1. CDI and Coder Collaboration
Maximizing Documentation Quality and Revenues
Andy Tolep, CCS, CCDS, CPC
April 30, 2016

2. Agenda Program Overview Regulatory Impact to CDI – Coder collaboration
CDI Program objectives
Importance of quality documentation
Coding role in accurate and quality reporting
Regulatory Impact to CDI – Coder collaboration
Explanation of the APR-DRG system
Risk adjustment
Impact on CDI, coding, and quality measures
Case studies
Demonstrate the value of improved collaboration to maximize quality and optimize revenue
Importance of the ongoing evolution in the relationship among CDI, Coding, and quality staffs.

3. What is CDI?
Reference : Guidance for Clinical Documentation Improvement Programs DocName=bok1_047343
CDI Professionals are responsible for:
Provider Documentation
Completeness and specificity
Knowledge of clinical documentation requirements:
Clinical indicators for common inpatient diagnoses/comorbidities
ICD-10-CM and ICD-10-PCS coding guidelines
MS-DRG assignment and other reimbursement methodologies
Present On Admission (POA) documentation for medical/surgical complications and other hospital-acquired conditions
Education
Providers and medical leadership regarding documentation guidelines
Completeness and specificity – capturing severity of illness and expected risk of mortality within diagnostic documentation. Ensuring Operative Reports are specific and detailed enough to code in ICD-10 PCS (approach, body part, etc.) – Coronary Stent insertion – number of sites treated (even if multiple sites are treated within same coronary artery), what type of stent was inserted at each site (drug-eluting stent, non-drug eluting stent, no device).
2) Clinical indicators – Sepsis, Acute Respiratory Failure, Encephalopathy, ATN (acute tubular necrosis)
3) As of – providers hopefully received comprehensive education on documenting using the ICD-10 guidelines.
4) More and more payers are now using APR-DRGs to reimburse facilities.
5) Was the femur fracture POA or did patient fall from bed on day 2 and suffer a femur fracture?
Was the patient’s urinary retention POA or did it occur after the patient’s prostate resection? If the urinary retention occurred postoperatively, was it an expected complication or not? Only unexpected complications should be coded as such.

4. Clearly defined CDI program and goals - not so much
Current State
Clearly defined CDI program and goals - not so much
Many facilities have no clearly defined CDI goals
No formal CDI program
CDI objectives vary from one facility to another.
ACDIS roadmap:
Pre-Implementation
Implementation
Clinical documentation impacts the work of many hospital departments.
Does CDI exist just to maximize CMI or does CDI look at documentation of each and every diagnosis and procedure to maximize SOI? Does CDI work closely with Quality / Performance Improvement to ensure documentation meets criteria for inclusion in quality measures (CMS, commercial)? Depending on the relationship between the CDI program and the HIM department, the CDI staff may hand off records to the HIM department following discharge or they may continue to follow up on open questions before the final billing process.
Provider staff, Clinical Documentation Improvement, Coding and HIM
Quality Management / Performance Improvement
Case Management
Denials and Appeals
Billing and Revenue Cycle

5. Payments will be adjusted for physicians, as well as hospitals
Why is this important?
Payments will be adjusted for physicians, as well as hospitals
ACA mandate - Value-Based Payment Physician Fee Schedule
January 26, 2015 HHS Secretary announced timeline for Medicare (“and the healthcare system at large”) to pay physicians “based upon the quality, rather than the quantity of care they give their patients”
October 1, % of Medicare payments tied to quality (based on 2015 data and earlier)
October 1, % of Medicare payments tied to quality
Provider reimbursements will be adjusted based on cost and quality
This was the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments. As of August 2015, over 420 ACOs currently participate in the MSSP and Pioneer ACO program, serving over 7.8 million beneficiaries.
Overall, in performance year 2014, Medicare ACOs in Pioneer and MSSP have resulted in combined total net savings of $411 million.
Cost / Quality
Low Quality
Average Quality
High Quality
Low Cost
0.0% increase/decrease
4.89% increase
9.78% increase
Average Cost
0.5% decrease
0.0% increase/decrease
High Cost
1% decrease

6. APR-DRGs and Risk Adjustment

7. Introduction to APR DRGs
MS-DRGs
Severity-based system that assigns a reimbursement level based on principal diagnosis, principal procedure, and up to 3 levels of severity
It only takes one secondary diagnosis to shift the MS-DRG into one of those three assignments
Utilized by Medicare in every state and some commercial payers.
APR-DRGs
All secondary diagnoses are incorporated into the decision of the APR-DRG assignment.
Adjusts for severity of illness (SOI)
Calculates a risk of mortality (ROM)
Utilized by many Medicaid payers and some commercial payers

8. APR-DRG Utilization by State as of 2015

9. Subdivide each base APR DRG into subclasses
Summary of APR DRGs
MDC
Subdivide each base APR DRG into subclasses
Four Severity of Illness Subclasses
Minor
Moderate
Major
Extreme
Four Risk of Mortality Subclasses
315 base APR DRGs (v33)
1260 Subclasses
25 MDCs
Severity of Illness is used for payment
Severity of Illness (SOI): is defined as the degree of physiological decomposition of body systems and describes how ill a patient is
Risk of mortality (ROM): is the likelihood of dying.
SOI and ROM share the same leveling reporting metrics.
Level 1 = Minor
Level 2 = Moderate
Level 3 = Major
Level 4 = Extreme
© 3M All rights reserved.

10. SOI example of impact on APR-DRG
SOI scores change as a secondary diagnosis of diabetes progresses through various stages:
Uncomplicated diabetes: SOI 1
Diabetes with renal manifestations: SOI 2
Diabetes with ketoacidosis: SOI 3
Diabetes with hyperosmolar coma: SOI 4

11. ROM example of impact on APR-DRG
ROM scores change as a secondary diagnosis of cardiac dysrhythmia progresses through various stages:
Premature beats: ROM 1 (minor)
Sick sinus syndrome: ROM 2 (moderate)
Paroxysmal ventricular tachycardia: ROM 3 (major)
Ventricular fibrillation: ROM 4 (severe)
CDI and coding will focus on queries for SOI. If the highest level of SOI is captured, the ROM takes care of itself. SOI is more important for the risk adjustment that is part of value based purchasing and risk adjustment.

12. Risk-Adjustment
Why Good Documentation Matters
Risk Adjustment levels playing field: Sicker patients are expected to have worse outcomes
Strong collaboration among coders and CDI staff
Ensures appropriate risk adjustment
Older patients with multiple health problems are more likely to have problems surviving hospitalizations for pneumonia
Sicker patients are less likely to have elective procedures, such as hip replacements, unless the surgery is performed for emergent reasons such as falling down and fracturing the hip.

13. GMLOS Also Impacts Reimbursement GMLOS=Geometric Mean Length of Stay
Why Good Documentation Matters
Advance in technology and quality of care
GMLOS decreases for Total Joint Replacement
Many hospitals currently targeting 2 day LOS for TJR
The target for TJR was 5 days in 2000
The target for TJR was 4 days in 2010
Decreased LOS leads to decreased facility costs

14. Case Studies

15. Case Study: Bringing it all Together
Pneumonia
Background:
79 y/o male brought to the ED by family due to weakness, increased sleeping, fever and recent 30 lb weight loss.
Pt lives at nursing home
PMH includes “diet-controlled diabetes”, hypothyroidism
Hx of “heavy drinking” but quit in 2007
Clinical Findings:
VS: Temp 37.3, heart rate 96, BP 81/46, respiratory rate 20, O2 sat 79% on RA
Labs: WBC 11.3, Hgb 13.1, Hct 38, platelets 288, Na 133, K 4.2, BUN 23, creat 0.98, glucose 64, calcium 8.5, Lactate 1.6
Chest x-ray shows new ill defined patchy opacities in right perihilar region and left lower lobe which may represent multifocal pneumonia or multifocal adenocarcinoma

16. Pneumonia Case Study Plan: Current documented diagnoses:
IV Levaquin and Zosyn
PT / OT/ Dietary Consults
Blood cultures
Current documented diagnoses:
Nursing home acquired pneumonia
Hypoxia
Failure to thrive
Hyponatremia
Anemia

17. Pneumonia Case Study MS-DRG RW SOI ROM GMLOS Reimbursement 195 0.711 2
Current documentation supports:
Principle Diagnosis: Pneumonia. Secondary diagnosis: Hypoxia, Hyponatremia, Failure to Thrive
MS-DRG: Simple Pneumonia w/o CC/MCC
Query Opportunity:
Respiratory Failure?
Clinical documentation supporting the query: O2 Sat on RA, 5L O2 required in ED, decompensated respiratory status, non-rebreather required following admission
Malnutrition?
Clinical documentation supporting the query: weakness, 30 lbs unintentional weight loss
Complex Pneumonia? Organism being empirically treated by Levaquin and Zosyn?
MS-DRG RW
SOI
ROM
GMLOS
Reimbursement
195
0.711 2 1
2.8
$10,459.46
MS-DRG assignment is used as most of our audience has better knowledge of the system. The SOI/ROM scores are an average of the various risk adjustment scoring systems.

18. Pneumonia Case Study If queries were addressed in the medical record:
Principle Diagnosis: Pneumonia due to presumed pseudomonas and/or gram negative organism
MS-DRG: 177 Respiratory Infections and Inflammations with MCC
Secondary diagnosis: Aspiration pneumonia, severe protein-calorie malnutrition, cachexia, acute respiratory failure
MS-DRG RW
SOI
ROM
GMLOS
Reimbursement
195
0.711 2 1
2.8
$10,459.46
177
1.9033 4 3
5.1
$19,926.28
Starting Point
Opportunity
The higher relative weight the sicker your patient.
The higher the SOI the sicker your patient.
The higher the ROM the sicker your patient.
If the patient expires within 30 days of discharge, which documentation explains the complexity of the patient?

19. Case Study
Pneumonia
3 days later the lab results indicate the blood cultures grew Pseudomonas
The progress note indicates “blood cultures +” “Continue antibiotics”
Query placed to clarify sepsis and whether it is due to pneumonia vs. other known infection process
If query is addressed in the medical record:
Principle Diagnosis: Sepsis due to Pseudomonas pneumonia
MS-DRG: 871 Septicemia or Severe Sepsis w/o MV +96 hours w MCC
MS-DRG RW
SOI
ROM
GMLOS
Reimbursement
195
0.711 2 1
2.8 $
871
1.8 4
8.2
$19,814.90
Starting Point
The higher relative weight the sicker your patient.
The higher the SOI the sicker your patient.
The higher the ROM the sicker your patient.
If the patient expires within 30 days of discharge, which documentation explains the complexity of the patient?

20. Altered Mental Status Case Study
20 year male with recurrent pyelonephritis has documented elevated ammonia with mental status changes.
Presents to the hospital with a number of hours of altered mental status seemed to be generally disoriented.
Presented last night with altered mental status and found to have hyperammonemia and UA concerning for UTI. CKD Stage I and positive for instability when standing documented in Nephrology Consult, which suggests continued trending of ammonia for hyperammonemia.
Current documentation supports:
Principal Diagnosis: Pyelonephritis, unspecified
MS-DRG: 609 Kidney and Urinary Tract Infections w/o MCC
Secondary Diagnosis: Hyperammonemia.
MS-DRG RW
SOI
ROM
GMLOS
Reimbursement
690
0.7794 2
3.2
$5,928.49

21. Altered Mental Status Case Study
Query Opportunity: Altered mental status due to clinical indicators for metabolic encephalopathy
Clinical documentation supporting the query
Infection: Recurrent pyelonephritis
Abnormal lab tests: Elevated ammonia documented over first and second days of admission.
Hepatic/renal failure: Diagnosis of CKD I.
Documentation of mental status changes and altered mental status with specific instances documented throughout the chart.
The provider must document in the medical record any response to the question presented in the query.
The higher relative weight the sicker your patient.
The higher the SOI the sicker your patient.
The higher the ROM the sicker your patient.

22. Altered Mental Status Case Study
If queries were addressed in the medical record:
Principal Diagnosis: Pyelonephritis
MS-DRG: 689 Kidney & Urinary Tract Infections with MCC
Secondary diagnosis: Encephalopathy, unspecified
MS-DRG RW
SOI
ROM
GMLOS
Reimbursement
690
0.7794 2
3.2
$5,928
689
1.1172 3
4.2
$8,497
Starting Point
Opportunity
The higher relative weight the sicker your patient.
The higher the SOI the sicker your patient.
The higher the ROM the sicker your patient.

23. Why Good Documentation Matters Why Good Documentation Matters
Public Reporting Programs Rely on Coded Data
Coders cannot code what is not documented by the provider
CMS uses MEDPAR data to calculate an actual/expected ratio for the following programs
30-Day Readmission Program
MCARE reduces hospitals base operating DRG payments to account for excess readmissions in the following DRGs – AMI, CHF and Pneumonia, COPD, and Total Joint Replacements
Added for 2017: CABG (data collection started in 2015)
30-Day Mortality Measures:
Acute myocardial infraction (AMI)
Heart failure (HF)
Pneumonia (PN)
THA/TKA
COPD
Medicare spending per beneficiary (MSPB) - started 2015 and risk adjusted.
All of the programs are adjusted and calculated as ratio of actual versus expected (MEDPAR data)

24. Documentation, Coding, and Quality Indicators

25. Documentation and PSI Definition of PSI (Patient Safety Indicators)
Common documentation and coding issues:
For example, clarifying if pressure ulcer was POA when the H&P indicates the skin is intact
Clarifying if case of blood stream infection is due to a device or procedure vs. multifactorial in nature
The Patient Safety Indicators (PSIs) are a set of measures that screen for adverse events that patients experience as a result of exposure to the health care system. These events are likely amenable to prevention by changes at the system or provider level.

26. Where to Start?
PSI 90 is referred to as a composite measure because eight different PSIs are rolled up to provide an overview of hospital performance. The eight PSIs included in the CMS PSI 90 composite measure include:
PSI 03, pressure ulcer
PSI 06, iatrogenic pneumothorax
PSI 07, central venous catheter-related bloodstream infections
PSI 08, postoperative hip fracture
PSI 12, postoperative pulmonary embolism or deep venous thrombosis
PSI 13, postoperative sepsis
PSI 14, postoperative wound dehiscence
PSI 15, accidental puncture or laceration

27. PSI 15 – Accidental Laceration
CMS defines accidental puncture or laceration (PSI 15) as a complication; a condition, that when present, leads to substantially increased hospital resource use. This includes intensive monitoring, expensive and technically complex services and extensive care requiring a greater number of caregivers.
The most common vulnerabilities identified in PSI 15 audits include:
Incorrect reporting of dx (mapped to many ICD-10 codes) in situations where use of this code is excluded (e.g., incidental durotomy)
Incorrect reporting of E codes (now Y codes in ICD-10)
Over-reporting dx in situations where the puncture or laceration was not accidental and/or was unavoidable due to the patient's anatomy and/or other circumstances (e.g., dense adhesions)
Under-reporting dx when physicians incorrectly guide the coder not to assign a perforation or laceration as a complication

28. PSI 15 – Accidental Laceration
Determination of a complication or expected outcome lies with physician documentation. When a tear or laceration is noted in operative note or progress notes; the physician should be queried as to whether the tear or laceration was an incidental occurrence inherent to the surgical procedure or whether the tear is a complication of the procedure.
(Coding Clinic, Third Quarter, 2009, p.5, First Quarter, 2011 pp.13-14)
An American College of Surgeons article published in May (
Degree of bowel penetration
Incidental occurrence
Do not code diagnosis
Accidental occurrence
Code diagnosis

29. Knocking Down the Silos

30. CDS Reporting Structure
2015 CDI Week Industry Overview Survey -

31. Areas of CDI Expansion
Please expand on what ED CDI is… Is it a CM gate keeper that performs a CDI review of the ED physician documentation of patients being admitted? Is it a review of all cases seen to assure medical necessity is met for all testing performed in the ED (for example, the reason a head CT was performed) along with the SOI/ROM of the patient, or is it both?
2015 CDI Week Industry Overview Survey -

32. CDI/Coder/Quality Collaboration
Coding Managers and CDI Directors should work together to implement the following processes:
Ongoing ICD-10 education is available for coders and CDS staff.
DRG discrepancies are reviewed with the coder/CDS on an individual basis and common DRG discrepancies are reviewed with the two teams
Coder/CDI queries are modified to meet ICD-10 compliance – about 15-20% of the ICD-10-CM guidelines affecting when and how a code is assigned were revised and PCS requires much more specificity (approach, device, body part, etc.)

33. CDI/Coder/Quality Collaboration
All HACs are reviewed pre-bill collaboratively by the Coding Manager/CDI Director to ensure the appropriateness of HAC reporting.
All DRG denials accepted by the facility are reviewed with the individual coder/CDS who coded the account and reviewed with the coder/CDS teams

34. ICD-10 Coder/CDI/Quality Meetings
Review any trend in DRG or APR-DRG discrepancy between the coding team and the CDS staff.
Discuss clinical indicators of commonly targeted CCs/MCCs by RACs (ex. encephalopathy, postoperative respiratory failure, acute cor pulmonale, etc.)
Review any recently reported HACs with the coding team, CDS staff, and quality leadership so the facility is in agreement with when a HAC is to be reported.

35. Why Good Documentation Matters
As of October 1, 2015, 65 percent of value-based purchasing (VBP) scores, 25% of the new hospital- acquired conditions (HAC) payment reduction program and 100% of the readmission reduction program scores will be derived from coded data.
The composite PSI-90 is of particular importance for VBP and HAC reduction program initiatives.
A good starting place: educate CDI and coders on the PSI 90 composite.
The Agency for Healthcare Research and Quality lists ICD-10-CM/PCS equivalent codes for Patient Safety Indicators (PSI) at its website-

36. Quality Documentation
Summary
The key to improved documentation is a successful relationship among coders and CDS staff based on collaboration!!
Finance
Quality Documentation
Coding Team
CDI Team
Quality Team
Providers

37. Review reported HACs and PSIs on a regular basis as a team.
Takeaways
Work together (Coding, CDI, and Quality) to educate providers on quality documentation to meet ICD-10-CM and ICD-10-PCS coding guidelines. Explain to providers how SOI and ROM will impact their bottom line.
Review reported HACs and PSIs on a regular basis as a team.
Educate coding and CDI teams on all DRG denials accepted by the facility.
Andy Tolep, CCS, CCDS, CPC
MedAssets-Precyse
Senior HIM Consultant

38. Q&A