Off the Record with Brian Murphy Brian Murphy

Sepsis it seems is always in the news, never far from anyone who works in CDI or coding circles. And here we are again, back in the headlines due to its inclusion in the Office of Inspector General (OIG) Work Plan.

Sepsis has been discussed so much due to the complexity of disease, the cost of treatment, complexity of coding, and increased regulatory spotlight. What else is there to say? But with it back in the spotlight I wanted to turn from the usual insular conversations in the mid-revenue cycle to someone working on the front lines of care.

Amanda Hart is an ED nurse and a sepsis clinical nurse specialist at Tower Health, a regional integrated healthcare system based out of Pennsylvania. She spends a substantial amount of time battling this deadly disease, and her work has much to offer anyone who works to get it accurately documented and coded.

On this episode we discuss:

• Amanda’s background in the military and EMS, path into nursing and eventually the ED

• Her role as sepsis clinical nurse specialist and how it overlaps with CDI/coding

• Pathophysiology—clinical indicators of sepsis and what makes it such a deadly disease

• Problems inherent in lack of uniform definitions, what Tower Health uses, and her own take on Sepsis-2 vs. Sepsis-3 debate

• The importance of early screening, including processes, technologies and people. Are EHRs and alerts helping or hindering?

• Tower Health’s home-grown protocol that resulted in a 32% reduction in relative mortality rate in non-POA cases.

• Life on the front lines of care and how it changed Amanda as a person

If you’ve ever been a member of ACDIS you’ve almost certainly encountered Dr. Trey LaCharite’. ACDIS advisory board member? Check. Regular columnist for CDI Journal? Check. Author of the CDI Field Guide to Denial Prevention and Audit Defense? Check. Speaker at the physician advisor pre-conference every year since (at least) 2010? Yes, put a checkmark there, too.

Trey is the Medical Director for CDI and Coding and Clinical Associate Professor for University of Tennessee Medical Center. He’s got the holy trinity of credentials—a MD, plus CCS and CCDS (and others). On this show he brings his unique clinical and coding perspective, combined with real-world applications and trademark tell it like it is/no-nonsense perspective, in a candid interview.

Note: This show was recorded prior to the 2024 ACDIS conference in Indianapolis last week, where Trey presented the session “Beyond Problem Lists: How to Document Is Just as Important as the What.”

On this show we discuss:

• Trey’s path from hospitalist to CDI

• Problem lists: How UTMCK uses them and keeps them updated

• Denials and creating a “defendable narrative” using the patients’ clinical story

• Trey’s opinion on sepsis-2 vs. sepsis-3, now back in the news due to the recent OIG Work List update

• What ACTUALLY resonates with MDs, regarding the eternal question “what’s in it for me”?

• CDI pet peeves, proudest career accomplishment, things to do in TN, and an unexpected OTR playlist addition

Small community hospitals are the backbone of healthcare for most of the country, even today in this era of sprawling healthcare organizations and massive mergers.

But while they’re critical to the health of our nation, resources are often scarce, and CDI is no exception.

Jennifer Cummins, BSN, CCDS, is one of just two CDI professionals covering a 222-bed not-for-profit community hospital in rural Kentucky. Advanced technology and sophisticated AI are not in her toolbox, but that doesn’t mean Jennifer doesn’t take pride in her work.

In fact, she and her colleague are making a big impact with some old-school methods. Their CDI work helped the hospital earn the title of one of the 100 Greatest Community Hospitals in America. Proof that determination, creativity, and teamwork are still more important than tech, even in this day and age.



On this show we cover:

• Jennifer’s origin story—ICU and ER nurse, finding her way into CDI with the help of a nursing colleague

• CDI program--when it began, focus of reviews, and success metrics

• Conducting chart reviews with a basic encoder, books, creativity, and the help of other departments

• Logistical challenges as a small community hospital, including weekend coverage and PTO in a department of two, and rising to meet new initiatives with limited resources

• Expansion to mortality reviews: Identifying the need, process, early successes, and conducting deeper, more intensive reviews

• Fun things to do in Kentucky (aka., Bourbon Trail). Plus Jennifer’s addition to the Off the Record Spotify playlist (Kentucky bluegrass? Find out)

I don’t know about you but I'm FASCINATED with Medicare Advantage (MA). Massive growth, fueled by its shrewd marketing of added benefits beyond traditional Medicare. But also chaotic, messy, a program in need of reining in.  

It’s a bit of the wild west. 

I like some things about MA, including its emphasis on preventative care and aligning patients outcomes with rewards. But I'm also routinely disappointed by its excesses and denial of medically necessary care.  

Some days MA seems poised to overtake and end traditional Medicare. But every time I think that, another shoe drops. Intensive audits from the OIG, and sharp criticism from the likes of former CMS administrator Don Berwick. Two weeks ago we saw the nation’s largest ACO get hit with a whistleblower lawsuit for alleged upcoding abuses. 

To get a big picture overview and figure out where we are with the program I invited 4Sight Health’s David Burda to join me on the podcast. David is 4SightHealth’s news editor and columnist and hosts a podcast, the 4sighthealth roundup, covering MA and other adjacent topics. 

Listen in as we discuss: 


David’s journalism background and eventual path into covering healthcare 


MAs rapid adoption: Will it continue until Medicare is phased out—or is a reckoning coming?  


The problems with MA: Gaming of risk adjustment/upcoding to make patients appear sicker, denial of medically necessary care, prior authorization nightmares, and sky-high insurer profits 


What MA is doing well, should be preserved, and what needs reform 


Is healthcare compatible with a free-market economy and shareholder ROI?  


How David stays on top of the torrent of healthcare news, and his cool addition to the #OTR Spotify playlist 



  

Additional reading from 4sighthealth:  


What Will Happen to Traditional Medicare? https://www.4sighthealth.com/ken-terry-what-will-happen-to-traditional-medicare/  
Spy vs. Spy? More Like Medicare vs. Medicare Advantage https://www.4sighthealth.com/spy-vs-spy-more-like-medicare-vs-medicare-advantage/   

Listeners of Off the Record may recall our episodes on the OIG audit of severe malnutrition directed at North Carolina based Vidant, now ECU Health. Vidant/ECU won a landmark case against the OIG in large part because it had a multidisciplinary clinical and coding team in place to ensure that severe and other forms of malnutrition were appropriately documented in the record and captured.

That effort was spearheaded by CDI and coding experts, but also by a great clinical team including my guest today.

Ashley Strickland is the adult clinical dietitian supervisor and an surgical/trauma intensive care dietitian at ECU Health. Her primary focus is critical care, complex GI patients, and nutrition support. She's also an independent contractor and educator for the Academy of Nutrition and Dietetics and sits on the American Society for Parenteral and Enteral Nutrition’s Reimbursement Malnutrition Task Force.

On this show we cover:

• What is a hospital based registered dietitian (RD), and Ashley’s life-saving clinical work supporting critical care/trauma/surgical intensive care patients

• How her work impacts documentation/coding/diagnosis of malnutrition and obesity

• Strategies for appropriate capture of severe and other forms of malnutrition

• The OIG case from Ashley’s perspective, including prepping with mountains of paper records in the war room, courtroom experiences, and lessons learned

• Advice for professionals dealing with egregious denials, including flimsy justifications of “not enough care” directed at a condition, or denying conditions clearly reportable per Official Guidelines for Coding and Reporting

• Definitions and controversies: AND/ASPEN criteria vs. the Global Leadership Initiative on Malnutrition (GLIM), and compliance concerns with the emergence of “mild” malnutrition

• My Dave Matthews gaffe (sorry, heavy metal guy here)

In 2009 ACDIS was growing. The association’s boot camps were taking off. We were at the point where we needed to hire our first full-time instructor and CDI educator.

That person was Lynne Spryszak.

Lynne had been in CDI since 2002 and volunteered as an inaugural ACDIS inaugural advisory board member in 2007. She married experience (rare in what was then a new profession) with passion and a desire to educate.

It was a perfect fit.

Lynne worked with me for a couple great years and then moved on. But I've continued to follow her career from afar—a career that has recently come to a well-deserved retirement. Well, sort of (she’s currently looking for some supplemental part time work).

Lynne is definitely one of CDI’s “OGs” and on this show we recap her career, wisdom, and the true purpose of CDI. We cover:

• Working full-time in a grocery store, late start in healthcare, early 90s nursing days in a medical-oncology unit, and transition into CDI

• Most memorable stops of her career including ACDIS, working as a consultant, performing GEM mappings for the transition from ICD-9 to ICD-10

• Taking over the CDI boot camp line and transforming it into her own (while working alongside annoying colleagues like myself)

• Surviving a bout with bladder cancer—dark days of diagnosis, aggressive treatment, and cancer free since 2016

• Biggest changes in CDI from 2002 to today—is Lynne optimistic or pessimistic for its future?

• The meaning she derived from CDI work and thoughts on its true purpose: An important part of the chain of patient care

• Retirement plans, grandchildren, part-time work, and her Off the Record Spotify playlist selection