Transcript Good Samaritan

3M Health Information Systems, Inc.
Good Samaritan Advocate
CPIC Draft
April 15
8 am
Innovating
Innovating
the
the
Thomas C Kravis MD
Language Language
of Health of Health
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Clinical Documentation Improvement
Goals and Objectives
 Clear concise accurate documentation
 Capture the severity of illness (SOI) and the Risk of Mortality (ROM)
 Support hospital and physician reimbursement
 Improve quality report cards hospital , physician
 Prepare for ICD-10
2
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Value of Accurate and Complete Documentation
MD and
Hospital
Quality
Reports
Core
Measures
ICD-9-CM
ICD-10
Preventable
Readmission
Complications
PSIs
Compliance
Fraud Abuse
RAC
Value
Base
Purchasing
Care
Coordination
Team
3
POA
HACs
Medical
Necessity
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2 MIDNIGHT
RULE
E&M Pro fees
Denial related
claims
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Documentation & Coding Issues at Advocate
Physician
Document in
CLINICAL terms
Two separate
languages
Documentation for
coding, profiling &
compliance requires
specificity in
DIAGNOSIS terms
This gap will be increased with ICD-10
Documentation
Improvement can help bridge the gap
4
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Clinical
Diagnostic
Unable to Code
5
Able to Code
Multi-system organ failure
Liver failure, renal failure, resp failure
Severe respiratory distress
Respiratory failure : acute, acute on chronic
Hemodynamically unstable
Hypotension, shock-cardiogenic/septic
Will rehydrate
Dehydration, hypovolemia
“Urosepsis”
Simple UTI
↓ K = 2.0, will give KCL
Hypokalemia
Chest X infiltrate
Pneumonia Left Lower Lobe
↓ Platelets ↓ Wbc ↓Hct
Pancytopenia secondary to Chemotherapy
↓ HgB 5.2, Transfuse
Acute/Chronic Blood Loss Anemia
Altered Mental Status
Coma, Encephalopathy
Emaciated, Total Protein/Albumin Low
Protein Calorie Malnutrition
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Physician and advanced practioners role






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Focus remains on patient care
Real time 3M 360 :Natural Language Processing
Respond to query and document in the EMR
Do not need to learn coding
Minimal impact on day-to-day routine
Clinical Documentation Specialists – a resource to
the physician
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When should a physician be queried regarding
clinical documentation?
“ whenever there is conflicting, ambiguous, or
incomplete information in the health record
regarding any significant reportable condition
or procedure”
AHIMA Practice Brief “Managing an Effective Query Process” October 2008
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Impact of Responding to Query
Query: “The magnesium level is 1.6 and the patient is receiving
magnesium sulfate” “Please provide a corresponding diagnosis ”
Physician documents: “hypomagnesimia”
Cranial Procedure
Impact w/o Response to Query
 RW = 2.9797
 GLOS = 8.98
 SOI = 2 Moderate
 ROM = 2 Moderate
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Impact w/ Response to Query
 RW = 2.9797
 GLOS = 8.98
 SOI = 3 Major
 ROM = 2 Moderate
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All Patient Refined DRG
APR-DRG
3M™
Subdivide into subclasses
9
Severity of Illness Subclasses
Risk of Mortality Subclasses
1. Minor
1. Minor
2. Moderate
2. Moderate
3. Major
3. Major
4. Extreme
4. Extreme
Mortality at < 4
Quality
Coding
Documentation
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Principal Diagnosis "XYZ"
Impact of Secondary Diagnosis
10
1
2
3
4
Severity of Illness
Minor
Moderate
Major
Extreme
1
2
3
4
Risk of Mortality
Minor
Moderate
Major
Extreme
Secondary Diagnosis-Diabetes Mellitus
Uncomplicated Diabetes
Diabetes w Neuropathy
Diabetes w Ketoacidosis
Diabetes w Hyperosmolar Coma
Secondary Diagnosis-Cardiac Dysrhythmias
Premature Beats
Sinoatrial Node Dysfunction
Paroxysmal Ventricular Tachycardia
Ventricular Fibrillation
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Risk-Adjusted Mortality Analysis: Quality Measure
Advocate
Medical Specialty
Behavioral
Cardiology
CT Surgery
Medicine
Neurology
Neurosurgery
Ophthalmology
Orthopedics
Pulmonary
Renal
Surgery
Transplant
Vascular
Women's Health
Total
Medicare
Volume
Actual
Deaths
14
568
0
15
105
3
51
7
1
0
3
28
1
9
0
0
0
118
1,265
224
31
9
626
539
273
263
0
53
18
3,988
Actual
Death
Rate
0.00%
2.64%
2.86%
4.03%
3.13%
3.23%
0.00%
0.48%
5.19%
0.37%
3.42%
0.00%
0.00%
0.00%
2.96%
Expected Variance,
Variance,
Expected
Death
In
As A %
Deaths
Rate
Deaths
Of Expected
0.0
0.00%
0.0
0.0%
17.3
3.05%
-2.3
-13.3%
2.4
50.4
10.5
0.1
0.0
7.2
31.6
3.5
9.8
0.0
1.2
0.1
134.1
2.29%
3.98%
4.69%
0.32%
0.00%
1.15%
5.86%
1.28%
3.73%
0.00%
2.26%
0.56%
3.36%
0.6
0.6
-3.5
0.9
0.0
-4.2
-3.6
-2.5
-0.8
0.0
-1.2
-0.1
-16.1
25.0%
1.2%
-33.3%
900.0%
0.0%
-58.3%
-11.4%
-71.4%
-8.2%
0.0%
-100.0%
-100.0%
-12.0%
Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of
actual to expected mortality variance without further study. GS Hopital
11
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RISK OF MORTALITY
APR DRG 194, HEART FAILURE
State Average
APR DRG
Subclass
1
2
3
4
Total
Cases
2,268
15,761
13,606
5,300
36,935
Actual
Deaths Mortality Rate
4
0.2%
101
0.6%
402
3.0%
758
14.3%
1,265
3.4%
Example Hospital
Actual
Cases
9
100
83
32
224
Actual
Expected Actual Mortality
Deaths Deaths
Rate
0.0
0
0.0%
0.6
1
1.0%
2.5
2
2.4%
4.6
8
25.0%
7.7
11
4.9%
Quality
Documentation or
Coding
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Mortality
Rate %
Variance
0%
67%
-20%
74%
43%
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Heart Failure

Acuity
Acute, chronic, acute on chronic/exacerbation

Type
Systolic and/or diastolic heart failure

Etiology If known or suspected:
― Ischemia
― Anemia
― Hypertension
― Myocarditis
― Kidney failure
― Structural heart disease
― Supraventricular tachycardia
― Cardiomyopathy : Alcoholic congenital, congestive, constrictive, dilated, endomyocardial,
idiopathic hypertrophic sub aortic stenosis ,nonobstructive hypertrophic, obstructive hypertrophic, restrictive
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Acute Kidney Failure – Impact of Documentation
 Insufficient documentation
― Acute renal insufficiency
SOI 1; ROM 1
― Acute kidney injury (AKI)
SOI 3; ROM 3
― Acute kidney failure
SOI 3; ROM 3
Preferred specificity if clinically appropriate
― Acute kidney failure due to:
14
• Acute tubular necrosis
SOI 4; ROM 4
• Cortical necrosis
SOI 4; ROM 3
• Medullary (papillary)necrosis
SOI 4; ROM 3
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Heart Failure
Training objective:
 Sample Physician: SOI less than Peers
 Target for training
 Respond to query
 Document the drivers of SOI
 Treat underlying cause: clinical effectiveness
Top 10 secondary diagnoses from National Norms driving SOI subclass 3 and 4
194 - Heart Failure
SOI
Subclass
1
2
3
4
Overall
Cases
Actual Days
1
10
3
0
14
1
40
19
0
60
ALOS
1.0
4.0
6.3
0.0
4.29
Peer Comparison
Sample Physician
Peer Group 1 - Cardiology
Peer Group 2 - Physician Practice Group
Peer Group 3 -National
Distribution
7%
71%
21%
0%
100%
Actual
Weight
0.4868
Total
Weight
0.4868
0.6127
0.9591
2.0096
6.1270
2.8773
0.0000
9.4911
Severity
Index
0.6779
Variance
0.7311
0.7982
0.8695
Lower SOI
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--7.3%
-15.1%
-22.0%
Subclass 3
Subclass 4
Dx Code
Description
Dx Code
Description
5849
486
42833
42823
4271
5119
42831
42821
2639
51883
Acute Kidney Failure Nos
Pneumonia, Organism Nos
Ac On Chr Diast Hrt Fail
Ac On Chr Syst Hrt Fail
Parox Ventric Tachycard
Pleural Effusion Nos
Ac Diastolic Hrt Failure
Ac Systolic Hrt Failure
Protein-cal Malnutr Nos
Chronic Respiratory Fail
51881
41071
5070
51884
5845
4275
78551
262
99592
570
Acute Respiratry Failure
Subendo Infarct, Initial
Food/vomit Pneumonitis
Acute & Chronc Resp Fail
Ac Kidny Fail, Tubr Necr
Cardiac Arrest
Cardiogenic Shock
Oth Severe Malnutrition
Severe Sepsis
Acute Necrosis Of Liver
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Probable, Possible, Suspected Diagnosis Uncertain Diagnosis
Inpatient application only:
 These conditions may be coded as though they exist
 Applies to hospital setting only
 If condition is ruled out, it may not be coded
Outpatient application:
Must code signs/symptoms, not the suspected condition
Supports appropriate E&M professional component
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Possible/Probable Cause of Chest Pain ICD-10
Biliary Colic
MS-DRGs
444/445/446
RW = 1.5055
Anxiety
MS-DRG 880
RW = 0.6191
Cardiac Cath
MS-DRGs
286/287
RW = 1.9634
GERD Gastritis
MS-DRGs 391/392
RW = 1.0958
Anterior CP
Pleuritic CP
Chest Wall Pain
MS-DRG 204
RW = 0.6472
Psychogenic
Angina Pericarditis
MS-DRGs
314/315/316
RW = 1.7589
Chest Pain
MS-DRG 313
RW = 0.5404
Pleurisy
MS-DRGs
193/194/195
RW = 1.4378
Psychogenic
Chest Pain
MS-DRG 882
RW = 0.6676
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Costochondritis
Tietze’s Disease
MS-DRGs 205/206
RW = 1.2566
Pulmonary
Embolism
MS-DRGs 175/176
RW = 1.6121
Shingles
MS-DRGs
595/596
RW = 1.7691
CAD
MS-DRGs
302/303
RW
= 0.9999
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Angina
MS-DRG 311
RW = 0.5128
Cardiac
Arrhythmia
MS-DRGs
308/309/310
RW = 1.2188
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Documentation for Pulmonary Embolism ICD-10

Document acuity:
―
―
―

Specify meaning of “history of PE”
―
―
―

Chronic PE being treated
no longer has the condition
“chronic pulmonary embolism” /“healed
PE” or “old PE”
Specify if related to any other
condition such as:
―
―
―
―
―
Specify type:
―
―
―
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Acute
Chronic
Healed/old

Saddle
Septic
Postprocedural or due to a vascular
device
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―

Atrial fibrillation
DVT (specify site and laterality)
Hypercoagulable state
Malignancy/Orthopedic
surgery/Sepsis/Trauma
Not POA and after an operative
episode is considered a patient
safety indicator (PSI 12)
A hospital acquired condition
(HAC) when following certain
orthopedic procedures
Cor pulmonale (acute
/chronic)
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Myocardial Infarction
ICD-10-CM :
Type of infarction (STEMI or NSTEMI)
Specific site of myocardium involved
( anterior wall, inferior wall)
Coronary artery involved (LAD, RCA,
LMCA, LCx)
New MI within 4 weeks of a previous
MI
Specify date of onset)
ICD-10
19
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Sepsis
 Sepsis is classified by the bacteria
causing the infection
― Streptococcal sepsis (group A, group
B, Streptococcus pneumoniae, other
streptococcal) or
― Other sepsis (e.g., MRSA,
pseudomonas)
 Severe sepsis is associated with
organ dysfunction/failure
― Document the specific associated
organ dysfunction (not MOD) and
― Document presence of septic shock
20
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Respiratory Failure
 Acute/chronic/acute on chronic
 Etiology :pneumonia,COPD,drug,trauma
 If following surgery was it POA ( PSI ) or due to underlying pulmonary
condition, failure to wean
 Signs :RR> 26, accessory muscles use, altered mental status
 Arterial blood gas and pH:
 pH of <7.30 or >7.50
 pCO2 of >50
 pO2 of <60 (impacted by hemoglobin level)
 Type I Hypoxemic : pO2 60 mm Hg normal or low pCO2
 Type II Hypercapnic: pH < 7.30 and increased bicarbonate;pCO2 >50
 Chronic : As above and low flow 02 at home; polycythemia ;cor pulmonale;
heart failure
21
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“Postoperative” Diagnosis: Two Definitions
Clinical Definition
“A condition occurring in the postoperative period”.
Coder Definition
“A diagnosis related to the surgical procedure”
Complication-900 code
“Coder cannot make the determination if it is a complication or an expected
outcome”
(Coding Clinic 4/27/2011)
.
22
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Examples
Complication
Non-Complication
 Postop ileus (997.4 + 560.1)
 Ileus
 Ileus secondary to surgery
 Prolonged ileus
(997.4 + 560.1)
 Expected ileus
 Post op atelectasis (997.39 +
518.0)
23
 Post op anemia
 Incidental atelectasis
 Atelectasis
(998.11 + 285.1)
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 Acute blood loss anemia
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Impact of Documentation and Quality
MS-DRG 330
2.4981
MS-DRG 329
5.1396
MS-DRG 329
5.1396
Bowel Procedure
with MCC
Bowel Procedure
with CC
Bowel Procedure
with MCC
PDx: Colon cancer
PDx: Colon cancer
PDx: Colon cancer
SDx:
SDx:
SDx:
Dehydration
Acute Renal Failure – ATN
Acute Renal Failure – ATN
Post-op ileus
(codes to 997.4 + 560.1)
Expected ileus
(560.1)
Expected ileus
(560.1)
“Ulcer/Wound” noted by RN
Pressure Ulcer, site unspecific
Pressure Ulcer Stage IV
on Sacrum
PPx: Left hemicolectomy
PPx: Left hemicolectomy
PPx: Left hemicolectomy
APR DRG:
SOI Level:
APR Weight:
ROM Level:
Peer Group
24
221
2
1.7681
1
0.0%
APR DRG:
SOI Level:
APR Weight:
ROM Level:
Peer Group
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Highest MSDRG payment
221
3
2.9531
3
2.5%
APR DRG:
SOI Level:
APR Weight:
ROM Level:
Peer Group
221
4
6.3732
4
24.2%
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ICD-9 vs. ICD-10
Structural Changes
 ICD-9 (Diagnoses)
#
#
#
#
#
3-5 characterst
Category
etiology, site,
manifestation
 ICD-10 (Diagnoses)
a
#
a/#
a/#
a/#
a/#
a/#
3-7 characters
Category
25
etiology, site,
manifestation
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extension
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ICD-10 Documentation Requirements for Procedures


26
Laterality of site
―
Left
―
Right
―
Bilateral
Specificity of approach
•
Open
•
Percutaneous
•
Percutaneous endoscopic
•
Via natural or artificial opening
•
Via natural or artificial opening- endoscopic
•
Open with percutaneous endoscopic assistance
•
External
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Example:Angioplasty with Stent Procedures
 Objective of the procedure
― Root operation “dilation” is defined as “expanding an orifice or
the lumen of a tubular body part”
 Vessel and laterality
 Approach
― Open
― Endoscopic
― Percutaneous endoscopic
 Type of stent inserted
― Drug-eluting intraluminal device
― Non-drug-eluting stent
― Bare metal stent
27
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ICD-10 Trauma Documentation Tips
 Cause and effect
― Subarachnoid hemorrhage secondary to fall during skiing accident
 Specific
― Salter Harris Type I physeal fracture proximal left femur
 Anatomical site and laterality
― Displaced fracture of olecranon process with intraarticular extension of right
ulna
 Encounter
― Initial vs. subsequent vs. sequela
28
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ICD-10 OB/Gyn Documentation Tips
 Use adjectives
― Acute, chronic, acute on chronic, mild, moderate, severe
• Example: Moderate pre-eclampsia
 Indicate cause and effect
― Use “due to” or “secondary to”
• Acute salpingitis secondary to Neisseria Gonorrhoeae
 Clinical aspects of the disease
― Gestational hypertension without proteinuria
 Patient’s trimester or number of weeks
― Admitted for proteinuria in 34th week of pregnancy
 Specify anatomical site
― Example: Acute salpingitis and oophoritis
29
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ICD-10 Documentation Tips Mental Health
 Adjectives
― Acute, chronic, acute on chronic, mild, moderate, major, severe, persistent
• Bipolar disorder, acute episode manic, moderate
 Cause and effect
• Dementia due to Alzheimer’s disease
30
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