on explicit physician documentation of such in the medical record or in response to a query regarding the POA status for a diagnosis. The coding professional cannot make the decision on their own that the diagnosis was clinically undetermined. (DESCRIPTION) Text, POA indicator based on provider documentation. (SPEECH) Documentation from any provider involved in the care and treatment of the patient may be used in the POA assignment determination. This documentation may include signs and symptoms documented by the provider at the time of admission, the POA assignment may also be based on a culture or lab value obtained at the time of admission, with the diagnosis established after study. However, the POA assignment may not be based on non-provider clinician documentation, such as nursing documentation, regardless of when it was documented. However, this information can be used in a query to the provider. For example, if the initial nursing assessment included a stage three sacral pressure injury, but the provider did not document the diagnosis and tell the discharge summary, the provider could be queried for the POA status, using the clinical information from the initial nursing assessment. (DESCRIPTION) Before and after table. Case example. (SPEECH) So here's an example with a recommendation for a query of the POA status of pulmonary embolism. This was a patient admitted with an infected arterial venous fistula. The patient was noted to have an internal jugular thrombus on admission. On hospital day five, the patient had a CT scan, which was performed due to the abdominal issues which incidentally found a pulmonary embolism. The discharge summary noted, "Pulmonary emboli due to non-compliance. Patient is a poor candidate for Coumadin. We will place her on Eliquis." Since this patient was noncompliant with medications on admission, and the PE was incidentally found, and there was a presence of an internal jugular thrombus, it would be appropriate to query for POA status of the pulmonary embolism. In this case, the pulmonary embolism was present on admission. If-- I'm sorry. If the pulmonary embolism was present on admission, it would eliminate PSI 12. Now, remember, each case has to stand on its own merits. So you're looking at, at each individual case, what were the signs and symptoms? What were the circumstances for testing? What was the documentation? What was going on with the medication? So look at everything on each individual case. (DESCRIPTION) Text, Clinical validity. (SPEECH) Moving on to our next topic of discussion, which is clinical validity. Although it appears we are discussing the code assignment of a diagnosis, this topic really goes beyond the coding process. (DESCRIPTION) Impact of clinical validity on quality. (SPEECH) It is important to clinically validate certain high risk diagnoses or complications because we do not want to over report them, which may impact PSI, HACs, or PPCs. In addition, it may falsely elevate the expected rate in some of those quality metrics as well. (DESCRIPTION) Text, Official coding guideline. Code assignment and clinical criteria. (SPEECH) Now shown here is the official coding guideline related to code assignment and clinical criteria, sometimes referred to as guideline 19. For coding purposes, code assignment is based on the provider's diagnostic statement that the condition exists. As I have stated many times, code assignment is based on the provider's documentation. It is not within the coders responsibility to determine that the diagnosis did not meet clinical standards. Now, that's the information that's put into the coding guidelines. The code assignment is not based on clinical criteria used by the provider, and the provider statement that the patient has a particular condition is sufficient. Once again, that's from the coding guidelines. (DESCRIPTION) Flow chart. (SPEECH) That being said, it is absolutely necessary to clinically validate the diagnosis prior to final code assignment. Facilities need to validate that the documentation appropriately reflects the patient's clinical condition. Although the clinical validity process is a separate function from the coding process, coders need to be trained to recognize when a diagnosis may not meet clinical validity, so that they can escalate the review to the appropriate person. Providers, CDI staff, and coding personnel need to work together to ensure the clinical evidence, provider documentation, and code assignment are aligned. If a provider's documented diagnosis does not appear to meet clinical criteria, additional documentation from the provider is necessary. That additional documentation may include supporting evidence for the condition, or it may state the diagnosis was ruled out or not clinically supported. The coder cannot simply omit coding the diagnosis if it does not meet the facility's clinical criteria. And there's some good information in coding clinic 2017 fourth quarter, and also 2016 fourth quarter for some information on this topic. (DESCRIPTION) Before and after table. Case example. (SPEECH) So here's an example of a clinical validity recommendation for a post-operative pneumothorax. You'll see that this patient was admitted with septic shock secondary to UTI and an obstructing stone. The patient underwent cystoscopy with stent placement. The chest X-ray on hospital day two, after the procedure, included suspicion for small left pneumothorax. Repeat chest X-rays, which stated, "No definite pneumothorax is identified." And then another repeat chest X-ray stated, "No evidence of pneumothorax." The chest X-ray for the next day did not mention anything about pneumothorax. The progress notes on hospital day three stated, "Left apical pneumothorax. Doubtful pneumothorax resolved." Pneumothorax was originally coded with POA N, resulting in PSI 6. We recommended a clinical validity review of the pneumothorax, in this case. And if the pneumothorax was not confirmed, then this case does not qualify for PSI 6. And at this time, I'd like to turn the presentation back over to Sue to discuss our final topic. OK. Thank you, Audrey. So I'll be wrapping up with discharge disposition. (DESCRIPTION) Discharge disposition compliance. (SPEECH) So the discharge disposition is the code that identifies where the patient was discharged to at the end of their hospitalization. So patients can be discharged to home, they can expire, they can be transferred to another acute care facility to name a few examples of discharge disposition. And I think that most of us who work in the coding arena and the inpatient setting are very familiar with discharge disposition. So as mentioned before, some of the components of discharge disposition may impact PSIs, CMS's mortality, and readmission measures, as well as other quality reporting organizations metrics. So it's very important to correctly report the discharge disposition. I would also be remiss if I didn't mention that there's also a compliance aspect to reporting the discharge disposition. I'll spend a few minutes talking about CMS's acute care transfer policy, as well as their post-acute care transfer policy. So-- but first, let's talk about capturing and reporting the discharge disposition. Obviously, this can't be identified and reported until the end of the patient's hospitalization when it's known how they're going to disposition. (DESCRIPTION) Table. (SPEECH) Here are some examples of disposition code. I think I-- one of the slide had some disposition code choices. (DESCRIPTION) Quality metrics using discharge disposition. (SPEECH) Patient went home. They went to rehab. They died. Or they're going to home health care. The discharge disposition code is entered into the registration system. And what is a little different here from some of the other components we previously talked about today is that the inpatient coding professional, who performs the final medical coding after discharge, is usually the person tasked with validating that the discharge disposition is correct, or updating it in the system if it's not. And that sounds easy enough, but I can assure you that that's not. So before joining 3M, I spent many years as a coding manager. And one of the recurring challenges we faced in coding was making sure we got the discharge disposition correct. It was not uncommon at all to find conflicting documentation about the patient's disposition in the medical record. One note may say that the patient was being discharged to home. Another note or maybe case manager or social worker note might say that the patient was going to rehab. And a third might say the patient was going home with home health care. So we had to develop a process with our case management department because typically, case management departments and organizations have the best handle on what's happening to the patient post-discharge. That resulted in us receiving a daily 20 to 30 page fax of patients who were discharged the previous day, and their correct discharge disposition. And then we use that list to update our coding extracting system with that discharge disposition. So when the coding professional finished the case and sent it to the claim form, it would automatically be updated. (DESCRIPTION) Quality metric and facility table. (SPEECH) So I wanted to talk about the quality metrics piece. So mortality outcomes are attributed to the admitting hospital. And in cases of transfers, the sequence of hospitalizations is treated as one episode of care. And the admission and associated outcomes are attributed to the first admitting hospital. So for example, if a patient is admitted to acute care hospital A, and then transfer to acute care hospital B, the admission and the associated outcome-- by outcome, meaning, they survived or they died within 30 days-- is attributed only to hospital A. For readmission measures, if the patient left against medical advice as a discharge disposition, that record is excluded from the measure. And then for other quality organizations, we know that discharge disposition is used in risk adjustment and/or exclusion criteria. So again, we've mentioned the intricacies of the quality metrics. And this is definitely in that same vein. And you think about everything being attributed to hospital A, and it's concerning, but that is the methodology today. So the acute care transfer policy. I mentioned the compliance aspect of discharge dispositions. Under the acute care transfer policy, Medicare makes full MS-DRG payments to inpatient perspective payment systems, IPPS hospitals, when the patient is discharged to home or certain types of health-- other types of health care institutions such as patient discharge status code of 4, which means the patient is going to an intermediate care facility. I don't want to really get into the weeds about this policy-- this webinar. And I've summarized it or tried to simplify it, if you will, on the screen. But please know that this is far more detailed and complex than you see on screen. And the bottom line is that an incorrect discharge disposition may lead to incorrect payment for the organization. And this would become a compliance issue that would need to be rectified. So in addition to quality metrics, which is our focus today, you know what? There's also this other big important thing that discharge dispositions support. (DESCRIPTION) Text, Post-acute care transfer. (SPEECH) I also wanted to mention the post-acute care transfer policy. A post-acute care transfer occurs when a patient is classified to one of a group of specified MS-DRGs, and the transfer occurs to one of the facilities listed here on screen. So when this happens, the transferring hospital is paid based on a per diem rate up to an-- including the full DRG payment. The final discharging hospital or facility or agency is paid based on the full prospective payment rate, which may include a cost outlier, if applicable, and a special payment post-acute transfer occurs, and a special pay DRG resulting in the transferring hospital being paid 50% of the payment and 50% of the transfer payment. So suffice it to say, again, intricacies here. But if the discharge disposition is incorrect, payment to the facility will be incorrect, and again, a concern for a compliance issue. (DESCRIPTION) Before and after table. (SPEECH) So just a quick look at a discharge disposition example. So in this particular case, a patient was admitted for a malignant small bowel obstruction due to peritoneal cavity metastasis. The discharge disposition was reported as home, that the patient went home. However, the discharge summary stated, "Discussed with cancer hospital liason. Patient will be transferred this evening as there is a bed available. Disposition, transfer to cancer hospital for higher level of care." Based on this documentation, we recommended revising the discharge disposition from home to the discharge disposition for another institution, in this case, a cancer hospital. OK. At this time, I will turn this over to Audrey to wrap up. Audrey. (DESCRIPTION) Key takeaways. (SPEECH) Thank you so much, Sue. And so what are the key takeaways from today's presentation? As you have heard from this presentation, these minor abstracting-- what we call minor abstracting items may have a major impact on quality outcomes. However, we cannot really call these minor abstracting items. They are very important and ones that should not be overlooked. We recommend incorporating these five components into your daily auditing process. The audit may be a coding or DRG accuracy audit, compliance audit, or a quality audit. To ensure the accurate and consistent application of some of these components, it is important to review the definitions with those involved, those who would initially capture the information and those who are validating the information. Then it is important to create a process to correct the inconsistencies. Finally, it's necessary to establish a clinical validity review process. Work with your medical staff to develop clinical criteria for these high impact diagnoses. But remember, you may still need to obtain additional documentation when the provider documents a diagnosis, and it does not meet the facility's established criteria, either to support the diagnosis or to eliminate it. And then thank you so much for your time and attention today. At this time, I'd like to turn the presentation back over to Lisa. And let's see if we have any questions that have been posed. (DESCRIPTION) Q and A. (SPEECH) Great. Thank you, both Sue and Audrey. We do have a lot. So we will get to as many as we can. A couple of questions that did come in was about the recording. If there's going to be a recording, and if there's a handout. So before we get to Q&A, I just wanted to answer those real quickly. So in a few weeks, we will be adding this recording as well as all of our other quality and CDI innovation webinars. They're all on our website. So in the next few weeks, this recording will be there. So be sure to check back for that. And then a couple other questions were about is the presentation available for download. And it is-- it's in the Resources section under, I believe, I call it Handout. So that is the presentation for today. So you can download that as well. And lastly, the certificate of attendance is in there too. So make sure you-- while we're answering questions, go into the Resources section, and you can download those PDFs. All right. So let's go ahead and start with questions. Our first question is, is it possible for a condition designated as W to be the principal Dx? I'll take that one. Yes, it is possible. W, remember, means clinically undetermined. So the provider has told us that they cannot clinically determine if it was present on admission or not. And I know it does seem strange for a W-- a condition that would have a W as the POA indicator to be sequenced as the principal diagnosis. But it is allowed, it can happen, but it should be extremely rare that it happens. Some of those times could be the sepsis, because sepsis is sometimes difficult to find out when it occurred. And you may have queried the provider to find out, was this present on admission or not? The physician is not able to really state. But that is the condition that necessitated the inpatient status. So it is possible to put a W as the POA indicator on the principal diagnosis. There's nothing that does not allow it. It's just going to be rare. And I'm not advocating for it to be your principal diagnosis. But it can happen. All right. Our next question is, what is your point of view adding condition was evolving at the time of admission order when, specifically in sepsis as query response option? So I believe this is saying like the POA status, basically, of this condition. And they're saying it's evolving at the time of admission. Because I'm getting documentation like that from the provider, it does indicate that it was present on admission. I believe the physician is trying to put as much information that they know clinically about this. They're not willing to wholeheartedly say, yes, it was present on admission, but saying that was evolving at the time of admission means that it probably was there at the time of admission. And I, personally, would put a POA Yes for that type of a condition. Sue, do you have any additional thoughts? No. I think you answered that how I would answer it. All right. A couple questions did come in about CEU. So I do want to pause on that real quick. So the certificate of attendance that we provide can be submitted to an accredited association. And so whether you want to submit it at AHIMA or ACTIS. For CEUs, you can. And that's what that certificate of attendance is for. We don't actually provide the CEU. You provide that certificate to one of the accredited associations. So hopefully, that answers some of those questions. All right. Let's go to a question from Sarah. Are all patients admitted from ED, urgent or other? I'll take that. So I think it's-- if a patient is being admitted through the ED, they would be urgent or other. But I would say, you should go back to your patient registration department to see what type of guidelines they follow or they have to follow. I mentioned the job aids, what is their policy. There might be some extenuating circumstances where it might not be urgent or emergent. I can't think of what that might be at the moment. I also would say that with this situation, more and more nursing is involved in the determination of what is the patient's status as well, and more and more nursing is involved in the bed placement process in hospitals today. It's a partnership with patient access. So a lot of the policies or decisions may be made by the nursing people responsible to work with patients who are being admitted to the hospital. So it just stands to reason if you're coming through an ED, would be urgent or emergent. But there could be some other reason that they wouldn't be. So I would say, go back and check with your organization. Great. All right. Let's go to a question from Sandra. If a patient is admitted from an assisted living facility, what would be the point of origin? So I-- unless there's something specific for assisted living facility, it would probably-- oh, good. Thank you for going back there. Let's see. (DESCRIPTION) Point of origin table. (SPEECH) I'm going to wager, it's probably one. But Audrey, do you have a thought on that? Well, I see for the value 5, that assisted living facility is added-- Oh, there. --into the-- OK. There you go. OK. Yeah. It's a non-newborn admission transferred from a skilled nursing facility, ICF, or even the assisted living facility or others. So I think that would capture a lot of those how they're coming into the facility. All right. Another question about patients at home on hospice. What is their point of origin? Now I do see that F is transferred from a hospice facility. But I think if they're on home hospice, that that would be a non-health care facility point of origin, because they are coming from home. I think the intent of this is where are they really coming in from? They want to know, was it a facility or not? I do see on here that the home health agency was officially retired in 2010. So I'm thinking 1 for the home hospice. And I see that we also loose a question there about the point of origin for an LTA. So that's a long term acute care hospital. So I'm thinking that it might be 4, because it's long term acute care. And I don't see another specific listing like in 5, for example. (DESCRIPTION) Text, 4, Transfer from a hospital, different facility. (SPEECH) All right. Our next question is, are you saying there wasn't enough documentation on that surgery-- so this will probably be referencing one of our earlier slides going back-- on that surgery report to use that complication as the primary diagnosis, or we should query it-- query if we feel the connection is not made clear enough? (DESCRIPTION) Before and after table. Colon perforation. (SPEECH) I think, on this particular example, and basically, on a lot of these types of cases. And once again, each record stands on its own merit, that it is better to query to get the provider to answer the question, why was the patient converted to the inpatient status? It's-- the providers are not always clear on why the patient was switched over. And I think that that either querying or even having some verbal conversations or education to the physicians-- to the providers to say, please document the reason why the patient is becoming into the inpatient status. That will help be able to prevent any denial-- or well, help to assist in any denials or any rebuttals to denials. So that's why it is always best to query when the documentation is not clear why it's coming in. It did seem like-- I mean, this one was a good example where we almost had enough documentation there to be able to support it without a query, putting the POA of yes, and that was the reason why they're coming in. But going back to what I was saying, that different payers have different rules regarding observation and when they're going to count the observation to-- or the admit date be before-- at the point of observation or is it going to be after the observation status. So I think that's always good too to be able to get that documentation in there to support what's going on. And then you can still work with what was the actual admit date for that payer. And this could be one of those task force meeting to be able to find out some of the rules and guidelines regarding different payers and working with physicians, and getting that documentation to be able to help support what would be the admit date, and then-- so you can establish your principal diagnosis. All right. So we probably have time for one more question. And I know it's tough to scroll through all of them. Audrey or Sue, is there one last one that you think would be a good one for us to get to? And while you're looking, there was a question about AAPC CEUs. I, unfortunately, do not know that answer. We recommend either-- oh, go ahead, Sue. Yeah, I was going to say, AAPC typically requires organizations to have prior approval, and their specific code number assigned to the certificate in order for you to submit it. So my recommendation would be that you contact AAPC, and ask them if they will accept this without prior approval. So that's up to them. They're usually pretty specific, unless they've changed recently. Perfect. Thanks, Sue. Yeah. Was there a question that you were wanting-- Well, I just-- --from the audience? I think there's a question here about the patient who was transferred to the cancer facility. And the question is, what happens if there is-- there's a days delay for the patient to be transferred to the cancer facility because of no bed. So if-- I guess, if the patient goes somewhere else, if they go home and then they're going to be admitted from home to the cancer center, then the discharge disposition would be home. It doesn't indicate-- I mean, they said, would they need to document discharge to home? I mean, I think, you could say patient is going home to be admitted to cancer hospital. One bed available. If there's some-- that sounds like a very specific kind of situation. And a lot of these questions are very specific kinds of situations. You might need to do some investigation on that on your end. (DESCRIPTION) The Q and A slide reappears. (SPEECH) And then there-- I agree with that. I was to go on to another question in here that, please review what 3M has to offer for coders to identify PSI prior to bill drop. There is a-- in 360, there's a flag in CRS plus that you'll get a flag if there is a PSI on the case. So that is some of what 3M has identified to be able to flag if PSI. All right. Great. Well let's go ahead, since we are just about at time, and this will give everybody time to take a quick break before they're on to their next thing for the day. As a reminder, the handout is in the resources section as well as a couple other resources in there. There are links to our upcoming boot camps. We encourage you to click on those if you are interested in getting more information about that. And we will have one more-- oh, what month are we in? September, October, November. Yes. We will have one more quality webinar this year that we will send communications out on that. If you are interested in registering for those, we always appreciate you joining. We had a very large number today, which is great. This is such an important topic. So we certainly appreciate your time as well as the information from Sue and Audrey. We are getting comments in about how informative it was. And so we know this will be something that people will want to go back and listen to. So make sure you do check our website here in the next few weeks. And we also have, coming up in October, our CDI innovation webinar. So if you are interested in that, you can certainly register for that as well. And so again, we appreciate all of your time today. We appreciate the information. And if you have any questions, please feel free to reach out. And again, thank you to both Sue and Audrey for today. And we will talk to you all in November. Thank you very much. Thank you. (DESCRIPTION) Text, 3M Education boot camps. Virtual advanced CDI training. The advanced CDI training week offers comprehensive CDI education addressing fundamental CDI skills and the clinical and coding concepts behind many key major diagnostic categories. This training week is a crucial starting point. Upcoming advanced CDI training week. November 1st through 5th. Virtual advanced quality training. Discover how CDI, coding and quality efforts can impact the quality of care across various value-based purchasing initiatives. The. quality training is a great followup to the Advanced CDI training. Upcoming Advanced quality training weeks, November 15th through 19th.

(DESCRIPTION) A 3M Web Page, Text, New year, new webinar platform! 3M Quality Webinar Services. (SPEECH) Hi, and good afternoon. Thank you for joining today's July quality webinar. We're going to get started here in just another minute. A couple emails are coming through that a couple of people aren't able to join so I am just getting some of these emails out to a few people, sending them a different link. And hopefully, they will be able to join. So we'll just give them maybe a couple extra 30 seconds to join, and we'll get things started. All right, let's go ahead and get started. Hopefully, the ones that weren't able to join will be able to join here soon. Again, welcome to the July CDI-- oh, I'm sorry, July quality webinar. I'm losing track of months. (DESCRIPTION) Evolution of CDI, Part 2: A new frontier, the emergence and growth of outpatient CDI. (SPEECH) As we kick off our part two in this series of the evolution of CDI. Before we get things started, I just wanted to go over a couple of housekeeping items. This is a new platform so if you joined us last year and haven't joined us yet, you'll see that we have a new platform with a lot of new features. It's definitely more interactive, which is great. So you're able to minimize and bring up those different sections if you want to. If you do need closed captioning, you can get that into the media player. If you are having any issues with audio, check your settings. You will join via your computer, not a dial-in information. Again, you have the ability to move these sections around, making it a bit more interactive. We certainly encourage questions. You can put that in the Q&A section of the dashboard. We'll get to as many as we can at the end. We do offer a certificate of attendance, and that is in the resources section. There's a bunch of resources in there. That's the handout, the certificate of attendance. If you do want to go back and listen in to the part one from May, you can click on it there all in the resources section. And we always appreciate at the end if you can complete the survey, just to let us know how we're doing. We have a great group of speakers today, with Colleen Deighan, Chris Berg, and Richard Wetherbee. And so I'm going to pass it on over to Colleen to get us started. (DESCRIPTION) Text, Meet our speakers. Photos of each speaker appear with bios. Chris Berg is an Outpatient Consultant with 3M H,I,S Consulting and has over 30 years of experience in Health Information Management, including extensive experience in outpatient coding, documentation integrity, and health care compliance. Colleen Deighan is a consultant with 3M Health Information Systems, where she provides advisory services on outpatient CDI, clinical coding and revenue cycle management to 3M clients. Richard Wetherbee, M,S, BSN, RN, is a Registered Nurse and currently works for 3M Health Information Systems as a Process Improvement Clinical Consultant. (SPEECH) Thank you, Lisa, and good afternoon, everyone. We are very excited to talk to you about this topic. I know I speak for myself, Chris, and Rich. We've been preparing this talk to you and anxious. We're all three of us very interested in this topic. So just quick agenda items that we really want to talk about the impact to your CDI programs. We definitely see many inpatient CDI programs expanding into the outpatient area. So what are some of those impacts? Talk about how to effectively implement an outpatient CDI program. There's definitely some differences, obviously, between outpatient and inpatient CDI so talk a little bit about that and close with some lessons learned. So we really want to make this informational, and we encourage you to ask questions. We're going to leave some time at the end to really address some of our questions we find sometimes in our surveys that that's a common question. Response is wish we had more time to go through the questions so we definitely want to dedicate some time. So we're just going to go ahead and get started here. Lisa did mention part one. So this slide here is from Cheryl Manchenton's part one evolution, which again, was from May of 2022, just a few months ago. And Lisa did present that link in the resources if you haven't had an opportunity to listen to that. You can definitely do that on demand at any time, and it's a really good informational session, as well, around the journey. And one of the questions here was presenting was where do we go from here so I really think this particular slide of her sets the table for us as we go through those waves there around that initial CDI program that goes way back to around 2000. So 20-plus years CDI, starting in the DRG assurance arena, has been around and just really, again, that financially based, that generational waves as we moved into the severity of illness, risk of mortality in our APR DRG world, expanding into looking at severity of illness and clinical validations. And then she talked about in phase four really a full comprehensive CDI program with mortality reviews with a look at patient safety indicators, hospital acquired conditions. Even we see maturation of some programs focusing on HCCs as part of that inpatient concurrent review, just really more around documentation integrity than documentation improvement. So the term CDI started out as Clinical Documentation Improvement. I think it was in 2019 we saw ACDIS and AHIMA adopt that word integrity. And then Cheryl talked about phase five, which again sets the table for what we want to talk about today in the outpatient arena on really just a comprehensive review of documentation in all care settings and, again, expanding into just not necessarily impact to the case but overall integrity of the documentation. (DESCRIPTION) What is Outpatient CDI? Outpatient definition source, medicare dot gov. And Clinical Documentation Integrity, CDI, a-h-i-m-a dot org. (SPEECH) So this is a good question. We've tossed around a lot internally. So what actually is outpatient CDI? So I put up on here, first of all, Medicare's definition of outpatient. So this comes from a Medicare website to its beneficiaries. So they define for their beneficiaries what it means to be an inpatient, which means you have, as we all know, a formal order from your doctor to admit you to the hospital. And the time you're in the hospital till you're discharged, you're considered an inpatient. And then there's outpatient. So if you look at what's there-- so it's really everything else. And that adds to some of the conundrum of outpatient CDI. So whether you're in the emergency department having observation services, seeing a physician in the clinic, having a diagnostic radiology test, or an outpatient surgery, or an endoscopy, all of those services certainly can happen during an admission. But if your doctor hasn't written an admission order, you're considered an outpatient. And CMS even adds the caveat that even if you spend the night in the hospital doesn't necessarily mean that you're admitted. So I think I like to define outpatient because it really helps to really, for me, talk about so many different areas that the Clinical Documentation Integrity program can go or focus on in the outpatient setting. And then we look at the definition of CDI. So what I really struggled with was finding a definition of outpatient CDI. Does the industry have a definition for outpatient CDI? So we start with essentially what Medicare says is everything other than an inpatient is considered outpatient services and just the wide breadth of those services. And then the CDI program really focusing on the accuracy, the completeness, the preciseness of the documentation that accurately reflects a patient's disease burden and the services provided to that patient and then how that data then, which we always said whether it's written with an ink pen, it's keyboarded, it's -- scribed, it's dictated, all that translates into coded data that then translates in and used in so many different areas, a few of them listed here, such as reimbursement, public health data, disease tracking, and so on. Chris, anything that you think about when we think-- we tried and really struggled with kind of finding a definition of outpatient CDI for the industry. We did. We looked at different websites, looking at also ambulatory CDI as it's also called. It is going back to those documentation integrity specifics of being clear, consistent, complete, what we see on the inpatient side, transferring that into the outpatient arena. And again, I think that arena, that funnel is so huge. That's really what some of the things we want to talk about here today as we get into this. So we're going to-- I'm going to turn it over here to you, Rich, to ask our first question. Great. Thank you, Colleen. Good afternoon, everyone, or good morning, or good evening, depending on where you are today. My name's Rich Weatherby, registered nurse, 3M clinical consultant. And today's first question is, do you currently have a dedicated outpatient CDI program within your organization? Please trigger yes, no, or unsure. And we'll give you a few seconds to do that right now. Yeah. I think that we see a mixture of responses when we ask this question. I think there's still a lot of chatter about outpatient CDI. I think a lot of people say we should be doing something, just not really sure where to start. I'm a proponent of that inpatient CDI team. Under that leadership, developing an outpatient CDI team within that same leadership structure. And I think, again, we see, whether it's an ACDIS poll, an AHIMA poll, a 3M poll, this is a common question we like to ask just to see what's going on in the industry because this pulse is-- even though it's been around for a while, it's still sort of a new concept to a lot of folks. Especially [INAUDIBLE]. Colleen, we have over 700 folks and attendees today. And looks like we're tallying up to close to 400 responses. So why don't I segue towards what that response looks like? So with respect to-- go right ahead. No. Go ahead, Rich. Here's the answer. The question again is do you currently have a dedicated outpatient CDI program within your organization. And 31 and 1/2% said yes. 55% said no. And unsure at 13.4%. So that's a great stock for us. So why don't we move us forward? Yeah. So just one comment on that. I think, again, it's good to see all three of those responses, because I think, again, we hope a lot of you are here to think about CDI and some of the information that we have. So go ahead with poll question number two there, Rich, please. Here we go. So if you do not have an outpatient CDI program, are you considering implementing an outpatient CDI program in the next 12 months? Again, the answer is yes, no, or unsure. And one of the things that I have in here is the survey, so ACDIS, the Association of Clinical Documentation Integrity Specialists, of which I am a member-- Chris is a member. I'm sure many of you listening in are members. They have a CDI week in September. So I have some of the data around a similar question here of what we saw. There's still a lot of people thinking, again, I know I need to do something. I'm just not sure really what to do. So just curious to some of the responses here around-- and maybe you're not sure as you're listening. We know not everybody is a CDI specialist listening in. But if you know within either your planning or within your organization, you're hearing anything about outpatient CDI. And as we give folks a couple more seconds, we asked in the next 12 months because it is a time consuming process. There's a lot that goes into it and on top of all the other initiatives that may be going on. But it gives us a key ballpark figure with these responses. So I'm going to move us forward. And we have about 250 responses here. And here we go. 22% said yes. 24% said no. And 53.3% are unsure if whether or not within the next 12 months they'll be implementing a CDI program. (DESCRIPTION) What is driving the need for Outpatient CDI? Like inpatient clinical documentation, outpatient and professional services documentation is important to the quality of care, reimbursement, population health and overall success of the healthcare industry. Who are the users of outpatient clinical documentation? Providers, public health agencies, payers, pharmaceutical industry, government organizations, non-government organizations, health systems, researchers. (SPEECH) Well, then again, those of you that, again, this was a caveat of 55% that said, no, we don't have a current program, what percentage of those were a yes And whether, again, you've got some plans or you don't have any plans. Hopefully, you'll learn something today that maybe will get your organization moving forward on this. So thank you again for our poll questions. We do have one more in just a moment. But I think that's, again, it helps us understand our audience and who's listening. And so we appreciate those that did respond to those. So again, the need is pretty diverse. But just like inpatient documentation integrity that we've been doing for 20 plus years I've been involved in CDI-- I'm not going to lie. I've been around since the paper days of 2000. Those first days of DRG assurance is what it was called with paper books, and paper DRG worksheets, and going up to the floor and reviewing documentation so this is long before the electronic medical record, but that same impact that we need in both the outpatient areas and professional services for quality of care, payment, population health. And really the industry itself, we see the shift from inpatient and outpatient and the shift from fee for service to value base. And really sort of the physician space is kind of the last base of that when we think about DRGs in that perspective. Payment model APCs of 2000 ambulatory payment classifications of CMS is another prospective payment model for outpatient facility services. And then some of these risk-based plans that we see organizations and physician practice entering into is also a prospective model so that overall success of not only population health but the industry itself. So I have a textbook that I actually-- there's an AHIMA book. It's called Clinical Documentation Improvement for Outpatient Care. It was written by Pamela Carroll Hess. It goes back to 2018, which I think is when you search either ACDIS or you search AHIMA, which are two big industries for documentation integrity coding, there's a lot of information that starts around 2015, 2016. There was discussion for the case for outpatient CDI, how the time is now for outpatient CDI, what to consider. So it's been a conversation for the last six or seven years. Still seeing a lot of us hearing about it for the first time, a lot of us still doing that discovery. But I think this textbook identifies these important areas. And we talk about providers and this need for documentation Integrity in the outpatient setting for, again, the same when we think about all that journey of 20 years of inpatient CDI and the success of those programs for organizations. When we go into the outpatient area, the physician clinic area, identifying providers using documentation for disease process, for treatment option, even collaboration of care, and the public health agencies for tracking informational diseases, infectious disease type. Other public health issues are payers setting a lot of payment policy, the pharmaceutical industry, government organizations. When we think about the Department of Health and Human Services, the Office of Inspector General, all of those, they have the same sort of CMS initiative to secure the Medicare Trust Fund, so fraud and abuse, a lot of this data integrity used in those different types of programs and certainly research, health systems utilizing this information for strategic. So we're only as good as the documentation in the record. Right. So we've talked about that for a long time on the inpatient side. So I think it's an important driving force here as well. So we're going to go on to our last question here. All righty. So this last question. For those of you with active outpatient CDI programs and/or planning for an outpatient CDI, what is your focus area? And these are our choices. ED/observation surfaces, E and M accuracy, HCC diagnosis capture, medical necessity, denials management, or other. Please take a few minutes. We'll tally them up. So in our first poll, there was about 33%, 34% that said they did have a dedicated outpatient CDI program. So those are the folks are-- even those that are again thinking about it, planning something, have you thought about where do I want to start or where did I start? And that's what we're trying to get at here. These are some top ones and not all of them. That's why we added the other bucket. But this is some of the common areas that we see initial focus on the CDI program in the outpatient setting. I think it's also important-- Yeah. We didn't put them in any relevance order. I did want to say that. I was going to just add that I think it's also important with all these choices as you're planning, the consideration-- and we'll get into this a bit more. You don't want to boil the ocean. That's for sure. But with respect to a specific area, this kind of gives you some key opportunities here. Yeah. And maybe some of you have heard that second item there, E and M accuracy, we do know some folks do focus on that. Certainly in 2021, there were some changes to the office E and M category, significant changes. First time in 25 years that there were changes made to those. And they were really around focusing the physician into more of how to intuitively care for patients with the medical decision making component. So we're going to see some changes again in January 2023 when the fiscal year for the outpatient or the amulatory setting and the physician fee service setting. So ED, observation, hospital inpatient services are undergoing those same changes we saw last year in 2023. So again, potential area of focus for many different reasons around the accuracy of that E&M or what some people refer to it as the E and M bell curve selection of the acuity of the patient. So interesting thought there. Yeah. Go ahead and read those off, please, Rich. Here we go. For those of you with active outpatient CDI programs or a plan of an outpatient CDI, what is your focus area? ED obs services, 14%; E and M accuracy, 13%; HCC diagnosis capture, 38%; looking at medical necessity at 13, almost 14%; denials management at 9.2% is the lowest percentage at this point and other at 10%. (DESCRIPTION) Text, A-C-D-I-S 2021 (September) CDI Survey. Question 27, Outpatient CDI Expansion, year over year. 29, Primary outpatient review focus. (SPEECH) Yeah. That's some good information, which takes us to the survey. So I clipped this out of the ACDIS 2021 CDI survey. So during CDI Week for the Association of Clinical Documentation Integrity Specialists or ACDIS, this survey-- I have actually last year's survey. They put the 2020 data into one of their questions. So this is a multiquestion survey. It's actually going on right now for 2022 which will be, again, revealed the findings in the September CDI Week. So interesting. I know for 2021, there were close to 1,000 people that responded, ACDIS members, to this survey. So it's a pretty robust survey. And I was really interested in outpatient CDI. So the question was around have you expanded into the outpatient arena. So interesting to see the '20 to '21 data there around, yes, we have a standalone. Yes, my inpatient CDISes or me as an inpatient CDI specialist, I do look at some outpatient records or, no, we don't have any plans. Yes, we're planning. So not a lot of shift in those. I think there was a shift-- we see about a 4% shift between, yes, we have a standalone or, no, we don't but we're planning. So that 20. So still when you think about that, we have 45% of the listeners in that particular survey, which is pretty similar to what we see here, really don't have any plans to really do anything with CDI and some that are working in CDI. This is a little lower than our percentage that we asked our listeners today. But then I think we don't but we're planning, we don't and we're not planning-- those are some of the drivers that are just interesting. I don't think there's a right or wrong answer, but it's just interesting to see. That's really probably the most reliable survey of the pulse of the outpatient CDI industry. And then I purposely put the full question before we showed this slide to question 29 in that survey, which was what is the primary focus. So 39% of our listeners today indicated HCCs. And then you can see from this particular survey and the survey questions, anywhere from 10% to 14% on ours today, whether it's E and M's, it's denials prevention, it's medical necessity, which could be next level of care for patient status, and emergency department and observation. The survey was low. It was 2 and 1/2%. It was 13% when we asked, 14%. And we like the ED obs. We think it's a natural area for an inpatient CDI to expand. So interesting just to see that. So I think, again, it calls to the wide funnel of outpatient CDI and where, again, I don't think there's a right or wrong answer of where you start your focus, just that there's so many different areas that you could really focus your program on. And I think, again, that adds to some of the conundrum about what should I do with outpatient CDI. So we're going to move on. And we've got some questions. Kind of make this a panel interactive between Chris, and Rich, and I. All right. Real quick I did want to mention to those who have joined, there were a couple that made a couple comments in the Q&A about not being able to see the slides. Just make sure you're checking that you are in Chrome and closing out of any VPN. And if you want to do a quick refresh, that might help. But we are going to have this presentation on demand on our website soon so you can always go back and listen as well. As well as a couple CEU questions. We do offer again that certificate of attendance to download. And you can submit that for CEU to associations to ACDIS and AHIMA. OK. So the first panel question we have is to you, Colleen. What are some of the things to consider when expanding CDI into outpatient settings? Thank you, Lisa. So I did work in the industry for a long time at a big academic medical center. I stood up an outpatient CDI program. I've been a director of CDI as well in the past. So I think there's a lot to think about here. But I kind of listed my top four things that I think about around what you should consider. So along with Rich's boil the ocean comment, I always say, first of all, you don't have to have everything figured out to get started. You can just get started. So it's OK to not have everything figured out. I also encourage you to think big and start small. So you really want to have those early wins and start in a small area. I think one of the things that is really important is understand the industry and do your homework on what the industry is saying. Spend those three hours of dedicated learning-- some people like to say 5 hours of deliberate learning a year. Focus on what is the industry saying. Between ACDIS, AAPC, AHIMA, and many other organizations, there's a lot of information, CMS being another one, about the expansion of clinical documentation integrity into the outpatient setting. So really do your homework and make sure then once you really feel like you can confidently speak about outpatient CDI, you want to align where you want to focus to what your organizational needs and strategic goals are. So that talks a little bit about collaborating. But really you want to work in conjunction with what's important to your organization. And that's why I say everybody's different. There's no right or wrong answer, but aligning what you want to do with CDI into what's important to your organization. And I think too, know the differences between inpatient and outpatient. Again, I'm a proponent of an inpatient CDI team standing up an outpatient team. But there are some differences. We're going to talk a little bit about that too but I think just at a high level, just the sheer volume of encounters in the outpatient setting is overwhelming. The timing of the reviews are going to be different. There's staffing considerations. What am I going to measure? What's important to measure? As some of the examples, as part of that research in the industry, and talking to leadership within your organization, and being prepared to know what am I getting myself into so to speak. And then certainly, senior leadership support is really important to help drive this forward from your starting point. And Chris, anything you would add to what I said there? Just that, again, it's not a one size fits all. And outpatient CDI is new compared to inpatient CDI. So if you start in one area and don't feel that that is an area that you're successful at, there are other areas to choose from and to consider when looking into an outpatient CDI program. So don't fix yourself into a box. There are other opportunities. Yeah. Anything, Rich, from you on that? Yeah. You know, I like to always consider the patient first. It's one full contiguous circle of care, the transition from walking through-- whether it's a PCP office, walking through an ED, from disposition of the physician of record, whether I'm an ops status, or whether I'm going to an inpatient unit, and whether I'm discharged in a timely manner. I consider the fact that why would I want to work toward an outpatient program if I have a viable inpatient CDI program. So I think about the patient experience and how achieving a quality driven program will reflect not only on patient outcomes, not only on ROI, but on your organization's overall rankings of quality measures, public opinion, and you'll have a consideration of matching up against your local peers and do it nationally. So there's a lot of reasons to do this. Yeah. Rich, you bring up a point. There are some outpatient CDI quality metrics that are part of the outpatient perspective payment system. I've talked about those on different webinars, too. And there's not a lot of awareness to them. But it seems like the hospital compare that we see those inpatient metrics. There are 25 or so metrics from an outpatient perspective. They do affect payment, but they're really about, again, the beneficiary and outcome. So a good point. Thanks for bringing that piece up. [INAUDIBLE] (DESCRIPTION) The next question appears regarding outpatient CDI. (SPEECH) All right. What advice would you give to an organization looking to implement a CDI program? And that is to Chris. Thanks, Lisa. So the advice that I would give to an organization looking to implement an outpatient CDI program is, again, it's not one size fits all. It's really looking at where your pain points are. Is it denials? Is it medical necessity-specific denials? Is it looking at the physician clinics, not only from an HCC perspective but from an E and M level accuracy with that physician, making sure that they're documenting everything that they do when they're seeing that patient in the clinic? We know that they're seeing the patient in the clinic and providing these services. We want to make sure that they're documenting what they do. And then also looking at the ED obs area. This is a great area from an inpatient perspective to an outpatient perspective when it comes to a CDI program. Using our inpatient CDI folks, focusing on those ED obs cases, we can look at making sure that POA is appropriately documented. In an obs case, we can make sure that the infusion and injections are being documented correctly, any other procedures that are being done in the ED obs area. We have so many opportunities specific to the ED obs area, making sure that patient status is correct, collaborating with the care management team, and making sure the process flows well for the patient as Rich said before, and just what are the pain points that you have at your facility that you want to make better? Also having the right people at the table. You want to make sure that you have leadership from not only HIM but finance, your contract management team. You need to have physician leadership, possibly population health folks at the table. And then really review your data. Your data shows a lot of information where to focus, specific to denials, HCC capture rates, those capturing those chronic conditions year over year. The E and M levels can be a great opportunity to help physicians, educate physicians as well as coders. Those are the big topics that I had as far as advice that I would give to an organization. Anything to add, Rich? Number one, your advice is spot on. That's so important. Also to understand your organization process. What is the process of the patient experience? And how does that tie into the outpatient CDI capture? Literally perform a step by step overview of who, how, when, and where. It's almost peeling back that layer of time after time to assure that you get this right. Dive into the patient experience flows. Dive into your CDI flows on the inpatient side and how that piece can actually segue way towards the outpatient-specific opportunity. Look at your emergency services. Look at the way that the ambulatory settings are actually communicating coming through your front doors. Look and consider the revenue leakage associated with the appropriate level of care from observation status versus inpatient status and how that actually gets captured in the record. How is that-- I call it the triangle of communication between the physicians on the outpatient side, the inpatient side, and that third point being the patient and where they end up. How efficient is that process? There are so many tangible flows, so many pieces to this puzzle that, again, it's very important to understand and really drill down what that process is at many levels. Thank you. And Colleen, do you have anything to add? Yeah, the only thing that I would say is, Chris, you really spoke to an assessment, right? So that's the beginning point. And if you go back to the active survey and even if you just use those five or six items that are there and do an assessment talk like Chris mentioned, if you want to think about ACC's talk to your health team, talk to your manager care, what kind of covered risk, how many covered lives are we talking about, how many risk contracts are we in, where is our ACC scores. A lot of people have that information. They're not always sure who to distribute it to, but sometimes going into those areas. So really doing that assessment and figuring out, again, by talking to different folks, where is my biggest opportunity, do I have a denials opportunity, are our risk scores very low, have we entered into some new risk contracts, do we have a lot of revenue leakage-- that's a common term we use in the ED to observation versus inpatient status or short stay ED denials, this condition 44 claims-- is that a big area for us that maybe we could focus some efforts on. So that, and I always say whichever area you focus on, don't forget as we all know the stories in the medical record, right? So you want to do those record reviews. But thinking again about staffing, where am I going to start where I've got some engaged physicians or engaged leadership that's going to really help us be successful. And again, I always say start small, think big, but start small, but really do a good assessment educational. There's new knowledge that's going to be needed to do some of this work that you maybe haven't done before. So what are the educational needs that we have? Not only our CDI team and our coding team, but our physicians and other providers-- where is there an educational gap? And communication, of course, is a big part of being successful. But really that all those points that Chris mentioned is really just doing a thorough assessment. Thank you. We'll go on to the next question. (DESCRIPTION) Quote, Don't be afraid to fail. Be afraid not to try. Michael Jordan (SPEECH) All right. How is outpatient CDI different than inpatient CDI? And that is another question for Chris. OK. From an outpatient CDI perspective, when you think about the ED and you think about those office visits, those are short stays, very little time, high volume cases that we are seeing on the outpatient side. The query perspective is different. So on the inpatient side, we're looking at it concurrently. On the outpatient side, we may be looking at it prospectively in the clinics. And then concurrently in the ED and the OBS area to get that documentation up to what the physician is treating the patient for. And the regulatory laws for outpatient CDI-- there are many different rules and regulations, even specific to coding guidelines. The outpatient coding guidelines are different than inpatient coding guidelines. In the outpatient area, really in the ED, we may see a lot of symptom diagnoses because of those short stays that the ED docs are seeing patients for. So we may not have a definitive diagnosis to code. Also having the communication with the coding team, making sure that you collaborate with your coding team on the outpatient side for those office visits as well as those ED and OBS cases. So if you're sending a query on those OBS cases and it is answered, you want to make sure that on the coding end of it, did they see that query, did they see that it was answered and appropriately documented in the record, as well as did they code it. So we want to have that communication that they have on the inpatient side. They discuss the DRG, they discuss the documentation in the record, still having that great communication and collaboration between CDI and coding teams. So again, just as far as what the difference is-- also the education, going from an inpatient CDI to an outpatient CDI, the coding guidelines, documentation guidelines are different. So that learning curve maybe for a short stint in the outpatient. But many RNs are going from an inpatient to an outpatient perspective and then in looking into getting credentialed for that outpatient coding credential and having both the CDI and the coding credential which is needed on the outpatient side. Also think about those physicians that are in the office that are billing their own levels and billing their own ICD-10 codes. They may need assistance with that. So education to physicians is important in the outpatient side. So as Michael Jordan said, "Don't be afraid to fail. Be afraid not to try." So there are so many opportunities in the outpatient side. It's getting specific to where you want to focus and then educating your CDI team to those specific regulations. So, anything to add, Colleen? Yeah, the only thing that strikes me too is that I think the awareness, right? So again, CDI been around for a long number of years, but a lot of the providers that you're going to see whether you're working in the clinic or you're working in the ED area, they aren't familiar with CDI, they aren't familiar with queries. And so some of it is just that awareness of that piece. Again, I'm a proponent of utilizing your bench, your inpatient bench, and having some of those [INAUDIBLE] start on the outpatient area, know those gaps of a learning curve. But they bring a lot to I think it's easier to backfill that bench than start completely new. But one thing too consider I think when I-- the majority of specialists in CDI on the inpatient side are our clinical. I think there is a need for a good mix, maybe a more of a mix between CDI and coding professionals in that outpatient area that can really work together. But again, just the timing of the review, the volume of the records, the awareness, I think is the one big takeaway. It's almost like starting over in some cases because there's not the same awareness, which was kind of surprising to me, especially in the ED. Different customers that we've worked with-- it's really just that awareness to what CDI and what we bring to the table. It was something they weren't as familiar with as our doctors that work in the hospital. Thanks. And Rich, do you have anything to add? No, I would just add that one of the differentiators would be on the PCP side when you really consider and looking at the HCCs and how the HCCs are tied in crosswalk with the ICD-10 codes. And that example would be an 80 or 70 or a 65-year-old patient who walks in, comes in with congestive heart failure as well as diabetes controlled, say. And you look at that patient and the risk scores that are associated with that and the demographic scores that are associated and cumulatively how that really looks from a CDI perspective. And then whether or not there's a disease interaction between the two in this particular case and this particular those two HCC there are. So the bottom line here is that with excellent documentation, with very specific inclusion criteria for meat, that the meat objective for the physicians, you come up with that rahf score and there's a reimbursement strategy that's associated with that. I think the importance to this statement is the fact that if you're doing it correctly, number one, you have a quality outcome. You have better outcomes with your patients. You're not really missing anything. At the same time, you increase in the revenue. So there's a lot of opportunity there just in that one example. Thank you. You're welcome. All right. So for our last question, what are some lessons learned from inpatient CDI that can translate into outpatient CDI. And that is for Colleen. Yeah, we want to just wrap up here quickly because we do have a number of questions. So I want to get to some of those. But I think the lessons-- I just have for lessons learned again. I think, again, going back to Cheryl and her presentation in part one in May just a few months ago was-- as you thought about that journey, we started out in a bubble in a HIM, and then SOI and ROM came into play in the mortality reviews and the shift to MSTRGs and the need to work with quality on patient safety indicators and hospital acquired conditions. And then Cheryl mentioned infectious disease and those different impacts. And I think that was a good lesson learned when you come into the outpatient area, which is more revenue cycle focus than our sweet spot as CDI professionals I always say is in the middle of the revenue cycle. But that collaboration that Cheryl talked about that really-- the growth of CDI, the evolution of CDI, a collaboration is a big piece of that. My second point is always, again, remember the journey. One of the things that I struggle with sometimes is we've been doing inpatient CDI for a long time and we've gotten good at that and we have good industry metrics that we measure. We have technology to assist us with our reporting. There are some lacking of that in the outpatient area. And again, depending on where you're going to focus your efforts-- one of the things we noticed as an example is the query rate. So we have an industry benchmark around query rate for inpatient. When you get to the ED and OBS area of that query, what should it be, what's a good query rate, watching that month over month or quarter over quarter. There aren't so same industry benchmarks. So I always say, remember the journey and be sort kind, I guess, to outpatient that is still very new and we need some of the technology. So when I think about that, how can my existing technology help me in particular in the [? ED-Obs ?] area, can we leverage some of the technology and some of the reporting that we do in our inpatient solutions to help us in the outpatient areas, or can I start without a technology solution, how do I get there. So I think thinking about what can I leverage in my existing reporting structure to help me tell the story of my outpatient. And just sort of finally stay committed. Like Chris said, start somewhere. It's OK to not have it all figured out. Maybe you need to shift your focus. But stay committed to what you wanted to do, but flexible on the details because it is still going to be very new. A lot of people compare outpatient CDI to inpatient CDI and just, again, the technology solutions and reporting and the metrics. There's still a lot to figure out that we need to, as an industry, help figure out together. So I'm going to turn it over to you, Nisa. And I did see some questions in the chat. One of them, there's a question from David Gaff around demonstrating measurable CDI impact. I think that's a good question. Do you want me to address that one? Yeah, go for it. Yeah, let's start off there. Yeah. So David asked the question about how do you demonstrate measurable impact to CDI, and use HCCs as an example. So one of the things you can do with HCCs is look at your overall buy plan, buy health plan, how many covered lives do we have per plan because it is based on a plan. So do I have a Cigna plan, do I have a plan with a Blue plan or whatever and how many covered lives are in there, and what's the average RAF score. So I could I do some kind of a metric to predict how I could improve that. And some of it's just looking at the HCC categories and seeing from a starting point, do I do I focus on a location or do I focus on an HCC category such as diabetes, which brought up a little bit about diabetes, it's actually hypoglycemia in the outpatient settings. One of the biggest opportunities we see a similar hierarchy in diabetes that we see in DRG is where there's a triplet of HCCs for diabetes. So you could look at it from the HCC perspective and say, do I want to focus on a certain HCC? Or do I want to focus on a certain plan and look at that with a low RAF score or a particular location? So being able to track either baseline RAF or HCC capture by category are two ways you can really-- you want your baseline and then measure your impact as those increase because of the impact of CDI. One thing I do say though-- the caveat is this is a prospective payment model. So HCCs that you're predicting next year's cost of care. So it's not like increasing the CMI or the CCMC and seeing that immediate impact to the bottom line. It takes some time, but you can still see those capture rates increase by focusing on something specific. All right. Is there any other questions that you wanted to start with first? Or I can just start from the bottom and work my way up. So one of the questions that Robin Gonzales asked about credentials. So she mentioned a coder who has the CRC which is an APC credential for risk adjustment. And should they get their CCDS or another certification? So I did want to point out that ACTUS has a CCDSO which is certified clinical documentation specialist for outpatient. So Robin, the CRC is very risk based. And I think when I look at the CCDSO as a potential certification that's much broader into all of those areas that we talked about, not just risk based coding. So I think the CRC is a really good place to start. But as coders and CDI specialists, continue to learn, I think the CCDSO is something to definitely look at. I don't know, Chris, if you look at those questions, if there's anyone-- Her next question was, does outpatient CDI use only ICD-10 codes and what are the best resources for an outpatient CDI coder. So outpatient CDI does not only use ICD-10 codes. Many outpatient CDI also need to know CPT coding guidelines specific to either the ED or when you're working in the physician clinics, the outpatient visits. They also use E&Ms there. So knowing those coding guidelines which, again, have been updated over the past years. As far as documentation requirements, they're trying to simplify the documentation requirements for physicians. So knowing both ICD-10, outpatient coding guidelines, as well as CPT coding guidelines is very useful in an outpatient setting. And then the resources again-- your basic ICD-- I'd always go back to the books-- the ICD-10 book and the CPT books. Using those first. And once you've mastered that, many folks have access to an encoder and using that encoder appropriately. So Chris, one of the questions also came from Bradon Bills was about the 2021. So I mentioned the 2021 outpatient. It's actually office and other outpatient E&M categories, the new and established patient. And those coding changes from January 1st of 2021, how they affect the need for CDI. And when I think about E&Ms-- and again to Chris' point, what we see is a very large percent in clinic the physicians do their own coding. They see the patient, they document the care, and they capture the E&M level and they associated diagnoses through [INAUDIBLE] or some charge capture component. A lot of them don't have a good sense of E&Ms in general. And then there were these significant changes where really the decision was made to the key components of a history and physical no longer relevant for payment, relevant for specific to the care, but not as a requirement for payment. So when you think about the shift to just medical decision making, there were significant changes to how medical decision making is done. But again, it's looking at bell curves of a particular physician or physician group against industry standards and this becomes more educational. And maybe the review is looking at a particular physician's bell curve against his peers or against his industry peers and then doing a record review and seeing if somebody is sort of falling outside the bell curve, is there an opportunity to really connect the dots around the care they deliver and the level of service because I do know in my many discussions with physicians, they struggle with this. Some of them even consider it an administrative work and why do I have to assign a level of service. But I think it's a great opportunity for CDI to get involved and really drive proper acuity of patients on physician profiling is impacted by this even actually. So I think those opportunities. And again, we see some changes coming. And I know 3M aggregate data from one of our solutions, we saw a shift to the bell curve to the right with more of a focus just on medical decision making, which again, it was around giving the provider, the physician, the nurse practitioner, more time with the patient and making the level assignment more intuitive to how they work today and tie into the decisions they make today. So did we give our physicians more time with their patients-- that was the driving factor from both the AMA and CMS. And maybe using CDI to help with templates. Did we look at the templates and all the information that's in there and understand the downstream impacts? I think there's a lot of different areas that CDI can actually help with E&M services. Any of those other questions? Yeah. I think there was one question-- yep, go ahead, Lisa. I'll go ahead. I was going to say, so there's a bunch. And I think some of these might be getting answered as we continue to go. So I'm going to pick one that I don't think we got to. And this will be our last one because we only have a couple of minutes left, and I'm hoping this one isn't too hard. When working with providers to improve their documentation or when-- maybe not that one because it looks like it got cut off. That one is talking about the certification. Sorry, I apologize. I'm just scrolling through a bunch of them. Is there a collaborative coding in CDI partnership for review of cases for coding? So I do see that question there. This came from Edith, right? Yeah. Yeah, so if we're talking in patient, there should be. We have a working DRG from the CDI team and a final DRG from coding. And there should be a reconciliation of those two because there's clinical information that a coder can learn and there's coding information that a CDI professional can learn. So it's really important that there is reconciliation of that. And we take that same thing into observation cases [INAUDIBLE]. If you're talking about HCC as another example where the CDI team is looking pre visit or prospectively a few days out from the visit and looking longitudinally over two years of visits, and then there may have been a query posed to the provider. And then post the visit, the coding team is often validating those services and making sure the claim is accurate and the diagnosis meet the guidelines for reporting structure. So there's a very important collaboration in HCCs, in observation services. I think when you talk even about denials, and a CDI team is looking retrospectively at denial patterns and then working with different areas where they see a high pattern of denials. And then the coding teams working in real time with those cases. So there's lots of opportunity to collaborate together for sure. And I just wanted to add really quick-- Carol, Karla asked about the title of the textbook. The book is in Ahima book, and is Clinical Documentation Improvement for Outpatient Care. Author was Pamela Carol Hess. H-E-S-S. Great textbook from the Ahima. (DESCRIPTION) Chris Berg, c berg 3 at m m m dot com. Colleen Deighan, c deighan at m m m dot com. Rich Wetherbee, r wetherbee at m m m dot com. (SPEECH) Awesome. All right. Well, we are seconds away from time. And so I do apologize. We weren't able to get to all questions today. There were a lot. So if you do have any questions, I am going to go ahead and put up a contact information if you'd like to reach out for any additional questions. We do also have resources for you as well. We have some upcoming boot camps for CDI training, quality training, and advanced CDI pediatric training. All of those resources are available to you both in the handout as well as links within the resources section. And so again, we can't thank you all enough for attending today. And to our expert speakers, it's amazing just how much knowledge you all have. So we really appreciate it. And if you do get a chance, please complete the survey at the end. We like to know how we did. And if you do want to go back and re-listen to this webinar, it will be available in hopefully in the next month or so. It'll be available on our website to go back and listen again. So again, thank you to our speakers. And we will see you again in September. So thank you. Have a great rest of your day. (DESCRIPTION) They smile and Rich waves. (SPEECH) Thank you.

(DESCRIPTION) Slide, New year, new webinar platform! A great company is showing what interesting applications a fantastic product can bring for motivated users. Blank elements are labeled in an image of the platform. On the left, a media player, Resources field, and a Q&A box. In the middle, a slide box and Ask An Expert button, and on the right, a speaker bio with a photo and a box with two survey questions. (SPEECH) Hello, and good afternoon. (DESCRIPTION) Title slide, 3M Quality Webinar Series. Part one: The evolution of C.D.I.. See how far your C.D.I. program has come. May 2022. An image of a woman holding a tablet while speaking to a doctor wearing scrubs as they sit at a table. (SPEECH) Thank you for joining our May quality webinar where we are going to be talking about the evolution of CDI. This is a part 1 to a two-part series within our series. Part 2 will be in July. And we'll be sending you information about that soon. But again, this one is the evolution of CDI. See how far your CDI program has come where we're going to be welcoming one of our regular presenters that you've all grown to love Cheryl Manchenton. Before we get started, I did just want to go over a couple of housekeeping items. (DESCRIPTION) Slide, New year, new platform. (SPEECH) If this is your first time joining our webinar, we are on a new platform this year called ON24. And it really is a better experience for our attendees. Because this is a web-based platform, we do ask that you use Google Chrome. Close out of any VPN or multiple tabs because that will slow down your bandwidth. And because this is a web-based platform, there's no dial in number. So any audio is going to be coming through your speakers. So if you are having any issues, do a quick refresh and hopefully that'll take care of it. We do have more engagement sections, so you can make the video larger, presentation larger, close out of anything that it's distracting to you with those engagement sections. There is a Q&A section. So we ask that you put all questions in there. We'll get to as many as we can at the end. We do provide a certificate of attendance. That is in the resources section as well as the handouts. If you are or if you did join us in our March webinar, we told you that we would provide the questions and answers. We had a lot from that last webinar. So we did compile all those. So if you were on that one in March, you can download those as well. Again, with that certificate of attendance as well as the handout section. And at the end, we always appreciate you completing the survey. So let us know how we did. You can either fill that out during or at the end. But let's go ahead and get started. I'm going to pass that over to you Cheryl and to go over the agenda and to get started. Thank you so much. (DESCRIPTION) Slide, Agenda. Evolution of C.D.I.. Challenges on the journey. To infinity and beyond? Fine print: The information presented herein contains the views of the presenters and does not imply a formal endorsement for consultation engagement on the part of 3M. Participants are cautioned that information contained in this presentation is not a substitute for informed judgement. The participant and/or participant's organization are solely responsible for compliance and reimbursement decisions, including those that may arise in whole or in part from participant's use of or reliance upon information contained in the presentation. 3M and the presenters disclaim all responsibility for any use made of such information. The content of the webinar has been produced by 3M, and its authorized third parties will use your personal information according to 3M's privacy policy (see Legal link). This meeting may be recorded. If you do not consent to being recorded, please exit the meeting when the recording begins. (SPEECH) Absolutely. So good afternoon or good morning to whoever we are at in the United States, et cetera. It's my pleasure to talk to you. Really going to talk about how is CDI evolved because it really, really has even in the 13 years that I've been involved. What challenges have we stumbled upon on the way. And what's next? Where are we going from here? (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement. A blue panel above a right-facing arrow labeled "Inpatient" reads, Initial Model for C.D.I. Programs - Financially based review of Medicare population. (SPEECH) So the way you want to think about this, and we're primarily talking about inpatient. And again, as a reminder in July, our inpatient-- our outpatient people will talking about that. And by the way I just saw a typo which is why I was somewhat. It's not a query rat, it's a query rate. So you love when you see your typos right in front of you. But let's talk about how CDI programs got into being. There over 25 years old, almost 30 years of doing this work. And the initial model was really financially based. Wow. We're missing money. If we had done some chart reviews and ask them questions, we'd improve our CMI. And really in the beginning, it was very much focused on Medicare clients only. You start in somewhere for a couple of reasons. One, Medicare is usually the biggest volume or was 25 years ago of our inpatients. And the second piece being very clear rules of documentation coding, et cetera. But knowing it was at that time your primary payer, it made sense to cover just on that one. There was not as much collaboration with coding. It's not that there wasn't any, but we did not have big dialogues. We just have some discussions sometimes or again. CDI operated in one world and coding operated in another world and the two did not meet. And I still have some programs where that is the actual state today. Definitely had no collaboration in the early days with quality or quality outcomes. And we had traditional key performance indicators or KPIs. Such as how is the CMI changing? What is that MCC/CC capture rate? What is the coverage rate. How many cases we're able to see. And again, what does that query rate. (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement continued. A green panel to the right of the blue panel reads, Next Generation Model for C.D.I. Programs. Financially based review of Medicare and other D.R.G. based payers. Focus on severity of illness and risk of mortality in reviewed populations. (SPEECH) Moving forward, that next generation is we expanded not just from Medicare to other DRG-based payers. And certainly as we had more managed care, in the managed Medicare is outpacing Medicare as the highest volume in most hospitals. So let's look at all of our DRG-based payers. And Yeah. Let's look at that severity of illness and risk of mortality now that we have good tools that calculate our severity mortality, let's take a look at those. You had the same KPIs. Your leadership might have added or included that observed expected mortality rate as a measure. Of course, to have that next generation where you're doing more, you need to actually have a way to measure how well you were doing. So you had to look at your baseline and your current state on severity mortality. Certainly there are proprietary models out there. Not just the three on APR-DRG methodology. And many of the outcomes or the measures are only on war, back in the day only on the O/E ratios only. Of course, when you started adding new payers in, you brought some challenges. The payers, depending on what type of payer it is, they can set up their own rules. And certainly, it's not that we never had denials in the past in the traditional model, but it was normally what we'll call coding errors. And again, I use that word very lightly. Please take it how I meant it. Those were perceived coding errors. But as we started adding or covering new payers, we would see an increase in the denial rate. And again, as those teams really started focusing not just on the financial, there really need to be more engagement with coding, but still really not a whole lot of involvement with quality. And again, less that program, that organization was what we'll call a next-gen or a little bit more advanced program. But again, this is certainly how the programs in general have evolved for those that have been around a long time. Some programs starting new have zipped past these first two and really done a more advanced model. (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement continued. A teal panel to the right of the green panel reads, Phase 3. Financially based review of Medicare and other D.R.G. based payers. Focus on severity of illness and risk of mortality in reviewed populations. Documentation integrity and clinical validity. (SPEECH) So that next phase three. It's not just financial review of Medicare and other DRG-based payers because remember, that can also be APR-DRG-based payers. Not just those in the Medicare or the MS-DOG groupers. But we've moved into a world or have experienced where our payers are now including Medicare, getting involved in clinical validation. And we've seen a huge uptick especially in the last five years in those payer denials for what they'll consider clinically nonvalid conditions. Because of those denials, that alone has really impacted us in terms of the reimbursement certainly. But I think a cost that we forget about is the loss of productivity. What are the labor costs and fighting? Reviewing and fighting those. Second thing that we have found is more and more payers have decided they're going to dip their toe into the clinical validation pool. There's different rules. And I will say, a commercial payer that only has acronyms for their name as an example has very clear criteria for when obesity as an example is reportable. Where other payers don't ever challenge the diagnosis. Another thing that we have consistently seen at this point in a CDI journey. The CDI department was not always given access or insight to trends. What was happening? If the CDIs don't know what's happening, how could they avoid those denials. How can we preemptively review that chart, ask some clarifying questions. How do we preemptively help the providers. The providers are certainly frustrated because why am I getting more queries on this and why you challenge my diagnosis. And that did, no matter what we say it is definitely increase the minutes. We need to spend on each chart because we're now having to apply an additional layer of scrutiny through that to really look for integrity and clinical validation. (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement continued. A blue panel to the right of the teal panel reads, Phase 4 - Comprehensive C.D.I. Program. . Review for financial opportunity, severity of illness and risk of mortality in all patient populations. Documentation integrity and clinical validity. Quality outcomes review of P.S.I., P.P.R., H.C.C., P.P.C.. Second level review for financial, profile, and quality opportunities. (SPEECH) Third, next sort of phase four, shall we say, is really a comprehensive CDI program. And you're looking at not just financial opportunity or severity of illness and risk mortality, but you're looking at all inpatient populations. Not just those that reimburse me appropriately. And of course, we're continuing on with integrity and clinical validity. But now the CDI teams have really been asked to understand and/or participate in quality outcomes reviews of such things such as Patient Safety Indicators, PSI; Potentially Preventable Readmissions, or PPRs; Historical Condition Categories, HCCs; or Potentially Preventable Complications, PCCs. And then certainly many CDI programs now have incorporated a second level review process to not just look at this financial or profile opportunity, to also look for quality opportunities. And again, for us that is a much more quality. Comprehensive look is really having those second level reviewers. And I use air quotes when I say full pay for performance because really it is an acronym. There are multiple ways that are reimbursement, that the hospitals are receiving for inpatients could be affected whether it be the hack, reduction program, or CMS star ratings, value-based purchasing, ACO relationships, through accountable care organizations, shared savings models. And of course, getting those HCCs allows us to negotiate better for those blended rates with our payers. And again, it requires a lot more second level reviews and truly requires a lot of collaboration. Not just between CGI and coding, but certainly with quality and sometimes beyond quality. Sometimes infection control and some focused departments in our organization. But here's my question. If you have moved into really a phase four program. If you have moved beyond phases one two or three on your CVI journey, have you changed your KPIs. And again, I think this is an important distinction I'm making. Why are we using the same old metrics if we're asked to do more? And it's not that we should maybe remove some of those even though I could argue about removing some of those, but should we be adding in some? And that's really what we're going to spend a lot of our time today talking about. (DESCRIPTION) Slide, What C.D.I. metrics should be deemphasized and why? Coverage rate. Number of initial versus continued stay reviews. Financial goals per individual C.D.I.. "Match Rate." (SPEECH) So what metric should be de-emphasized and why. So let's talk about that first one. That coverage rate. Why is coverage rate so important? Are there cases that truly don't need a review because they don't have any opportunities, such as short stay elective surgical procedures, one or two-day stays? Why is the coverage rate so important? What benefit-- what happens when a CDI does or does not review that case? If you're not seeing opportunities there, and I had a client and it's been golly, eight or nine years ago. They did a test project where they had a second level review or look at all those discharges that happened over the weekend that were admitted and discharged before we could get a CVI review on the case. And what happened if that second level reviewer, again, a really seasoned reviewer looked at those cases. How many opportunities did he find? And the answer was very few. And it didn't justify the loss of productivity for a whole day for him to perform all those reviews. So I think coverage rate may or may not be the best thing. And secondly, when you think about what cases should have review, that's where prioritization comes into play. And we will talk about that a little bit later. But is coverage rate the best metric? Second thing, the number of initial verses continue to do reviews. I think sometimes CDI managers say you have to have 10 new and 15 continuous day reviews. I'm not putting numbers out there as in these are three goals. My point is, why is that an appropriate metric? How does that benefit? What happens if we see less initials? Certain days of the week obviously like Mondays, we're going to see a lot more initial patients trying to catch some of those new ones, but why are we trying to see every patient? What is the goal now. Please understand that there are some programs that do really advanced work with some of the proprietary methodologies such as Vizient or Premiere. So their coverage is different because their focus is very different. But instead of saying how many I do, how many charts did we actually perform quality reviews on. So maybe this should not be a big measure but maybe a KP around the quality of the work that I did in that chart is more important than the volume of initial or continued stay. This third one, I still have one program and I know of a few out there that sets a financial goal for queries on an individual CDI. I think this is harmful. I will say that. I do not like it. Yes. My client knows, I've told them many times. I think it pushes the envelope. It pushes the CDI too hard to say, oh, wow, have I hit my number this month? But what it also does is I think it also demotivates us. Well, I already hit my 50,000 this month. I don't really need to work so hard the rest of the month on finding opportunities. So I dislike it. Intensely, I don't find any value. I think there's better ways to measure the effectiveness of our CDIs and attract and train them. The last one that match rate and I use that in quotes because it has different names and thoughts. So I want to make sure that I explain what I mean there. Is how often do the CDI and the coder get the same DRG. With a really expense program, that match rate again, air quotes, is usually really high. So if the number really never changes much, why is it a metric? And when you think of a match rate, it's usually just a DRG match. And they're using in the softwares reason codes for why we had different DRGs or not or optimal to assess that match rate. But I find that it is not helpful other than to trend a new employee. And it's not telling the story. What if we got the same DRG and it's really not a good DRG for the patient to be in. Or we have the same DRG, but our severity and mortality are very different. And/or we have the same DRG, the same severity and mortality, but we have very different amounts of coded data or diagnoses listed and not the same POA. So I think match rate is as a global metric overmatched. And I think the other thing that I just saw in one of the charts is can I comment on CMI being a goal for the CDI program. My comment would be, we have to have some goals. We have to keep the shops in business. We have to keep our staff employed. So I am putting a slight caution sign on removing that. But what I would say is it's become increasingly difficult in the time of code, but I was actually trending. Two of my clients CMI recently watching them longitudinally. And again, I could see that CMI go up and down and we could draw arrows to exactly where their COVID spikes were. So a CMI goal is fine if your patient population is stable. We haven't had a stable population in over now almost 2 and 1/2 years. And I hate to say that we're approaching the half year mark. But not certain that it's the best KPI. (DESCRIPTION) An interactive poll question with four options. (SPEECH) So you'll see here an opportunity to please interact and answer this polling question. And the question is, does your CDI and/or your coding team because I think it pertains both, have KPIs, or those Key Performance Indicators, for quality metrics such as the hack reduction program, value-based purchasing, star ratings, O/E ratios or the readmissions reduction program. And you'll see your choices in terms of we have all of these, some of these, none of these, or that's OK to say, I don't know. And it's not-- and it doesn't mean that it's a bad thing if you don't have any of these The question is, we're curious to see how many hospitals, organizations, departments actually do incorporate those additional KPIs. (DESCRIPTION) Poll results appear. 6.1% chose "All of these," 37.8% chose "Some of these," 28.9% chose "None of these," and 27.2% chose "I do not know." (SPEECH) And what you see is we have-- 6% of our audience said yes. It's all of those. I'm like, Wow. Again, not saying that's good or bad. I'm just-- I'm very impressed. 37% said some of these. And again, I'm glad. Usually I would expect it's around-- PSI is a really common one or the PSI 90. For those that said none of these, again, the question is why not. And again, we're going to talk about that here in the next couple of slides. But I think we're doing ourselves an injustice by not having nontraditional KPIs. (DESCRIPTION) Slide, What workflow should be added? Prioritization of C.D.I. reviews. Focused second level reviews (not just mortality) by clinical coding and quality staff. 100% reconciliation between C.D.I. and coding (S.O.I./R.O.M., code set, AND P.O.A.). C.D.I. and provider participation in denials. Collaboration with infection control on H.A.I. definitions and measures. (SPEECH) So what workflow do I think we should add. As we're trying to move to that advanced model, that comprehensive CDI model, how do I still get my-- I'm sorry. I was thinking of a bad phrase. How do I maintain my productivity when asking the CDIs or the coders to do more. I think the first thing, the prioritization of the review is making sure that we're seeing the right patients. Does this DRG in general have a high likelihood of being moved with an additional MCC or an alternate. But I'll also say that when you think about the prioritization of reviews, I'm trying to think of a really, really good example. And the one that comes to mind is in the female in the obstetric population. There are now CCs and MCCs for our moms. But those DRG are fairly low weighted. So getting a CC on a really low weighted case might add $100 or $200 to the case where prioritizing the case that getting a CC is worth $2,000 or $3,000 or more makes sense. So it's making sure that we're getting our bang for our buck. And it's not just prioritization for financially, it's those length of stay outliers. Those low severity mortalities, and adjusting your priority tool to do that. So I do think if you're not doing some sort of prioritization beyond this is my primary period that we review. How are you-- I would ask you to consider that. Again, second thing if you're not doing it. Those really in-depth focus level reviews. not just mortality reviews. And I think the second thing that happens is we have a different glasses or lenses that we're wearing when we review the chart. Our coding professionals are looking for coding opportunities. They're not looking to say, what clinically should we have queried? Meaning, the coder should focus on, is this coded correctly? Is there anything absent? Our clinical staff should be looking for again, what is clinically missing. What could be clinically clarified. Letting each of us use our areas of expertise and our quality staff saying, that seems very strange that you have this with the POA of no. And my favorite example of this was anaplasmosis. And I don't know if any of what that is. I had to look this one up when I read the chart. And it is a tick bloodborne infection. And this was coded at one of my hospitals with a POA of no. And my physician advisor smiled when I told him that he says, yes, it's not like we have deer walking up and down the halls of our hospital. So a quality person might be the one to recognize it. It might be a clinical person recognizing something seems strange here. And not just looking at just the complication codes. So I think that's another workflow if you're not doing is really and again, I think you have to be focused. Pick a couple of DRGs or if I'm working on the CMS mortality measures, those DRGs that are in the CMS mortality measures on the star ratings. Focus your DRGs, your second level you use on those patient populations. This third one, I will tell you. I get a lot of pushback on this from clients that haven't known me a long time. And I'm going there. We should have not just the same DRG. We should also have the same severity mortality or coding. You should have a higher one. Why is CDI reporting 30 codes and coding is only reporting 10? And I'm using a gross exaggeration. Normally coding reports more codes than CDI. But is there a specific code that CDI captured that coding didn't and why not? Is it because it's not reportable? Is it because it was not auto suggested in a way that we could see it? What is the reason that we did not capture a particular code. But the one that really sets people's teeth on edge is looking at the present on admission status. And one of my clients last week said, I want you to reemphasize that we should be doing a comparison on present on the mission. And the reason why it's important is because that is a specific necessity for the risk-adjusted models. They won't consider or utilize certain conditions when they're not present on admission. So it doesn't matter that you get the code on the chart if it's not going to be utilized in risk adjustment. That fourth one. Several of my clients actually have the CDIs whether it be the leaders or second level reviewers. They have clinical people participating in those denials reviews and those appeals. And having the providers also join in. Certainly when it goes peer to peer with a physician involved, we have found with some of our clients, especially those that are good at it, they tend to overturn a lot of those denials. So that's something that you're not doing. We certainly encourage you to have clinical people take a look at that. And again, participate in the formal denial process. This last one. The collaboration with infection control on those hospital acquired infections or HAIs. Our coded data should be as close as it can be to actually what is reported to CMS to the National Health Safety Network HAIs. They're very clear, maybe hard to understand, but they're very well-defined definitions for the hospital acquired infections. What is a CLABSI? What is a CLAUDI? And working collaborating with them and deciding who's going to have that conversation with the provider. Either we're underreporting it on our claims data or we have overreported. I had one that I looked at this week that the provider said that. That patient was intimated less than 48 hours. That is not a vap by definition on anybody's criteria. Even though that's a very convoluted definition, the patient had to be on the vet more than 96 hours. So already there's an opportunity to do some clinical validation on why we're calling it vap. And I the CDI or the coder may not know that criteria inside and out. So I might need to work with my friends to get clarity and say, is this on your list or not. I mean, that one like I said was really obvious for me. It just was not a vap. It literally was an aspiration pneumonia as he was seizing. OK. (DESCRIPTION) Slide, What metrics should be added and why? Query compliance. Missed opportunity for risk-adjustment. Average codes per case (Coding). P.O.A. accuracy (Coding). (SPEECH) So let's talk about-- so we talked about what workflow will still allow you to-- that you should consider. But what about what KPI should we add and why. And again, I see a really-- a couple of really good comments over there. And I appreciate. I see one of my new coworkers who joined us with a really good comment. What about your query compliance? We should be reviewing those queries making sure they're compliant. Did you offer all appropriate choices? Did you pad your clinical information to point the doctor in a certain position? And I know that is time consuming and cumbersome, but it goes back to the Hippocratic oath, first do no harm. Did we the CDI or the coder miss an opportunity to capture a career for risk-adjusted diagnoses? How many diagnoses did we miss? And again, the audit that I'm working on this week, I am very carefully looking. And actually the manager said, I want them to stop thinking about how will this affect the chart. Instead of how will this affect the chart, does this diagnosis belong on the chart. Not, what does it do to the chart, but why shouldn't it be there. I think another really good metric that one of my clients is really tracked and noted was the number of codes for case that were captured. Again, they have to meet UHDDS reporting requirements. But if all things are equal, meaning if I don't have specialized coders, so I do realize that we have to make some considerations there. We should be able to trend our department over time. And again, one of our clients we specifically watched and looked and we actually did some extra education with the coders on the use of our software. And said, are you taking full advantage of the software. And we saw a dramatic increase in the number of codes per case. And remember, those extra codes are part of risk adjustment. Now, of course, that leads what when you're reporting more than 25 codes. So again, we'll talk about that in just a second. And the last thing that I really do think should be-- and again, I could argue CDI as well on this one. But primarily when it goes out the door are we getting the appropriate POA assignment on this case. Do we misread it? Do we miss an opportunity to ask a question? So POA accuracy is not just did you assign the right one, but did you miss an opportunity to query to get the appropriate POA. And remember, this is just a short list. I could come up with probably 20 or 30. But realistically I think you have to start small and say, are some things that we should add in. This is really where our programs need to evolve. (DESCRIPTION) Slide, What else? Shared metrics between quality, coding, and C.D.I.. Extensive provider education. E.M.R. enhancements (smart phrases etc.). Standardized definitions for high value diagnoses. Collaboration with infection control on H.A.I.. Definitions and measures. (SPEECH) But what else? My question is, why don't we share the metrics? Why are we not all held accountable. And it has been really interesting to watch one of my clients on their journey. They weren't allowed at the table in the meetings. And they fought for a place at the table when it came to quality outcomes such as star ratings or their premier rankings, et cetera. And they're all held accountable for that performance. In other words, quality should be working on the quality of the actual physical care. Meaning can we improve the care that we're delivering or are patients on a daily basis. Where coding and CDI can look at the accuracy of the claims going out the door and making sure that we're doing all that. But why don't we share the metric. I think we need to really, do more education with our providers. I was doing some education this morning with an ICU CDI specialist specifically on NICU. And helping-- some of the struggles that we were having. And that she was having, we think could really be mitigated by some education. Helping them understand why is this question being asked. Why is this important to get this accurate on this baby's chart? What are the implications not just today, but on the transfer of care to that pediatrician in the outpatient setting. Letting them know what we're focusing on and where it's affected. EMR enhancements. Many people have instituted smart phrases. The smart phrases are a good thing and a bad thing. Again, we could spend three hours debating that. But for example, if a provider keeps using a dropdown for a very unspecified choice, why aren't we giving them the specified choices? Why don't we customize that to that type of physician so that we are getting better documentation out of them. A great example is now with our nonacute nonischemic myocardial injuries. Why aren't we adding that to the cardiologist drop down choices instead of demand ischemia? Why don't we remove demand ischemia and replace it with better smart phrases? Or really for example, with malnutrition because of the OIG. When the provider-- a lot of my clients have ways to have the provider sign off on the diagnosis. Well, I just worked with one to say, not just that they agree with the dietician but they agree with the dietician and it impacts the patient in the following ways and gave the providers some choices, some smart choices that they could choose. And then, of course, a free text and requiring them to comment on that. That fourth one again. Many hospitals have been able to achieve this and some have not. We should have standardized definitions for what we call high-value diagnosis, meaning those that are frequently denied. Our sepsis, our encephalopathy, our respiratory failure, renal failure, ABLA, hyponatremia, things like that. And not only is helping all of us when we approach the charts, but it's also helping in that defense in case it does try to get denied. And again, I do think we need to collaborate with infection control. If you weren't collaborating, why aren't we? And understand that. We're reporting in two different worlds in two different sets of metrics, but we should have the same understanding of what is the clinical picture here. (DESCRIPTION) Slide, Non-Traditional C.D.I. R.O.I. Metrics. Decrease in medical necessity denials. Decrease in external auditor denials for clinical validity. Increased success rate for appeals, A.L.J., etc.. Decrease in P.S.I. rates and improvement in A.H.R.Q. performance. Improvement in Value-Based Purchasing (V.B.P.) score and H.A.C. reduction program total score. Improvement in Medicare Spending per Beneficiary by increasing expected expenditures via capture of HCCs. Decrease in rate of potentially preventable readmissions and decrease in readmissions penalties where applicable. Increase in national quality rankings (U.H.C., U.S. News and World Reports Best Hospitals, Star Ratings/Care Compare, etc.). (SPEECH) Some nontraditional CDI ROI metrics for you. Is we should see our medical necessity denials. So the clinical validation denials really can substitute either one there. You should go down. If we have a cleaner chart going out the door, we should have less denials. That's not solely on the backs of the CDI, I know that there is a lot more behind that. There's payer negotiations that has to occur. But overall, and I'll give you a great example, that same NICU senior specialist their hospital has seen an increase in denials in that population. Why? Because she's asking the doctors to document more. So we have to put that in context that is once you've stabilized and worked with those payers, if we have cleaner charts going out the door, per chance we should be able to see that trend down. And I would set very, very minimal changes here. I would not ask for big ROI gains in either the medical necessity or the clinical validation because again, sometimes it takes time. We should have-- what is our success rate for turnovers? Whether or not we got in denial, how is our success rate? I know again, one of my clients is presenting this summer at the client experience summit on how well that they have done on winning. Successfully winning their appeals. So why is that not a metric. Again, if the chart stands well and is documented well and then the CDIs are insurance clinically valid, we should have a higher success rate. Certainly, decrease in PSI rates because that is coded data. What I will say, though is at a certain point that's going to tap out. Meaning you're going to hit a certain nadir there where you're probably not going to make any other improvements. And an example, one of my clients they had horrific, I'm going to use their words, not mine horrific PSI performance. And it was publicized on the front page of a national newspaper. And the one facility in particular. So they underwent a very long journey. And they put these PSI metrics in their KPIs for the CDI performance. And they got everything down into the top five decile performance for how well they are doing on their PSI except for one category or two. But the one in particular that was way out of their control was their DVT PE, post-op PE and DBTs. They had validated them as much as they could. They had done everything they could. And they hit a point where they weren't seeing any missiles anymore. There weren't miss queries. There weren't miss coding opportunities. They then took that back to the providers and said, you know what, it's on you now. We need to figure out how we can clinically improve this. So again, that decrease or that maintaining of a good PSI rate might be a better metric. It may not be just a decrease, have we maintained this exceptional performance. Again, value-based purchasing and hack reduction program. There are components that are very much based on claims data and some that is not based on claims data. But, again, it is still worth a certain portion of your score. So why aren't we sharing in the both success and/or the failures in doing well on those? Why aren't we taking the same credit that quality does? What is that Medicare spending per beneficiary? It's very easy to track and trend. It's out on the CMS compare every year. If we are getting additional HCCs captured in any setting that, Medicare spending per beneficiary should reflect the care or the necessary cost that we're delivering. Again, the decrease in the readmissions and the penalties again where applicable. Alternate principle diagnosis and risk adjustment. Just focusing on those CMS mortality and remissions it's the same group of cohorts. They have the same risk adjustment. So if we're adding extra diagnoses that are clinically appropriate, we're extending our expected rate of readmissions. And so we should see that we're either continuing to do well or improving our performance in that. That next one. Again, our hospital focuses on those. As a whole our quality does, but why aren't we part of that. As an example again, the client that's speaking this summer is talking about their leapfrog scores. And it's one of their metrics because the organization came to them and said, we've got a bad rating, how are you going to help us improve. So if CDI and coding are being asked to participate in the performance, we should be allowed to measure and be appreciated for the improvement. And they did actually move up to several of their hospitals, that being five stars and leapfrog and now one is a four star. And again, they were much worse than that. So I mean, sorry, A rating. I'm so sorry. A rating now. In one hospital and a B compared to where they were before. And again, sorry, that last one is a duplicate. I already did discuss that. (DESCRIPTION) A thought bubble pointing to "Decrease in P.S.I. rates and improvement in A.H.R.Q." reads, Shared between C.D.I. Coding and Quality. (SPEECH) OK. And again, it's a reminder that the CDI metrics, I just want to remind you that they don't have to be my metrics and your metrics and their metrics. Why aren't they our metrics? And we present to leadership our performance. Because again, almost all of these have some involvement. There are parts of CMS star rating out of our control. There are parts of value-based purchasing that are out of our control. But we should be sharing those together. (DESCRIPTION) Slide, Challenges. (SPEECH) So what are some challenges on the journey. We don't have good measurement tools. Or we may not have good measurement tools to measure that ROI. And stay tuned on my next slide because I'll also show you what I mean by that. But many times we're waiting for publicly reported data and we don't have internal reporting to know how we're doing. Secondly, we may not have really good artificial intelligence or prioritization tools. One of the biggest things I'll say for those of you on the line that are 3M clients. It should be customized by you based on your facility population. It should also include quality specific prioritization factors. And if not, I'm-- and if you don't have a 3M product, your tools should do this. It should be able to help you prioritize based on certain DRG that your focus or again are unique. In other words, you can keep telling me that this is a priority and that I might find an MCC here, but we've audited these 80 times. I want to take this weight down because we never find anything. It's a waste of time to continue to see this patient. Second challenge is really sometimes getting the buy in from senior leadership it's usually not a problem, but where it becomes a lack of buy in from senior leadership is, it does require some extra personnel to do this work. Even with prioritization and computer assisted coding and all the technology we have, it's sometimes hard to get the senior leaders to agree. That's why you need those non-traditional ROIs so that you can say, look, the extra three FTEs you gave me, here's what happened with our quality scores. Another good reason to try and put that in. The fourth one, sorry, I roll my eyes here. The frontline staff, but that's your job as a leader. And it's my job as a frontline staff to do my job. This isn't my job. I'm supposed to look for this and that. I'm not supposed to be checking up on the coders work. You're not checking up on the coders work. The question is, are we as a team looking at this chart before it goes out the door to ensure it's tucked in appropriately. Well, this. Is going to take more time OK. I laugh when somebody says, I didn't have time to write all those queries because I have to get my reviews done. That drives me crazy. I had somebody saying if you're salaried like, I'm so tired of working over 40 hours. I'm like, but you're salaried. So I think we have to manage that behavior. We also have to share the ROI successes with them and the opportunities. Let them see we've added these extra personnel, we've given you more time, and look at what's happened to the performance. This last one, again, is probably my personal frustration. We don't always get timely return on investment because there is a significant lag time for your publicly reported measures whether it be CMS or US News and World Report, Healthgrades, Leapfrog. Their weight they're either utilizing Medicare data and/or they're using two or three years of data. And again, my next slide is probably my favorite. And I encourage you all to share this next slide with your leadership. Do know that there is some proxy, shall we say? That will give you some real time results. So you'll have an idea how you're going to look publicly or it's a good guesstimazation of how you're going to look publicly. (DESCRIPTION) Slide, C.M.S. reporting and payment adjustment. A timeline lists data collection periods across the top - July 1, 2017 to December 1, 2019, July 1, 2018 to June 30, 2021 (excluding January 1 to June 30, 2020), July 1, 2019 to June 30, 2022 (excluding January 1 to June 30, 2020), July 1, 2020 to June 30, 2023 (excluding January 1 to June 30, 2020), July 1, 2021 to June 30, 2024, and July 1, 2022 to June 30, 2025. Listed below are yearly Public Reporting/Star Ratings and H.A.C. V.B.P. and H.R.R.P. payment adjustments between 2021 and 2026, with arrows labeled "What the public and executive leadership see" pointing to 2021 and 2022, and arrows labeled "What C.D.I., Coding, and Quality can influence" pointing to 2025 and 2026. (SPEECH) And again, this next slide is probably my favorite. And I actually created this for a CFO who said, I am wanting to improve our CMS mortality. So he was very specific about what he wanted. And so we wanted to show him where we were on the journey, where we were working today, and where that data is going to be reported. And of course, when you look at the timeline across the top, look at the times of data, the data time collection periods. 2017 to '19. With their reporting out in 2021 and 2022 what we did several years back and the work that we are in right now, anywhere between July because we're in May of 2022. So even one more arrow over to the left that purple. That's the area that we're currently in that we still have an ability to influence So helping your C-suite and your board members understand the slide is probably the biggest thing that I encourage you all to do. It's the ship is sailed. But it also says, look, what we're doing right now, we're not going to see results until 2024, 2025, 2026, that's frustrating. You've got to give us time to put these measures in place. And they have to give us the grace and be patient. So I'll add in that other thing is it's giving them and then begging them for some patience with this. (DESCRIPTION) Slide, Where should we go from here? A fifth green panel is pictured to the right of the other four from the The Evolution of Clinical Documentation Improvement slides, with that and the fourth panel now above a right-facing arrow labeled Outpatient. The pane reads, Phase 5 - Holistic Clinical Documentation Improvement. Comprehensive review of documentation in all care settings. Comprehensive review of all payers. Comprehensive review of all diagnoses. Focus change from case impact to documentation completeness. (SPEECH) Where should we go next? Well, what you see is phase five, holistic clinical documentation improvement. You'll notice I also incorporated outpatient. This is my reminder that in July our outpatient team will be talking about that evolution. But the one that I really want you to think about is the second, third, and fourth dots over there, still apply to inpatient. Are you looking at all payers? Are you looking at all diagnoses, not just those that move the needle. And you know again, as my CDI director said, I want them to stop thinking about what does this do to the case and change it to does this condition belong on the case, the software, our software will tell you what it did to the case. It added an elixir. It added an additional MCC. Removed to PSI whatever it might be. The other thing sorry that I didn't even throw in here and I meant to is the advanced sequencing. As we're coding more diagnoses using the advanced sequencing tools to make sure our most impactful diagnoses, those that are needing to be there for risk adjustment end up in the top 25 positions. And I have a CDI that I am going to smile because he is a coder by nature. I love having CDIs coders respiratory therapists. I have all sorts of people. So it's not a specialty thing. But being a coder, you can't quite let go of his coding hat. And so he organizes all of his working CDI codes in a hierarchical order himself. And he moves all the Z codes down to the bottom because those aren't important to him. And I'm like, oh, but for risk adjustment, a lot of those Z codes need to make it up in the top 25. And they're about to go live with automated resequencing. And I've told them like, oh, you're going to have to let go of that because it's going out the door looking very differently than how you're looking at this chart. So again, let the technology be your friend where it can, but we need to focus more on documentation completeness. And by that, of course, I do mean accuracy being specific to that. (DESCRIPTION) Slide, Q&A. (SPEECH) So. Again, I purposely left a little bit of time. I see we had some great questions coming in. And Lisa, I think we can start right with question two. I think that's so-- I think the question so far really do look good and worthwhile. I think we can get through most of them. Awesome. OK. I think you had said question two, correct, with Helen with Forge Health. Yeah. OK. Perfect. So first question, do you think at some point in the future CDI encoders will become one in the same just with a different title. No. I think we still need some specialization. I think we need people to really get immersed in the code and the code accuracy and the coding guidelines. I think we also need people with real world clinical experience. I know what this patient looked like when I see them. I think we. Again, I don't mean all CDI should be nurses. I'm not saying that at all. I am saying, I think we need to have distinct skill sets and in trying to find what I'll call the super person that has good clinical and good coding-- sorry, that's looking for needles in haystacks. So I do think that we should still have those specialists but then we need to collaborate. I think a lot of the work we do is similar, but it's still different and we need different lenses. If everybody looks through life with the same prescription lens, I think will be missing things. But I'd like to the question. It's just definitely I don't think we should get there. All right. Next question from Ellen, are most CDI programs reporting up through quality departments? So the answer is, I have seen pretty much every model. Probably the most common one nowadays is where CDI and coding both report up through HIM. I have seen some report through quality, I have seen some report through nursing. I don't think there is a perfect model there. That's why I like the shared metrics so that regardless of where you're reporting your collaboration and your shared metrics bring you together as a team. But I've seen so many different versions that I don't think there's a-- I have one that they report directly to the CFO, which has always been interesting to me. And actually they started out reporting through case management and then through nursing. And then finally directly to the CFO. So they have all also changed their model, the reporting structure over time. And then Lisa, we did already answer question 5 so we can skip that one. Because I saw that pop up and I could cover it while we were there. Yep, I thought so. All right. Perfect. Next one, do you recommend match of other elements besides DRG? Absolutely. As I said, we should be looking at the severity and the mortality. We should be looking at what codes has CDI accepted. Again, many times CDI could be an error, but other times you know CDI is recognizing that this is an impactful diagnosis that means reporting requirements. But I think where we have failed to push to the next frontier is really even the present on a mission. So I really think that when we consider a match, we need to define that for our staff and decide how far. But as far as I'm concerned, one of my clients, yeah, they go code to code and I mean code to code and POA to POA. But remember, they're working in a specific proprietary model so they have to be that diligent to hit those outcomes. Great. Great. Next question from Michelle, how do clinical validation queries calculate into the financial goals? My metric would show negative dollar since clinical validation is what I primarily do to prevent denials. So that depends on how you value your clinical validation. So forgive me for using a double negative there. But the way that I think about this is if you're asking if something is clinically valid, you should not count the negative dollars when you take that code away if it was not valid in the first place. And I will tell you philosophically as recently as three months ago, I was having a really strong debate with a new client and saying, why are you taking the dollars away? Well, because the chart isn't going out that way. But the question should be, if it should not have gone out the door that way because this is not valid sepsis. And my favorite example, a patient was eating a chicken wing. The dog was at his feet trying to get the chicken wing out of his hand and bit the web of his hand right here, and he got cellulitis. And the doctor said, he had sepsis due to cellulitis. The patient was there with two days, no fever, no elevated white count, I mean like nothing for sepsis. I did a clinical validation of it. We should never have gotten paid for sepsis. So I'm not going to take the negative impact from that financially. I absolutely think that is inappropriate to count that as a negative value. Great. The next question is, how do you tie these quality metrics back to individual staff levels, the CDSes? Ah. That's a tough one. I think the quality metrics need to be department and not individual. I think you should focus on individual metrics such as again, a thorough chart review. Appropriate POA assignment. I think quality for an individual CDI should be query compliance. Should be accuracy of my code that should be missed opportunities for quality risk adjustment, yes or no. I think we need to not say a PSI score should be assigned to Susie because understand if I have a reviewer and one of my clients is very much specialty based. And I have a couple of reviewers that cover the surgical floors. Wow. A lot of those PSIs are postsurgical. So it's not fair to set PSI goals for individual CDIs because they're going to get a higher percentage. So I like to think of different types of quality metrics at the individual level. Next question is, this is the long one. So regardless of productivity, the quality of a CDI review should always-- let's see. Always be there. Yes? OK. Sorry. There's something goofy that was happening when I'm reading it. It's grayed out. So you want me to continue with this one? Yeah. For some reason it's not working for me. Go ahead. Yeah. Initial reviews are extremely important to establish the working DRGs set up the CDI to file a medical care and get a clinical picture of why the patient was admitted. It continue to say is the body of the documentations. CDIs or the non-MD Tracking. The consistency of the assessment plan of care. So I believe these are in line with the expectations on productivity where the quality is not negotiable. And as I long as a supervisor to think of this way. I don't think it's an or thing. In other words, yes, an initial review is important to get the theme of the chart going. But that subsequent review is normally where most of the queries occur and where the gaps in the documentations are. So setting metrics on those solely or making those so heavily weighted in an employee's performance says and again, I've seen CDI as they literally count. Oh, good, I hit 10. Now let me jump to this. I hit my 25 charts for the day. We had a reviewer that years ago. I've had a couple not more than, not one, but several reviewers that would suddenly stack a bunch of reviews in two hours at the end of their day to hit their numbers. What's the point of having the number of reviews if you did nothing with them? So I think we need to expand the way we think about it. Years ago when it was financially driven, that might have been a better metric. But I think we need to move beyond that because there's so much more important than how many charts or types of charts I reviewed. Onto the next one. Quality shouldn't be the only department capable of identifying when something is unlikely to-- unlikely to-- I'm not sure what that means. To be hospital-acquired, yeah. I expect CDI to be able to do this and understand HRRP, readmissions, mortality, complications, HCCs, et cetera. And yes with a focus on correct POA for all codes. Do you want to comment on that? I do. And, again when I said I see my new coworker out there, I don't disagree with Ellen's statement. Ellen and I are actually on the same page on many things. And what I would say, though, is you have to meet your people on where they're at on the journey. And so I have to train them and guide them to get them there. And if I don't have the people and I don't have the training yet, get the training for them. But I think we have to meet each of our programs where they're at on the journey and help them move along the journey because I think that is important. And the other part is I may not stay current. I'm also depending on quality. And I'll also say, quality doesn't always know their metrics the way we think they do. I have found that more often than not that sometimes as I'm doing some quality education I'm like, no. The metric was written this way and this is the criteria. And this is how it works. So it is that collaboration. But I think we have to yes, I want my CDI to understand quality. And again, I think we just have to guide them in a journey, but not wait. Who can I lean on until I've gotten my team up to that skill set. Awesome. Well, I am going to go ahead and stop here since we are just about out of time. I did want to remind everyone that there are some resources in the resources section. The handout is there, the certificate of attendance is there. And we also have links to like I said some other resources for you. (DESCRIPTION) Slide, 3M Education boot camps. Virtual advanced C.D.I. training - August 1 - 5. Virtual advanced quality training - June 13 - 17. (SPEECH) We do have our educational bootcamps, we have the advanced CDI training, and the advanced quality training both coming up here in June and August. So if you are interested in learning more about those, there's links in the resources section. And after the webinar, you will be getting just an email with more information that if you would like to get that we would like to get that information you can as well as registering for our upcoming webinar in July. So that'll be part 2 of this series of the evolution of CDI. (DESCRIPTION) Slide, That's a wrap! (SPEECH) So again, we really appreciate everybody's time today. If you do have any questions, please fill that out in the survey. We'll be happy to follow up with you. And Cheryl, is there anything else that you would like to add for today? No. I see some of the extra questions we didn't get to. And again, I think you have to figure out where you're at in your journey and set yourself some realistic goals to get there. A goal should be SMART-- Specific, Measurable, Attainable, Realistic, and Timely, all the pieces of whatever that would be. But the point being give yourself reasonable goals. And again, think of your nontraditional metrics. The other question that I saw in there I just want to comment on is yeah, 3M is limited on what we can incorporate into the software because a proprietary methodology. So things such as Vizient or Premier can't be built in because we don't have a relationship with them. And until they agree to partner with us, we can incorporate them. And that advanced sequencing, the last one I want to cover yes it includes HCCs, CMS risk adjustment, PSI and/or PSI, exclusion criteria, and the Alex Hauser criteria. And it will incorporate a little bit more in the future. And I liked one of the suggestions about prioritization. I'm going to share that with the team on one of those great questions about the fact that patients covered under an ACO. That's a great question that I'm going to share back with our development team. So I thank you guys for the really lovely comments, questions, challenges. I like when you provoke and stimulate my thinking as well. (DESCRIPTION) Slide, Thank you! (SPEECH) Awesome. Well, thank you so much again, Cheryl. We certainly always appreciate your knowledge and information. And so thank you all again for your attendance today. We will be posting this recording on our website in the next couple of weeks. So if you do want to go back and listen in, you certainly can. So again, thank you for joining, and we will see you in July. Thank you.

(DESCRIPTION) Slide show. (SPEECH) Good afternoon, and thank you all for joining us for our March Quality Webinar Series. We are excited, if you haven't noticed. Last year, if you were with us, and you joined us, it was a different webinar platform. So we are excited that we have a new platform to really enhance the user experience. So before we kick things off, I just want to go over a few things with you. (DESCRIPTION) Text, New year, new webinar platform! 3M. A great company is showing what interesting applications a fantastic product can bring for motivated users. The left column of the page shows boxes labeled Media Player, Resources, and Have a question? Let us know. The center column has a large box labeled Slides. Under that is a red button that reads, Ask an Expert. The right column has a box headed Speaker Bio. Under that is a box headed Survey with two questions: 1. How would you rate the subject? 2. How would you rate the speaker? (SPEECH) Some of the new features and layout just to make sure you're finding everything as you're navigating this new system. So because this is a web-based platform, there is not a dial-in number. So you cannot participate by phone. So if you are having audio issues, please check your speaker settings, clear your cache, and then you can refresh your browser. There is an engagement toolbar down at the bottom of the screen where you can see the different resources that we have. You can move things around within this portal which is great. You can minimize, close it out, so it is much more interactive than our last platform. If you do need closed captioning, that is available as well. So in the actual media section in the live stream, you can click on closed captioning there which is fantastic. We always encourage Q&A. We'll get to as many as we can. So if you do have any questions, you can put that in the Q&A box there are not CEUs, but we do provide a certificate of attendance. So you can add the-- I'm sorry, you can download the certificate of attendance and submit the CEUs that way. That is also available in the resources section. I do see a couple questions that are saying that there's no slides in the resource section. So what I'll do, again, because this is a web-based platform, I'll double check. In order for you to get that, you will just have to refresh the browser. So by the end, just make sure you do a quick refresh, and the presentation slides will be there for download, as well as that certificate of attendance. I'll double check to make sure it's there. If you would like to learn more about our products and solutions, if you click on the learn-more button under the slides, you can let us know if you'd like us to follow up with you there. We always appreciate your feedback, so please complete the survey either in the portal, or it will launch at the end of the webinar. And, again, if you do have any questions or comments, you can put it in the Q&A section or in the engagement tools. You'll see a little envelope with the at sign. That would send us an email there. OK, so enough from me. We are really excited to get started with the COVID-19's continued impact on CDI and coding across the care settings. (DESCRIPTION) New slide. Text, 3M, Science. Applied to Life. 3M Quality Webinar Series. COVID-19's continued impact on CDI and coding across care settings. March 2022. New slide. Text, New year, new platform! On24 Webinar Platform for a better user experience! Check speaker settings and refresh if you are having audio issues. Ability to move engagement sections. Ask questions! Certificate of Attendance available to download. Engagement tools and CC available. Resources Section. Complete the Survey. (SPEECH) We have a great panel of speakers today. They are no strangers to you. (DESCRIPTION) New slide titled Meet our Speakers, showing a head shot for each speaker. Text, Colleen Deighan, RHIA, CCS, CCDS-O. Sue Belley, M. Ed., RHIA, CPHQ. Audrey Howard, RHIA. Bobbie Starkey, RHIT, CCS-P, AHIMA. Cheryl Manchenton, BSN, RN. To see their full bios, check out the Meet our speakers in the portal. (SPEECH) If you have been with us before, you recognize all these lovely faces. If you would like to learn more about them in the speakers' section, in our meet our speakers' section of the portal. You can read a little bit more about them. So I'm going to go ahead and turn things over to Sue to go over the agenda and get started. Sue. Oh, and Sue, it looks like you're still muted. (DESCRIPTION) New slide. Text, Agenda. Inpatient COVID-19 challenges, admitted with versus admitted for COVID-19, History of COVID-19 versus sequelae of COVID-19, Present on admission. Outpatient COVID-19 challenges. New COVID-19 codes and guidelines effective after 1/1/22. Public Health Emergency. Update on COVID-19 and quality metrics. (SPEECH) Thank you, Lisa. My name is Susan Belley, and I wanted to thank you all for joining us today to continue our conversation on COVID-19. This is the third time that we're coming together since the start of the pandemic to talk to you about COVID, and its impact and how it impacts us with regard to CDI coding initiatives. We actually started developing this particular webinar during the Omicron surge in early January. We started to hear and read all of the national discourse about patients being admitted with COVID-19, and patients being admitted for COVID-19, and we thought it was some very interesting dialogue. A lot of it from people who might not understand how we represent patience being admitted with versus for COVID-19. So what we'd like to do today is talk about ongoing COVID-19 challenges in the inpatient setting, and we're going to start out with this conundrum of admitted with versus for COVID-19, as well as a few other topics that we see people having questions with or perhaps struggling with. We'll move on to outpatient COVID-19 challenges, and then we'll spend some time talking about new COVID-19 codes and guidelines that became effective after January 1 of this year. And I'm sure most of you are aware that we're going to be seeing a few new codes and guidelines go into effect on April 1, just two days from now, and then we're going to finish out by talking a bit about the public-health emergency and have a small update on COVID-19 as it pertains to quality metrics that our facilities report. And I think we'll definitely have time at the end to take any questions or comments that any of you might have, and we'll do our best to answer those. If we can't answer them on this particular webinar, we will respond after. So again, thank you for joining us, and I'm going to turn the first part of the presentation over to my colleagues, Cheryl Manchenton and Audrey Howard. (DESCRIPTION) New Slide. Text, Inpatient COVID-19 challenges. (SPEECH) Good morning, afternoon, I should say. There might be some morning people here. We will specifically talk about those challenges. Not only have we vocally heard or read that, we have actually performed some chart reviews where we have seen the struggle. So I do think it's a global one. The first topic, again, is that admitted with COVID versus admitted for. (DESCRIPTION) New slide titled COVID-19: Admitted with versus admitted for. Two columns, the right labeled Before and the right labeled After. Text, Before: PDx, Pulmonary embolism. SDx, Septic shock. SDx, COVID-19. SDx, DVTs, cardiogenic shock, COVID-19 pneumonia. After: PDx, Query: COVID-19 versus sepsis. SDx, SDX, and PPX are blank. Before: MS-DRG, 175. Relative weight, 1.5460. After: MS-DRG, 177 versus 871. Relative weight, 1.8491 versus 1.8722. Before: APR DRG, 134. SOI subclass, 4. ROM subclass, 4. SOI weight, 1.5965. After: APR DRG: 137 versus 720. SOI Subclass, 4. SOI Weight, 1.5682 versus 2.0860. ROM Subclass, 4. Explanation: Patient transferred from OSH for possible thrombectomy. Patient still in septic and cardiogenic shock and with active COVID-19 infection with COVID-19 pneumonia (confirmed COVID-19 status on this encounter versus query). Consult noted PEs due to hypercoagulable state from COVID-19 and from immobility from previous hospitalizations, but attending did not connect all the pieces. Recommend confirming PE and DVTs and sepsis are due to COVID-19. Per the COVID-19 guidelines, manifestations of COVID-19 are sequenced as secondary diagnosis (meaning U07.1 would be sequenced as PDx over the PE/DVT) but the sepsis and COVID-19 guidelines note sepsis would be sequenced as PDx over COVID-19. (SPEECH) So just to orient you to the screen, on the left side were not all of the codes, but some of the secondary or significant secondary diagnosis. And you'll see the first listed diagnosis on this encounter was the pulmonary embolism, with secondary diagnosis of septic shock, COVID-19, DVTs, cardiogenic shock, and COVID pneumonia, and you can see the MS-DRG assignment. Its relative weight. The APR-DRG assignment. The severity of illness, subclass four, risk mortality, subclass four. On the right side, you can see what would happen based on some clarification. In other words, the documentation was insufficient for what we consider to be telling the whole story. So at the bottom, of course, you can see that the come in-- this patient did come into this inpatient facility for thrombectomy. That was the intent, and we know that when you think about circumstances of principal diagnosis, the reason for transfer is typically sequenced as your principal diagnosis. However, reading the whole story, this patient had just been recently diagnosed. So they literally went from hospital A to hospital B still in an active, really bad COVID situation and also had DIC. There's other codes of course not listed here, but she had not recovered from her COVID. She was not doing well, and had this massive pulmonary embolism. And so, of course, they were sent in here to see-- it was possibility to do a rescue thrombectomy on this patient. Again, still on maximum pressers, active treated, and everything. The consult notes came close. They said the patient's PE was due to the hyper-coagulable state from COVID-19 and from, of course, immobility from that long hospitalization. Unfortunately, the attending didn't really connect all the pieces, tell the whole story. It's clear this was still an active COVID, and this was an active manifestation of an active infection. So of course, we can't just code it the way we think the story should be told. We need to place a clarification and say is this PE due to COVID-19, and again, there's this whole picture ongoing due to the COVID-19 and, again, is it sepsis. And of course, depending on our physician answer, either COVID-19 would be sequenced as principal, or the sepsis would be sequenced as principal. And, of course, what you see is that MS-DRG depended on the principal diagnosis with definitely a higher weight. The other piece I will tell you is unfortunately this patient did expire. She ended up having a hemorrhagic stroke and was made comfort care and expired during this encounter. So when you think about this mortality, this is not to me the right story that we told. And so again, of course, we needed a clarification. And I'm going to hand it over to Audrey to discuss, again, our coding guidelines around that. (DESCRIPTION) New slide titled Sequencing of COVID-19 manifestations. Diagram. A blue circle in the center of the slide reads, Sequence of COVID-19 (UO7.1) as principal diagnosis. Above and to the left of the circle is a purple box with an arrow pointing to the circle. It reads, Acute respiratory manifestations related to COVID-19. To the right of that box is a light purple box with an arrow pointing down to the blue circle. It reads, Non-respiratory manifestations related to COVID-19. Text in the bottom right corner of screen: Assign code(s) for the manifestation(s) as additional diagnoses. (SPEECH) Right, because we know when it comes to COVID, we are still looking at the principal diagnosis definition, which is that condition established after study. That's chiefly responsible for occasioning the patient's admission to the hospital. So we're always looking at why did the patient come in, but there is an additional guideline for COVID that if they are relating the presenting manifestations or the presenting condition to the COVID that according to the COVID coding guidelines that we are supposed to put the COVID as the principal diagnosis. So this kind of still plays into are they admitted with COVID or are they admitted for COVID, and the fact that if the documentation is linking the condition to the COVID, then according to the COVID coding guidelines, we will put the COVID code as our principal diagnosis. And it doesn't matter if it's an acute manifestation. I'm sorry. An acute respiratory manifestation or a non-respiratory manifestation of the COVID. Either one. The fact that it's a manifestation of the COVID, you'll put the COVID as the principal diagnosis. And that's what is being shown on this slide. (DESCRIPTION) New Slide. Text, Current COVID-19 infection versus residual effect. Before: PDx, Myoclonus. SDx, COVID-19. SDx and PPx are blank. After: PDx, Myoclonus. SDx, Add: Post COVID-19 condition (U09.9). Sdx, Delete COVID-19 (U07.1) Before: MS-DRG, 091. Relative weight, 1.6508. After: MS-DRG, 093. Relative weight, 0.7822. Before: APR DRG, 058. SOI subclass, 2. SOI Weight, 1.0587. ROM Subclass, 2. After: APR DRG, 058. SOI Subclass, 1. SOI Weight, 0.8002. ROM subclass, 2. Explanation: Patient admitted with myoclonus secondary to post-COVID-19. As this is a post-COVID-19 condition and COVID-19 was diagnosed a month prior with no active signs of infection or treatment on this visit, this should be assigned to U09.9, not U07.1. (SPEECH) So our second scenario, again, is this a current COVID-19 infection, or is it a residual effect. This was definitely an unusual chart, and it really piqued my interest. We have learned over the last two years lots of different manifestations, or we'll call long-call conditions that we might have seen from COVID. This patient came in with tremors, and they were really admitting him to determine what the source of these tremors were, wondering if he had new onset seizures. After study, again, after this whole chart, the doctors actually get a really nice job here of saying, this myoclonus was actually secondary to a post COVID-19 state. In other words, he had had COVID, it was cleared up, and this is one of his residuals from his infection. And because of that, of course, we would not assign the UO7 code. We would have added the post-COVID condition, the UO9.9 code. And of course, what you see is in this case, it did drop our reimbursement and our severity and mortality, but that would be consistent. In other words, that is the true story. So it's not just whether or not COVID should be your principal diagnosis or not. It's is it a secondary diagnosis. Is this still an ongoing COVID infection. In this case, again, I thought the providers did a fabulous job of noting that. And again, for those that use computer-assisted coding tools, many times, again, the engine is not smart enough to know it shouldn't assign UO7, that perchance there should be a UO9.9 code. That natural language has not been processed yet, so we have to look at the codes and determine is that the appropriate code, or is there an alternate code that should be assigned. (DESCRIPTION) New slide. Text, Post COVID-19 (U09.9). Assigned when the patient no longer has an active COVID-19 infection but has continued residual effects of COVID-19. Do not assign code U09.9 in cases that are still presenting with active COVID-19. However, an exception is made in cases of re-infection with COVID-19, occurring with a condition related to prior COVID-19. (SPEECH) And as always, the code assignment is going to be determined based off the provider's documentation. And sometimes, it's not easy to decipher when a patient is admitted with a condition. Is that COVID infection an active infection, or is it already cleared up. It's no longer current, and therefore, it is going to be a sequelae of the COVID-19. So if it is documentation saying it's an active infection, then we would still put the U07.1 code for the active infection of the COVID. However, the documentation that they are coming in that it's related to the COVID, but the COVID is no longer an active infection. The new code was created for U09.9, and that was effective October 1, 2021. (DESCRIPTION) New Slide titled Coding for long haulers. Flow chart, starts with a light blue box on the left side that reads, Admitted with COVID-19 related condition. Two bright blue boxes are connected to the first box with lines. The top one reads, Documentation supports the condition is an acute manifestation of a current COVID-19 infection. Two navy blue boxes connect to this box. The top one reads, PDx/first listed: U07.1. The bottom one reads, SDX: acute manifestation. The bottom bright blue box that stems from the first light blue box reads, Documentation states patient no longer has an active COVID-19 infection. Two navy boxes are connected to this box. The top one reads, PDx/first listed: presenting condition. The bottom one read, SDx: U09.9. (SPEECH) On the next slide, you're going to see kind of a decision tree, if you will, regarding which code to be assigned. Once again, always based on the provider's documentation of how it relates to the COVID-19. So the documentation is linking that condition to the COVID-19, but then you have to decipher is it an active infection, or is it no longer active to help you decide which code you're going to put. And you may need to query the provider to get that clarification, because we're, once again, even though we're two years into this pandemic, we are still learning more and more about the virus, and about how long it may stay in the body, and if it's active or a past medical history. (DESCRIPTION) New slide. Text, COVID-19: Current infection versus residual virus. Before: PDx, atrial flutter. SDx, Type 2 myocardial infarction. SDx, COVID-19. After: Atrial flutter. SDx is blank. Second SDx reads, Clinical validation: COVID-19. Before: MS-DRG, 280. Relative weight, 1.6069. After: MS-DRG, 280. Relative weight, 1.6069. Before: APR DRG, 201. SOI Subclass, 3. SOI weight, 0.8214. ROM Subclass, 3. After: APR DRG, 201. SOI Subclass, 3. SOI weight, 0.8214. ROM Subclass, 3. Explanation: Patient presented with palpitations. New diagnosis of atrial flutter. Ablation planned as outpatient. Recent COVID infection. Tested positive on this admission. COVID infection 2 months prior. Recommend confirming if positive test is reflective of residual virus (e.g., viral shedding) versus continued active infection. (SPEECH) So this is a nice segue. Is this a current infection, or is it residual virus. So this patient presented with palpitations with a new diagnosis of A flutter and also had a type-two MI. They plan to complete the ablation outpatient. They had had a recent COVID infection, and they were still positive submission. Again, what was nice about the documentation is the provider had said that COVID infection was two months prior. So the fact that they are still having antibodies in their bloodstream, is this an active COVID infection, or is this residual virus. (DESCRIPTION) New slide. Text, Sample query COVID-19. Patient presented with new diagnosis of atrial flutter. Noted to have received COVID-19 infection 2 months prior and COVID-19 test positive on this admit. Please clarify current status of COVID-19: COVID-19 infection not current; positive test due to residual virus. Active COVID-19 infection current on this encounter. Other (please specify). Clinically unable to determine COVID-19 status on this admit. (SPEECH) And so what we have done for you on this next slide is given you an example of how to ask this question. Please clarify the current status of COVID-19. Of course, you'd put all the appropriate clinical indicators, reference, your documentation, et cetera. But your options here, is COVID-19 infection is not current. The positive test is due to residual virus. An active COVID-19 infection current on this encounter, other, unable to determine. And again, the point being, you want to make your query as explicit as you can. You're not introducing. You're not leading the providers, but the more specific you are in your choice, the better that provider understands the question. Because I think most of us would agree that the provider's answer is probably going to be that first choice that is just a positive test to the residual virus. And of course, this is an educational opportunity to the provider saying don't make me query you. Be a little bit clear. You know, and I actually have seen some providers that have noted that where they have made the distinction for us without a query. But when it's not clear, we would want to actually, again, place a query similar to this. (DESCRIPTION) New slide. Text, Current Infection versus residual virus. According to the CDC, people who have recovered from COVID-19 can continue to test positive for up to three months after their infection. Viral shedding can mean either that the patient has an active (current) COVID-19 infection or a personal history of COVID-19. If active COVID-19 infection, assign code U07.1, COVID-19. Viral shedding in a patient with a history of COVID-19 is classified to code Z86.16, Personal history of COVID-19. If documentation is not clear, then query the provider for clarification. (SPEECH) And this goes into that what code assignment will be assigned based off that documentation. You may see documentation in the record about viral shedding, and viral shedding still, once again, could mean that it is an active infection, or it's a past medical history, or the virus is no longer current. So we still sometimes need to get that clarification, and that previous slide was showing a great example of how to word that query to the providers. And that example was actually written by Miss Howard and myself. We actually crafted that one together to think of-- we wanted to make sure that it met both a coding need, but it also was reflective of the clinical condition. And so that's an example of sometimes you need to partner with each other to ensure that we're hitting all the state of objectives of a clarification. (DESCRIPTION) New Slide. Text, Present on admission status. Before: PDx, Cerebral infarction. SDx, COVID-19 (POA N). SDx, Hemiplegia of right dominant side. After: PDx, Cerebral infarction. SDx, Query: COVID-19 (POA Y) The rest of the chart is the same in both the Before and After column. Text, MS-DRG, 064. Relative weight, 1.9189. APR DRG, 045. SOI Subclass, 3. SOI weight, 1.2650. ROM subclass, 3. Explanation: Patient admitted with CVA. First COVID-19 test negative. PN stated, "Reportedly, patient had some COVID + family members who she has been in contact with prior to admission." Discharge delayed until past quarantine period. Recommend clarification of POA status as this does not reflect well on hospital to have hospital acquired COVID-19. (SPEECH) Our last category is present on admission. Again, in the literature has been this discourse, this conversation, regarding patients getting COVID while in the hospital. Did we the hospital give this patient COVID-19? And our data, our coded data, is how they're making research determinations, how they're studying, how they're analyzing to determine whether or not these conditions were present on admission or were hospital acquired. So it is so important to get this right. I can't stress enough how it may reflect bad on our hospital that we didn't protect this patient. There are those times where you've got a roommate who you didn't had some sort of exposure, and it happens. But overall, through our testing and through all of our stringent protocols, this should be a relatively rare occurrence. So on this particular case, this patient came in with a CVA. And of course, on admission as most hospitals do, she was tested for COVID, and her COVID test was negative. A few days, six days after, she's ready to be placed in a SNF facility, and again, as many know, she had to have a negative COVID test yet again right before she had left to ensure that she wasn't going to be transmitting COVID to the nursing home. And unfortunately, that test turned positive. So of course, this patient had to then stay in house in quarantine until she tested negative, so she could be transferred. There was a progress note from the provider that said, reportedly, the patient has some COVID-positive family members who she's been in contact with prior to admission. So of course, my alarm bells popped right up on that sentence. And again, I think the provider was speculating. Was that sufficient enough? No, I do not believe that was sufficient enough to have changed the POA assignment. I think we can also debate, discuss, depending on which variant is out there, what is that incubation time. We know the BA.2, as an example, the Omicron BA.2 has had a much shorter incubation. But the Delta, and this would have been actually more so in the Delta-variant time, did have a little bit of a longer incubation period. So again, to me, it is conceivable that this patient had been exposed to the virus on admission. And again, that first test she had not had enough virus to turn positive. So of course, again, we would have to place the clarification, and what we've done is, again, also given you the guidelines on that POA. But please do know we would not routinely just assign POA. We would need to ask that provider that question. (DESCRIPTION) New Slide. Text, Present on admission status. Present on admission is defined as: Present at the time the order for inpatient admission occurs. POA guidelines state, "The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of the findings." (SPEECH) And that's basically what these guidelines are saying. So what's on this slide is that the highlights from what I felt like was the most pertinent part of the present on admission guidelines related to this sort of a situation. It's not much. Basically, the definition of present principle-- I'm sorry. The definition of present on admission is just that it's present at the time the order for inpatient admission occurs. So that's not a lot of guidance when it comes to assigning the correct POA indicator in this sort of a situation where the initial test was negative, and then the subsequent test was positive. It makes you think, well, of course, they had to get the infection while they are in house. But because, as Cheryl was saying, the incubation period can vary, and we're not for sure when they were exposed, that it is good to query the provider in this sort of a circumstance, and that's the other part of the guidelines that if you're just not sure based on when did they develop any signs or symptoms. And a lot of times that a patient may be asymptomatic when it comes to COVID-19. So there are no signs or symptoms. So what's the timing of the test results, or the timing of the findings. So if it is unclear, it is appropriate to query the provider to get that information regarding the present on admission indicator. The whole thing about present on admission is did the patient bring it in with them, or is it something that is hospital acquired, and are we sure that the patient really got exposed, and therefore, got the virus after admission to the hospital. So that's kind of really the question that we're really trying to decipher. Was the virus in the body prior to the inpatient admission. And so that's kind of the deciding question that we need to have the provider tell us so that we can assign the most appropriate POA indicator on these cases. So that is the end of our section on inpatient. Again, as Sue had noted, we do have a Q&A portion coming back, and I do see a lot of very nice questions in there, but I'm going to turn it over now to my colleagues from the outpatient side. (DESCRIPTION) New slide. Text, Outpatient COVID-19 challenges. (SPEECH) Thank you, Cheryl. Thank you, Audrey. So now, I want to talk just a little bit about some of the outpatient challenges that we're seeing. (DESCRIPTION) New slide. Text, Reporting Z20.822. Reporting Z20.822 - Contact with and (suspected) exposure to COVID-19. ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Pages 38 to 39. For asymptomatic individuals with actual or suspected exposure to COVID-19, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, for encounters prior to January 1, 2021, and code Z20.822, Contact with and (suspected) exposure to COVID-19, for encounters after January 1, 2021. For symptomatic individuals with actual or suspected exposure to COVID-19 and the infection has been ruled out, or test results are inconclusive or unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases or code Z20.822, Contact with and (suspected) exposure to COVID-19, depending on the encounter date. Official Coding Guidelines I.C.21.c.1. c. Categories of Z Codes. 1, Contact/Exposure, Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who are suspected to have been exposed to a disease by close personal contact with an infected individual or are in an area where a disease is epidemic. (SPEECH) One of the things I wanted to mention was the reporting of code Z20.822. And that code is the contact with and suspected exposure to COVID-19. And I think we're seeing people hesitant to use this when the physician doesn't specifically state that there is suspected exposure or actual exposure. But if you look at-- there are two coding clinics. One is here on the slide. The other one is coding clinic second quarter 2020, pages 8 and 9. They refer to this coding guideline for the Z20 contact and exposure code. And it says that categories Z20, which is on the right of your slide here, indicates contact with and suspected exposure to communicable diseases. And it says these codes are for patients who are suspected to have been exposed to a disease by a close personal contact with an infected individual or, and the or part is where we're at, or in an area where disease is epidemic. So during the PHE, the public health emergency, we are in a pandemic. It would be appropriate to report the Z20.822 when a patient has a COVID test that comes up negative, because they are assumed, due to being in an area of an epidemic, that they were exposed. And so we just want to make sure that people are reporting this in those instances. (DESCRIPTION) New slide. Text, Coding signs and symptoms with COVID-19. Per updated FAQs from AHA, August 27, 2021: Response was revised on 8/25/2021 to read, "People infected with COVID-19 may vary from being asymptomatic to having a range of symptoms and severity. Therefore, for coding purposes, signs and symptoms associated with COVID-19 may be coded separately, unless the signs or symptoms are routinely associated with a manifestation." (SPEECH) The next thing I wanted to address for outpatient is coding signs and symptoms with COVID-19, and we have these coding guidelines ingrained in our heads, so we are very hesitant to code symptoms with a confirmed condition. It goes against coding guidelines, but COVID-19 has made a couple of different exceptions to the rules that we've been following, the guidelines that we've been following in the past. So the AHA puts out a list of frequently asked questions regarding reporting codes for COVID-19 conditions. And they revised this list of frequently asked questions on August 27, 2021, and it actually went into effect August 25, 2021, and they revised it to say people infected with COVID-19 can either be asymptomatic or have a range of symptoms and severity. For coding purposes, signs and symptoms that are associated with COVID-19 can be reported separately, unless the sign or symptom is routinely associated with a manifestation of COVID. So if you have a patient that comes in, and they have shortness of breath and a cough, and they test positive for COVID-19, you can report those signs and symptoms even though they are respiratory signs and symptoms with that COVID-19 that use 07.1 diagnoses. Unless in the case where you have a patient who has a cough, and they are diagnosed with pneumonia due to COVID-19. That cough would be integral to the pneumonia, which is the manifestation of COVID, and then you would not be able to report that symptom. And the reason for this is it explains how severe the case of COVID is. So they want to make sure that you're reporting all of the signs and symptoms with the COVID. (DESCRIPTION) New slide. Text, CS Modifier. Application and appropriate use of the CS Modifier. The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients for COVID-19 testing-related services. These services are medical visits for the HCPCS evaluation and management categories described below when an outpatient provider, physician, or other providers and suppliers that bill Medicare for Part B services orders or administers COVID-19 lab test. Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the Public Health Emergency (PHE); that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and management codes. For services furnished on March 18, 2020, and through the end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under these payment systems should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services. At the right of the screen is a table labeled CS Modifier Appropriate HCPCS codes for OPPS with a list of codes. G0463, C9803, G0378, G0379, G0380, G0381, G0382, G0383, G0384, 99281 through 99285, 99291, 99304 through 99310, 99315, 99316, 99318, 99324 through 99328, 99334 through 99337, 99340 through 99345, 99347 through 99350, 98970 through 98972, 99421 through 99423. (SPEECH) The next thing that I wanted to talk about as far as an outpatient challenge is the CS modifier. The CS modifier, they had used it prior. I think the Gulf spill, they used this modifier for, but when the Families First Coronavirus Response Act was put into place, which waives cost sharing under Medicare Part B, and cost sharing is the patient's payment of co-insurance and any deductible amount. For COVID-19, the Families First Act waived these payments. So in order to show that these payments needed to be waived, we were instructed to apply the CS modified. While back when this first happened, we didn't have a lot of clear guidance. CMS told us in a report to CS modifier, but they really didn't give us good instructions until August. I think it was August 27th of 2020, they did send a MedLearn Matters article that said this is how you need to use the CS modifier. And they said it shouldn't be reported with COVID lab test codes. It should instead be reported with the evaluation and management service, and then they gave us this list of-- a small list of evaluation and management code that you could attend the CS modifier to. And then in October of 2020, we finally got-- our Mac finally instilled the edits for the CS modifier. So from middle of March until October, before we actually had edit to catch any errors with the CS modifier. We're still seeing hospitals that either are applying the CS modifier to the lab code, or no one's applying the CS modifier. And I think it may be a matter of the front end and the back end doing it, and the back end thinks the front end is doing it. So CMS gives us guidance about if you put the CS modifier on the wrong code, they will return those claims to the provider. So RTT those claims, but they don't address what's going to happen if the modifier is not there at all. So since the modifiers put on the evaluation and management code to keep the patient from having to pay the co-insurance and the deductible amount, think about what's going to happen when those modifiers aren't applied if we have to go back. And just one more note, the CS modifier can be applied to the ENM service in this table on the right any time the ENM service results in either performance of a COVID test or ordering of a COVID test. So if the physician orders the COVID test, even though it's done at maybe an outside laboratory, that physician's office can still put the CS modifier on the ENM service. It's also only for testing for COVID. It's not for treatment of COVID. So I'm going to use the emergency department as an example. It happens to be the codes on this table are the emergency department range, and the patient comes in. They test positive. They've already tested positive for COVID prior, but now, they're really having shortness of breath. So they come to the emergency department. They're not going to test the patient again, then they would not be able to apply the CS modifier to that service in that case. (DESCRIPTION) New Slide titled CPT/HCPCS code changes for COVID vaccines, treatments and administration. A table with a column labeled Vaccine Code and one labeled Administration Code. The vaccine code column is blank for the first five administration codes: 0003A, 0004A, 0013A, and 0034A. Vaccine Code 91305, Administration code, 0051A, 0052A, 0053A, 0054A. Vaccine code 91306, Administration code, 0064A. Vaccine code 91307, Administration code 0071A, 0072A. Vaccine code 91308, Administration code 0081A, 0082A. Text, 2022 CPT Manual Appendix Q lists all COVID-19 vaccine codes that were created and effective prior to 9/22/2021. (SPEECH) So another out-patient challenge. You probably wouldn't be surprised if I told you there are currently 31 COVID-19 CPT/HCPCS vaccine codes, and 24 antibody therapy codes for COVID-19. That doesn't even count all the new CPT codes for the lab testing. So these codes have been coming at us fast and furious since COVID started. They're coming so fast and furious that I actually have a new one that was just approved that is not on this slide. This slide, it is all of the codes that were effective after 9/22, 2021, that did not make it into the 2022 CPT manual. So because it was September, 2022, was the earliest one and after, the manual was already published. They didn't have time to get those codes in. So this is a listing of all the codes that are not in your code manual. I will add the CPT code 91309, and the administration code is 0094A, and that is for a new Moderna booster vaccine. The reason that it has a new code is because the 91306 is the old Moder-- not old. It's the first Moderna booster vaccine. This new code 91308 a different dosage, and in addition to that, it comes in its own packaging. So it's administered-- I guess, the 91306, they were drawing the medication from the same vial that they use for an initial dose of a Moderna vaccine. This 91309 is actually its own packaged vaccination. If you aren't sure or just to keep track of all these vaccine code, new vaccine codes, Appendix Q can be looked up online. If you just search the CMS Appendix-- I'm sorry. AMA Appendix Q, it will give you the table that has all of the codes. It gives you the NBC numbers I think also, but it's a great way to keep track of these. Now, you also want to make sure whoever is doing your chargemaster knows about the new codes. You're educating physicians coders on the new codes as well. (DESCRIPTION) New slide titled COVID-19 Vaccines. The new ICD-10-CM codes for reporting COVID-19 vaccination status effective April 1, 2022, are: Z28.310, Unvaccinated for COVID-19, Z28.311, Partially vaccinated for COVID-19, Z28.39, Other under immunization status The 2022 Official Guidelines for Coding and Reporting are updated at Section I.C.1.g.(1),n to include this guidance: Code Z18.310, Unvaccinated for COVID-19, may be assigned when the patient has not received at least one dose of any COVID-19 vaccine. Code Z28.3111, Partially vaccinated for COVID-19, may be assigned when the patient has received at least one dose of a multi-dose COVID-19 vaccine regimen, but has not received the full set of doses necessary to meet the Centers for Disease Control and Prevention (CDC) definition of “fully vaccinated” in place at the time of the encounter. Code Z28.39, Other under immunization status would be reported for non-COVID vaccinations. CDC Definition of “fully vaccinated”: Fully vaccinated means a person has received all recommended doses in their primary series of COVID-19 vaccine. Up to date means a person has received all recommended doses in their primary series COVID-19 vaccine, and a booster dose when eligible. People who are moderately or severely immunocompromised have specific COVID-19 vaccine recommendations for the primary series and booster dose due to their different immune response following COVID-19 vaccination. (SPEECH) And then as far as new codes go, I wanted to talk a little bit about the new COVID-19 vaccine code. As we stated, they will go into effect the day after tomorrow, and there are three new ICD-1-CM diagnosis codes. The first one is Z28.310, and it's unvaccinated for COVID-19. It would be assigned when the patient's not received at least one dose of any COVID vaccine. So that's pretty clear cut when we would use that. The next code, Z28.311, that's for partially vaccinated for COVID-19. And this would be a sign when the patient's received at least one dose of a multi-dose COVID-19 vaccine regimen but has not received the full set of doses necessary to meet the CDC's definition of fully vaccinated. That is in place at the time of the encounter, and that is a key part of that sentence. On the right hand side of the slide, I do have CDC's definition, and this may change now that FDA has approved new doses, but this was, at the time, the definition of fully vaccinated, and it means a person who's received all recommended doses in their primary series of a COVID-19 vaccine. Up to date it's also a definition that CDC has on their site, but up to date doesn't affect our assignment of the status codes for COVID vaccines in any way. Up to date, this includes all the booster shots. The booster shots aren't included at this time in the fully-vaccinated definition. The fully-vaccinated definition also changes for patients who are moderately or severely immunocompromised. So there's a different vaccine recommendation for those primary series and also the booster doses due to that immune response. So think about that and what kind of documentation do we need to see in order to assign these codes appropriately. So hopefully, our physicians can document fully vaccinated or partially vaccinated. In some cases, that may even change from one visit to the next depending on if you're immunocompromised patient. We just got an additional dose approved for those immunocompromised patients. Now, last week, they may have been fully vaccinated. Now, this week, they may be partially vaccinated. It's just going to depend on the CDC's definition at that time. That third code, Z28.39 is the code for other under immunization status, and that code isn't going to be reported for COVID-19 at all. It would be reported for any other measles, mumps, those chickenpox, those types of vaccinations when patients are under immunized. And so, again, these code are not going to be in our current ICD-1-CM manual. So it's important that your providers are aware of the new codes, and what supports those codes as well as your coders. I think that's everything for this slide. (DESCRIPTION) New slide. Text, Monoclonal antibodies for pre-exposure prophylaxis of COVID-19. CMS created new code, Q0221, effective February 24: Long Descriptor: Injection, tixagevimab and cilgavimab (EVUSHELD™), for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg. Use the existing administration codes — M0220 and M0221. The FDA authorized the use of this monoclonal antibody combination for the pre-exposure prophylaxis of COVID-19 in adults and pediatric patients (12 years and older weighing at least 40 kg) under these conditions: They aren’t currently infected with SARS-CoV-2. They haven’t had a known recent exposure to an individual infected with SARS-CoV-2. One of the following apply: They may not mount an adequate immune response to the COVID-19 vaccine because their immune system is moderately or severely compromised due to a medical condition or because they got immunosuppressive medications or treatments. They aren’t recommended to get vaccinated with any available COVID-19 vaccine, according to the approved or authorized schedule, due to a history of severe adverse reaction (for example, severe allergic reaction) to a COVID-19 vaccine. (SPEECH) And then lastly, we have a new code, which was effective February, 24. It's for a prophylaxis for monoclonal-- I'm sorry. For COVID, it's a monoclonal antibody, and it's to be used for pre-exposure. So it's the first emergency-use authorization approval for a prophylaxis for COVID. It was first approved back on December 8 of 2021. But the FDA just recently approved a different dosage, and at that time, CMS created the new code Q0221. This is actually called the brand name currently is Evushield. It's administered as two separate consecutive intramuscular injections. There's one injection per each type of monoclonal antibody, and I'm not going to talk to you by trying to pronounce those two antibodies, but they are given in immediate succession. It's to be effective for pre-exposure prevention for six months. It's not authorized for individuals for the treatment of COVID-19 or for post-exposure prevention of COVID-19. So my question here would be, how do you define pre-exposure since you don't know if you had it, but this code is also not in the HCPCS 2022 manual. So we want to make sure that we're making our coders and our providers aware that these codes are available. And at this time, I'm going to turn this table over to Colleen Deighan. (DESCRIPTION) New slide. Text, Public Health Emergency (PHE) (SPEECH) Good afternoon, everyone. This is Colleen. I'm just dialing in via the phone. I apologize for not being on the internet today. Sue, if you could advance the slides for me, I'd appreciate it. And now you have Colleen. (DESCRIPTION) New slide. Text, Public Health Emergency. First issued 1/31/2020, effective 1/27/2020. Duration of the emergency or 90 days. Renewed eight times. Last renewed January 14, 2022. Effective 1/16/2022, expires April 16, 2022. Will HHS extend? CMS 1135 Waivers as a result of PHE: Flexibility for Medicare Telehealth Services, Emergency Medical Treatment & Labor Act (EMTALA) enforcement, Verbal orders, Reporting requirements, Patient rights, Physical environment, Nursing services. Public Health Emergency declaration: The Secretary of the Department of Health and Human Services (HHS) may, under section 319 of the Public Health Service (PHS) Act, determine that: A, a disease or disorder presents a public health emergency (PHE); B, or that a public health emergency, including significant outbreaks of infectious disease or bioterrorist attacks, otherwise exists. Duration and Notification: The declaration lasts for the duration of the emergency or 90 days. (SPEECH) Thank you. Sorry, so I can't also see the slides, so I apologize. So I wanted to talk a little bit about just the public-health emergency, reminding us of this process. So this is what we refer to as the PHE. It was a declaration and is a declaration by the Secretary of the Department of Health and Human Services. And when a PHE is declared, there's an opioid crisis declaration right now as well, and as Bobbie mentioned, sometimes there's local declarations around the Gulf oil spill as one example when she talked about the CS modifier. So this public-health emergency that HHS declared when a disease or disorder presents a public-health emergency, or a public-health emergency, including significant outbreaks of infectious disease, bio-terrorist attacks, et cetera, that declaration can be made. And it's made for a duration of the emergency or 90 days. So if you recall, just on the slide here, this was first issued back in January of 2020, and it was effective 1/27 2020. And this, again, the duration of these is the duration of the emergency or for 90 days. So this is a 90-day declaration that was renewed so far up to eight times. Last renewed on January 14, which made it effective January 16th of this year, and it expires in mid-April in a few weeks here on April 16. So the question there-- I've brought a lot of information-- yes or no? So will the Department of Health and Human Services, the Secretary, extend this again. If it does get extended, it will be for an additional 90 days and expire on July, 16. So I've read that there's likely an extension that will happen, but I've also read that this will be the last extension. So I point that out to just to really be aware of that, and then what are we going to hear in the next couple of weeks about the extension of the PHE for an additional 90 days. And I also wanted to remind everyone that as part of that declaration, CMS created some flexibilities. So 1135 waivers that CMS declared as a result of the public-health emergency. There were many in there. I've highlighted a few of them here. So expansion, what they refer to as flexibility of telehealth services. There's also relaxation of the EMTALA enforcement in the emergency department, relaxation of verbal orders, reporting requirements related to different breakout events. How we notify patient rights, waivers and flexibility around that. Even the physical environment, which was, again, when they created different ways that patients could receive care without being in the hospital. So the physical walls of the hospital, the flexibility related to that. And the nursing services is just one other example around the requirement for care plans for all patients. So all of those flexibilities and many other ones are part of this declaration that's PHE, and they're set to expire whenever HHS declares the public-health emergency-- I guess, we could use the term over. So I think with relation to this, I wanted to talk primarily about telemedicine. I think that was-- if there's anything that I would say as a silver lining, I've used this term before, I think telemedicine is-- could be considered a silver lining of COVID-19. There are many, many people for many years behind the scenes that have been trying to advance telehealth or telemedicine services. There are many things in the way of that that will relax as part of this waiver 1135. So telemedicine in just a brief definition is the delivering of care at a distance. So using technology to deliver care at a distance, and CMS and its prior to the public-health emergency only allowed telehealth services to be covered for their Medicare beneficiaries. If the patient lived in a rural area, or a particular service was not available to that patient. The patient did have to travel to a local medical facility and then receive those services from a medical doctor at a remote location. So very narrow window, and I wanted to share that CMS wanted to expand. It was a very important expansion in the PHE. Remember, it was around access, making sure their beneficiaries had access to care. They wanted to keep their beneficiaries safe at home, avoid travel, contain the spread of COVID-19. And this was and still remains in its PHE status, regardless of the patient's diagnosis. So this isn't just for treating COVID. It's for treating any patient condition during the public-health emergency. And statistically, I found some statistics on the HHS, the Department of Health and Human Services website that said in 2019, there were approximately 840,000 claims for telehealth services. And then in 2020, the year 2020, during that main year of that first year of the PHE, there were 52 million claims. So we went from 840,000 claims to over 52 million, and this is just the Medicare population that's in the traditional Medicare services. So that was a 63-fold increase reported by HHS, and they also reported that 92% of those patients received telehealth services in their home. We saw telehealth being delivered in physician setting in the hospital. There were many different areas, at 92% in the patient's home. So the question that I have that I think is important to think about is what's going to happen. So telehealth really, the expansion of this was successful. There were many things that were wavered as part of this regarding licensure as one example. The state licensure requirements for physicians, the relaxation of those requirements, the payment of them. Many of our commercial carriers went online. So with these changes that CMS really encouraged to have happen during the pandemic. So you as we think about the public-health emergencies and the end of this declaration, what's going to happen to telemedicine. And I think that there's still today many behind the scenes working on post the PHE. The American Medical Association, Congress, physician bodies have been working, I say, to define the new normal. And I also wanted to say is part of this, one of the key things that happened last week was the-- excuse me, sorry. That as part of the Consolidated Appropriations Act of 2022, that omnibus funding bill that President Biden signed into law last week, there were some telehealth flexibility extensions for the Medicare program as part of that omnibus funding bill. And the key thing that it did was it allowed the continuation of a broad range of telehealth services for 151 days beginning on the first day after the end of the PHE period. So whenever the PHE period ends and is declared by HHS as ending, that then begins the 151 days that this omnibus funding bill is creating the extension of those telehealth flexibility. So Medicare wants to continue to provide those services post the pandemic, and what does that look like. So there isn't a gap. There has to be a clear transition here. So this is the initial steps of that transition. So again, keeping in place any sites, including the patients home, is eligible for delivering of telehealth. The other key thing is telehealth initially pre the pandemic was for services by professional services. What we refer to as physician services, and it did not include occupational therapists, physical therapists, speech, language, audiologist that provide key care in patients home. So the extension of those eligible practitioners will be included as well in this. So I think those are the things that I think about. I guess I have more questions than I have answers, but I really wanted to bring this to everyone's attention because telehealth is really-- what's going to happen to telehealth post the pandemic. And I think what we really see is that telehealth works, and it meets the patients literally where they are. It does exactly that. So I wanted to keep those dates in your mind for your providers of services and making sure that telehealth gets to continue post the pandemic in its current fashion, almost the whole degree that it's available during the public-health health emergency. And with that, Sue, I will turn it back over to you. OK, and I'm going to turn this to Cheryl, who's going to wrap up with our last mini topic, I'll say. (DESCRIPTION) New slide. Text, COVID-19 and quality metrics (SPEECH) Thank you, Sue. So I did see a question about post-op sepsis, and COVID was not listed as an exclusion, because HRQ uses their data for, specifically, it would have been time periods 2017 and 2018. COVID was not a diagnosis. So COVID cannot be an exclusion in an HRQ world. Now, in terms of CMS, CMS per the final rule last year, so we're almost up to the proposed rule this year. But final rule last year, CMS indicated they would remove COVID-19 claims. Any patient who had it listed as principal or secondary, any U071 on a code, those claims would be removed from any of the quality reporting programs meaning the half reduction program, value-based purchasing, and the hospital re-admissions reduction program. So CMS has already done their best and did some specific exclusions also during this time period, during our public-health emergency. The provider's profiling system. The merit-based incentive payment system did allow physicians to apply. So you notice the key there. The physicians had to apply for an emergency exemption, an extraordinary use exemption, meaning that they could not participate in their quality-improvement activities because they were working under the pandemic. That was extended from the first year into the second year, and CMS did indicate that by tomorrow, the providers can also request an exemption for 2022 for that Emergency Hardship. Now, what's going to happen next year? How HRQ is or isn't going to include COVID or CMS? As Colleen said, I'm waiting with bated breath. I would not hang my hat on what the proposed rule says. Many times, they do change their mind before the final rule comes out. I think sometimes it's a good indicator, but many times, they propose some radical changes that don't fall through. So we really won't know until August what CMS is going to do. And as for HRQ, they typically have been releasing late July, early August. So we won't know until then how HRQ is going to address it. And again, the challenge for HRQ is it would need to be in both the baseline, and it would have to be in the current period for them to determine how much it's affecting the complications, although we clinically understand that it probably is having an increase in the number of complications those patients with COVID that they're not going to make any decisions until they have both. So this is a big question mark that we didn't want to not address what's happening to quality. I think CMS has done a decent job, to be honest with you, in how they've handled it this year, and I'll be curious to see how they do it for the upcoming years. And with that, Sue, I'm going to turn it back to you. (DESCRIPTION) New slide. Text, Q&A. (SPEECH) OK, well, thank you, everyone. This was, I think, a great smorgasbord of COVID information. So we hit it from many different angles. So Lisa, I think you've been monitoring the questions that are coming in on the chat. So do you want to throw some of them out to our group here and try to address them? Thank you. Yeah, absolutely, there's a ton, so I'm going to try to get to a couple of them. We will have to follow up after with any questions that we don't get to. Just a quick reminder, the resources section does now have the slides. So if you don't see them, do a quick refresh of your browser, and they will populate at that point. There have been a couple questions on CEUs. We do not provide CEUs. That's what the certificate of attendance is for. So if you do download that certificate, you can always submit that to an accredited association to obtain CEUs. This is recorded. We will add it to our website in the next couple of weeks, as well as the handout as well. So if you still aren't able to get the handouts, then it will be available on our website soon. OK, so with that, let's get to some questions. I hope I don't hit any repetitive ones. So I'm just going to kind of start down at the beginning and work my way up to get to as many as we can. So what code would you assign if the provider answers unable to determine. This was on slide 13, whether the COVID was current versus-- oh, I'm going to butcher this-- Sequela. I think that's right. So Audrey, tag. I saw that question come through. I mean, that is always the option that the provider can answer unable to determine. It is highly possible. As we are learning more and more, is the virus current or not. I mean, you have to take it based on the documentation that's available on the record and stop and consider, well, how long ago was the initial diagnosis? Was it last week? Was it last month? What's the corresponding treatment towards the COVID-19 to help maybe decipher that as well. I mean, obviously, a code has to be assigned, and you're going to be taking it based on the documentation. Cheryl, I'm kind of floundering, because I'm not quite sure where to go when the provider can't answer. Do we escalate it? Do we have another peer review look at it? I think if, ultimately, they cannot tell you if it's current or sequelae, I think we just have to code the history of COVID, because we can only code confirmed conditions. And if they can't confirm it to me, I would just be doing history of COVID, because I don't know how else I would assign it. That might also be a very good example to submit to coding clinic, that specific example, and how a situation like that should be handled. And Linda did make a note, and I think Linda was responding during this time. She said, you would need to say clinically UTD. Linda Gavellin, does that ring a bell of anything with that? Well, clinically unable to determine is what she is saying with that. Yeah, I just think, as Audrey said and Sue said, I do think it's appropriate to-- I'd love to see coding clinic answer this one, because heaven forbid, and many times Audrey and I have given advice, and then coding clinic comes out and says the opposite. And we kind of smile and go, we're giving it our best guess, but I do agree that having a physician advise on these difficult ones because the data integrity is so important. I think it might be important to go through an escalation process and have those providers have their conference and say, what is your best guess Dr. Jones? What are we going to put on this record? What do you believe is the clinical truth? And usually, from what I have seen, when those difficult conversations do occur, they do give us some sort of definitive answer. But I can appreciate the fact that this is kind of a wild one. Absolutely, and so because we are so close on time, I am going to pause, because there are a lot of questions left. And so after the webinar, I will collect all of the questions and get them over to our panel to reach out, and it might be worthwhile, and this is something we'll discuss too, do we combine it and put it into a document to send, because there's just so much. So (DESCRIPTION) New slide. Text, That's a wrap! (SPEECH) as you can see, and as you heard today, there is so much information that this team knows, and it's just so impressive to hear all of you talk and just the knowledge that you provide is just wow. (DESCRIPTION) New slide titled 3M Education boot camps. Text, 3M experts offer a variety of education boot camps to keep you informed and meet the growing need for more specialized trainings in the clinical documentation integrity (CDI) space. Our educators include clinicians, documentation specialists, and coding experts with decades of industry and education experience, they will deliver the insights you need to make an impact on your CDI programs. Virtual Advanced CDI training: The Advanced CDI training week offers comprehensive CDI education addressing fundamental CDI skills and the clinical and coding concepts behind key major diagnostic categories (MDCs). This training week is a crucial starting point for any inpatient CDI or coding professional before moving to other more advanced topics. Upcoming Advanced CDI training week: November 1 through 5. Virtual Advanced quality training: Discover how CDI, coding and quality efforts can impact the quality of care across various value-based purchasing initiatives. The quality training is a great follow up to the Advanced CDI training and is great for seasoned professionals and multidisciplinary CDI teams looking to take their programs to the next level. Upcoming Advanced quality training weeks: November 15-19. Dates are subject to change. Learn more at go.3m.com/cdibootcamps. (SPEECH) And so with that, in the resources section, again, if you are not able to download the presentation slides, if you did not refresh your browser, the slides will be available in the next couple of weeks on our website. And usually, during the promotion of our next webinar, which you can actually register for. We already have that one, part one in the series that Cheryl is going to be presenting on. Cheryl, do you actually want to talk about that one, kind of give them a quick preview, because that registration is in the resources section. Not necessarily. Sorry, I wasn't prepared for that question. No, that's OK. Don't worry about it. No, that's OK. I can comment. I am so sorry. I am looking forward to it, and I think similar to today, we'll probably have a lot of questions and probably need to tabulate those and get you all some feedback on them, but I do look forward to meeting with you all next month. Yeah, the registration is there. It's up, and so if you are interested in registering for the next one, you can do that. You also can see that there are educational boot camps that we have coming up. So a lot more of this information is available to you. You can get to those resources. The links are in that section as well, as well as that certificate of attendance. And so if you have any questions, like I said, in those engagement tools, there's a little envelope there if you do want to send us a direct question, that does come to me directly. And I'll try to get your questions answered if there is any follow up. And so with that, again, this panel is just incredible to hear. We've had a lot of great presentations. Thank you for the information. So we do appreciate your feedback as well in that survey. So if you could complete that as well, that also helps us to provide good webinars. And so with that, again, thank you for joining us today, and don't forget too, we do have our CDI innovation webinar coming up in April. You can register for that on our website as well. So thank you all again, and we look forward to hosting you next time. Thank you.