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Clinical Documentation Update Cardiology Service Line.

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Presentation on theme: "Clinical Documentation Update Cardiology Service Line."— Presentation transcript:

1 Clinical Documentation Update Cardiology Service Line

2 1 Physician documentation is received in CLINICAL terms Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms. Breakdown between the two. 2 separate languages The Challenge

3 2 Our Goal  Clarify documentation in the medical record to reflect the true severity of the patient’s illness.  Achieve and maintain an administrative database that: –Accurately reflects the high quality of care provided –Ensures compliance with regulatory guidelines –Accurately reflects the complexity of our patient population –Provides a complete medical record for communication among providers

4 3 Case Mix Index Case Mix Index (CMI) –Used for resource allocation such as nursing, PA/NP staffing levels –Compare peer hospitals –Calculate Medicare reimbursements –Designate length of stay allowances –A low CMI may result from DRG assignments that underestimate the patient acuity and the actual resources used in treatment

5 4 CMS Present on Admission Reporting Requirements  CMS defines POA: present at the time of order for inpatient admission  Conditions that develop during an outpatient encounter, including ED, observation, or outpatient surgery, are considered present on admission  POA indicator is assigned to the principal and secondary diagnoses  Provider must resolve inconsistent, missing, conflicting or unclear documentation  Conditions that occur during the inpatient stay are called “hospital Acquired Conditions” (HACs) Source: CMS Manual System Transmittal 1240, May 11, 2007 Subject: Present on Admission Indicator

6 5 Before DRG 217 Cardiac valve procedure w/o MCC Severity Weight Principal Diagnosis Mechanical complication due to heart valve Secondary Diagnosis  Severe MR  COPD  HTN  Hypothyroidism ProcedureS/P tMV Replacement SOI Level2 After DRG 216 Cardiac valve procedure with MCC Severity Weight Principal Diagnosis Mechanical complication due to heart valve Secondary Diagnosis  Severe MR  COPD  HTN  Hypothyroidism ADDEDPost op acute pulmonary edema ProcedureS/P tMV Replacement SOI Level Increased 3 Items to Query MD note stated- CXR shows increased pulmonary edema & R effusion POD 4 Documentation to Impact SOI Post op acute pulmonary edema Case Study 1: Specificity of Pulmonary Edema as Secondary Diagnosis 74 y/o F Hx of AVR/MVR 1999; admitted with worsening SOB, Echo- severe MR. S/P tMVR. CXR- pulmonary edema treated with Lasix. No history of Heart Failure. Impact: Increased Severity Level and Service Weight with the documentation of Acute pulmonary edema.

7 6 Before DRG 251 Perc Cardiovasc Proc w/o Corn Artery Stent w/o MCC Severity Weight Principal Diagnosis CAD Secondary Diagnosis  USA  Systolic CHF  UTI- E.coli infection  DM2  CKD Procedure PTCA SOI Level2 After DRG 250 Perc Cardiovasc Proc w/o Corn Artery Stent with MCC Severity Weight Principal Diagnosis CAD Added  Acute on chronic Systolic CHF Secondary Diagnosis  USA  Systolic CHF  UTI- E.coli infection  DM2  CKD Procedure PTCA SOI Level Increased 3 Items to Query Cath cancelled due to elevated BNP, pulm edema on CXR. CHF exacerbation treated with IV Lasix Documentation to Impact SOI Acute on chronic Systolic CHF 81yo F with HTN, hyperlipidemia, DM 2, transferred from OSH for cath /possible PTCA which was cancelled due to CHF exacerbation. Impact: Severity Weight and Severity Level Increased with documentation of Acute on chronic systolic CHF. Case Study 2 –Specificity for systolic CHF as Secondary Diagnosis

8 7 Before DRG 104Cardiac Valve Proc w/o MCC Severity Weight Principal Diagnosis Mitral Valve Disorder Secondary Diagnosis  Congestive Heart Failure - unspecified  CAD  HTN  UTI  Post-op anemia  Hyponatremia Procedure Replacement of Mitral Valve Mean LOS11 Days SOI Level 3 After DRG 545 Cardiac Valve Proc with MCC Severity Weight Principal Diagnosis Mitral Valve Disorder Added  Acute on chronic Diastolic CHF Secondary Diagnosis  Congestive Heart Failure - unspecified  CAD  HTN  UTI  Post-op anemia  Hyponatremia Procedure Replacement of Mitral Valve Mean LOS17 Days SOI Level3 Items to Query Can CHF be described with specificity. Patient treated with IV diuretics/ CXR- pulmonary congestion this admission. Documentation to Impact Reimbursement/ LOS Congestive Heart failure documented as Acute on chronic Diastolic CHF 59yo F adm. with dyspnea. S/P cath showing severe MR/ 3V CAD. Echo- impaired LV relaxation. S/P MV replacement & coronary bypass. Impact: Increased severity weight with documentation of specificity of CHF. Mean LOS 17 days vs. 11days Case Study 3: Specificity of Congestive Heart Failure as Secondary Diagnosis

9 8 Before DRG 175Percutaneous Cardiovasc w/o AMI Severity Weight Principal Diagnosis CAD Secondary Diagnosis  USA  Hyperlipidemia  HTN  Subendocardial infarction, subsequent episode of care  Hx coronary angioplasty Procedure PTCA with DES Mean LOS2 Days SOI Level 1 After DRG 175 Percutaneous Cardiovasc w/o AMI Severity Weight Principal Diagnosis CAD Added  Dissection coronary artery Secondary Diagnosis  USA  Hyperlipidemia  HTN  Subendocardial infarction, subsequent episode of care  Hx coronary angioplasty Procedure PTCA with DES Mean LOS2 Days SOI Level3 Items to Query Is dissection clinical significant? Dissection was documented by fellow in hand written cath report; however, no dissection documented in official cath report. Documentation to Impact Reimbursement/ SOI Dissection coronary artery, area stented. 39y/o male with HTN,hyperlipedemia, USA…NSTEMI on 3/18/11- S/P cath with PTCA/ xience stent x2; returns for staged PCI. Coronary artery dissection documented only in fellow’s proc. note. Impact: Increased severity weight with documentation of coronary artery Dissection. Case Study 4: Clinical Significance of Dissection

10 9 Before DRGCirculatory Disor. W AMI Case Mix Expected LOS 4 days Principal Diagnosis NSTEMI Secondary Diagnosis  DM type 2 -controlled  Hx tobacco use  Overweight  HTN  Cannabas (marijuana) abuse ProcedureLt heart Cath Severity1 Query Pt with non-obstruc CAD on cath. Urine tox + for tetrahydro cannabinols (THC); is NSTEMI possibly due to THC? Response NSTEMI probably due to marijuana use. 55yo male with 20yr hx of tobacco use, HTN..c/o severe chest pain radiating down Lt arm, fatigue, diaphoresis…urine tox positive for THC…troponin 0.67 to cardiac cath showed non-obstructive CAD. Query: Is NSTEMI possibly due to THC? Impact: Case mix index, Expected LOS, SOI increased Case Study 5 : Impact of Principal Diagnosis Change After DRG Injuries, Poisoning & Toxic effect of Drugs Case Mix Expected LOS 6 days Principal Diagnosis Poisoning by hallucinogen Secondary Diagnosis  DM type 2 -controlled  Hx tobacco use  Overweight  HTN  Cannabas (marijuana) abuse  NSTEMI ProcedureLt heart Cath Severity3

11 10 Clinical Documentation Update Questions about this presentation? Please contact:  Thenia Nesbeth-Blades,RN,MSN Documentation Improvement Specialist (212)


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