Presentation on theme: "The DRG Assurance Program creates a bridge between the gap."— Presentation transcript:
0Clinical Documentation Update Cardiology Service Line NameTitleRole: ensure coding accurately reflects the clinical picture.- Each service line reviews their LOS, CMI, and Quality measurements._ Lori Armstrong and DR. Dalton requested a review inpatient medical records in OB and MFM looking for any opportunities where documentation would impact the clinical Scores.Starting this past march I began to review the documentation for this service line and found there were opportunities.Lori Armstrong and Dr. Dalton wanted my department to give in-services to update the providers on the changes in coding.With most service lines, including this service line, there are not many changes. How ever there is an incredibly high volume of cases where clarification is needed thus affecting the scores.
1The DRG Assurance Program creates a bridge between the gap. The ChallengeDocumentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms.Physician documentation is received in CLINICAL termsBreakdown between the two.2 separate languagesThe DRG Assurance Programcreates a bridge between the gap.
2Our Goal Accurately reflects the high quality of care provided 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 providedEnsures compliance with regulatory guidelinesAccurately reflects the complexity of our patient populationProvides a complete medical record for communication among providers
3Case Mix Index Case Mix Index (CMI) Used for resource allocation such as nursing, PA/NP staffing levelsCompare peer hospitalsCalculate Medicare reimbursementsDesignate length of stay allowancesA low CMI may result from DRG assignments that underestimate the patient acuity and the actual resources used in treatment
4CMS Present on Admission Reporting Requirements CMS defines POA: present at the time of order for inpatient admissionConditions that develop during an outpatient encounter, including ED, observation, or outpatient surgery, are considered present on admissionPOA indicator is assigned to the principal and secondary diagnosesProvider must resolve inconsistent, missing, conflicting or unclear documentationConditions 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
5Case Study 1: Specificity of Pulmonary Edema as Secondary Diagnosis BeforeDRG 217Cardiac valve procedure w/o MCCSeverity Weight6.8038Principal DiagnosisMechanical complication due to heart valveSecondary DiagnosisSevere MRCOPDHTNHypothyroidismProcedureS/P tMV ReplacementSOI Level2Items to QueryMD note stated- CXR shows increased pulmonary edema & R effusion POD 4AfterDRG 216Cardiac valve procedure with MCCSeverity WeightPrincipal DiagnosisMechanical complication due to heart valveSecondary DiagnosisSevere MRCOPDHTNHypothyroidismADDEDPost op acutepulmonary edemaProcedureS/P tMV ReplacementSOI LevelIncreased3Documentation to Impact SOIPost op acute pulmonary edema74 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.
6Case Study 2 –Specificity for systolic CHF as Secondary Diagnosis BeforeDRG251Perc Cardiovasc Proc w/o Corn Artery Stent w/o MCCSeverity Weight1.6038Principal DiagnosisCADSecondary DiagnosisUSASystolic CHFUTI- E.coli infectionDM2CKDProcedurePTCASOI Level2AfterDRG250Perc Cardiovasc Proc w/o Corn Artery Stent with MCCSeverity Weight2.9914Principal DiagnosisCADAddedAcute on chronic Systolic CHFSecondary DiagnosisUSASystolic CHFUTI- E.coli infectionDM2CKDProcedurePTCASOI LevelIncreased3Items to QueryCath cancelled due to elevated BNP, pulm edema on CXR. CHF exacerbation treated with IV LasixDocumentation to Impact SOIAcute on chronic Systolic CHF81yo 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.
7Documentation to Impact Reimbursement/ LOS Case Study 3: Specificity of Congestive Heart Failure as Secondary DiagnosisAfterDRG 545Cardiac Valve Proc with MCCSeverity WeightPrincipal DiagnosisMitral Valve DisorderAddedAcute on chronic Diastolic CHFSecondary DiagnosisCongestive Heart Failure - unspecifiedCADHTNUTIPost-op anemiaHyponatremiaProcedureReplacement of Mitral ValveMean LOS17 DaysSOI Level3BeforeDRG 104Cardiac Valve Proc w/o MCCSeverity Weight8.3988Principal DiagnosisMitral Valve DisorderSecondary DiagnosisCongestive Heart Failure - unspecifiedCADHTNUTIPost-op anemiaHyponatremiaProcedureReplacement of Mitral ValveMean LOS11 DaysSOI Level3Items to QueryCan CHF be described with specificity. Patient treated with IV diuretics/ CXR- pulmonary congestion this admission.Documentation to Impact Reimbursement/ LOSCongestive Heart failure documented as Acute on chronic Diastolic CHF59yo F adm. with dyspnea. S/P cath showing severe MR/ 3V CAD. Echo- impaired LV relaxation. S/PMV replacement & coronary bypass.Impact: Increased severity weight with documentation of specificity of CHF. Mean LOS 17 days vs. 11days
8Case Study 4: Clinical Significance of Dissection AfterDRG 175Percutaneous Cardiovasc w/o AMISeverity Weight2.2627Principal DiagnosisCADAddedDissection coronary arterySecondary DiagnosisUSAHyperlipidemiaHTNSubendocardial infarction, subsequent episode of careHx coronary angioplastyProcedurePTCA with DESMean LOS2 DaysSOI Level3BeforeDRG 175Percutaneous Cardiovasc w/o AMISeverity Weight1.6232Principal DiagnosisCADSecondary DiagnosisUSAHyperlipidemiaHTNSubendocardial infarction, subsequent episode of careHx coronary angioplastyProcedurePTCA with DESMean LOS2 DaysSOI Level1Items to QueryIs 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/ SOIDissection 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.
9Case Study 5 : Impact of Principal Diagnosis Change BeforeDRGCirculatory Disor. W AMICase Mix1.6352Expected LOS4 daysPrincipalDiagnosisNSTEMISecondary DiagnosisDM type 2 -controlledHx tobacco useOverweightHTNCannabas (marijuana) abuseProcedureLt heart CathSeverity1QueryPt with non-obstruc CAD on cath. Urine tox + for tetrahydro cannabinols (THC); is NSTEMI possibly due to THC?AfterDRGInjuries, Poisoning & Toxic effect of DrugsCase Mix2.3338Expected LOS6 daysPrincipalDiagnosisPoisoning by hallucinogenSecondary DiagnosisDM type 2 -controlledHx tobacco useOverweightHTNCannabas (marijuana) abuseNSTEMIProcedureLt heart CathSeverity3ResponseNSTEMI 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
10Clinical Documentation Update Questions about this presentation? Please contact:Thenia Nesbeth-Blades,RN,MSNDocumentation Improvement Specialist(212)