Clinical Documentation Improvement Program In-Patient Status University of New Mexico Hospital Alethea Martinez, RN, MSN, MSC HIM Director Clinical Documentation Improvement

From the Clinical Documentation Improvement Department Welcome From the Clinical Documentation Improvement Department

Why Documentation Matters: Quality Management Profiling Joint Commission Core Measures State Reporting Supports DRG & Coding Assignment… Severity of Illness and Risk of Mortality More accurate Case Mix Index Links with Compliance Program Key Driver: DOCUMENTATION Helps justify LOS inconsistencies RAC Audits-CMS recovery audit program Appropriate Reimbursement Supports Medical Necessity/ Denials Reduction

What is Your role? you are here to treat the patient. The most important thing to remember is you are here to treat the patient. Nobody else can coordinate and direct the medical care of the patients like you have been trained to do. The CDI role is to assure accurate documentation is in the record to support the medical diagnosis, the medical necessity of the care being given, and obtaining the most complete record to meet the Centers for Medicare & Medicaid Services guidelines.

Some history…… In case you haven’t heard, you are only as good as the patients you treat. Over the past few years the Centers for Medicare and Medicaid Services (CMS) has released information about how well hospitals meet certain criteria for patient care and satisfaction and it is posted on the internet at www.healthgrades.com CMS is also making information about hospitals and physicians public through their websites hospital compare and now physician compare The safety indicators, clinical quality and patient experience are listed. This is an ongoing process. Where does this information come from? The coding and billing of patients seen by you supply the data for these criteria and it also creates your physician profile. Think about it – If you handle more complex patients, don’t you want to get that credit and recognition?

How documentation can impact the Length of Stay Patient presents from nursing home with pneumonia. Pneumonia (simple) With no comorbid conditions DRG 195 SOI 1 ROM 1 R.W. 0.7099 GLOS 2.7 days With comorbid condition of chronic systolic heart failure DRG 194 SOI 2 ROM 2 R.W. 0.9332 GLOS 3.4 days With major comorbid condition of acute respiratory failure DRG 193 SOI 3 ROM 3 R.W. 1.3731 GLOS 4.5days Pneumonia due to gram negative bacteria (or complex pneumonia i.e. aspiration) DRG 179 SOI 1 ROM 1 R.W. 0.9300 GLOS 3.4 days DRG 178 SOI 2, ROM 2 R.W. 1.2952 GLOS 4.5 days DRG 177 SOI 3 ROM 2 R.W. 1.8507 GLOS 5.7 days

How documentation paints the picture we see Symptom Lab Value No Dx Lab Value Vital Sign “75y/o chronic lunger w fever, leukocytosis, SOB with hypoxia and altered mental status.” How about: “75 y/o with COPD exacerbation with acute and chronic hypoxic respiratory failure; now presenting with pneumonia, probably Gram negative in view of age, and likely a gram negative empyema, probable severe sepsis, with acute septic encephalopathy as well.” Clinical Finding DRG 204 Respiratory Signs and Symptoms SOI 1 ROM 1 R. W. 0.7662 GLOS 2.2 days CC MCC MCC Principal Dx MCC MCC DRG 871 Sepsis w/o MV 96+ hours w/MCC SOI 4 ROM 4 R.W. 1.8229 GLOS 4.9 Same patient, same treatment, may “ look “ different with more complete documentation and the acuity of the actual care given will be reflected in the code assigned after discharge

Our goal is to have the most complete record at the time of discharge. Our Process Daily review of the information available in Cerner. (from ER, H/P, Anesthesiology, progress notes, OP notes, tests, labs, x-rays, CT’s) With this information and the specific software, we identify gaps in documentation . With complete documentation we will have an accurate reflection of the acuity of care given for each hospital admit. Our goal is to have the most complete record at the time of discharge. To be sure each comorbid condition (CC) or major comorbid condition (MCC) is identified and documented This can get challenging with the shorter lengths of stay ------

How do you know when additional documentation is needed ?

Our expectation is that any Clinical Documentation Clarification or Coder Query will be addressed within 48HOURS – A clarification is delivered to your email Please Document your response in the progress notes and discharge summary If you need to communicate with the CDS you can respond to the message with any additional information

The most important aspect is to have the accurate information IN THE BODY OF THE MEDICAL RECORD to support any future audits regarding the care provided. We try to capture the most complete picture of our patients’ condition during the hospitalization. As part of the team any feedback and suggestions are appreciated

Now what do you do???? Include the information in your daily progress notes along with the ongoing status and you’re done! Include all medical diagnoses treated or monitored in the discharge summary to support the treatment rendered through the hospital stay Carry the information forward and verify any notes that are copied and pasted forward are accurate for documenting continuity of care. the discharge summary should be a synopsis of the patient's condition(s) and treatments(s) received from admission to the time of release

2 Simple things to remember! If you treat it, DIAGNOSE IT! If you are monitoring it, DIAGNOSE IT!

We are here for You!

Our Staff 14 UNMH CDS’s 1 CDS SRMC Questions? Email: Ask_ClinicalDocumentation@salud.unm.edu

Thank you for working with us to take care of our patients Health is the thing that makes you feel that NOW is the best time of the year Franklin P. Adams