Author Archives: Kelly Vanek

Today’s Tip: Lupus

Lupus Coding TipWhen Lupus (unspecified) is documented in a record, there is no default code. Therefore, it is important to have providers document this condition as precisely as possible.

For instance, document SLE (systemic lupus erythematosus) instead and add any complications that accompany this diagnosis.  It is often accompanied by Sjogren’s syndrome or Sicca syndrome, which have very specific codes.  Another solution is to develop facility or provider-specific guidelines to report M32.9 (SLE, unspecified) as a default for Lupus, unspecified.

Welcome Lori Harbison

Intellis is pleased to announce the addition of Lori Harbison, LPN, CCDS, CDIP, CCS as our Manager of Clinical Documentation and Quality Services.

Lori brings over 30 years of experience in nursing, including 13 years of experience in Clinical Documentation Integrity. A proven subject matter expert with a deep understanding of review, audit, and education, Lori is respected for her contributions and vast knowledge in the Clinical Documentation field.  

Lori is a credentialed CDI specialist holding a CDIP from AHIMA and a CCDS from ACDIS. Additionally, Lori is a clinical LPN and credentialed CCS. Lori’s philosophy is built on the principle that to meaningfully affect clinical documentation, the physician, CDS, and coder must work together as a cohesive unit. She is committed and passionate about fostering and advancing physician engagement and clinical documentation integrity education.  Lori has developed and presented customized education programs for individual physicians, large-scale physician groups, and health care systems, which has driven increased physician engagement and quality documentation. Lori is recognized for the advancement of the CDI profession by her work on many innovative targeted projects, including early adoption of CDI at patient round table discussions and CDI discussion at physician rounding and other progressive initiatives. 

Prior to joining Intellis, Lori led the CDI training program at the Cleveland Clinic for 13 years. As the Quality and Education Coordinator, Lori was charged with the comprehensive training of clinical nurses, coders, and HIM professionals in their complete education as CDI specialists. In this capacity, she developed detailed training programs and continuing education for the growth and development of skilled and experienced CDI specialists. Lori is an accomplished educator and mentor with a proven record of successfully training adult learners.  Lori prides herself on the long-term accomplishments of her trainees, many of whom hold CDI leadership positions as well as other health care executive roles. 

Contact Lori

Certifications

  • Certified Clinical Documentation Specialist (CCDS)
  • Certified Clinical Documentation Practitioner (CDIP)
  • Certified Coding Specialist (CCS)
  • Licensed Practical Nurse (LPN)

Industry Areas

  • Inpatient clinical documentation integrity
  • Clinical documentation education-physician 
  • Clinical documentation education-CDI specialist
  • Medical Record Review and Auditing
  • Query compliance
  • Inpatient Coding

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Media Contact:
Dan Cooke, President

Today’s Tip: Drug-induced Neuropathy

Drug-induced neuropathy (D62.0) is a diagnosis often missed by even the savviest and seasoned coders. It is sometimes seen in documentation as ‘CIPN’ (chemotherapy-induced peripheral neuropathy) and is a common side effect caused by antineoplastic agents.  Treatment includes steroids and nerve pain medication such as Gabapentin.

Drugs related to neuropathy

The most likely chemotherapy drugs related to neuropathy include platinum drugs, such as oxaliplatin; taxanes, such as docetaxel; vinca alkaloids, such as vincristine; and myeloma treatments, such as bortezomib.  This code can also be accompanied by another code for the adverse effect (T36-T50) to identify the drug. 

In the Know – March 2022

For March 2022, our IN THE KNOW newsletter focuses on:

    Ransomware Recovery
    • Earning CEUs
    • Employment Opportunities
    • Welcoming Elaine Lips
    • Coding Tips
Welcome Elaine Lips

Elaine Lips

Intellis is honored to announce the addition of Elaine Lips, RHIA, SHIMSS as Business Development Strategist to support company growth ambitions and client expansion initiatives in the Western Region of the U.S.

“I’m pleased and inspired to join Intellis to expand their western region client presence.” — Elaine Lips, RHIA, SHIMSS

An innovator with an entrepreneurial spirit, Elaine comes to Intellis with over 40 years of experience in healthcare consulting and information services. She has owned two successful national Health Information Management (HIM)/Mid Revenue Cycle consulting firms. She has held various leadership roles, including strategic business planning, development, operational management using best practices, clinical documentation improvement, and mid revenue cycle outsourcing.

Elaine is an Advanced Member of the Healthcare Financial Management Association (HFMA) and  Senior Member of the Health Information Management Systems Society (HIMSS). Further, she has been active with the American Health Information Management Association (AHIMA), and she was elected and served on the California Health Information Association (CHIA) board of directors.

Currently serving on the Editorial Board for HcPRO’s HIM Briefings, Elaine is a frequent speaker and author. She was the recipient of AHIMA’s Visionary Award and CHIA’s Industry Champion award.

Elaine’s proactive approach, respected thought leadership, extensive client development experience, and strong communication skills will help drive innovation and fuel our growth through client expansion as she begins her partnership with Intellis.

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Media Contact:
Dan Cooke, President

Today’s Tip: Cachexia (R64)

Cachexia (R64) is also known as ‘wasting’ or ‘wasting syndrome’. It is a general state of weakness involving marked weight and muscle loss. Emaciated is another term that may be found in the documentation that also maps to code R64.

These diagnoses are often missed since they are commonly only seen in the Physical Exam or Review of Systems portion of a record. There are often ‘knee-jerk’ reactions that can lead a coder to investigate further if a patient may have these diagnoses. 

What to look for

Cachexia is commonly seen in patients who have AIDS, cancer, or other advanced heart or lung disease. You will often see a lack of appetite, fatigue, low BMI, and malnutrition. Look for nutritional consults and a PEG tube in the documentation to trigger the search for cachexia in the documentation. 

Why is this so important? 

Cachexia is a diagnosis that can affect reimbursement for both Inpatient and Risk Adjustment. Don’t miss it!

 

E/M Hot Topic: Telemedicine Update

Jeanie Heck, our Director of Education, begins our 2022 series of E/M Hot Topics with a discussion on Telemedicine. January’s Hot Topic provides an update from the CMS Final Rule​ as well as some reliable and reputable sources of information regarding telehealth.

For additional information about E/M Guideline Updates education, contact us.

Follow us on LinkedIn to keep up-to-date.

E/M Hot Topic: 2022 Principal Care Management Services

Jeanie Heck, our Director of Education, wraps up our E/M Hot Topic series for 2021 discussing the new 2022 Principal Care Management Services codes. In 2022, we will have three general categories of Care Management in our E/M section. The new PCM codes allow providers, qualified health care practitioners, and clinical staff to report a code(s) for the management of a single chronic condition.

For additional information about E/M Guideline Updates education, contact us.

Follow us on LinkedIn to keep up-to-date.

E/M Hot Topic: Social Determinants of Health (SDOH2)

In our E/M Hot Topic discussions, we previously addressed the proper capture of Social Determinant of Health (SDOH) codes that can make a difference when determining the level of service for office visit codes. When used properly, they can impact the final MDM selection and subsequent reimbursement. In the November E/M Hot Topic, Jeanie Heck, our Director of Education, re-addresses this topic and reviews the new 2022 Chapter Specific Coding Guidelines for SDOH.

For additional information about E/M Guideline Updates education, contact us.

Follow us on LinkedIn to find out when the next E/M Hot Topic is released.

E/M Hot Topic: Telehealth

In September’s E/M Hot Topic, Jeanie Heck, our Director of Education at Intellis, discusses telehealth. The 2022 Medicare Physician Fee Schedule Proposed Rule proposes that CMS allow some telehealth services to remain on the list until the end of 2023. This is intended to help determine if some of the services should be permanently added to the telehealth list following the COVID-19 PHE. During this presentation, Jeanie reviews some trustworthy and reliable sites to reference regarding telehealth.

For additional information about E/M Guideline Updates education, contact us.

Follow us on LinkedIn to find out when the next E/M Hot Topic is released.

E/M Hot Topic: Drug Therapy Requiring Intensive Monitoring for Toxicity

August 2021

In this month’s E/M Hot Topic, Jeanie Heck, our Director of Education, discusses “Drug Therapy Requiring Intensive Monitoring for Toxicity”. This falls under the HIGH level in our Risk element or level 5 (99205/99215). We now have a published definition for this in our 2021 CPT manual.  This definition was further clarified by the CPT editorial panel in the Errata & Technical corrections document.


For additional information about E/M Guideline Updates education, contact us.

Follow us on LinkedIn to find out when the next E/M Hot Topic is released.

Engaging at the Bedside

Chart Police“Here come the ‘chart police.’” 

Every clinical documentation specialist (CDS) has heard it. “Chart police.” For those CDSs with a nursing background, it is often heard from those nurses they have worked alongside in the following ways: 

(1) when discussing their new role

(2) while explaining their current role

(3) when attempting to recruit bedside nurses into the CDS career path. 

How do we educate our bedside-loving peers about the value that their documentation brings to the final coded record? Show them. 

Nurses love evidence.

It has been the foundation of nursing practice since Florence Nightingale demonstrated that good hygiene improved outcomes. Pull up a stand-alone encoder and show them the difference made by inclusion of wound staging or body mass index. Clinical documentation integrity is an obscure role to most nurses so take the opportunity to translate the language. Instead of demonstrating the MS-DRG, show the difference in severity of illness (SOI) and risk of mortality (ROM) when including their documentation. Interpreting SOI and ROM is a quicker soap box discussion than CC/MCC capture and translates clinically with almost no discussion. 

ICD-10-CM Guidelines for Coding and Reporting allow us “few exceptions” to the rule that “code assignment is based on the documentation by patient’s provider” but, nurses need to know that their documentation often triggers CDSs to know that a query opportunity exists. Default templates utilized by providers may repeatedly explain that the patient is oriented, but night shift nurse documentation may paint a different picture of a sundowning patient. That picture is incredibly valuable to the accuracy of the coded record, particularly when the provider is documenting in progress notes when assessing the same patient during the day. 

The remote world has done wonders for production but can put a strain on those opportunities to engage our healthcare partners and demonstrate value. Other ways to engage our nursing colleagues in understanding the value of their education: round with them during an onsite day, engage nursing management to become part of the nursing skills fairs (quality documentation is inarguably a skill), or seek out the opportunity to present to new nursing hires during orientation.