Richard D. Pinson, MD, FACP, CCS Co-Founder and Principal HCQ Consulting Chattanooga, TN Using Outcomes Data to Effect Change With Clinical Documentation Improvement

The Hospital 520 licensed beds Over 750 physicians Affiliate Mount Sinai School of Medicine Internal medicine residency program Vascular surgery fellowship program NJDOHSS primary stroke center Service area: Total population over one million people

The Hospital Areas of Expertise Heart and vascular institute Cardiac surgery and interventional cardiology Neurosurgery Vascular surgery Orthopedic surgery Bloodless medicine and surgery Breast care center Breast surgery Maternal fetal medicine Oncology services

The Problem Poor quality scores on external and internal performance reports High surgical mortality and complication rates inconsistent with the high quality of care in: – Major cardiac – Orthopedic – General surgery

Mortality Valve Replacement Surgery

Orthopedic Complications Hip Fracture Repair

Complications/Mortality General Surgery

*User-selected service line including DRGs 215–221 and DRGs 231–236 Complications/Mortality Major Cardiac Surgery*

Complications/Mortality Orthopedic Service Line

Physician Practice Comparison Major Joint Replacement Clinically adjusted LOS range: 3.1 to 4.3 Clinically adjusted charge range: $53K to $66K High complications in addition to high charge

The Analysis: General Surgery Performance data revealed a higher than expected complication and mortality rates for the general surgery service. There was a very high incidence of the following complication codes from Jan 2008–Sept 2009: – (respiratory insufficiency following surgery) – (arrhythmia) – (bowel ileus)

Specific General Surgery Complications: Jan ’08–Sept ‘09

The Analysis Major Cardiac Surgery Performance data revealed a higher than expected complication rate for major cardiac surgery Very high incidence of complication codes (respiratory insufficiency following surgery) and (arrhythmia) Mortality rate was low for major cardiac surgery

Specific Major Cardiac Surgical Complications: Jan ’08–Sept ‘09 [Slide Here]

The Analysis: Orthopedics Performance data revealed a high complication and mortality rate for orthopedic surgery Further drill down to the individual DRGs and specific complications for the primary orthopedic DRGs revealed a total of 49 complications for April 2008–March 2009 Of the 49 complication codes, 25 were in DRG 470 (major joint replacement) 18 of the 25 DRG 470 records were reviewed 13 of these 18 records (72%) included complication codes that should not have been coded as a complication of care or surgery

The Analysis: Orthopedics Problematic complication codes were: – – post-op respiratory failure/ARDS – – post-op arrhythmia – – post-op DVT – – post-op fever (w/o identified infection)

Specific Complications Orthopedic DRGs April 2008 – March 2009

What We Did Reeducated and retrained the inpatient coding staff and documentation specialists Updated the concurrent review processes to improve efficiency Hired and trained third documentation specialist Implemented CDI performance monitoring and reporting system

What We Did Educated the medical staff, emphasizing clinically appropriate terminology and complications of care – General surgery, orthopedics, CV surgeons – Hospitalists, intensivists, ED, residents – Internal medicine, cardiology, pulmonary MD documentation awards Screen savers

Complication of Care Unexpected/unusual occurrence – A major amount of bleeding with joint replacement surgery? – Ileus following bowel surgery? – Minor basilar atelectasis following open cholecystectomy? Cause-and-effect relationship must be established – Code assignment is based on the provider’s documentation of the relationship between the condition and the care or the procedure

Complication of Care References 2012 ICD-9-CM instructional note preceding categories 996– Official Coding Guidelines section I.B.18 and section I.C.7.c Coding Clinic 1992 Q2P15 Coding Clinic 1994 Q1P20 Coding Clinic 2009 Q3P5 Coding Clinic 2011 Q1P13-14

“Post-op” Use of the term “post-op”* should be avoided – “Post-op” means “occurring after surgery” – Does not necessarily establish a cause-and- effect connection. – Many qualified, experienced coders may not be aware of the nuances of these coding rules for complications of care – Flawed encoder logic “Complicated by …” = “Complication of …” *Arkansas Foundation for Medical Care (QIO), “Physician Documentation and Inpatient Prospective Payment System (IPPS) Reimbursement,” January 2008.

The Focus on Complications of Care Acute respiratory insufficiency “following” surgery = Acute respiratory failure or ARDS = Code – MCC = increase revenue – Major surgical complication = poor quality score Post-op arrhythmia Post-op bowel ileus Post-op fever (ICD-9-CM coding change) DVT following orthopedic surgery

Code V66.7 Hospice / palliative / comfort / terminal / end-of- life care initiated and documented prior to discharge Not simply DNR / no code Involves deliberate withdrawal of life-sustaining care Initiate or boost narcotic and sedative medication Cases coded with V66.7 excluded from HealthGrades (and others) mortality analysis Never principal diagnosis code

The Outcome Significant and appropriate reduction in code assignment for surgical complications of care Rapid and dramatic improvement in quality scores for surgical procedures Annualized revenue improvement = $2.3 million

Surgical Complication Volumes Service line Quarterly avg Jan 08–Sept 09 Quarterly avg Oct 09–June 10 % change General surgery % Cardiac surgery % Orthopedic surgery % Overall %

Specific Surgical Complications Complication*Code Quarterly avg Jan 08–Sept 09 Quarterly avg Oct 09–Jun 10 Respiratory failure following surgery Cardiac complication Digestive system complication Total10230 *All surgical cases

Code V66.7 CY 2009 CY 2010 (thru August) Total no. deaths V667 – all cases85171 V667 – mortality3496 V667 % / # deaths10%40%

Overall Surgical Care Quality Rating

General Surgery Quality Rating

Major Cardiac Surgery Quality Rating

Major Orthopedic Surgery Quality Rating

Medical Case-Mix Index Period Medical CMI Annual cases Hospital rate Projected annual improvement Jan 09–May ,300$7,600- Dec 09–Aug 10 (Actual) ,300$7,600 $2,120,000* Target ,300$7,600$3,468,000 *Improved surgical MCC/CC rate = $230,000 additional annualized revenue

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