Transcript 280216

‘Rock-A-Bye Baby’—
Implementing CDI in Women’s and
Children’s Units
Linda Rhodes, RN, BSN, CCDS
Manager, Clinical Documentation Improvement Program
New Hanover Regional Medical Center, Wilmington, NC
Monique Halyard, RN, CNOR
Clinical Documentation Specialist
New Hanover Regional Medical Center, Wilmington, NC
New Hanover Regional Medical
Center, Wilmington, NC
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Licensed for 760 beds
Teaching hospital
Level II trauma center
Full cardiology service—
Cardiac Center of Excellence
by BC/BS of NC
• NHRMC Rehab Hospital
• NHRMC Behavioral Health
Hospital
• Orthopedic specialty hospital
Betty H. Cameron Women’s and
Children’s Hospital
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45-bed Level III NICU
6-bed pediatric ICU
17-bed pediatric unit
13-bed antepartum unit
35-bed mother/baby unit
20-bed women’s unit
Goals
• Share the NHRMC implementation of a CDI
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program in women’s and children’s units
Describe benefits/challenges of
NICU/pediatric/OB/GYN reviews
Present methods for physician/staff engagement
and education
Discuss various CDIS staffing model options
Identify pediatric/OB/GYN documentation
opportunities
Demonstrate program metrics for success
Why?
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Quality
Opportunity
Education
Relationships
Program growth
Women’s/Children’s CDS Timeline
08/2011
Pediatrics
04/2011
02/2011
12/2010
10/2009
Women’s Unit
NICU
PICU
Antepartum
Mother/Baby
Getting Started:
Women’s Unit
• Payer source—DRG system
– Medicare
– Medicaid
– TRICARE
– Self-insured UHC
Women’s Unit
• Diagnoses/procedures
– Cervical, ovarian, and uterine malignancy
– Hysterectomy, pelvic evisceration
– Pelvic peritonitis, inflammatory dx, abscess
– Sepsis, wound infection
– Pelvic organ prolapse
– Incontinence
– Sling/suspension procedures
– Bariatric procedures
– Medical overflow
Women’s Unit
• Query opportunities
Postop confusion (293.9)cc
UTI (599.0)cc
Drug-induced delirium (292.81)cc
Drug dependence, continuous use (304.91)cc
Atelectasis (518.0)cc
Opioid dependence, continuous use (304.01)cc
Postop pulmonary insufficiency (518.52)MCC
BMI <19 (V85.0)cc Along with descriptor
BMI >40 (V85.4)cc Along with descriptor
Postop pulmonary edema (518.4)MCC
Sepsis (995.91)MCC
Acute/chronic syst/diast CHF(428.23)MCC
Cachexia (799.4)cc
(428.33)MCC
Malnutrition (263.9)cc
Severe protein-calorie malnutrition (261.0) MCC
Ileus (560.1)cc
Pancytopenia d/t chemo (284.11)MCC
Postop ileus (997.49)cc
Pancytopenia (284.19)cc
Metastatic sites (cc)
Hyponatremia (276.1)cc
Postop wound infection (998.59)cc
Acute blood loss anemia (285.1)cc
Potential HACs/core measures
Postop blood loss anemia (285.1)cc
Women’s Unit
• CDIS staffing
– Utilized current CDS from surgical floor to
cover women’s unit
– No additional training required
Women’s Unit
• Physician/staff engagement and education
– Presentation by CDI physician advisor/CDS
team
– Case scenarios
– One-on-one MD education by CDS
– Physician education
posters/lounge
– Laminated documentation
hint pocket cards
– CDI presentation to
women’s unit management
Moving on Up: NICU
• Payer source—DRG system
– Medicaid 70%
– TRICARE 10%
– Self-insured UHC
• MD electronic documentation (NeoData)
– Diagnosis dropdowns
NICU
• Neonatal DRGs—a different animal
– DRG 790 Extreme immaturity or
RDS
• <1499 grams
• <26 weeks gestation
• Extreme fetal immaturity
• Respiratory distress syndrome (769)
– respiratory signs/symptoms
– CXR-ground glass opacities
– mechanical ventilation, CPAP, HFNC
>24hrs, reintubation
– surfactant administration
NICU
– DRGs 791–794
• Determined by weight (fetal immaturity) and
diagnosis of prematurity (weeks of gestation)
• Require a principal or secondary diagnosis
with/without major problems
• Challenging to designate DRG without encoder
• Focus on documentation of all diagnoses/problems
NICU
• NICU documentation tips
– Perinatal period is birth through 28th day
– Differentiate between RDS and TTN
(transitory tachypnea of newborn)
– Specificity of acute and congenital
– Documentation of all congenital anomalies
– Review pregnancy and labor history for
maternal conditions affecting newborn (codes
760–763)
• 763.4 Newborn affected by C-section
NICU
• Major problems (principal or secondary diagnoses)
– (747.83) Persistent fetal circulation, persistent
/primary pulmonary hypertension
– (756.71-.73) Prune belly, omphalocele, gastroschisis
– (768*) Severe birth asphyxia, moderate/severe HIE
(hypoxic ischemic encephalopathy)
– (770*) Congenital pneumonia, fetal/newborn
aspiration, meconium aspiration, aspiration of
amniotic fluid, blood, stomach contents,
pneumothorax, pulmonary immaturity, pulmonary
hemorrhage, respiratory failure
– (771.81) Sepsis of newborn
– (772*) Fetal blood loss, IVH/grade, SAH, GI
hemorrhage
NICU
– (775*) Neonatal diabetes, hypocalcemia,
hypomagnesemia, hypoglycemia, late metabolic
acidosis
– (776.1) Neonatal thrombocytopenia (transient)
– (776.6) Anemia of prematurity
– (777.5*) Necrotizing enterocolitis
– (779) Convulsions
– (779.85) Cardiac arrest
– (285.1) Acute blood loss anemia
– (292) Drug withdrawal
– (377*) Papilledema complications
– (530.84) TE fistula
NICU
• CDIS staffing
– 2 NICU case managers
– 1.8 FTE
– Rotate CDI workload
– Training—documentation
software—Midas CDI module
• MDC 15 only
• Query process
• DRG reconciliation process
• Coding summaries
• Frequency of reviews
NICU
• Physician/staff engagement/education
– CDI presentation to neonatology
– Case scenarios
– Review of charts
– Physician education posters/lounge
– Laminated documentation
hints pocket cards
– CDI presentation to NICU
nursing management/staff
– CDI rounding
We’re Growing Up:
PICU/Pediatrics
• Payer source—DRG system
– Medicaid
– TRICARE
– Self-insured UHC
PICU/Pediatrics
• Top 5 MDCs
– 1 Nervous system—seizures,
meningitis, migraines
– 4 Respiratory—pneumonia,
asthma, respiratory arrest, cystic
fibrosis, reactive airway disease,
bronchiolitis, bronchitis
– 9 Skin—cellulitis, impetigo
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Endocrine/nutritional/metabolic
—diabetes, DKA, hypoglycemia
– 16 Blood—Sickle-cell
anemia/crisis
PICU/Pediatrics
• Query opportunities
Anoxic brain damage (348.1)cc
Postop wound infection (998.59)cc
Severe/profound mental retardation (318*)cc
Cellulitis and abscess (682*)cc
Grand/petit mal status (345.3, 345.2)cc
Thrush (112.0)cc
Airway obstruction d/t tracheitis, epiglottitis,
laryngitis (464.11, 464.31, 464.01)MCC
Bacterial intestinal infection (008.5)
Atelectasis (518.0)MCC
Acute renal failure (584)cc
Aspiration pneumonia (507)MCC
Malnutrition (263.9)cc
Gram-negative pneumonia (482.83)MCC
Severe protein-calorie malnutrition (261)MCC
Acute respiratory failure (518.81)MCC
Septic shock (785.52)MCC
Acidosis/alkalosis (276.2,276.3)cc
Hypovolemic shock (785.59)MCC
Shock (785.50)cc
Hyponatremia (276.1)cc
Sickle-cell crisis (282.42)MCC
Sepsis (995.91)MCC
Signs & symptoms (possible diagnosis?)
PICU/Pediatrics
• CDIS staffing
– Different combinations of staff
– NICU case managers/CDS—
trained on top 5 MDCs, then …
– OB case manager/CDS—trained
on CDI and pregnancy DRGs,
then …
– CDS (0.8 FTE)—experienced
CDS trained on both neonatal
and pregnancy DRGs
• WHEW!
PICU/Pediatrics
• Physician/staff engagement and
education
– CDI presentation to pediatricians
– Case scenarios
– Review of charts
– Physician education
posters/lounge
– Laminated documentation hints
pocket cards
– CDI presentation to
PICU/pediatrics nursing
management/staff
– Documentation tips for nursing
staff
We’re Having a Baby!
Antepartum/Postpartum
• Payer source—DRG system
– Medicaid 70%
– TRICARE 10%
– Self-insured UHC
Antepartum/Postpartum
• Documentation tips—review prenatal
record, anesthesia record
– Factors to consider:
• Lack of prenatal care
• Age
• Parity
• BMI
• Drug/alcohol dependence
• Diabetes
• Hypertension
• Anemia
• Thyroid disease
• Mental conditions
• Preexisting infections
Antepartum/Postpartum
• Other considerations:
- Pt admitted pregnant with
ANY
diagnosis codes to complication of
pregnancy
UNLESS
provider documents that the pregnancy is
incidental to the encounter!
Antepartum/Postpartum
• Preterm labor
– Before 22 wks = threatened abortion
– After 22 wks but before 37 wks = threatened
premature labor
• 5th digit codes
• Postpartum period = delivery to 6 weeks
• Postpartum complication = any complication
during 6-week time frame
Antepartum
• DRG 781/782 Principal and secondary diagnoses
– (641*) Placenta previa w/w/o hemorrhage,
hemorrhage
– (642*) Severe pre-eclampsia, PreE, PIH, other
HTN
– (643*) Hyperemesis, vomiting
– (644.2) Premature labor before 37 weeks
– (646.63) GI infections
– (648*) Maternal DM, thyroid, anemia, drug
dependence
– (657.03) Polyhydramnios
– (658.03) Oligohydramnios
– (658.13) PROM
Antepartum
– (647*) Syphilis, gonorrhea, STDs, HIV,
hep B/C
– (648.63) Other maternal CV (MI)
– (648.93) Other conditions
(pneumothorax, asthma, etc.)
• Once delivery occurs, some secondary
diagnoses will not move the DRG!
Postpartum
• DRG—Vaginal or C-section delivery
– Principal and/or secondary diagnosis
(In addition to the antepartum diagnoses)
• (641.21) Abruptio
• (648.24) Acute blood loss anemia
• (659.21) Maternal fever during labor, delivered
• (659.31) Generalized infection (sepsis) during labor
• (666*) Postpartum hemorrhage
• (667.02) Retained placenta
Postpartum
– (668*) Complications of anesthesia
– (669*) Maternal shock, hypotension,
ARF
– (670*) Major puerperal infections,
sepsis, peritonitis
– (671*) DVTs
– (673*) Pulmonary air embolism,
amniotic and blood clot embolism
– (674*) CVA
– (675*) Nipple infections, nonpurulent
mastitis
Antepartum/Postpartum
• CDIS staffing
– OB case manager/CDS—
trained on CDI and
pregnancy DRGs, then …
– CDS (0.8 FTE)—
experienced CDS trained on
both neonatal and
pregnancy DRGs
Antepartum/Postpartum
• Physician/staff engagement and
education
– CDI presentation to OB
department
– Case scenarios
– Review of charts
– Physician education
posters/lounge
– Laminated documentation hints
pocket cards
– CDI presentation to OB nursing
management/staff
– Documentation tips for nursing
staff
Results So Far …
Quality documentation!
FY12
DRG 765 C-section w/ MCC/cc
DRG 766 C-section w/o MCC/cc
DRG 774 Vag delivery w/ comp dx
DRG 775 Vag delivery w/o comp dx
DRG 791 Prematurity w/ major problem
DRG 792 Prematurity w/o major problem
FY11
45.4% 44%
FY10
42.1%
18.1% 18.5% 18.1%
49.6% 53%
43%
Next Steps …
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SOI/ROM
Continued physician education
Train additional CDS staff
Prepare for ICD-10
ICD-10-CM Considerations
• Pregnancy—categories O00-O9a
– O = Obstetrics
– O80 = full-term uncomplicated delivery
– New codes identify trimester when condition
occurs
– New codes identify # fetuses when condition
occurs
– Category Z37.x- Outcome of delivery
– New codes for multiple births beyond twins
ICD-10-CM Considerations
• Diabetes in pregnancy
– Type 1 diabetes
– Type 2 diabetes & identify when patient is on
long-term insulin
– Diabetes secondary to another condition &
name the condition
• Gestational diabetes
• Identify peripheral manifestations of diabetes (e.g.,
retinopathy, nephropathy, neuropathy)
• Clarify trimester of each visit
ICD-10-CM Considerations
• Obstetrical embolism
– Identify source
– Venous from leg vs. from pelvic veins
– Amniotic fluid embolism
– Septic embolism
– Air embolism
– Specify trimester that it occurred or childbirth
– Identify severity
– Acute respiratory failure
– ARDS when it occurs
– Identify when saddle embolism
ICD-10-CM Considerations
• Newborns—category Z38
– Identifies # births—single, twin, triplet
– Born in/outside of hospital
– Vaginal/C-section
ICD-10-CM Considerations
• Newborn aspiration
– Clarify the substance aspirated:
• Meconium
• Blood
• Gastric content
• Amniotic fluid
– Clarify manifestations:
• w/o respiratory manifestations
• w/ hypoxia
• w/ atelectasis
• w/ acute respiratory failure
• w/ ARDS
ICD-10-PCS Considerations
• Obstetrics—Section 1
– Procedures performed on “products of
conception”
– Procedures performed on mother—med-surg
– Body system = pregnancy
– Root operation
• Abortion: artificially terminating pregnancy
• Extraction: C-section
• Delivery: manual & vaginal delivery
– Body part—products of conception
Questions?
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this program, you must complete the online evaluation which
can be found in the continuing education section at the front
of the workbook.