Sepsis – Impact of Coding upon Metrics

Sepsis – Impact of Coding upon Metrics Paul Evans, RHIA, CCS, CCS-P, CCDS Manager, CDI Sutter West Bay San Francisco, CA (evanspx@sutterhealth.org)

Agenda WHY Care About Coding? WHAT is Required for Accurate Data? HOW is Sepsis Coded? Impact of Key Terms Upon Data (ROM) Documentation “Tips” for Sepsis

Why Care About Coding? Accuracy of severity and predicted mortality – factors are adjusted for risk using coding • Public Reporting Coder - Function as compliant translator to compliantly and accurately report data – subject to many restrictive conventions and audits

Data Trends Financial Consumers Pay for Performance 3rd parties use coded data for reimbursement, audits and compliance Consumers Healthgrades – Leapfrog – State Organizations – CMS Pay for Performance RAC, Value-Based Purchasing, Never Events

Why Does Data Matter? (Hospital and physician profiling data is available to the public) Coded Data used to report to increasing number of 3rd parties – private and public

Graphic Portrayal

Public Websites on Outcomes – Coding Used to Report Outcomes

Increased Physician Scrutiny Without all factoring conditions documented, profiles will inappropriately reflect higher than expected mortality • Complete documentation, reflective of the true severity of your patients, helps justify outcomes Profiles are used for both commercial and public use - Future reimbursement methods will likely incorporate profiles in the formula (pay for performance) Example: A patient expiring on ICU with urosepsis, acute renal disease and hypotension will be ‘underrepresented’ in terms of SOI/ROM

Formulas for Sepsis = MD & Facility Scores Combined mortality for Severe Sepsis (ICD-9 995.92) and Septic Shock (785.52) (Number of expired severe sepsis patients + Number of expired septic shock patients) / (Number of severe sepsis cases + Number of septic shock cases). Ratio of Observed to Expected Mortality for Septicemia & Disseminated Infections (APR-DRG 720) Number of observed expired septicemia & disseminated infection patients / Number of expected expired septicemia & disseminated infection patients. IMPACTED BY – Coding of Septic Patients

Sepsis Coding “Formula” Note the codes for Severe Sepsis and Septic Shock must be applied in order for accurate reporting of outcomes The coding is driven by very explicit clinical documentation of discharges noted ‘at the time of discharge’ It is possible that Severe Sepsis with Shock will be treated, and the Bundles will be completed, but cases will not be in the study due to coding issues? Persistent hypotension with pressors is not coded to septic shock – in this scenario, will patient be placed in correct ‘bucket’ for bundle complaince?

Problematic Terms Urosepsis, Bacteremia, Pneumonia & Hypotension: = Severe Sepsis or Septic Shock! Severe Sepsis with Multi-Organ Failure – Explicitly document the specific organ failure

The AHRQ Quality Indicators and the APR-DRGs The APR DRGs - used by Agency for Healthcare Research and Quality (AHRQ) for risk adjustment to the Inpatient Quality Indicators (IQI) The IQI - indicators of inpatient mortality for selected procedures and conditions. APR-DRG Methodology universally accepted to report risk-adjusted ROM across many quality organizations

APR-DRG – Gold Standard for Risk-Adjusted Outcomes Data The determination of the severity of illness and risk of mortality is disease-specific (Different ROM for patient admitted with Acute Exacerbation of Asthma, Simple or Complex PNA, CVA, Sepsis, so forth) How do we achieve a high score? Should we always expect a high score (no) – Young male admitted with simple PNA will have low acuity. Older patient admitted with gram-negative or asp pna with acute renal or respiratory failure or underlying chronic conditions, such as Type I DM or AIDS or CM will have higher level of acuity. The ‘presenting problem’ and presence of 2ndry factors both important factors.

APR-DRG – Gold Standard for Risk-Adjusted Outcomes Data In APR DRGs, high severity of illness or risk of mortality are primarily determined by the interaction of multiple diseases Patients with multiple comorbid conditions involving multiple organ systems represent difficult-to-treat patients who tend to have poor outcomes

Uses of APR-DRG To quantify demographic and clinical risk factors. Comparisons between disparate populations or groups. Clinical outcomes Mortality Complications Utilization measures Length of Stay Cost

APR-DRG – Structure Set of patient groups (APR-DRGs) that include adjustments for Severity of Illness (SOI) and Risk of Mortality (ROM) The groups are designed to describe the complete cross-section of patients seen in acute care hospitals Four subclasses (Grade 1 -4) for both SOI & ROM Clinical model that has been extensively refined with historical data from all payers and the logic is open to users.

System Generates SOI/ROM for All Acute Admissions Four Severity of Illness Subclasses Minor Moderate Major Extreme Physiologic decompensation or organ system loss of function Four Risk of Mortality Subclasses Minor Moderate Major Extreme Likelihood of dying ROM Drives Observed/Expected Mortality Data = compiled data. Some payers now pay on SOI rather than MS-DRG

APR Examples: 65 y/o admitted with Severe Sepsis – Note Impact of Types of ARF Option 1 Option 2 Option 3 Option 4 Option 5 Severe Sepsis SDx: None SDx: ATN SDx: Acute Cortical Necrosis SDx: Acute Medullary Necrosis SDx: ARF, Not Specified SOI : 1 SOI : 3 SOI : 2 ROM: 1 ROM: 3 ROM: 2 Problems - Abbreviations, Insufficiency, Azotemia, Cr levels noted as abnormal w/o statement of renal dysfunction

Note Impact of Other Organ Failure Option 1 Option 2 Option 3 Option 4 Option 5 Severe Sepsis SDx: Critical Illness Myopathy SDx: DIC SDx: Encephalopathy SDx: Shock Liver SDx: Septic Shock SOI : 3 SOI : 2 ROM: 2 ROM: 3 Impact of Other Single Organ Failures 2/2 Severe Sepsis is Illustrated

Impact of Multiple Organ Failures on SOI/ROM Option 1 Option 2 Option 3 Option 4 Severe Sepsis SDx: UTI SDx: UTI & (ADD) Septic Shock SDx: UTI & Septic Shock & (ADD) Acute Renal Failure SDx: UTI & Septic Shock & Acute Renal Failure (ADD DIC) SOI : 1 SOI : 2 SOI : 3 SOI : 4 ROM: 2 ROM : 3 ROM: 4 Notice how ROM/SOI elevate when multiple body systems are affected – increased clinical complexity and mgmt = higher scores

Clinically Significant but Low SOI: Lower to Greater SOI Clinically Significant but Low SOI: Greater SOI Captured: Severe Hypoxia (S&S) Urosepsis Uncontrolled NIDDM Severe COPD on continuous O2 Community Acquired Pneumonia and dysphasia, s/p CVA. Serum Na of 145 mEq/L Early or mild Acute Respiratory Failure UTI with Sepsis Type 2 DM with Hyperosmolarity, uncontrolled. Chronic Respiratory Failure Possible Aspiration Pneumonia - Community Acquired Hypernatremia Common coding conundrums – our facility has MD-Approved and evidence-based query forms for each because these are high-volume scenarios

Examples: Documenting Consequences of Sepsis Acute Kidney Failure - not insufficiency Acute Respiratory Failure – not hypoxia Critical Illness Myopathy – not weakness DIC – not coagulopathy Encephalopathy – not AMS Acute Hepatic Failure – Not Elevated Liver Enzymes Septic Shock – not hypotension State ALL manifestations of Sepsis in the Discharge Diagnosis! This language is directly and compliantly coded

Importance of Reliable Documentation: Best Place = Discharge Summary Discharge summary documents all significant conditions Discharge summary must be consistent with documentation in the body of the record. If not, query the physician Gold Standard = D/C Summary - Attending Documentation carries great weight

Discharge Documentation - Example The summary should clarify if conditions were present on admission and have resolved, are still to be ruled out, or were in fact ruled out. Admission note: “Sepsis with Septic Shock secondary to Pneumonia.” Progress note: “Sepsis, and Shock improving.” Discharge summary: “Sepsis, Septic Shock and pneumonia, resolved”

Coding – Brief Notes Bacterial Sepsis and Septicemia In most cases, it will be a code from category 038, Septicemia, that will be used in conjunction with a code from subcategory 995.9 such as the following: Streptococcal sepsis If the documentation in the record states streptococcal sepsis, codes 038.0, Streptococcal septicemia, and code 995.91 should be used, in that sequence. Streptococcal septicemia If the documentation states streptococcal septicemia, only code 038.0 should be assigned, however, the provider should be queried whether the patient has sepsis, an infection with SIRS

Coding – Brief Notes Sepsis or severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission If the documentation is not (crystal) clear whether the sepsis or severe sepsis was present on admission, the provider should be queried May have quality implications

Special Note – Comfort Care Document reasons for “Comfort Care” All patients factor into the MD personal O/E (Outcomes) data and the facility O/E (Outcomes) Data Provide Example: ICH with Midline Shift versus with hernia of brain - Severe Sepsis - Multiple Trauma with Shock due to Hemorrhage

Query?? A coder or other concurrent reviewer may ‘query’ a clinician regarding Severe Sepsis if certain conditions are present and the condition is not stated (or, sepsis IS stated, but not ‘supported’ by clinical indicators) AHIMA released “Guidelines for Achieving a Compliant Query Practice,” in the February 2013 edition of the Journal of AHIMA. The document, created in collaboration with ACDIS volunteers and approved by the ACDIS Advisory Board, states that coding (or CDI) staff should query the physician if a diagnosis is not supported by clinical indicator(s) in the medical record

Query?? “The focus of external audits has expanded in recent years to include clinical validation review. The Centers for Medicare and Medicaid Services (CMS) has instructed coders to ‘refer to the Coding Clinic guidelines and query the physician when clinical validation is required.’ The practitioner does not have to use the criteria specifically outlined by Coding Clinic, but reasonable support within the health record for the diagnosis must be present. When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy” Source: AHIMA Practice Brief Guidelines for Achieving a Compliant Query Practice

Query?? The generation of a query should be considered when the health record documentation: Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure Provides a diagnosis without underlying clinical validation Is unclear for present on admission indicator assignment

Query?? Best Practice for Facility Accredited Coders/CDI Staff Linkage to Physician Advisors & Quality Staff Facility formulation, to the ‘extent possible’ of evidence-based and physician approved definitions for major/key conditions – AMI, ARF, Sepsis, Septic Shock, Acute Respiratory Failure, CHF Define, Document, Defend using approved definitions Support Quality Measures and generate ACCURATE coding to support risk-adjusted outcomes data

Sample Study – Why is O/E Not on Par? ROM and O/E Trended Data for APR-DRG 720: Note. The Site Mortality Data exceeds CDB in ROM 3 & 4. Also note the O/E = 1.28 Also, note the data reflects Septic Cases with ROM scores of “1” exceeding the norm.

Data Mining Ensure all expired cases with low scores (2 or less) are reviewed systematically by clinician and coder prior to final coding Review APR/DRG 720 for ROM/SOI Scores Review cases with code assignment for 995.92 : Severe Sepsis – with a ROM of ‘2’ or less (995.92, Severe Sepsis) implies an organ failure – the ROM is could be greater than ‘2’ when certain organ failure or combinations is/are reported with Severe Sepsis Review cases with major infections that ARE NOT coded to Sepsis – Did these meet the SIRS Criteria and are not coded to Sepsis? Examples, patients with Pneumonia, SBP, Cholangitis – focus on those with high charges and/or extended LOS (GMLOS per MS-DRG Methodology)

Questions?