1. Indiana Association for Healthcare Quality
Denise Tinkel, RRT, MHA, CPHQ
Manager, Clinical Documentation Improvement
Huron Healthcare
Carol Huffman, RN, MSN
Associate, Clinical Documentation Improvement
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2. Clinical Documentation Improvement
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3. 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
Increase case mix index
Appreciate maximum compliant reimbursement

4. Documentation Effects
Severity of Illness
Reimbursement
Medical Necessity
&
Length of Stay
Profiling
Hospital
Physicians
POA
RAC Audits
Compliance

5. Accurate Documentation
Risk
Loss
Violate Regulatory Guidelines
Accurate Severity of illness
Financial Loss
Inaccurate 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 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

7. 3 Phases of CDI
Assessment
Implementation
Continuing Support

8. Concurrent, Multi-Disciplinary TEAM Approach
Patient Admitted Concurrent Medical Patient Discharged Coder Receives Record Review Complete Record
Reflects the appropriate severity of illness
Supports CMS, OIG, Joint Commission Standards
RAC Readiness

9. Clinical Documentation Improvement Process

10. 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

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”1
1- National Coalition for Health Care, Charting the Cost of Inaction 2003

12. 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

13. HEALTHGRADES: Pneumonia

14. 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.

15. It’s Not Just Semantics
Bacteremia
Renal Insufficiency
CKD V
ECF Pneumonia
Infiltrate
TIA
Acute Coronary Syndrome
Altered Mental Status
Sepsis
Renal Failure
ESRD
Aspiration Pneumonia
Pneumonia
CVA
Acute MI
Encephalopathy

16. Sepsis versus UTI DRG DRG RW SOI ROM Documentation UTI w/o MCC .7864
Expected LOS
SOI
ROM
Expected Cost*
Documentation
UTI w/o MCC
.7864
3.4 1
$4061
UTI, death unlikely
UTI w/MCC
1.2185
4.8 3
$6292
UTI, encephalopathy
Sepsis w/o 96 MV, w/o MCC
1.1545
4.6
$5962
Sepsis due to UTI
Sepsis w/o 96 MV w/MCC
1.9074
5.4
$9850
Sepsis due to UTI, shock, death likely
Sepsis w/96+ MV
5.8305
12.9 4
$30,109
Sepsis, 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 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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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 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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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.
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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 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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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.
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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 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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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.
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24. 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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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.
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26. DRG Grouping Factors that impact DRG assignment: Principal diagnosis
Secondary diagnosis
Procedure
Gender
Discharge status
Birth weight for Neonate
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27. 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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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.
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29. 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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30. How a DRG Is Assigned NO YES YES NO
Identify Co-morbid condition or complication (CC/MCC)
Identify the Medical Principal Diagnosis and MDC
How a DRG Is Assigned
Surgical Procedure Same MDC? NO
Assign Medical DRG
YES
YES NO
Was a
Surgical Procedure Performed? NO NO
DRG in same MDC is assigned with appropriate CC/MCC
Was procedure a PROSTATIC procedure?
Was procedure classified as
MINOR?
Was procedure classified as
EXTENSIVE?
Note: If a surgical procedure is one of the Pre-MDC DRGs, this is the DRG that is directly assigned.
Assign
DRG
Assign
DRG
Assign
DRG
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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 .
DRG
Severity of
Illness
Risk of
Mortality
Min 1
Low 2
Moderate 3
Severe 4

32. Acute Care Hospital (IPPS)RW
Blended Rate
DRG Reimbursement*
*Regardless of length of stay
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33. 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
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
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34. Reimbursement Calculations
Diagnosis
DRG RW
Expected Reimbursement*
(BR $ )
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
$136,040**
* $ is a Blended Rate example used for this demonstration **Regardless of length of stay
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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.
Census
Service lines
Length of Stay
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36. Sum of Relative Weights
CMI – a demonstration
Sum of Relative Weights
Number of Cases
CMI
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37. 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/ Cath w/o mcc
234 Coronary Bypass w/ cardiac cath w/o mcc
4.8281
DJD w/ ORIF w/ acute blood loss anemia
481 Hip & femur procedures except major joint w/ cc
1.8896
Total cases = 6
Sum of RW = 10.12
CMI = 1.69
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38. Sum of Relative Weights
CMI – a demonstration
10.12
Sum of Relative Weights
Number of cases 6
1.69
CMI
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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.
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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)
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41. 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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42. CDI Team Members Physicians Professional Coders (PC)
Clinical Documentation Specialists (CDS)
Case Managers (CM)
Healthcare Quality
Allied care providers
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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 consumption
Provide ongoing education regarding clinical documentation for the multidisciplinary team.
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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 day
Physician query rate (verbal and written)
Physician response rate
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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 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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46. 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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47. 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

48. Clinical Documentation Program
PHYSICIAN IMPACT
Inpatient Documentation
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49. 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

50. Case Study
Final Coded Diagnosis: Medical Back
Outcome: 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.

52. 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.

53. Consider the Possibilities for Precise Documentation
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 53
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54. Consider the Possibilities for Precise Documentation
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 54
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55. 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.

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
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: , 2000

58. This Definition of Sepsis in the Literature
NEJM: 351: , July 8, 2004

59. Classification/Staging System for AKI
Acute Renal Failure
Classification/Staging System for AKI
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
Some 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. 59
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60. 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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61. 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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62. Physician Query Process (continued)
Concurrent Queries should include:
Risk factors
Signs and symptoms
Treatment
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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.
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64. 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 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)
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65. Present on Admission POA
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
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66. Present on Admission POA
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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67. Dislocation of patella-open due to a fall (code 836.4 (CC)
POA Payment Example
MS-DRG Assignment
DRG
Present on Admission
Median Payment
PDX: Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCC
MS-DRG 066
$5,347.98
PDX: Intracranial hemorrhage or cerebral infarction (stroke) with SDX:
Dislocation of patella-open due to a fall (code (CC)
MS-DRG 065
Yes
$6,177.43 No 67
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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)
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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)
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70. 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

71. 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

72. Clinical Documentation Improvement
Documenting Excellence