Transcript Document

Indiana Association for Healthcare
Quality
Denise Tinkel, RRT, MHA, CPHQ
Manager, Clinical Documentation Improvement
Huron Healthcare
Carol Huffman, RN, MSN
Associate, Clinical Documentation Improvement
Huron Healthcare
Clinical Documentation
Improvement
Clinical Documentation Improvement Program
Clinical Documentation Improvement (CDI) “bridges the gap”
between clinical language and technical language
CDI Goals
Accurately
reflect the
severity of
illness
Improve
physician and
hospital
profiles
Appreciate
Increase case
maximum
mix index
compliant
reimbursement
3
Documentation Effects
Documentation Effects
Severity of
Illness
RAC Audits
Reimbursement
&
Compliance
Documentation
Medical
Necessity
&
Length of Stay
POA
Profiling
Hospital
&
Physicians
4
Accurate Documentation
Risk
Violate Regulatory Guidelines
Accurate Severity of illness
Loss
Financial Loss
Inaccurate Physician/Hospital Profiling
5
Accurate Documentation
Key indicators that trigger a need for a CDI program:
MS-DRG implementation October 2007 – (Severity Adjusted)
Decreasing/low case mix index (CMI)
High length of stay (LOS)
Denials for lack of medical necessity
Present on admission (POA) indicator requirement
Increasing number of core measure reporting requirements
Recovery Act Contractors (RAC)
Medicare Administrative Contractors (MAC)
High Mortality Index
6
3 Phases of CDI
Assessment
Implementation
Continuing Support
7
Concurrent, Multi-Disciplinary TEAM Approach
Patient Admitted
Concurrent Medical
Record Review
Patient Discharged
Complete Record
Coder Receives
• Reflects the appropriate severity of illness
• Supports CMS, OIG, Joint Commission Standards
• RAC Readiness
8
Clinical Documentation Improvement Process
9
Sustaining the Program
Quarterly monitoring of the program to ensure the long-term success
Clinical Record Review
Compliance Evaluation
Analysis of data
Communication with the leadership team
Monitoring of CMI and MS-DRG trends
Educational sessions
Coding guideline updates
Clinical and technological reviews
10
Documentation Improvement
Poor quality documentation in a patient’s record has been
linked to both excessive health care costs and poor quality
of care”
1
1- National Coalition for Health Care, Charting the Cost of Inaction 2003
11
Physician Profiling
Data utilized for physician profiling:
Length of stay
DRG Assignment
E & M Levels of physician service
Mortality and Morbidity
Documentation improvement assists with creating accurate profiles
12
HEALTHGRADES: Pneumonia
13
Coding Guidelines
For reporting purposes the documentation that must be followed are those
by the 4 cooperating parties:
American Hospital Association (AHA)
American Health Information Management (AHIMA)
National Center for Health Statistics (NCHS)
Centers for Medicare and Medicaid Services (CMS)
Clinical Documentation Improvement (CDI) follows all coding guidelines identified by the 4 cooperating
parties.
14
It’s Not Just Semantics
1.
2.
3.
4.
5.
6.
7.
8.
Sepsis
Renal Failure
ESRD
Aspiration Pneumonia
Pneumonia
CVA
Acute MI
Encephalopathy
1.
2.
3.
4.
5.
6.
7.
8.
Bacteremia
Renal Insufficiency
CKD V
ECF Pneumonia
Infiltrate
TIA
Acute Coronary Syndrome
Altered Mental Status
15
Sepsis versus UTI
DRG
DRG RW
Expected
LOS
SOI
ROM
Expected
Cost*
Documentation
UTI w/o MCC
.7864
3.4
1
1
$4061
UTI, death unlikely
UTI w/MCC
1.2185
4.8
3
3
$6292
UTI,
encephalopathy
Sepsis w/o
96 MV, w/o
MCC
1.1545
4.6
1
1
$5962
Sepsis due to UTI
Sepsis w/o
96 MV
w/MCC
1.9074
5.4
3
3
$9850
Sepsis due to UTI,
shock, death likely
Sepsis w/96+
MV
5.8305
12.9
3
4
$30,109
Sepsis, Acute
Respiratory Failure
16
The Development of ICD-9-CM Coding
•
•
•
Developed by the World Health Organization (WHO)
Refined by the US Department of Health and Human
Services (DHHS) for use in the United States
Designed to be mutually exclusive and reliable
– There is only one correct code for each diagnosis and
procedure
– Every coder should arrive at the same codes using this
system
•
The coding system uses “cataloging” concepts:
– Main term (example: noun » pneumonia)
– Sub terms (example: adjective » viral)
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17
The Development of ICD-9-CM Coding
•
•
•
•
•
•
ICD-9-CM Codes (17,000) are assigned to specific diagnoses and procedures.
ICD-9-CM Codes group to Diagnostic Related Groups (DRG) based upon
similar resource consumption and care provided
Coding Conventions that include complex and detailed information on how
to use the system appear in the front of each ICD-9-CM Coding book.
Most HIM departments use an automated version, called an encoder.
Official Guidelines are composed and updated regularly by DHHS’ Centers for
Disease Control and Prevention (CDC).
ICD-10-CM Codes (155,000) have a projected target start date of October 1,
2013.
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18
The Development of Diagnostic Related Groups (DRGs)
•
•
•
•
In 1982, the Tax Equity and Fiscal Responsibility Act (TEFRA) modified
Medicare hospital reimbursement limits to include a case mix adjustment
based on DRGs.
In 1983, Congress amended the Social Security Act to include a national
DRG-based hospital prospective payment system for all Medicare patients.
The design and development of the DRGs began in the late 1960’s at Yale
University. The initial motivation for developing the DRGs was to create a
system for monitoring the quality of care and the utilization of clinical
resources in the inpatient setting.
DRGs are a patient classification system that provides a methodology of
relating the type of patients a hospital treats (i.e. the case mix) to the costs
incurred by the hospital.
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19
Medicare Severity DRGs (MS-DRGs)
•
•
Began October 1, 2007 and are planned to be the system used permanently
for IPPS payment.
Revised to more effectively capture severity of illness and use of resources
based on the complexity of the patient’s illness.
– Decrease the amount of cost variation within DRGs
•
•
•
Change the outlier threshold, the transfer DRGs, and Case Mix Index (CMI).
Improve accuracy of payment rates in the IPPS and decrease financial
incentives to create specialty hospitals due to changes in relative weights
based on hospital costs vs. hospital charges.
Eliminate age-specific DRGs and incorporate those DRGs into the closest
matching DRG categories to reduce the number of low-volume DRGs and
improve the stability of DRG relative weights.
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20
MS-DRGs (continued)
•
•
•
Improve the ability to place patients in proper DRG assignments with
severity levels.
Mandated a review of the Complications and Co-Morbidity (CC) list originally
created in 1980 -1981 that assigned patients to a DRG if they had a CC on the
list or if they were > 70 years old. The age requirement was dropped with
the 1988 CC list revision.
CMS revisited the CC list and reviewed all secondary diagnoses that originally
qualified as a CC. The list has been revised now to include only those
conditions clearly demonstrated to require a substantial amount of hospital
resources.
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21
MS-DRGs (continued)
•
•
Prior to FY 2008, approximately 78% of patients had a CC assigned. With the
advent of the MS-DRG system, only 40% of patients will have a CC/MCC.
Many chronic conditions have been eliminated from the CC list because
most chronic conditions do not consume significant amounts of hospital
resources unless there is an acute exacerbation of the disease or condition.
Exceptions to this rule are conditions such as advanced stages of chronic
diseases like end-stage renal disease or extreme obesity.
There are now three different CC categories:
– MCCs represent the highest level of severity
– CCs represent a diminished level of severity
– Non-CC/MCCs are those diagnosis codes that do not require significant
additional amounts of hospital resources and are not reflective of
increased severity
•
CMS expects to make revisions to the MCC and CC lists each year.
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22
MS-DRGs (continued)
•
•
A primary purpose of going to the 3 different levels of severity categories is
to encourage complete and accurate documentation in the medical record
by providing financial incentives to do so.
There is an exclusion list for CCs and MCCs. Each diagnosis on this list is
excluded from being a MCC or CC if coded with certain Principle Diagnoses.
Exclusions are conditions that are closely related, chronic and acute
manifestations of the same disease process. These conditions co-exist or are
anatomically proximal sites of the same diseases.
– An example of a co-existing condition is cardiomyopathy with congestive
heart failure.
•
There are DRGs that do not change with the presence of a CC or MCC.
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23
MS-DRGs (continued)
•
Examples of Major Severity Complications and Co-morbidities that increase
risk of mortality:
– Sepsis
– Severe sepsis (septic shock or sepsis with identified organ failure)
– Systemic inflammatory response syndrome in non infectious cases with or
without organ failure
– Acute systolic congestive heart failure
– Acute on chronic respiratory failure
– Toxic/metabolic encephalopathy
** Risk of mortality increases by 60%
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24
Severity of Illness & Risk of Mortality
∙ The severity of illness (SOI) and risk of mortality (ROM) system
provides a higher level of detail about a patient's condition
and the care provided. Improving SOI and ROM indicators
strengthens hospital quality data and physician report cards
by more accurately detailing the nature of the patient’s illness
and expected outcome. And while those numbers are crucial
to a hospital's success, an SOI/ROM focused program can also
have a positive effect on revenue and help reduce compliance
risk.
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25
DRG Grouping
•
Factors that impact DRG assignment:
– Principal diagnosis
– Secondary diagnosis
– Procedure
– Gender
– Discharge status
– Birth weight for Neonate
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26
Reporting Secondary Diagnoses
•
Additional and secondary diagnoses should be
reported when they affect patient care in terms of
requiring the following:
– Clinical evaluation
– Therapeutic treatment
– Diagnostic procedures
– Extended length of hospital stay
– Increased nursing care and monitoring
NOTE: The above is based on Coding Clinic, Second Quarter 1990,
p.13.
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27
Major Diagnostic Categories
•
•
•
•
There are currently 747 DRGs that are divided into 25 Major
Diagnostic Categories (MDCs). Each MDC was developed to
correspond to a particular organ system or is associated with a
particular medical specialty.
Each MDC is then further divided into Medical and Surgical
DRGs.
A patient’s stay is defined based on the principal diagnosis (PDx)
for which they were admitted to the hospital.
This PDx determines the MDC assignment.
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28
Surgical Procedures
•
•
After this determination has been made, patients are further
defined based on any surgical procedure performed.
A patient can have multiple procedures related to their
principal diagnosis during a single hospital stay, yet only one
surgical DRG may be assigned. Consequently, patients who
require multiple procedures are then placed in the surgical
group that is determined by the surgical hierarchy.
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29
Identify Co-morbid
condition or
complication
(CC/MCC)
Identify the Medical
Principal Diagnosis
and MDC
Surgical
Procedure
Same
MDC?
How a DRG Is Assigned
NO
Assign
Medical
DRG
YES
YES
NO
DRG in same
MDC is assigned
with
appropriate
CC/MCC
Note:
If a surgical procedure is one of
the Pre-MDC DRGs, this is the
DRG that is directly assigned.
NO
Was a
Surgical Procedure
Performed?
NO
Was procedure
a PROSTATIC
procedure?
Was procedure
classified as
MINOR?
Was procedure
classified as
EXTENSIVE?
Assign
DRG 984-986
Assign
DRG 987-989
Assign
DRG 981-983
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All Patient Refined DRGs
DRG
Severity
of
Illness
Risk of
Mortality
Min
1
1
Low
2
2
Moderate
3
3
Severe
4
4
• Proprietary DRG system by
Ingenix.
• It accounts for severity of
illness and risk of mortality
based on documentation of
complications and comorbidities.
• Lack of CCs and now Major
CCs will suggest higher than
expected mortality.
• Used by Thompson
Solucient .
Acute Care Hospital (IPPS)
RW
Blended
Rate
DRG
Reimbursement*
*Regardless of length of stay
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32
Relative Weight –Examples
•
Relative Weight (RW): The relative weight assigned to each DRG is intended
to reflect resource consumption and severity of illness.
Diagnosis
DRG
RW
Allergic Shock
(Anaphylaxis)
916 Allergic Reactions w/o mcc
0.4867
CHF
293 Heart Failure & Shock w/o cc/mcc
0.6853
Pneumonia
195 Simple Pneumonia & Pleurisy
w/o cc/mcc
0.7096
Pneumonia w/ UTI
194 Simple Pneumonia & Pleurisy w/cc
1.0152
Pneumonia w/ ESRD
193 Simple Pneumonia & Pleurisy w/mcc
1.4796
Heart/Lung Transplant
w/ ARF
001 Heart Transplant w/ mcc
26.3441
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33
Reimbursement Calculations
Diagnosis
DRG
RW
Expected
Reimbursement*
(BR $5164.00)
Allergic Shock
(Anaphylaxis)
916 Allergic Reactions w/o mcc
0.4867
$2513**
CHF
293 Heart Failure & Shock w/o
cc/mcc
0.6853
$3538**
Pneumonia
195 Simple Pneumonia & Pleurisy
w/o cc/mcc
0.7096
$3664**
Pneumonia w/ UTI
194 Simple Pneumonia & Pleurisy
w/ cc
1.0152
$5242**
Pneumonia w/
ESRD
193 Simple Pneumonia & Pleurisy
w/ mcc
1.4796
$7640**
Heart/Lung
Transplant w/ ARF
001 Heart Transplant w/ mcc
26.3441
$136,040**
* $5164.00 is a Blended Rate example used for this demonstration
**Regardless of length of stay
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34
Case Mix Index
Case mix index (CMI) is driven by case mix complexity.
CMI is derived by adding the total relative weights for all Medicare patients
discharged within a specified timeframe, then dividing by the total number of
Medicare discharges within that same time period. This time frame is typically
by month or year.
• CMI is designed to reflect the level of severity and complexity of a hospital’s
patient population.
– A higher CMI indicates that the hospital treats patients who require
greater hospital resources.
– A low CMI may denote DRG assignments that do not adequately reflect
the resources used to treat Medicare patients.
• CMI fluctuates month-to-month and is impacted by several variables.
– Census
– Service lines
– Length of Stay
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35
CMI – a demonstration
Sum of
Relative
Weights
CMI
Number
of Cases
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36
Case Mix Index (CMI) – Example
The sum of the RWs divided by the # of cases = CMI
Diagnosis
DRG
RW
Chest Pain
313 Chest Pain
0.5499
CHF
293 Heart Failure & Shock w/o cc/mcc
0.6853
Sepsis
872 Septicemia w/o MV 96+ hours w/o mcc
1.1545
Pneumonia w/
UTI
194 Simple Pneumonia & Pleurisy w/ cc
1.0152
AMI w/ CABG w/ 234 Coronary Bypass w/ cardiac cath w/o
Cath w/o mcc
mcc
4.8281
DJD w/ ORIF w/
acute blood loss
anemia
1.8896
481 Hip & femur procedures except major
joint w/ cc
Total cases = 6
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Sum of RW =
10.12
CMI = 1.69
37
CMI – a demonstration
10.12
Sum of
Relative
Weights
CMI
1.69
6
Number of
cases
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38
Coding Clinic Guidelines
•
•
•
•
•
•
The purpose of a Coding Clinic is to promote accuracy and consistency in the
use of ICD-9-CM and the definitions specified in the Uniform Hospital
Discharge Data Set (UHDDS) and the Uniform Billing (UB-04) system for
hospitals.
There are many organizations that publish coding advice, but the only
publication endorsed by CMS is the Coding Clinic for ICD-9-CM published by
the American Hospital Association (AHA).
These guidelines have been developed to assist the user in coding and
reporting in situations where the ICD-9-CM manual does not provide
direction.
The guidelines are reviewed on an ongoing basis and new guidelines are
developed as needed.
New Coding Clinic guidelines are published quarterly.
A newer Coding Clinic on a subject will always override an older Coding
Clinic on the same subject and a current Coding Guideline will always
override a Coding Clinic.
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39
CMS Position on Clinical Documentation Integrity
“ We do not believe there is anything inappropriate,
unethical or otherwise wrong with hospitals taking full
advantage of coding opportunities to maximize Medicare
payment that is supported by documentation in the
medical record.” “… We encourage hospitals to engage in
complete and accurate coding.”
Source: CMS Federal Register August 2008 Final Rule (CMS-1533-FC page 208)
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf
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40
What is a Clinical Documentation?
Improvement Program?
•
A documentation program focuses on:
– A clinical approach to comprehensive, quality documentation
by the multidisciplinary team
– Concurrent documentation review
– Clear, accurate and complete documentation
– Continuing education to support Documentation
Improvement
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41
CDI Team Members
• Physicians
• Professional Coders (PC)
• Clinical Documentation Specialists (CDS)
• Case Managers (CM)
• Healthcare Quality
• Allied care providers
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42
A Clinical Documentation Program
The Role of the Clinical Documentation Specialist:
•
•
•
•
•
Monitor the clinical documentation so that it accurately
demonstrates the intensity of service and level of care provided
for the patient.
Review all Medicare admissions after the first 24 hours to
ensure comprehensive documentation outlining the reason for
admission, the patient’s treatment, and any POA indicators.
Review medical records for accuracy and compliance.
Clarify all documentation for accuracy of severity of illness and
resource consumption
Provide ongoing education regarding clinical documentation for
the multidisciplinary team.
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43
A Clinical Documentation Program
The Role of the Clinical Documentation Specialist (continued):
•
Query the physicians for clarification of diagnoses.
•
Adhere to metrics established by your specific facility:
– Daily caseload (new admissions and follow-up queries)
– Number of queries per day
– Physician query rate (verbal and written)
– Physician response rate
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44
Medical Staff Responsibilities
•
Respond to the CDS queries prior to discharge.
•
Provide accurate and timely documentation in order to:
– Assist in assignment of the proper codes for hospital and physician billing
– Assist in the planning, evaluation and delivery of patient care resulting in
the best outcome
– Provide other physicians in the organization clear opinions regarding the
patient’s condition, treatment options and response to the prescribed care
– Result in fewer payment denials and facilitate the overturn of denials
– Improve results in the areas of strategic planning, quality measures,
outcomes and physician profiling
– Lower potential litigation with focused and accurate documentation to
support the appropriate, best practice care
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45
A Clinical Documentation Program
The Role of the of the Professional Coder
• Continue retrospective review and coding of records
• Review record for any CDS query
• Determine if retrospective query is needed
• Assign DRG as usual
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46
Clinical Documentation and the RAC
• A good Clinical Documentation Improvement program
protects the hospital’s resources
– Accurate and complete documentation in the chart
ensures accurate coding practices
• Principle diagnosis
• Secondary diagnoses
• Appropriate capture of co-morbidities
• Appropriate capture of major complications
Clinical Documentation Program
PHYSICIAN IMPACT
Inpatient Documentation
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48
Case Study
• Chart notes a elderly female admitted for unsteady
gait, watery diarrhea, vomiting, chills and
leukocytosis.
• Lab: WBC 30K 94% PMNs, Hb 9.1 with MCV 72.9;
Albumin 2.0
• Pulse Ox 81%, BP noted 83/52
• X-ray: Acute Vertebral Compression Fracture, Rt
Basilar Infiltrate
Case Study
• Final Coded Diagnosis: Medical Back
• Outcome: Death
Case Study #1
• Risk of Mortality based on documentation 1 of 4.
• Undiagnosed: Severe Malnutrition, Aspiration Pneumonia,
Septic Shock.
• If documented ROM 4 of 4.
• Numerically this was an unjustified mortality…
• The patient’s chart suffered from Symptom Excess
Disorder.
Symptom Excess Disorder©
A hospital chart with many symptoms (and signs) such as:
• pain,
• chills,
• fever,
• low BP,
• demand ischemia
but no actual diagnosis. The disorder understates the patients
severity of illness, risk of death and expected resource
utilization. Insurers love this disorder because they tie
hospitals to DRG based symptoms rather than charge.
Physicians suffer because their profiles are fully loaded with
high costs, long LOS, deaths, complications but no real
diagnosis to justify their profiles.
Consider the Possibilities for Precise Documentation
53
If this is written:
Is it an INDICATOR of:
ACS w elevated troponin
Non Q wave MI
Any infection; bacteremia, C diff
Septicemia/Sepsis
Albumin 2.8/ underweight
Severe Malnutrition
Altered mental status
Acute confusion, encephalopathy, or 2nd Parkinson’s
CAD, Angina
Stable angina, Angina-at-rest, Progressive Angina
Cardiac Arrest
Cause-probable V Tach, V Fib/AMI
Chest Pain
Probable –cause GERD
arrhythmia/gallstones/angina/cocaine
Hypertensive emergency
Malignant/Accelerated HTN/Hypertensive
encephalopathy
Hypotension
Cause-hypovolemia/autonomic 2nd
Parkinson's/diabetic/septic shock
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Consider the Possibilities for Precise Documentation
54
If this is written:
Is it an INDICATOR of:
LLL infiltrate/Rx w Zosyn
Probable gram negative pneumonia
Na 125
Hyponatremia and cause –SIADH
Hgb 7 guaiac positive
Acute/chronic blood loss anemia
Neutropenic fever
Underlying cause- sepsis/bacterial infection of unknown
etiology
Pleural effusion
Underlying condition- CHF/empyema/malignancy
Ph 7.25, PCO2 34 PO2 80
Metabolic acidosis
CAP/NH acquired pneumonia
Organism covering for- Zosyn, poss aspiration/gram
negative- Vancomycin, prob MRSA
Respiratory Insufficiency
Respiratory
Acidosis/Hypoxemia/Hypercapnia
Respiratory Failure if – ph <7.35 pCO2 >50 pO2 <60 and
special resources utilized
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Pulmonary Edema & Respiratory Failure
• Remember that you do not need ABGs to identify Respiratory
Failure
• The absence of mechanical ventilation does not preclude the
diagnosis of respiratory failure
• Pulse Oximetry
– patient’s oxygen saturation on room air should be < 90% or < 95% if
the patient is on supplemental oxygen
– Documentation of tachypnea, respirations > 26, use of accessory
muscles, or cyanosis is necessary if oximetry is used instead of Arterial
Blood Gases
– In addition, documentation of labored breathing, and/or aggressive
respiratory treatments all can be supportive of a respiratory failure.
Prevalence of Malnutrition
• PEM is the most common form of nutritional deficiency
among patients who are hospitalized in the United States. As
many as half of all patients admitted to the hospital have
malnutrition to some degree. In a recent survey in a large
children's hospital, the prevalence of acute and chronic PEM
was more than one half.
• In hospitalized elderly persons, up to 55% are
undernourished. Up to 85% of institutionalized elderly
persons are undernourished. Studies have shown that up to
50% have vitamin and mineral intake that is less than the
recommended dietary allowance and up to 30% of elderly
persons have below-normal levels of vitamins and minerals.
The Laboratory Evaluation of Malnutrition
Protein
Half-life
Malnutrition
Severe
Malnutrition
Significance
Albumin
18 days
3.0 g/l
<2.8 g/l
For every 2.5 g/l
decrease there is a
24 to 56%increase
in mortality
Transferrin
9 days
<200 g/l
<100 g/l
As above
Prealbumin
2 days
<200 mg/l
<150 mg/l
Should increase by
10 mg/day with
adequate repletion
Total
Lymphocyte
Count
NA
<1,500/ml
<800/ml
4-fold increase in
mortality when
even a moderate
decrease is seen
Assessment of Protein Energy Malnutrition in Older Persons, Part ll: Laboratory Evaluation; ML Omran MD and J.E Morley MB, BCh; Nutrition 16:131-140, 2000
This Definition of Sepsis in the Literature
NEJM: 351: 159169,
July 8, 2004
te Renal Failure
Classification/Staging System for AKI
59
Stage
Creatinine Criteria
Urine Output Criteria
1
Increased serum creatinine of >0.3 mg/dl
or increase to ≥150% - 200% from
baseline
<0.5ml/kg/hr for > 6hr
2
Increase serum creatinine to > 200%300% from baseline
<0.5ml/kg/hr for >12 hrs
3
Increase serum creatinine to >300% from
baseline (or serum creatinine ≥4.0mg/dl
with an acute rise of at least 0.5 mg/dl)
<0.3ml/kg/hr x 24 hrs or
anuria x 12 hr
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Physician Query Process
Query timeframes for clarification
• Concurrently (recommended)
– Done while the patient is in the hospital
– Direct communication with the physician is optimal
– Documented in the record at the time of query request
• Retrospectively (prior to billing)
– Should be done as soon as possible but within 7 days of discharge
– Query answered, record completed, coded and billed by 14 days
• Post billing
– Within 60 days of discharge
– Understand that a change to the DRG will automatically force a full review
of the record, especially medical necessity
– Up to one year for other purposes, anything past a year infers suspicion
Reference: Empire Medicare Services, 2006
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60
Physician Query Process (continued)
•
Questions from the CDI staff to the physicians are intended to:
– Clarify unclear, incomplete, or inconsistent documentation
– Specify a suspected or implied diagnosis
– Link diagnoses
– Provide detail
– Ensure documentation of clinical significance of lab or test
findings
•
Queries are based on evidence in the patient’s record
•
Physicians are expected to respond to queries
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61
Physician Query Process (continued)
• Concurrent Queries should include:
– Risk factors
– Signs and symptoms
– Treatment
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permission.
62
Present on Admission (POA)
•
•
•
In its landmark 1999 report ‘‘To Err is Human: Building a Safer Health
System,’’ the Institute of Medicine found that medical errors, particularly
hospital-acquired conditions (HACs) caused by medical errors, are a leading
cause of morbidity and mortality in the United States.
As one approach to combating HACs, including infections, in 2005 Congress
authorized CMS to adjust Medicare IPPS hospital payments to encourage the
prevention of these conditions.
In 2007, CMS announced that it will curtail payments to hospitals for specific
conditions that a patient acquires while an inpatient and that can be
“reasonably prevented” by following established evidence-based guidelines.
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63
Present On Admission
•
•
•
The President’s FY 2009 Budget: (1) Prohibits hospitals from billing the
Medicare program for ‘‘never events’’ and prohibits Medicare payment for
these events and (2) requires hospitals to report any occurrence of these
events or receive a reduced annual payment update.
Generally patients with these diagnoses have a longer length of stay,
increased utilization of hospital resources, and are often elevated to a higherpaying DRG.
Present on admission is defined as present at the time the order for
inpatient admission occurs -- conditions that develop during an outpatient
encounter, including emergency department, observation, or outpatient
surgery, are considered as present on admission.
(ICD-9-CM Official Guidelines for Coding and Reporting, Effective October 1,
2008, Page 104 of 119)
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64
POA
Present on Admission
•
A diagnosis is considered to be ‘present on admission’:
– If the physician includes “present on admission” in the documentation
– If it is included in the PMH list
– If the condition was diagnosed during the admission, but was clearly
present on admission, i.e.:
• chronic conditions and cancers
– If the diagnosis was possible, probable, rule out, suspected, or a
differential on admission and was confirmed at discharge
– If the condition developed during an outpatient encounter, such as
emergency room, physician office, outpatient surgery or observation
– If the signs and symptoms of the condition were clearly present on
admission, listed later in the record as a diagnosis with a POA clarifier
65
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POA
Present on Admission
•
A diagnosis is considered NOT ‘present on admission’ if:
– The physician documents that it was not present on admission
– It occurs or develops after the admission, therefore during the
inpatient stay
– A final diagnosis cannot be linked to signs and symptoms
present at the time of admission or a suspected, possible,
probably, rule out or differential diagnosis on admission
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66
POA Payment Example
67
MS-DRG Assignment
DRG
PDX: Intracranial
hemorrhage or cerebral
infarction (stroke) without
CC/MCC
MS-DRG 066
PDX: Intracranial
hemorrhage or cerebral
infarction (stroke) with SDX:
Dislocation of patella-open
due to a fall (code 836.4
(CC)
MS-DRG 065
Yes
$6,177.43
PDX: Intracranial
hemorrhage or cerebral
infarction (stroke) with SDX:
Dislocation of patella-open
due to a fall (code 836.4
(CC)
MS-DRG 065
No
$5,347.98
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Present on
Admission
Median Payment
$5,347.98
ICD-9-CM Official Guidelines for Coding and Reporting
•
•
Two or more diagnoses that equally meet the definition for principal
diagnosis - In the unusual instance when two or more diagnoses equally
meet the criteria for principal diagnosis as determined by the circumstances
of admission, diagnostic workup and/or therapy provided, and the
Alphabetic Index, Tabular List, or another coding guidelines does not provide
sequencing direction, any one of the diagnoses may be sequenced first. (p
96)
Two or more comparative or contrasting conditions - In those rare instances
when two or more contrasting or comparative diagnoses are documented as
“either/or” (or similar terminology), they are coded as if the diagnoses were
confirmed and the diagnoses are sequenced according to the circumstances
of the admission. If no further determination can be made as to which
diagnosis should be principal, either diagnosis may be sequenced first. (p 96)
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68
ICD-9-CM Official Guidelines for Coding and Reporting
•
•
There is no required timeframe as to when a provider (per the definition of
“provider” used in these guidelines) must identify or document a condition
to be present on admission. In some clinical situations, it may not be
possible for a provider to make a definitive diagnosis (or a condition may not
be recognized or reported by the patient) for a period of time after
admission. In some cases it may be several days before the provider arrives
at a definitive diagnosis. This does not mean that the condition was not
present on admission. Determination of whether the condition was present
on admission or not will be based on the applicable POA guideline as
identified in this document, or on the provider’s best clinical judgment. (p
105)
If at the time of code assignment the documentation is unclear as to
whether a condition was present on admission or not, it is appropriate to
query the provider for clarification. (p 105)
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69
Summary
• An effective Clinical Documentation Improvement program
benefits the hospital in the following ways:
– Using a physician documentation review process, the CDI
team identifies missing, conflicting or incomplete
information in the medical record
– The CDI program uses a physician query process to obtain
clarification of documentation in the medical record to
• Identify the Principle Diagnosis
• Identify Co-Morbidities
• Identify Major Complications
• Facilitate timely capture of documentation to support
CMS Quality Indicators
Summary
• An effective Clinical Documentation Improvement program
benefits the hospital in the following ways:
– Reduction in clinical denials
– Appropriate assignment of patient status (Observation vs
Inpatient)
– Reduction in potential litigation
– Facilitating discharge planning needs of patients and
improved patient throughput
– Accurate reflection of severity of illness for
• Use of hospital resources
• Physician profiles
• Public reporting
Clinical Documentation Improvement