Off the Record with Brian Murphy

Severe malnutrition is a major predictor of mortality/morbidity.

In a five-year observational study cited by the National Institutes of Health, malnourished patients showed an eight times greater risk of harmful falls during hospitalization as compared to well-nourished patients. Further, malnutrition is associated with increased risk for septic shock, acute kidney injury, stroke, and intubation.

So it’s important to get severe malnutrition documented and coded. Unfortunately, doing so thoroughly and systematically can also make you an audit target.

Vidant Health—now part of ECU Health—found that out the hard way in January 2017, when it was the target of a high-profile audit by the Office of Inspector General (OIG). The report was scathing and seemed to indicate that Vidant had major problems reporting the condition.

What the OIG didn’t know was that Vidant had Dr. Vaughn Matacale.

Vidant fought back. And ultimately prevailed. It was not just a major win for the hospital, but for clinical integrity and autonomy of hospitals nationwide.

We talk all about this landmark case on this episode of Off the Record. And get caught up on what’s new with Vaughn, including his well-stocked beer cellar and a rock band recommendation for the OTR Spotify playlist I’ve never heard of before. How is that possible?

Tune in and listen as we cover:

• The initial OIG records request and onsite visit

• Reading the initial painful audit report with its 89% error rate: https://oig.hhs.gov/oas/reports/region3/31500011.pdf

• Fighting back: An extraordinary response letter and building a case

• Courtroom culmination (and celebration)

• Advice for other hospitals: Shoring up severe malnutrition claims from audit and denial

• Some broad discussion on the OIG and its work

• Fun stuff including beer and music

Stop hating on hospitals. It’s a sentiment most Off the Record podcast listeners would probably agree with. But not everyone.

Hospitals are under assault in some corners, including the media and in the halls of government. We need a villain and hospitals often find themselves playing the role of fall guy. For example, many blame them for out-of-control healthcare costs, citing a lack of cost transparency and exorbitant charging practices.

Jugna Shah, MPH, founder and president of Nimitt Consulting, Inc. pushes back on these assertions, making a compelling case that a broken system is to blame. Hospitals own a piece of the problem, but by and large are doing their best to navigate inadequate and complex rules and opaque payer requirements. Many of the gotcha soundbites on Twitter, especially ones that place full blame on hospitals, are misguided, she says.

On this show we cover:

• Jugna’s unique path into healthcare and hospital advocacy

• Pricing transparency: The problem with posting prices, and the real reason why outrageous hospital charges exist

• Why and how hospitals must charge to get adequately reimbursed for CAR-T and other expensive therapies, drugs, and services

• Site neutral payments. Why should hospitals be paid multiples of the same procedure done at an ASC down the street? There are reasons…

• Fighting back against payer denials of packaged/bundled services

• Best practices for commenting to CMS and making your voice heard

During my last conference as ACDIS Director in Oct. 2021 I had the pleasure of introducing Dr. Nicole Fox as our opening keynote. Nicole is not a professional lecturer but delivered one of the most impactful and inspiring speeches I’ve seen, covering her work as a pediatric trauma surgeon and her challenges as a single mother raising four children.

Understatement: Nicole is an impressive human being. In addition to a heavy clinical rotation, she’s the Associate Chief Medical Officer, Associate Professor of Surgery, and the Medical Director of pediatric trauma for Cooper University Hospital, a level 1 trauma facility in Camden, NJ.

Oh, and she also serves as Medical Director for the hospital’s CDI program.

Nicole is recently back from a World Trauma Congress in Tokyo and was married this year. We get caught up on all of this on this episode of Off the Record. We cover:

• Advances in trauma treatment and insights into Japanese culture and the philosophy of Ikigai

• A “typical” day in pediatric trauma—instructive for any CDI professionals who might be grumbling why queries aren’t always answered timely

• Nicole’s inauspicious path to CDI (she was one of the worst documenting physicians in her organization, with a number of outstanding charts so large you have to listen to believe) and unlikely path to medical director of CDI

• Vendor shortcomings—overpromise and under-delivery

• Mortality reviews—getting started, common clarification opportunities, and the delicate dance of querying a physician to provide further detail on an expired patient

• Recent domestic changes

• Her favorite song for the OTR Spotify playlist, and our personal encounters with Steven Tyler of Aerosmith (hers is much, much cooler than mine)

Books mentioned on the show include:

• Ikigai: The Japanese Secret to a Long and Happy Life, Hector Garcia and Francesc Miralles

• Ichigo Ichie (same authors)

• Wabi Sabi, Beth Kempton

Enjoy!

#OTR

It’s not easy moving into Clinical Documentation Integrity as a new nurse or coding professional.

But now imagine what it’s like if you’re from Maryland. And it’s 2006.

These were pre-ACDIS days, in a state which used APR-DRGs.

In other words, no best practice, little information, and no real community.

But Dawn Diven, Enterprise System Director of Clinical Documentation Improvement for WVU Medicine, is used to taking on difficult challenges—and overcoming them. And she’s got a track record to prove it.

Which you’d never know because she’s also humble and down to earth as they come.

On this episode we discuss:

Most people envision and expect careers to follow a straight line, gently upwards and to the right, in one direction. Once you’ve found the type of work you want to do you get promoted as high as fortune and talents will take you, until the day you retire.

Kim Higgins is an exception to this rule.

A year ago Kim was serving as the interim CDI director for AdventHealth West Florida Division, a massive health system (West Florida has 13 hospitals alone). Her responsibilities included day-to-day management but also helping build a case for new staff, demonstrating ROI, and growing the department.

That was in 2022, not so very long ago.

Today you’ll find her working as a remote CDI specialist reviewer for Valley Medical Center, a small, standalone acute care hospital located in Washington State.

And she couldn’t be happier, because it was the right move for her.

We get into the reasons why and much more on this episode of Off the Record.

On this show we cover:

To be an effective leader you have to have a vision and be willing to implement changes that disrupt the status quo.

But you also have to involve your team, and use diplomacy to obtain buy-in. In short, be a team player with a little bit of swagger.

It's a delicate dance, but it describes the tightrope Sheri Blanchard, Senior Director of Clinical Documentation Excellence and Revenue Management, had to walk.

And she did so skillfully. After taking over the Clinical Documentation Excellence program at Orlando Health in 2018 as a new leader Blanchard put her own unique stamp on the program--all the while recognizing her team is everything, and involving them at each step.

On this show we cover:

• The Clinical Documentation Excellence (CDE) program at Orlando Health.

• Arriving at the organization as a new face in 2018, seeking to make change

• A day in the life of a busy senior CDI director covering 11 facilities

• Orlando Health’s unique DRG reconciliation process, which includes a dedicated resource and final assignment authority given to CDI

• Out of the box CDI work including monitoring long LOS patients and patients that flip to observation

• Advice for new CDI leaders

• The most metal entries on the OTR playlist to date (Sheri likes AC/DC, GNR, etc., which automatically makes her cool in my book)

Few CDI professionals are rising as fast as Faisal Hussain, Executive Director of CDI at Wellstar Health System in Georgia.

Fewer still have come as far as he has, both literally and figuratively. A foreign medical graduate and native of Pakistan, Hussain has risen up through the ranks in a remarkable career in healthcare.

In his current role he is responsible for overseeing the CDI strategy and operations for the entire Wellstar health system, comprised of nine hospitals and more than 300 medical offices, as well as cancer centers, rehabilitation centers, hospice facilities, and urgent care locations.

It’s a huge task and he recently completed a firehose of a first year with the organization.

But in case that didn’t keep him busy enough, Hussain this year also ran for and was elected to the ACDIS advisory board, in addition to serving as a member of the ACDIS leadership council and the ACDIS regulatory committee. And he’s done it all with kindness and humility while raising a young family.

On this show we cover:

• A day in the life of Faisal Hussain, Executive Director of CDI

• WellStar’s CDI strategy and metrics for success, including a focus on chart touches that matter and a proactive rather than reactive approach to chart review

• Recent wins (build and pilot of a promising homegrown EHR documentation tool) and struggles as a new leader and new(ish) dad seeking better work-life balance

• An unlikely and winding path from graduate of Aga Khan University in Karachi, Pakistan, to MD, and finally to CDI

• Winning the organizational Diversity in CDI award at the 2023 ACDIS conference, and his own prior experience with discrimination

• His favorite classic pop or rock song (because, it’s Off the Record, duh). I refused to bend on “Baby Shark.”

News flash: Many (most?) physicians aren’t on board with CDI initiatives and coding practice. It’s understandable; they’re busy with patient care, and in their remaining hours are swamped with chart completion. Answering clinical queries and documenting with greater specificity is either seen as a chore or falls by the wayside entirely.

Sometimes it takes real-world impact to make the lightbulb go off and touch a match to tinder.

Tom Brazelton, MD is a practicing pediatrician and the CDI medical director for UW Health in Madison, Wisconsin. His passion for CDI was ignited by seeing how documentation and coded data was reflecting on organizational quality (and not in a good way).

So, he decided to get involved.

Brazelton helped a fledgling program comprised of four CDI professionals grow to more than 35 FTE across four hospitals, all while achieving a 98% physician response rate. His story of how achieving buy-in looked in a long-ago orthopedic surgery meeting is worth listening to alone.

Today CDI is in his blood. Brazelton was recently given an organizational award, “Superheroes in Scrubs,” for his efforts, and he now makes the ACDIS conference a regular stop.

On this program we cover:

There comes a point in our life when we all need to take an adventure. For most that means a vacation to an exotic faraway continent. For others, that might mean taking a new job, or changing careers altogether. Or starting a family.

All of these are adventures of one sort or another. All are wonderful.

But then there is Howard Rodenberg.

Howard decided at age 60 to take a real-life adventure. To the South Pole, where today he is serving as a physician at the Amundsen-Scott South Pole Station with the U.S. Antarctic Program.

Prior to this monumental decision Howard served as a physician advisor to the CDI program at Baptist Health in Jacksonville, FL, and chaired the ACDIS regulatory committee. And took adventures of the mind playing the fantasy role playing game Dungeons and Dragons. All of which immediately endeared me to him and led to this interview.

On this episode (conducted tenuously via satellite link) we cover:

• Why do this? What did your family think?

• What does an average day look like? Have you had any medical emergencies?

• Do you spend much time outside? Can you?

• What’s the hardest part about life in the South Pole and what don’t most people understand about the conditions and isolation?

• Do you have to document and code your work?

• What have you learned about yourself?

• What’s the first thing you’re planning to do upon your return?

While there is not as much CDI, coding, and health records management talk as you’d find on an ordinary episode of OTR (although we do get into this, and CDI may be part of Howard’s future plans), I guarantee you’ll be inspired by his story. And possibly find the courage to take an adventure of your own. Even if it doesn’t lead to the South Pole.

After a short break that was not really a break because we were on the road at ACDIS 2023 we're back with another episode of Off the Record. 

Today I’m joined by fellow conference-goer, presenter, and colleague Jason Jobes, senior vice president of solutions at Norwood. 

On this show we dive into the recently concluded ACDIS 2023 national conference in Chicago, which was my 15th (yes, I’ve been to every single one from 2008-present, not including the virtual event of 2020, and I think I’m the only person on the planet who can say this) and Jason’s first. We had a blast, learned a lot, and came back recharged and optimistic for the future of the CDI profession. I also had the honor of remembering my colleague Melissa Varnavas with a Day 1 keynote. 

We then switch gears to outpatient CDI and the ongoing transition to value-based reimbursement with a focus on Jason’s session from the ACDIS Outpatient Symposium, entitled The Importance of Risk Adjustment in Value Based Settings.  

We cover the following topics: 

And of course, we discuss Jason’s top 90s rock/pop hit. He's a little younger than me so I let him get into the music of his youth, rather than mine—the 80s. Against my better judgement.