Local chapter update: Getting involved in local politics

by Howard Rodenberg, MD, MPH, CCDS

ACDIS state and local chapters of play a key role in keeping our members informed, educated, and connected. They serve as opportunities for networking, sharing common concerns, and brainstorming solutions. But did you ever consider advocacy as a prime role for your local ACDIS group?

The ACDIS Regulatory Committee works for change within the federal structure. We propose new codes to the ICD-10-CM Coordination and Maintenance Committee, request DRG reassignments and MCC/CC considerations within the Inpatient Prospective Payment System (IPPS) and strive to interact with the Cooperating Parties in updating the Official Guidelines for Coding and Reporting. But much of what we struggle with as CDI specialists comes from the state level, especially where private payers and their coding and documentation policies are concerned. While Coding Clinic (2016) reminded us that outside parties are free to construct their own definitions of clinical conditions, state-level regulation empowers payers to use these unilateral definitions to deny claims or recoup payment. Where these practices are unfair to physicians, patients, and hospitals, they become fair game for advocacy by ACDIS state and regional chapters.

A great example of how state-level advocacy works comes from New York related to changing policies for sepsis.

It’s no surprise to anyone reading this that there is an ongoing conflagration between advocates for Sepsis-2 and Sepsis-3. Providers and institutions favoring Sepsis-2 do so because they believe in casting the clinical net as wide as possible to aggressively capture all cases, preventing excessive morbidity and mortality; by way of contrast, payers flock to Sepsis-3 because the narrower criteria for the diagnosis of sepsis means fewer high-dollar payouts for the condition.

The issue came to a head in New York, where advocacy on the part of the Hospital Association of New York State (HANYS) led to the state mandating that as Sepsis-2 was already established as the definition of sepsis in state rule and regulation, Sepsis-2 would remain the “official” definition of sepsis in New York. More importantly, Managed Care Organizations (MCOs) were advised to continue using the Sepsis-2 definition, and that “MCO clinical criteria do not deny payment for sepsis-related services defined under Sepsis-2 criteria.” State-level advocacy via HANYS and others was the driving factor.

Another example of how state-level action can affect our work comes from Maine.

Early this year, legislation proposed to regulate the prepayment claims review process submitted by healthcare providers (Maine SP 423-LD 1317). As signed into law, the legislation dictates time frames for the review process, specifies that reviews be conducted by a consistent and qualified professional peer, requires that payers adhere to documentation standards established by the provider’s relevant professional associations, and notes that claims cannot be denied due to minor errors such as misspellings or a correctable error (Maine Public Law Chap 272, Sec 1, 24A). While the final bill as signed by the governor specifically excludes claims submitted by hospitals or healthcare facilities and still allows payers to establish clinical guidelines for covered services, the positive implications for outpatient practices (and the coders and CDI specialists who work in this area) are clear.

Again, state-level advocacy makes the difference. And who’s to say that next year other claims, like those from hospitals, might not be the subject of a similar bill?

The first step in advocacy is not to just identify a problem, but to propose a solution. While it’s not always possible, legislators prefer plans that are pragmatic, inexpensive, easily implemented, and (as flippant as it sounds) will equally inconvenience all relevant parties. During my days as a state health officer, a legislator from the other side of the political tracks advised me that, “We don’t want to hear problems. We want to hear solutions, and if you’ve got the right people on board, we’ll probably vote for it.”

Of course, you’ll need to find the right people, and this is where ACDIS state and local chapters can reach out to partners such as state and local AHIMA committees. Likely partners can also be found in state hospital associations and with medical groups such as state-level chapters of the American Medical Association, American Association of Professional Coders, or the American Hospital Association. Groups focusing on healthcare finance and patient advocacy may also be valuable partners. Don’t get fooled by thinking your issue too small for others to take notice; the varied elements of the healthcare system are so intertwined that your small issue may exert a significant impact on the system as a whole. Sometimes it takes talking to those outside your usual sphere to see that.

The other thing you’ll need is a friendly legislator. That’s not as hard to do as you might think. Most state legislators are easy to find and want to be seen as actively working on behalf of their constituents. In smaller states, you may even know your state legislator through your child’s school activities, faith communities, or other means. Other partners in your efforts may have previously established relationships with legislators as well. And don’t worry about actually writing the bill; every state legislature has professionals who take legislative ideas and escribe it in the proper format (their own legalese version of ICD-10-CM). Your legislator may ask you to work with staff to make sure your thoughts are appropriately recorded.

Once the bill is introduced, the process takes on a life of its’ own. Responses to the bill means that within days you’ll know all the players, and you can reach out to those in opposition and look for common ground. Whether the legislation succeeds or fails, you’ve brought your concerns to policymakers and the public, raising awareness of issues important to you and the entire CDI community.

The ACDIS Regulatory Committee urges state and local chapters to adopt advocacy as part of their mission. We’ll be there to help in any way we can.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Opinions expressed are those of the author and do not necessarily represent those of ACDIS, HCPro, or any of its subsidiaries.

The following is a list of upcoming events for ACDIS local chapters. To join a chapter if you haven’t already or to update your chapter contact information/affiliation, click here.

September:

• The Kansas City, Missouri, ACDIS chapter meets Wednesday, September 8, 2-3:30 p.m., via webinar. For information, contact Debra Canova (Debra.Canova@tmcmed.org).
• The Pediatric Networking Group (APDIS) meets Thursday, September 9, 3-4:30 p.m. The speaker is Dr. Nicole Fox presenting “Playing to Win,” which focuses on physician engagement and strategies for communication and cooperation between CDI and physicians. For information, contact Amy Bush (bush-amy@cooperhealth.edu).
• The Maryland ACDIS chapter meets Friday, September 17, virtually for the annual conference. This will be an all-day conference. Final agenda and registration to be announced soon. For information, contact Deb McClain (dlmcclain@frederick.health).

October:

• The Florida ACDIS chapter meets Saturday, October 2, 8 a.m. to 4 p.m., at Shands Hospital in Gainesville for their quarterly meeting. Details to follow. For information, contact Edna I. Betances-Harold (betane@shands.ufl.edu).
• The Michigan ACDIS chapter meets Saturday, October 2, via webinar. Download the event flyer here. For information, contact Susan Fantin (susan.fantin@mclaren.org).
• The Minnesota ACDIS chapter meets Wednesday, October 27, 1-2 p.m., via webinar. More details to follow. For information, contact Jera Van Damme (jera.vandamme@essentiahealth.org).

November:

• The Arizona ACDIS chapter meets Friday, November 5, 12-1:15 p.m., via webinar for a WebEx Lunch and Learn. The topic is CDI and physician education presented by Fran Jurcak. For information, contact Sydni Johnson (sydni.johnson@bannerhealth.com).

December:

• The Kansas City, Missouri, ACDIS chapter meets Wednesday, December 1, 2-3:30 p.m. Details to follow. For information, contact Debra Canova (Debra.Canova@tmcmed.org).
• The Pediatric Networking Group (APDIS) meets Thursday, December 2. Details to follow. For information, contact Amy Bush (bush-amy@cooperhealth.edu).