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3rd Annual Association of Clinical Documentation Improvement Specialists Conference CDI and the ED Understand Physician Thinking to Conquer Documentation Challenges Pamela P. Bensen, MD, MS, FACEP [email protected] Medical Education Programs, Inc. 434/738-5584 Introduction Pamela P. Bensen, MD, MS, FACEP Drexel University Medical College of PA 1971 Dartmouth Medical School MS Quality 1997 MBA candidate Clemson University Emergency Physician – 38 years of Clinical Practice 3 decades as Physician Documentation Educator CDI, CPT, DRG, ICD-9-CM, APC, risk management, severity of illness, pay for performance Goals • Recognize ED CDI potential • Conquer documentation challenges – Understand physician thinking – Identify physician incentives – Strategize physician education & queries • Discuss ED CDI clinical problems Abbreviations & definitions • • • • • ACEP AHRQ BP CDI CERT • • • • • • • • • • • • • • • • • • • • • CMI CPT CTAS CVA ED EMP EMS ENA ESI FiO2 HACs HPI MAC MDC MDM MIC MS1-4 NTS O2 Sat P PERM American College of Emergency Physicians Agency for Healthcare Research & Quality Blood Pressure Clinical Documentation Improvement Comprehensive Error Rate Testing Medicare Contractor random audit Case Mix Index Current Procedural Terminology Canadian Triage & Acuity Scale Cerebral vascular accident (stroke) Emergency Department Emergency physician Emergency medical services Emergency Nurse Association Emergency Severity Index (AHRQ) Fraction of inspired O2 (RA is 0.21 or 21%) Hospital Acquired Conditions History of present illness Medicare Administrative Contractor Major Diagnostic Category Medical decision making Medicaid Integrity Contractor Medical student - year 1-4 National Triage Scale (Australia) O2 % saturation Pulse Medicaid Payment Error Rate Measurement Program • • • • • • PFSH PGW PGY POA PQRI PSC • • • • • R RA ROS RVU T – A - axillary – PO – per oral (mouth) – R – rectal – T or TM – tympanic (ear) Sign – What you see, hear, feel, smell – Objective Symptom – What patient feels – Subjective TIA Transient ischemic attack VBP Value Based Purchasing ZPIC Zone Program Integrity Contractor audit • • • • • Past, Family, Social History Players gone wild Post graduate - year 1-5 Present on admission Physician Quality Reporting Initiative Program Safeguard Contractor program integrity review Respiration Room air Review of systems Relative Value Units Temperature ED CDI potential • EMS – Minimal help • 50% of admissions “walk-in” • “Cabulance” abuse high – Treatment more useful for principal diagnosis ED CDI potential • Complaint – MDC directional sign – Principal diagnosis • CDI opportunity if dx = complaint (symptom) • CDI success if dx = ICD-9-CM terminology ED CDI potential • Triage category – Emergency Severity Index – National Triage Scale (Australia) – Canadian Triage & Acuity Scale – Urgency • 1 = most • 5 = least ill – May change at any moment ED CDI potential • Triage category – ESI – NTS – CTAS – Urgency ACEP A Uniform Triage Scale in Emergency Medicine, Information Paper ED Triage of Acute Myocardial Infarction Patients & the Effect on Outcomes, 22 January 2009, Atzema, et al, Annals of Emergency Medicine, June 2009 (Vol. 53, Issue 6, Pages 736-745) • 1 = most • 5 = least ill – May change at any moment – 50% AMIs triaged wrong ED CDI potential • Medication List – +/- Principal diagnosis – + Indicate secondary diagnoses • Currently being treated • Diagnosis for every medication • Chronicity – May be underlying cause of complaint • Toxic encephalopathy • Dehydration • Hypokalemia – May be reason for unusual clinical indicators • Beta-blockers Beta-blockers Do • • Treat Inhibit epinephrine-mediated (fight or flight) actions Decrease – – – – – – – – – • Effects of excitement Effects of physical exertion Social anxiety Tremor Breakdown of glycogen Heart workload Oxygen demand Sodium & water retention Nocturnal melatonin release, accounting for sleep disturbance Increase – Smooth muscle relaxation – Liver & skeletal muscle glycogen break down • • • • • • • • • • • • • • • • • • Hypertension Angina Mitral valve prolapse Cardiac arrhythmia Atrial fibrillation Congestive heart failure Myocardial infarction Glaucoma Migraine prophylaxis Symptom control (tachycardia, tremor) in anxiety & hyperthyroidism Essential tremor Phaeochromocytoma, used with α-blocker Hypertrophic obstructive cardiomyopathy Acute dissecting aortic aneurysm Marfan syndrome Prevent variceal bleeding in portal hypertension Mitigates hyperhidrosis Anxiety disorders Beta-blockers – adverse effects • Constitutional • – Nausea – Diarrhea – Fatigue • Eyes – Abnormal vision • Pulmonary • • Bradycardia Heart failure Heart block (Orthostatic) hypotension Edema Peripheral vasoconstriction • • Cold extremities Exacerbation of raynaud's syndrome Endocrine – – – – CVS – – – – – – GU – Sexual/erectile dysfunction – Bronchospasm - Asthmatics avoid – Dyspnea • GI • Alteration of glucose & lipid metabolism Hyponatremia Hyperkalemia Diabetes CNS – – – – – – Decreased concentration (AMS) Dizziness Hallucinations Clinical depression Insomnia Nightmares Beta-blockers • Acebutolol - Sectral® • Atenolol - Tenormin® • Betaxolol - Kerlone®, Betoptic® • Bisoprolol - Zebeta® • Carteolol - Ocupress® • Carvedilol - Coreg®, CoregCR® • Esmolol - Brevibloc® • Labetalol - Trandate® • Levobunolol - Betagan® • Metipranolol - OptiPranolol® • Nadolol - Corgard® • Nebivolol - Bystolic® • Metoprolol - Lopressor®, Toprol-XL® • Penbutolol - Levatol® • Pindolol - Visken® • Propranolol - Inderal®, Inderal LA, InnoPran XL® • Sotalol - Betapace®, Sorine® • Timolol - Betimol®, Blocadren®, Istalol®, Timoptic® Beta-blockers • Acebutolol - Sectral® • Atenolol - Tenormin® • Betaxolol - Kerlone®, Betoptic® • Bisoprolol - Zebeta® • Carteolol - Ocupress® • Carvedilol - Coreg®, CoregCR® • Esmolol - Brevibloc® • Labetalol - Trandate® • Levobunolol - Betagan® • Metipranolol - OptiPranolol® • Nadolol - Corgard® • Nebivolol - Bystolic® • Metoprolol - Lopressor®, Toprol-XL® • Penbutolol - Levatol® • Pindolol - Visken® • Propranolol - Inderal®, Inderal LA, InnoPran XL® • Sotalol - Betapace®, Sorine® • Timolol - Betimol®, Blocadren®, Istalol®, Timoptic® Beta-blockers • Acebutolol - Sectral® • Atenolol - Tenormin® • Betaxolol - Kerlone®, Betoptic® • Bisoprolol - Zebeta® • Carteolol - Ocupress® • Carvedilol - Coreg®, CoregCR® • Esmolol - Brevibloc® • Labetalol - Trandate® • Levobunolol - Betagan® • Metipranolol - OptiPranolol® • Nadolol - Corgard® • Nebivolol - Bystolic® • Metoprolol - Lopressor®, Toprol-XL® • Penbutolol - Levatol® • Pindolol - Visken® • Propranolol - Inderal®, Inderal LA, InnoPran XL® • Sotalol - Betapace®, Sorine® • Timolol - Betimol®, Blocadren®, Istalol®, Timoptic® ED CDI potential • Accurate Vital Signs – Temperature & route – Pulse – Respiration If R > 20, PO T not accurate! For each degree T is elevated, P goes up 10 R goes up 2 - 4 Beta-blockers alter P & R • SIRS – – – – T > 100.4 F T < 96 F P > 90 (100) R > 20 ED CDI potential • Accurate Vital Signs – Blood Pressure Right size cuff Right technique Stethascope at level of heart Quiet! Most important in shock Beta-blockers lower BP • Shock – SBP < 90 • Hypertension – Accelerated • SBP > 160 or • DBP > 100 and • Vague symptoms – Dizziness – Headache – Malignant • SBP > 180 • DBP > 120 and • End organ damage – Papilledema – Confusion - consider hypertensive encephalopathy – Heart failure • Requires aggressive Tx – ICU admission – Nitroprusside JAMA. 2003;289(8):1027-1030 Jones et al, Measuring Blood Pressure Accurately: New and Persistent Challenges ED CDI potential • Accurate Vital Signs – O2 Sat • Inspired air • RA, %, FaiO2% – Pain • Subjective • Respiratory failure – O2 Sat < 88% RA • Distress/severity ED CDI potential • Nursing notes – – – – – Appearance Distress Mental status Ability to move around Labor of breathing • Organ failure – CVS • • • • Pale Cool Clammy Shock – Brain • Encephalopathy – Altered mental status • TIA/CVA – Paralysis – Respiratory failure • • • • Distress Cyanosis Labored breathing Accessory muscle use ED CDI potential • Nursing notes – Times of events – Treatments – Changes in patient • TIA, CETI, or CVA? – Signs & symptoms • Duration • Resolution – Treatment used • TPA for TIA? – Effect of treatment ED CDI potential • Emergency physician – Documents last outpatient encounter – All diagnoses listed were POA – Establishes clinical terminology for entire record – Sets ‘severity tone’ – Counts for coding unless conflicting with attending Coding Clinic, First Quarter 2004, pp. 18–19 • Q: “…appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician.” • A: “Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician…physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician….” ED CDI potential • EMP notes – HPI • • • • • • • • Location Quality Severity Duration Timing Context Modifying factors Associated signs/symptoms • Associated comorbid conditions • Severity • Duration – Acuity • Associated comorbid conditions – Secondary diagnoses – POA/HACs ED CDI potential • EMP notes – Review of Systems – Past, Family, Social History • Other diagnoses – Symptoms = ?disease – Secondary diagnoses – POA/HACs • Severity – Chronic/ acute/ acute on chronic – Acute exacerbation of chronic… ED CDI potential • EMP notes – Exam – Lab – Radiology • Signs of disease – Principal diagnosis – Secondary diagnoses – POA/HACs • Severity • Acuity ED CDI potential • EMP notes – Medical Decision Making • Table of Risk – Disposition – Patient Status • Outpatient observation • Inpatient admission – Floor – ICU – Condition • Severity • Acuity • Secondary diagnoses – POA/HACs Conquer Documentation Challenges “Physicians understand this first equation, it’s these other ones they don’t get!” Theory and Reality E = mc2 Documentation = ICD-9-CM codes Codes = severity of illness Physician profile LOS ROM Reimbursement Change physician behavior • Hawthorne effect You change behavior by observing it • Reaction to you • Accept your assistance Improve your expertise • Patterson, Grenny, McMillan, Switsler – “Crucial Conversations” – “Crucial Confrontations” • Your mind-set, think like physicians – How physicians think & why • Training – Thought process evolution – Documentation evolution • Physician incentives • Educational strategies • Queries Your mind-set It’$ about money It is about quality & patient severity of illness Hi-Def clinical documentation Methods to 1. 2. Suspend your logic Think like a physician • Be the best • Avoid hassle • Document bare minimum madness No college degree required • • • • • • • • • • • • • • • • Accountant Air Traffic Controller Building Inspector Captains Cardiovascular Tech Chemical / Gas / Power Plant Operator Chemical Tech Dental Hygienist Emergency Management Specialist EMT & Paramedic Environmental Science Tech Fire Inspector Forensic Science Tech Forest Fire Inspector General Manager Insurance Claims • • • • • • • • • • • • • • • • • Interpreter Kindergarten / Preschool Teacher Law Clerk Loan Counselor / Loan Officer Logistician Manager of Police Detectives Nuclear Med / Nuclear Tech Optician Paralegal Pharmacy Tech Proofreader Radiation Therapist Radiologic Tech Real Estate Appraiser / Broker Respiratory Therapist Surveying Tech Tax Examiner Coders • Certification – Required for 50% of current jobs – 42% in 2007 – 89% in 2009 • • • • • CPC® CPC-H® CPC-P® CPC-A® Other certifications CCS, RHIT, CTR • 69% attended some college • 18% bachelor’s degree or above College Pilot Teacher Debt $23,000 Salary $53,000 Nurse Engineer Counselor Accountant Stockbroker Annual Tuition Debt $23,000 Salary $0 Tuition $43,000 $45,000 Private m edical school Public m edical school Private college $40,000 $35,000 $30,000 $25,000 $20,000 Public college $15,000 $10,000 $5,000 $0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Steinbrook R. N Engl J Med 2008;359:2629-2632 Think like a physician Medical School Pages 28,000 MBAs & architects graduate Think like a physician MS 1 Normal Medical words Anatomy Physiology Histology Genetics Case presentations Documentation Observer Physical therapists, psychologists, MPHs graduate Think like a physician MS 2 Microbiology Pathology Pathologic words Disease process Physical diagnosis Documentation History – 5 page Reviewed in class Exam – discussed Differential diagnosis Lawyers & judges graduate Think like a physician MS 3 Clinical clerkships Medical Surgical Peds Physical exam Medical terminology Diagnostic testing Documentation 6 page H&P Long differential diagnoses Rudimentary plan to narrow down diagnoses Resident reviews Rarely goes on chart Think like a physician MS 4 Clinical clerkships Medical Surgical Electives Discuss medical decision making & treatment Sleep deprivation Documentation 5 page H&P Shorter differential dx Tests to narrow Ddx Treatment suggestions Reviewed with resident Might go on chart Doctors graduate MDs & DOs PharmDs & Priests (MDiv) Dentists & Vets Some PhDs MD / DO Total Physician Student Loan Debt 10 0 % 90% >2 0 0 ,0 0 0 80% $10 0 - 2 0 0 ,0 0 0 70 % <$10 0 ,0 0 0 60% N o d eb t 50 % 40% 30% Steinbrook R. N Engl J Med 2008;359:2629-2632 20% 10 % 0% 2004 2005 2006 2007 2008 Residency – Post Graduate Year (PGY) 80–120 hrs/wk $35,000/yr • • • • 3 years – Family practice – Internal medicine – Pediatrics 4 years – – – – – $6/hr Anesthesia Emergency medicine Ob / Gyn Ophthalmic surgery Oral & maxillofacial surgery • 5 years – – – – – – – Endocrinology General surgery Geriatrics Orthopaedic surgery Otorhinolaryngology Plastic & Maxillofacial surgery Radiation oncology • 6 years – – – – – – – – Cardiology Colon & rectal surgery Nephrology Neurology Neurological surgery Pediatric nephrology Pediatric oncology Urology 7 years – – – – – Gynecologic oncology Oncology Pediatric surgery Thoracic surgery Vascular surgery 8 years – Cardiac surgery – Interventional cardiology – Electrophisologist Think like a physician PGY 1 Rotating or specialty focused Hone H&P skills Testing expertise Shared decision-making with upper-level resident Documentation 3–4 page H&P Narrow Ddx Testssss ordered Tx shared decision making Chart copy Think like a physician PGY 2 Specialty focused Test interpretation Treatment decision-making Documentation 2–3 page H&P or note on PGY1 Concise diagnosis & CCs Tests ordered TX Chart copy Think like a physician PGY 3 Specialty focused Testing Decision making Teaching others Documentation 2 page H&P or note on PGY1/2 Diagnosis Orders Chart copy H&P HPI ROS PFSH Exam MDM1 MDM2 MDM3 Diagnosis Plan Think like a physician PGY 3+ Specialty focused Specialty specific Decision-making Teaching others Documentation 1 page H&P Diagnosis Orders Chart copy or note on PGY1/2/3 for billing purposes Progression of physician thinking - Anemia • Medical school – Normal, abnormal, H&P – – – – MS1 What is normal blood? MS2 What is anemia? MS3 What kind of anemia could this be? MS4 What tests will diagnose this anemia? • Residency – Medical decision-making – PGY1 What do these tests results mean? – PGY2 What caused this anemia? – PGY3 How should I treat this anemia? • Fellowship - PGY4 – 8 – Specialty specific diagnoses, procedures, & treatments – Progressively more independence – Progressively more teaching responsibilities Think like a physician 7–12 years of post college education Medical School (Delayed G&D) PGY 1-8 CPT 2007 ICD9 CMS Rules & Regulations Pages Hours 28,000 14,000 2,000/yr 5,000/yr > 600 > 5,000 110,000 20 0 ? Think about the physician How can I ever learn all I need to know? Your words may push a button wired during those long years of training when the physician was belittled or demeaned, in public, for being wrong. Pushing wrong buttons • “Doctor, …have you considered…?” • “Please tell us what this patient has.” • “The chart shows X, Y, and Z. Could the patient have A, B, C, or D?” “Of course I have!” “I already did!” “Why do you think I ordered the #@%# test?” Think like a physician Think like a physician • • • • Education Documentation = zero CDI = zero ICD-9-CM = zero Tolerance for… …Medical ≠ coding terminology = zero …“Stupidity” = zero Sure… …they have to be right = 100% …you are questioning their medicine = 100% Relief to find out you are only questioning their words Priceless! Physician incentives • Carrot – – – – – – Be the best Less hassle Level of service – CPT Medical necessity support Quality Value Added • Stick County Clinic Vetrans Tertiary Primary University General Regional Medical St Elsewhere Central Be the best UTI (DRG 690, 691) Mortality 7% 6% 5% 4% Actual 3% Expected 2% 1% 0% Physicians Are Data Driven • Data – Evaluate physician performance – Identify missed opportunities – Individualize physician education – Reward physician performance Additional Information • Data mining and reports: Using data to drive your CDI program – Tomorrow 1330 – Track 2 – Nancy Rae Ignatowicz, RN, MBA Physician Incentives • Be the best • Look more competent – Accurately represent severity of illness • Differential diagnosis • Disease lists for – – – – – Medications Abnormal tests Monitoring Treatments Consults – ICD-9-CM knowledge • Offer to teach – Process – Pertinent terminology – Document resolution of conditions Patient-to-ICD-9-CM 123.45 678.90 987.65 DRG = 999 RW = 1.7890 SOI = 2 ROM = 1 ICD-9-CM >> Severity of illness Physician Incentives • Less hassle – Avoid CDI encounters – Prevent queries – Answer queries efficiently • You may have to give some up to teach – Use ICD-9-CM terminology • Offer to explain ICD-9-CM/CDI documentation needs • Offer to teach them how to meet CDI needs – Comprehensive documentation • • • • All conditions monitored, tested, treated, consulted Present on admission (POA) conditions More accurate severity of illness Coders/CDS have less questions Physician Incentives • Level of service – CPT – Medical decision-making driven • Severity of illness • Acuity • Risk of disease, diagnostics, treatment – Take credit for work done, get appropriate • Reimbursement to practice • Compensation to physician • Productivity bonus – RVUs – SOI/CMI CPT Coding Hospitalist CPT Coding Guide Not CM S OP Consult 99241 15 99242 30 99243 40 IP Consult 99251 20' 99252 40' 99253 55' Initial Hospital 99244 99221 30' 60 99245 80 99254 80' 99255 110' 99222 50' 99223 70' Observation Initial 99218 99219 99220 + same day discharge 99234 99235 99236 Subsequent Hospital care 99231 15' 99232 25' 99233 35' An interval hx (since last visit) replaces the HPI, ROS & PFSH. Only 2 of 3 (hx, exam, MDM) are needed Hx - HPI 1 Hx - ROS 1 1 4 4 4 4 4 1 1 2 2 2 10/caveat* 10/caveat* 1 1 1 3 3 Hx - PFSH Exam systems or 1 system Onl y2 of 3 MDM1 1 2 2 6 6 6 8 8 limite d limited limited extended extended extended complete complete 1 1 3 1 2 4 3 4 2 4 3 4 2 4 3 4 MDM2 MDM3 3 1 1 3 1 Table of Risk Highest level of risk in one category, presenting problem(s), diagnostic procedure(s), or management options, determines risk. Level of Risk Minimal Low Moderate High 1self-limited /minor cold, insect bite, tinea corporis >1 self-limited/minor 1stable chronic illness controlled HTN, NIDDM, cataract, BPH Acute uncomplicated illness/injury cystitis, allergic rhinitis, simple sprain Chronic illness(es) + mild exacerbation/ progression/tx side effects >1stable chronic illnesses, Undiagnosed new problem + uncertain prognosis lump in breast Acute illness + systemic symptoms pyelonephritis, pneumonitis, colitis Acute complicated injury head injury + brief loss of consciousness Chronic illness(es) + severe exacerbation/ progression/ side effects of treatment Acute/chronic illness/injury threaten life/body function multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness +potential threat to self/others, peritonitis, acute renal failure Abrupt change in neurologic status seizure, TIA, weakness, sensory loss Diagnostic Procedure(s) Ordered Rsk during and immediately following procedures or treatment Lab tests venipuncture Chest x-ray EKG/EEG, Urinalysis Ultrasound echocardiography KOH prep Physiologic tests not under stress PFTs Non-cardiovascular contrast imaging barium enema Superficial needle biopsies Arterial puncture lab tests Skin biopsies Stress tests cardiac, fetal contraction Diagnostic endoscopies no risk factors Deep needle/incisional biopsy Cardiovascular imaging + contrast no risk factors arteriogram, cardiac catheterization Get body cavity fluid lumbar puncture, thoracentesis, culdocentesis Cardiovascular imaging + contrast + risk factors Cardiac electrophysiological tests Diagnostic Endoscopies +risk factors Discography Management Options Selected Rest Gargles Elastic bandages Superficial dressings OTC drugs Minor surgery-no risk factors PT OT IV fluids no additives Minor surgery + risk Elective major surgery -open, percutaneous or endoscopic - no risk Prescription drug management Therapeutic nuclear medicine IV fluids + additives Closed tx fracture/dislocation no manipulation Elective major surgery open, percutaneous, endoscopic + risk factors Emergency major surgery open, percutaneous, endoscopic - no risk factors Parenteral controlled substances Drug therapy + intensive toxicity monitoring DNR decision/de-escalate care 2poor prognosis Presenting Problem(s) Risk related to disease process anticipated between present visit and next one Physician Incentives • Medical necessity support – Avoid denials for lack of medical necessity • ICD-9-CM code supports medical necessity • CDI helps get accurate ICD-9-CM Physician Incentives • Quality – Value Based Purchasing (VBP) • • • • • Physician performance based payments Prevent chronic disease complications Avoid hospitalizations Improve quality of care PQRI – 2% bonus on all Medicare claims – Based on ICD-9-CM code – ICD-9-CM drives patient inclusion in quality measure denominators • AMI Aspirin at Arrival Denominator – ED ICD-9 diagnosis codes: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71,410.81, 410.91 – Public profile better if severity of illness accurate • Patient won’t die of UTI because “urosepsis” documented Physician Incentives • Value Added – Contract maintenance • Why should the hospital contract with you, doctor? – Save hospital money • POA/HACs – Improve hospital reimbursement • Accurate severity of illness – – – – – Support correct Patient Status selection Correct principal diagnosis Secondary conditions (CCs/MCCs) Correct DRG for accurate Relative Weight & length of stay Improved CMI • AHRQ Patient Safety Indicators – Improve outcome measure » Renal failure, pneumonia, dementia – Market-basket update eligibility Additional Information • Risk adjustment methodology for Medicare’s outcome indicators – Tomorrow 1:30-2:30 – Track 1 – Kristen Geissler, MS, PT, MBA, CPHQ Physician Incentives • Stick – CMS-1500 back page, small print “NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties“. “I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me…” Physician Incentives • Stick – Physicians & other providers jointly accountable • Acute Care Episode (ACE) Demonstration (2010) – Pay the hospital – Hospital pays all physicians • Post Acute Care (PAC) Payment Reform Demonstration (2013) – Pay the hospital – Hospital pays all physicians for 30 days – Hospital pays all medical expenses for 30 days » Rehab » Home health » Medication • Denial of physician payment if: – – – – Hospital denied Wrong status - Inpatient vs. Observation POA not recorded Readmission in 30 days Additional Information • “Catch them & hold them: A CSI approach to documentation education” – Tomorrow 0900 – Track 2 – Monica Dancu, RN, BSN; Sylvia Hoffman, RN Physician Incentives • Stick – PGW (Payers gone wild) • MAC Ed Gaines, JD, CCP, VP & CCO, CBIZ MMP: [email protected] – Medicare Administrative Contractors – 1 computer for Part A & Part B comparisons • RAC – Concordance audits – Proximity audits • CERT – Comprehensive Error Rate Testing – Contractor random audit • PSC – Program Safeguard Contractor program integrity reviews • ZPICs – Zone Program Integrity Contractors • PERM – Medicaid Payment Error Rate Measurement Program • MIC – Medicaid Integrity Contractor Audits Additional Information • “Creating a point of entry CDI specialist/ case manager” – RAC, MAC, MIC, ZPIC – Admission denials – Physician queries – 9000 Tomorrow – Track 3 – Kathleen A. Bower, DNSc, RN, FAAN, CMAC – Arinda F. Kennedy, RN, CCDS Problematic ED diagnoses • CHF – Many EMPs don’t know about systolic/ diastolic heart failure – Type doesn’t change treatment – Teaching points • Clinical CHF/systolic/acute systolic failure – Diastolic ventricle cannot fill – Systolic ventricle cannot contract, EF < 35% – Echo should tell which • Can determine acute/chronic/acute on chronic • Value - zero/CC/MCC Problematic ED diagnoses • Pneumonia – Community acquired pneumonia permeates medical literature – logical in 1990s, out-dated now – Physicians don’t know antibiotic-organism relation • Poster – Teaching points • Clinical – Think alternative diagnoses » Why would you admit a simple pneumonia » Complex pneumonia » Sepsis » Respiratory failure – Sputum & blood cultures most often negative! • Value – DRG RW, quality measures, SOI Name that pneumonia organism • Simple Pneumonia “CAP”, “HAP”, “VAP” – Levaquin or (Claforan/Rocephin + Zithromax combo) • Presumptive Rx – – – – – – – – Clindamycin / Flagyl Zosyn / Unasyn Zyvox Gentamicin / Tobramycin Primaxin Fortaz / Maxipime Vancomycin Erythromycin / Doxycycline Anaerobes Gram (-) rods, anaerobes MRSA, other gm (+) Gram (-) rods Anaerobes, gm(-) rods Pseudomonas Enterococci, Staph Aureus Mycoplasma, Legionella, Rickettsia (Q Fever) – Amphotericin / fluconazole Fungus – INH, Rifampin, Ethambutol Acid Fast Bacillus Idsociety.org Gram negative Gram positive Problematic ED diagnoses • AMS – Shorter to write 3 letters! – Don’t have to make a commitment – Teaching points • Clinical – Look more competent » What is most likely cause? » Should patients die from symptoms? » Sign >> test >> abnormal result >> diagnosis, otherwise why was test done? • Value – Signs & symptoms low RW, SOI, ROM lll Problematic ED diagnoses • SIRS – Older physicians never heard of it – Every patient has it • Non-specific • P >100 = tachycardia – Codes to DRG 872 septicemia! – Beta-blockers hide it – Teaching points • Clinical – Reason for patient to need admission • Value – SOI in sick patients SIRS T > 100.4 F T < 96 F P > 90 R > 20 Problematic ED diagnoses • Acute renal failure – Physicians hate ‘failure’ • ‘Acute kidney injury’ • Azotemia = sign – Teaching points • Clinical – increased morbidity! – Provide literature » RIFLE criteria » AKIN criteria – Provide poster • Value – zero/MCC/SOI Problematic ED diagnoses • Acute respiratory failure – No universal definition – Teaching points • Clinical – – – – Sick patient Respiratory distress Respiratory support CMS criteria for home O2 Hypoxemia Classical definition: pO2 < 60 mm Hg ‘Significant’ Critical Care definition pO2 / FiO2 < 200-250 Hypercapnia pCO2 >50 pH < 7.35 +/- • Value – DRG, RW, SOI, ROM, zero/MCC Problematic ED diagnoses • Acute blood loss anemia – Get new abbreviation on hospital list • ‘ABLA’ – Beg • If bleeding + anemia is it ABLA? • Always think it • Always write it – Teaching points • Clinical – Well, DAH! – ‘Precipitous drop in HCT’ • Value – zero/CC Problematic ED diagnoses • Pressure ulcers & Malnutrition – Describe findings – Order wound / dietary consult – Leave staging to attending – But get it into record Educational strategies • Build a relationship with each physician • KISS! • Be specific – – – – Specialty Condition Physician Patient – – – – Posters / screen saver reminders Pocket cards Newsletters Scientific articles • Provide education aids • Make it fun – Contests / events Remember “delayed growth & development”! – Food / Sweets / Pins / Stickers Query • Preparation – Determine desired outcome – Focus on a one query at a time – List clinical indicators to support case • Don’t make physician do the work – Determine best physician-specific approach • Written – Keep the wording the same (make clinically specific templates) • Verbal – – – – Mentally prepare yourself to think like a physician Take the chart One on one Timing is right Query Avoid • “be more specific” Physicians think you are asking for test results Q: “Could you be more specific about the patient’s anemia?” A: “8/24” • “clarify” to free of confusion, to clarify his thoughts to make understandable Physician reaction, “clarify what”? Physicians do understand medicine! They don’t think there is any confusion, except on your part! http://www.merriam-webster.com/dictionary/clarify Query M.U.S.I.C. • Written & Verbal Request – “More detailed diagnosis” • Not manifestations / signs / symptoms – “Underlying cause of condition” • “Pathological condition causing clinical indicators” • “Relationship of clinical indicators to (un)stated diagnoses” – “Severity / acuteness of condition” • Severe/moderate/mild exacerbation… • Acute, acute on chronic, chronic… – “Instigating cause of findings” (precipitant) – “Consequences of conditions” • “Links between various conditions / diseases / findings” With apologies to Dr. James Kennedy Physician barriers – M.U.S.I.C. • Must know definitions – Sepsis • Uncertain of underlying pathology – Aspiration pneumonia • Severity unknown • Provide definitions • Reassure that ‘uncertainty’ OK • Request acuity – Mild, moderate, severe – Acute, acute on chronic, chronic • Ignorance of precipitating cause • Reassure ‘uncertainty’ OK – EtOH abuse • Complications look ‘bad’ – Acute respiratory / renal failure With apologies to Dr. James Kennedy • Natural consequence of disease Emergency physicians • • • • 5–10 physicians 30%–70% of admissions Last outpatient encounter Vested interest in hospital • • • • Constantly interrupted ADHD – short attention span Shoot from the hip Education – Over view of all conditions • EMP meetings – Reminders • Target one condition at a time • “Does this patient have sepsis?” • Queries – Verbal • • • • Captive for shift Catch during a lull Days or double coverage Food – Take chart • They will not remember – Wait for response Hi-Def Clinical Documentation It is about accurate severity of illness • “Complete” lists – – – – Present on admission Current acute conditions / diseases Currently treated chronic conditions Diagnosis for every • • • • Outpatient medication Test Treatment Abnormal test result • Magic words – ICD-9-CM friendly • Clinical congruence – If pt has atrial fibrillation, should not have “RRR” – If pt in sickle cell crisis, should not be in “NAD” Hi-Def Clinical Documentation • CDI program – Comprehensive - point of entry – Clinically oriented - accurate severity of illness Best practices – Collaborative - team effort • Administration – CEO / CFO – Removing all barriers CFO • Nurses – CDI & Floor • Physicians – Champions / Medical advisors – Emergency physicians / hospitalists – Medical staff • • • • HIM Coders IT RAC Team Nurses MDs HIM Coders IT Stewart Nelson Halifax Regional Hospital Talks the talk “Effect of accurate vital signs on the bottom line” Walks the walk Change ED EMR diagnoses Valley Regional Hospital Dr. Chan Everywhere I go Stars in every hospital Summa ED CDI Summary • Opportunity – – – – – – – Patient care Risk management Patient status Compliance Medical necessity Data quality Reimbursement • IPPS updates • Pay-for-performance – Revenue cycle • Challenge – Diagnosis is not simple • Physicians lack definitions • Physicians not sure of diagnosis – Physicians • Document in medical terms • Must learn ICD-9-CM terminology • Must overcome medical training – CDI under spotlight • RAC • Documentation & coding adjustment Additional Information • “Bring CDI to your ED STAT!” Positive impact of ED CDI program Kaleida Health, Buffalo, NY – Tomorrow 1:30–2:30 – Track 3 – Laurie Cianfrini, RN Thank You Questions?