Clinical Documentation

Objectives Upon completion of this presentation participants will be able to: Define Clinical Documentation State the purpose of a program State the key indicators of a successful program Discuss physician and hospital profiling Understand discharge disposition coding

Introduction to Clinical Documentation A Clinical Documentation Program is a performance improvement initiative utilizing a concurrent review process to promote accurate DRG classification. The regulatory compliance standards are set forth by the Centers for Medicare and Medicaid Services (CMS).

Why is it important to have an accurate and complete medical record? Improve medical record documentation to reflect the medical necessity of the inpatient stay. Improve accuracy of reimbursement to the hospital.

Why is it important to have an accurate and complete medical record? (Cont’d) Comply with Medicare, JCAHO and other regulatory guidelines for a complete medical record. Decrease resource utilization (tests & procedures). Improve hospital and physician profiling.

Coding 101 The physician must document clinical findings and diagnoses in the medical record. Coders finalize coding to close out the chart and drop the bill. Coders can’t interpret lab or test results!!

Why is it important to have an accurate and complete medical record? Example: Simple Pneumonia 2698 DRG 90 WITHOUT complications/co- morbidities - relative wt.6147=$ DRG 89 WITH complications/co-morbidities - relative wt =$4593

Clinical Documentation – A Team Approach Multi-disciplinary team consisting of: HIM Coders Physician Advisors Case Managers and/or Clinical Documentation Nurses

Specialized Training for Clinical Documentation Usually the hospital contracts with a company that specializes in programs for Clinical Documentation. Case Managers/Clinical Documentation Nurses receive training in the fundamentals of coding.

Clinical Documentation Process During initial review of the medical record, the Clinical Documentation team assigns a working DRG (diagnosis related group) by looking at: Principal diagnosis – responsible for admission Secondary diagnosis Principal procedure Complication or co-morbidity

Clinical Documentation – Review Process Case Managers and/or Clinical Documentation Nurses review the concurrent medical records for documentation opportunities. They query the physician by written or verbal communication to obtain documentation in progress notes.

Clinical Documentation – Review Process (Cont’d) A query asks the physician to clarify or add additional documentation to support the clinical picture. HIM Coder can assist the team with coding questions. A Physician Advisor may also be used as a resource for the team.

Documentation Flow Physician Documentation Principal Diagnosis Secondary Diagnosis Principal Procedures Secondary Procedures ICD-9-CM Codes DRG Assignment Severity-Level Profiles Risk-adjusted Profiles Reimbursement Quality Measurements (Physicians/Hospitals)

Critical Pathways Validating LOS Areas Impacted by Accurate & Complete Documentation Physician Profiling Risk Management Managed Care Regulatory Compliance Severity- of-Illness Accurate Coding JCAHO Quality Management (CQI, TQM) Utilization of Resources Case Management Reimbursement

Hospital & Physician Profiling Definition: Profiling is the analysis of practice patterns using discharge data to assess performance. Analysis of resources utilized on patients as compared to the severity of illness, risk of mortality, cost and LOS.

Hospital & Physician Profiling (Cont’d) Profilers: Federal/State regulatory agencies JCAHO, CMS, QIO Managed Care Payers Profiling Agencies Hospitals Physician Groups Employers Public--Internet

Hospital and Physician Profiling (Cont’d) Physicians and hospitals can be excluded from networks based on their performance. Monitor hospital and physician’s practice and encourage efficiency and quality. Perceived as measurement of quality, cost efficiency and timeliness of care delivery.

Hospital and Physician Profiling (Cont’d) Physician profiling reflects data regarding death rates of their patients. It is in the best interest of physicians to be sure that in the event of a complication or death, the patients level of acuity is coded.

Utilization and Importance of Profiling Compare Actual vs. Expected mortality. Compare average patient LOS and charges/cost of organization or physician to their peers to determine performance. May act as report card for physicians applying to a group or hospital for employment. Feedback on performance compared to peers and similar groups.

Discharge Disposition Coding CMS developed a list of transfer DRGs under the Post-Acute Care Transfer (PACT) policy. Compliance monitored by Medicare and the Office of Inspector General (OIG).

Discharge Disposition Coding Discharge Dispositions are required on all claims (inpatient, outpatient, ER). CMS does not have a requirement that disposition be provided by a particular discipline. Required to indicate where the patient is going and what level of care patient will receive once discharged from the inpatient setting.

Why Is This Important? To receive an appropriate MS-DRG payment. Ensure accurate public reported data of your hospital/health system. Avoid risk of being overpaid. Compliance with billing requirements.

Types of Discharge Dispositions Discharge to home/self care (anywhere residing and not requiring care) Includes discharge to home, jail, or law enforcement, home on oxygen if DME only, any other DME only, group home, foster care, and other residential care arrangement, outpatient programs such as partial hospital or outpatient chemical dependency programs, assisted living facilities that are not state- designated. Discharged/transferred to a short term general hospital for inpatient care. Discharge to Intermediate Care Facility (ICF) – must be licensed as an ICF.

Types of Discharge Dispositions (Cont’d) Discharged to a Skilled Nursing Facility – must be licensed as a SNF. Left against medical advice. Expired. Discharged/transferred to a Federal health care facility, VA or Dept. of Defense hospital or a nursing facility. Discharged to hospice (home). Discharged to hospice (medical facility). Transfer to a swing bed (only if Medicare approved providing skilled LOC).

Types of Discharge Dispositions (Cont’d) Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare. Discharged/transferred to a Critical Access Hospital (CAH). Discharged/transferred to inpatient rehabilitation facility including inpatient rehabilitation distinct part units of a hospital. Discharged/transferred to a long term acute care hospital (LTACH). Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital.

Important Follow Up If a discharged patient is admitted to another acute facility, skilled nursing facility (SNF), or receives home health services within three days of discharge, the hospital must submit an adjusted claim with the correct disposition. A patient who leaves AMA and becomes inpatient at another hospital on the same day, is identified as a transfer.

Multidisciplinary Approach to Success With Discharge Disposition Coding Include internal and external customers with your planning and follow up Relationships with external providers can provide you with valuable updates on your patients Collaboration between Case Management, Social Work and Nursing for accurate disposition identification Engage your HIM department to verify that the discharge disposition code matches the medical record documentation Define process and accountability in a policy and procedure

Key Indicators of an Effective Clinical Documentation Program Increased Case Mix Index Increased Severity of Illness Increased Risk of Mortality Increased capture of Surgical Complications/Co- morbidities Increased reimbursement More accurate coding of the medical record

Clinical Documentation ( Insert your Clinical Documentation policy and procedure here.)

References 3M, The Claro Group, Chicago, Illinois 2007 ACMA

Review Questions 1.What is a Clinical Documentation Program? 2.True or False: The importance of accurate documentation includes the improvement of reimbursement to the hospital. 3.True or False: Physician profiling reflects data on the death rates of patients.

Answers 1.A Clinical Documentation Program is a performance improvement initiative utilizing a concurrent review process to promote accurate DRG classification. 2.True 3.True