Presentation on theme: "Indiana Association for Healthcare Quality"— Presentation transcript:
1 Indiana Association for Healthcare Quality Denise Tinkel, RRT, MHA, CPHQManager, Clinical Documentation ImprovementHuron HealthcareCarol Huffman, RN, MSNAssociate, Clinical Documentation ImprovementAll text is Arial NarrowThe main graphic and logo has been decreased so that it does not show when a presentation cover is used.1
2 Clinical Documentation Improvement All text is Arial NarrowThe main graphic and logo has been decreased so that it does not show when a presentation cover is used.2
3 Clinical Documentation Improvement Program Clinical Documentation Improvement (CDI) “bridges the gap” between clinical language and technical languageCDI GoalsAccurately reflect the severity of illnessImprove physician and hospital profilesIncrease case mix indexAppreciate maximum compliant reimbursement
4 Documentation Effects Severity of IllnessReimbursementMedical Necessity&Length of StayProfilingHospitalPhysiciansPOARAC AuditsCompliance
5 Accurate Documentation RiskLossViolate Regulatory GuidelinesAccurate Severity of illnessFinancial LossInaccurate Physician/Hospital Profiling
6 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 necessityPresent on admission (POA) indicator requirementIncreasing number of core measure reporting requirementsRecovery Act Contractors (RAC)Medicare Administrative Contractors (MAC)High Mortality Index
7 3 Phases of CDIAssessmentImplementationContinuing Support
8 Concurrent, Multi-Disciplinary TEAM Approach Patient Admitted Concurrent Medical Patient Discharged Coder Receives Record Review Complete RecordReflects the appropriate severity of illnessSupports CMS, OIG, Joint Commission StandardsRAC Readiness
10 Sustaining the Program Quarterly monitoring of the program to ensure the long-term successClinical Record ReviewCompliance EvaluationAnalysis of dataCommunication with the leadership teamMonitoring of CMI and MS-DRG trendsEducational sessionsCoding guideline updatesClinical and technological reviews
11 Documentation Improvement Poor quality documentation in a patient’s record has been linked to both excessive health care costs and poor quality of care”11- National Coalition for Health Care, Charting the Cost of Inaction 2003
12 Physician Profiling Data utilized for physician profiling: Length of stayDRG AssignmentE & M Levels of physician serviceMortality and MorbidityDocumentation improvement assists with creating accurate profiles
14 Coding GuidelinesFor reporting purposes the documentation that must be followed are thoseby 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.
15 It’s Not Just Semantics BacteremiaRenal InsufficiencyCKD VECF PneumoniaInfiltrateTIAAcute Coronary SyndromeAltered Mental StatusSepsisRenal FailureESRDAspiration PneumoniaPneumoniaCVAAcute MIEncephalopathy
16 Sepsis versus UTI DRG DRG RW SOI ROM Documentation UTI w/o MCC .7864 Expected LOSSOIROMExpected Cost*DocumentationUTI w/o MCC.78643.41$4061UTI, death unlikelyUTI w/MCC1.21854.83$6292UTI, encephalopathySepsis w/o 96 MV, w/o MCC1.15454.6$5962Sepsis due to UTISepsis w/o 96 MV w/MCC1.90745.4$9850Sepsis due to UTI, shock, death likelySepsis w/96+ MV5.830512.94$30,109Sepsis, Acute Respiratory Failure
17 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 StatesDesigned to be mutually exclusive and reliableThere is only one correct code for each diagnosis and procedureEvery coder should arrive at the same codes using this systemThe coding system uses “cataloging” concepts:Main term (example: noun » pneumonia)Sub terms (example: adjective » viral)Property of Wellspring Partners. Reproduction prohibited without express permission.
18 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 providedCoding 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
19 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
20 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 DRGsChange 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
21 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 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
22 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 severityCCs represent a diminished level of severityNon-CC/MCCs are those diagnosis codes that do not require significant additional amounts of hospital resources and are not reflective of increased severityCMS expects to make revisions to the MCC and CC lists each year.Property of Wellspring Partners. Reproduction prohibited without express permission.
23 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
24 MS-DRGs (continued)Examples of Major Severity Complications and Co-morbidities that increase risk of mortality:SepsisSevere sepsis (septic shock or sepsis with identified organ failure)Systemic inflammatory response syndrome in non infectious cases with or without organ failureAcute systolic congestive heart failureAcute on chronic respiratory failureToxic/metabolic encephalopathy** Risk of mortality increases by 60%Property of Wellspring Partners. Reproduction prohibited without express permission.
25 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
26 DRG Grouping Factors that impact DRG assignment: Principal diagnosis Secondary diagnosisProcedureGenderDischarge statusBirth weight for NeonateProperty of Wellspring Partners. Reproduction prohibited without express permission.
27 Reporting Secondary Diagnoses Additional and secondary diagnoses should be reported when they affect patient care in terms of requiring the following:Clinical evaluationTherapeutic treatmentDiagnostic proceduresExtended length of hospital stayIncreased nursing care and monitoringNOTE: The above is based on Coding Clinic, Second Quarter 1990, p.13.Property of Wellspring Partners. Reproduction prohibited without express permission.
28 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
29 Surgical ProceduresAfter 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
30 How a DRG Is Assigned NO YES YES NO Identify Co-morbid condition or complication (CC/MCC)Identify the Medical Principal Diagnosis and MDCHow a DRG Is AssignedSurgical Procedure Same MDC?NOAssign Medical DRGYESYESNOWas aSurgical Procedure Performed?NONODRG in same MDC is assigned with appropriate CC/MCCWas procedure a PROSTATIC procedure?Was procedure classified asMINOR?Was procedure classified asEXTENSIVE?Note: If a surgical procedure is one of the Pre-MDC DRGs, this is the DRG that is directly assigned.AssignDRGAssignDRGAssignDRGProperty of Wellspring Partners. Reproduction prohibited without express permission.
31 All Patient Refined DRGs Proprietary DRG system by Ingenix.It accounts for severity of illness and risk of mortality based on documentation of complications and co-morbidities.Lack of CCs and now Major CCs will suggest higher than expected mortality.Used by Thompson Solucient .DRGSeverity ofIllnessRisk ofMortalityMin1Low2Moderate3Severe4
32 Acute Care Hospital (IPPS) RWBlended RateDRG Reimbursement**Regardless of length of stayProperty of Wellspring Partners. Reproduction prohibited without express permission.
33 Relative Weight –Examples Relative Weight (RW): The relative weight assigned to each DRG is intended to reflect resource consumption and severity of illness.DiagnosisDRGRWAllergic Shock (Anaphylaxis)916 Allergic Reactions w/o mcc0.4867CHF293 Heart Failure & Shock w/o cc/mcc0.6853PneumoniaSimple Pneumonia & Pleurisyw/o cc/mcc0.7096Pneumonia w/ UTI194 Simple Pneumonia & Pleurisy w/cc1.0152Pneumonia w/ ESRD193 Simple Pneumonia & Pleurisy w/mcc1.4796Heart/Lung Transplant w/ ARF001 Heart Transplant w/ mccProperty of Wellspring Partners. Reproduction prohibited without express permission.
34 Reimbursement Calculations DiagnosisDRGRWExpected Reimbursement*(BR $ )Allergic Shock (Anaphylaxis)916 Allergic Reactions w/o mcc0.4867$2513**CHF293 Heart Failure & Shock w/o cc/mcc0.6853$3538**Pneumonia195 Simple Pneumonia & Pleurisy w/o cc/mcc0.7096$3664**Pneumonia w/ UTI194 Simple Pneumonia & Pleurisy w/ cc1.0152$5242**Pneumonia w/ ESRD193 Simple Pneumonia & Pleurisy w/ mcc1.4796$7640**Heart/Lung Transplant w/ ARF001 Heart Transplant w/ mcc$136,040*** $ is a Blended Rate example used for this demonstration **Regardless of length of stayProperty of Wellspring Partners. Reproduction prohibited without express permission.
35 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.CensusService linesLength of StayProperty of Wellspring Partners. Reproduction prohibited without express permission.
36 Sum of Relative Weights CMI – a demonstrationSum of Relative WeightsNumber of CasesCMIProperty of Wellspring Partners. Reproduction prohibited without express permission.
37 Case Mix Index (CMI) – Example The sum of the RWs divided by the # of cases = CMIDiagnosisDRGRWChest Pain313 Chest Pain0.5499CHF293 Heart Failure & Shock w/o cc/mcc0.6853Sepsis872 Septicemia w/o MV 96+ hours w/o mcc1.1545Pneumonia w/ UTI194 Simple Pneumonia & Pleurisy w/ cc1.0152AMI w/ CABG w/ Cath w/o mcc234 Coronary Bypass w/ cardiac cath w/o mcc4.8281DJD w/ ORIF w/ acute blood loss anemia481 Hip & femur procedures except major joint w/ cc1.8896Total cases = 6Sum of RW = 10.12CMI = 1.69Property of Wellspring Partners. Reproduction prohibited without express permission.
38 Sum of Relative Weights CMI – a demonstration10.12Sum of Relative WeightsNumber of cases61.69CMIProperty of Wellspring Partners. Reproduction prohibited without express permission.
39 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
40 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)Property of Wellspring Partners. Reproduction prohibited without express permission.
41 What is a Clinical Documentation? Improvement Program? A documentation program focuses on:A clinical approach to comprehensive, quality documentation by the multidisciplinary teamConcurrent documentation reviewClear, accurate and complete documentationContinuing education to support Documentation ImprovementProperty of Wellspring Partners. Reproduction prohibited without express permission.
42 CDI Team Members Physicians Professional Coders (PC) Clinical Documentation Specialists (CDS)Case Managers (CM)Healthcare QualityAllied care providersProperty of Wellspring Partners. Reproduction prohibited without express permission.
43 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 consumptionProvide ongoing education regarding clinical documentation for the multidisciplinary team.Property of Wellspring Partners. Reproduction prohibited without express permission.
44 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 dayPhysician query rate (verbal and written)Physician response rateProperty of Wellspring Partners. Reproduction prohibited without express permission.
45 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 billingAssist in the planning, evaluation and delivery of patient care resulting in the best outcomeProvide other physicians in the organization clear opinions regarding the patient’s condition, treatment options and response to the prescribed careResult in fewer payment denials and facilitate the overturn of denialsImprove results in the areas of strategic planning, quality measures, outcomes and physician profilingLower potential litigation with focused and accurate documentation to support the appropriate, best practice careProperty of Wellspring Partners. Reproduction prohibited without express permission.
46 A Clinical Documentation Program The Role of the of the Professional CoderContinue retrospective review and coding of recordsReview record for any CDS queryDetermine if retrospective query is neededAssign DRG as usualProperty of Wellspring Partners. Reproduction prohibited without express permission.
47 Clinical Documentation and the RAC A good Clinical Documentation Improvement program protects the hospital’s resourcesAccurate and complete documentation in the chart ensures accurate coding practicesPrinciple diagnosisSecondary diagnosesAppropriate capture of co-morbiditiesAppropriate capture of major complications
48 Clinical Documentation Program PHYSICIAN IMPACTInpatient DocumentationProperty of Wellspring Partners. Reproduction prohibited without express permission.
49 Case StudyChart 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 2.0Pulse Ox 81%, BP noted 83/52X-ray: Acute Vertebral Compression Fracture, Rt Basilar Infiltrate
50 Case StudyFinal Coded Diagnosis: Medical BackOutcome: Death
51 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.
53 Consider the Possibilities for Precise Documentation If this is written:Is it an INDICATOR of:ACS w elevated troponinNon Q wave MIAny infection; bacteremia, C diffSepticemia/SepsisAlbumin 2.8/ underweightSevere MalnutritionAltered mental statusAcute confusion, encephalopathy, or 2nd Parkinson’sCAD, AnginaStable angina, Angina-at-rest, Progressive AnginaCardiac ArrestCause-probable V Tach, V Fib/AMIChest PainProbable –cause GERD arrhythmia/gallstones/angina/cocaineHypertensive emergencyMalignant/Accelerated HTN/Hypertensive encephalopathyHypotensionCause-hypovolemia/autonomic 2nd Parkinson's/diabetic/septic shock53Property of Wellspring Partners. Reproduction prohibited without express permission.
54 Consider the Possibilities for Precise Documentation If this is written:Is it an INDICATOR of:LLL infiltrate/Rx w ZosynProbable gram negative pneumoniaNa 125Hyponatremia and cause –SIADHHgb 7 guaiac positiveAcute/chronic blood loss anemiaNeutropenic feverUnderlying cause- sepsis/bacterial infection of unknown etiologyPleural effusionUnderlying condition- CHF/empyema/malignancyPh 7.25, PCO2 34 PO2 80Metabolic acidosisCAP/NH acquired pneumoniaOrganism covering for- Zosyn, poss aspiration/gram negative- Vancomycin, prob MRSARespiratory Insufficiency Respiratory Acidosis/Hypoxemia/HypercapniaRespiratory Failure if – ph <7.35 pCO2 >50 pO2 <60 and special resources utilized54Property of Wellspring Partners. Reproduction prohibited without express permission.
55 Pulmonary Edema & Respiratory Failure Remember that you do not need ABGs to identify Respiratory FailureThe absence of mechanical ventilation does not preclude the diagnosis of respiratory failurePulse Oximetrypatient’s oxygen saturation on room air should be < 90% or < 95% if the patient is on supplemental oxygenDocumentation of tachypnea, respirations > 26, use of accessory muscles, or cyanosis is necessary if oximetry is used instead of Arterial Blood GasesIn addition, documentation of labored breathing, and/or aggressive respiratory treatments all can be supportive of a respiratory failure.
56 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.
57 The Laboratory Evaluation of Malnutrition ProteinHalf-lifeMalnutritionSevere MalnutritionSignificanceAlbumin18 days3.0 g/l<2.8 g/lFor every 2.5 g/l decrease there is a 24 to 56%increase in mortalityTransferrin9 days<200 g/l<100 g/lAs abovePrealbumin2 days<200 mg/l<150 mg/lShould increase by 10 mg/day with adequate repletionTotal Lymphocyte CountNA<1,500/ml<800/ml4-fold increase in mortality when even a moderate decrease is seenAssessment of Protein Energy Malnutrition in Older Persons, Part ll: Laboratory Evaluation; ML Omran MD and J.E Morley MB, BCh; Nutrition 16: , 2000
58 This Definition of Sepsis in the Literature NEJM: 351: , July 8, 2004
59 Classification/Staging System for AKI Acute Renal FailureClassification/Staging System for AKIStageCreatinine CriteriaUrine Output Criteria1Increased serum creatinine of >0.3 mg/dl or increase to ≥150% - 200% from baseline<0.5ml/kg/hr for > 6hr2Increase serum creatinine to > 200%-300% from baseline<0.5ml/kg/hr for >12 hrs3Increase 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 hrSome hospitals are using BUN/Creatinine ratio as a routine lab test. A BUN/Cr ratio >20 occurs with sudden (acute) kidney failure, which may be caused by shock or severe dehydration. A blockage in the urinary tract (such as a kidney stone) can cause a high BUN-to-creatinine ratio. A very high BUN-to-creatinine ratio may be caused by bleeding in the digestive tract or respiratory tract.59Property of Wellspring Partners. Reproduction prohibited without express permission.
60 Physician Query Process Query timeframes for clarificationConcurrently (recommended)Done while the patient is in the hospitalDirect communication with the physician is optimalDocumented in the record at the time of query requestRetrospectively (prior to billing)Should be done as soon as possible but within 7 days of dischargeQuery answered, record completed, coded and billed by 14 daysPost billingWithin 60 days of dischargeUnderstand that a change to the DRG will automatically force a full review of the record, especially medical necessityUp to one year for other purposes, anything past a year infers suspicionReference: Empire Medicare Services, 2006Property of Wellspring Partners. Reproduction prohibited without express permission.
61 Physician Query Process (continued) Questions from the CDI staff to the physicians are intended to:Clarify unclear, incomplete, or inconsistent documentationSpecify a suspected or implied diagnosisLink diagnosesProvide detailEnsure documentation of clinical significance of lab or test findingsQueries are based on evidence in the patient’s recordPhysicians are expected to respond to queriesProperty of Wellspring Partners. Reproduction prohibited without express permission.
62 Physician Query Process (continued) Concurrent Queries should include:Risk factorsSigns and symptomsTreatmentProperty of Wellspring Partners. Reproduction prohibited without express permission.
63 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.Property of Wellspring Partners. Reproduction prohibited without express permission.
64 Present On AdmissionThe 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 higher-paying 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)Property of Wellspring Partners. Reproduction prohibited without express permission.
65 Present on Admission POA A diagnosis is considered to be ‘present on admission’:If the physician includes “present on admission” in the documentationIf it is included in the PMH listIf the condition was diagnosed during the admission, but was clearly present on admission, i.e.:chronic conditions and cancersIf the diagnosis was possible, probable, rule out, suspected, or a differential on admission and was confirmed at dischargeIf the condition developed during an outpatient encounter, such as emergency room, physician office, outpatient surgery or observationIf the signs and symptoms of the condition were clearly present on admission, listed later in the record as a diagnosis with a POA clarifierProperty of Wellspring Partners. Reproduction prohibited without express permission.
66 Present on Admission POA A diagnosis is considered NOT ‘present on admission’ if:The physician documents that it was not present on admissionIt occurs or develops after the admission, therefore during the inpatient stayA 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 admissionProperty of Wellspring Partners. Reproduction prohibited without express permission.
67 Dislocation of patella-open due to a fall (code 836.4 (CC) POA Payment ExampleMS-DRG AssignmentDRGPresent on AdmissionMedian PaymentPDX: Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCCMS-DRG 066$5,347.98PDX: Intracranial hemorrhage or cerebral infarction (stroke) with SDX:Dislocation of patella-open due to a fall (code (CC)MS-DRG 065Yes$6,177.43No67Property of Wellspring Partners. Reproduction prohibited without express permission.
68 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)Property of Wellspring Partners. Reproduction prohibited without express permission.
69 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)Property of Wellspring Partners. Reproduction prohibited without express permission.
70 SummaryAn 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 recordThe CDI program uses a physician query process to obtain clarification of documentation in the medical record toIdentify the Principle DiagnosisIdentify Co-MorbiditiesIdentify Major ComplicationsFacilitate timely capture of documentation to support CMS Quality Indicators
71 SummaryAn effective Clinical Documentation Improvement program benefits the hospital in the following ways:Reduction in clinical denialsAppropriate assignment of patient status (Observation vs Inpatient)Reduction in potential litigationFacilitating discharge planning needs of patients and improved patient throughputAccurate reflection of severity of illness forUse of hospital resourcesPhysician profilesPublic reporting