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‘Rock-A-Bye Baby’— Implementing CDI in Women’s and Children’s Units

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Presentation on theme: "‘Rock-A-Bye Baby’— Implementing CDI in Women’s and Children’s Units"— Presentation transcript:

1

2 ‘Rock-A-Bye Baby’— Implementing CDI in Women’s and Children’s Units
Linda Rhodes, RN, BSN, CCDS Manager, Clinical Documentation Improvement Program New Hanover Regional Medical Center, Wilmington, NC Monique Halyard, RN, CNOR Clinical Documentation Specialist

3 New Hanover Regional Medical Center, Wilmington, NC
Licensed for 760 beds Teaching hospital Level II trauma center Full cardiology service— Cardiac Center of Excellence by BC/BS of NC NHRMC Rehab Hospital NHRMC Behavioral Health Hospital Orthopedic specialty hospital

4 Betty H. Cameron Women’s and Children’s Hospital
45-bed Level III NICU 6-bed pediatric ICU 17-bed pediatric unit 13-bed antepartum unit 35-bed mother/baby unit 20-bed women’s unit

5 Goals Share the NHRMC implementation of a CDI program in women’s and children’s units Describe benefits/challenges of NICU/pediatric/OB/GYN reviews Present methods for physician/staff engagement and education Discuss various CDIS staffing model options Identify pediatric/OB/GYN documentation opportunities Demonstrate program metrics for success

6 Why? Quality Opportunity Education Relationships Program growth

7 Women’s/Children’s CDS Timeline
08/2011 Pediatrics 04/2011 Antepartum Mother/Baby 02/2011 PICU 12/2010 NICU 10/2009 Women’s Unit

8 Getting Started: Women’s Unit
Payer source—DRG system Medicare Medicaid TRICARE Self-insured UHC

9 Women’s Unit Diagnoses/procedures
Cervical, ovarian, and uterine malignancy Hysterectomy, pelvic evisceration Pelvic peritonitis, inflammatory dx, abscess Sepsis, wound infection Pelvic organ prolapse Incontinence Sling/suspension procedures Bariatric procedures Medical overflow

10 Women’s Unit Query opportunities Postop confusion (293.9)cc
UTI (599.0)cc Drug-induced delirium (292.81)cc Drug dependence, continuous use (304.91)cc Atelectasis (518.0)cc Opioid dependence, continuous use (304.01)cc Postop pulmonary insufficiency (518.52)MCC BMI <19 (V85.0)cc Along with descriptor BMI >40 (V85.4)cc Along with descriptor Postop pulmonary edema (518.4)MCC Sepsis (995.91)MCC Acute/chronic syst/diast CHF(428.23)MCC (428.33)MCC Cachexia (799.4)cc Malnutrition (263.9)cc Severe protein-calorie malnutrition (261.0) MCC Ileus (560.1)cc Postop ileus (997.49)cc Pancytopenia d/t chemo (284.11)MCC Pancytopenia (284.19)cc Metastatic sites (cc) Hyponatremia (276.1)cc Postop wound infection (998.59)cc Acute blood loss anemia (285.1)cc Postop blood loss anemia (285.1)cc Potential HACs/core measures NOTES FROM ED SERVICES: CC should be capped (same as MCC). Also, can we add spaces between the end parentheses and CC/MCC?

11 Women’s Unit CDIS staffing
Utilized current CDS from surgical floor to cover women’s unit No additional training required CDS

12 Women’s Unit Physician/staff engagement and education
Presentation by CDI physician advisor/CDS team Case scenarios One-on-one MD education by CDS Physician education posters/lounge Laminated documentation hint pocket cards CDI presentation to women’s unit management

13 Moving on Up: NICU Payer source—DRG system Medicaid 70% TRICARE 10%
Self-insured UHC MD electronic documentation (NeoData) Diagnosis dropdowns

14 NICU Neonatal DRGs—a different animal
DRG 790 Extreme immaturity or RDS <1499 grams <26 weeks gestation Extreme fetal immaturity Respiratory distress syndrome (769) respiratory signs/symptoms CXR-ground glass opacities mechanical ventilation, CPAP, HFNC >24hrs, reintubation surfactant administration NOTES FROM ED SERVICES: Use sentence caps for last four dash bullets?

15 NICU DRGs 791–794 Determined by weight (fetal immaturity) and diagnosis of prematurity (weeks of gestation) Require a principal or secondary diagnosis with/without major problems Challenging to designate DRG without encoder Focus on documentation of all diagnoses/problems

16 NICU NICU documentation tips
Perinatal period is birth through 28th day Differentiate between RDS and TTN (transitory tachypnea of newborn) Specificity of acute and congenital Documentation of all congenital anomalies Review pregnancy and labor history for maternal conditions affecting newborn (codes 760–763) Newborn affected by C-section

17 NICU Major problems (principal or secondary diagnoses)
(747.83) Persistent fetal circulation, persistent /primary pulmonary hypertension ( ) Prune belly, omphalocele, gastroschisis (768*) Severe birth asphyxia, moderate/severe HIE (hypoxic ischemic encephalopathy) (770*) Congenital pneumonia, fetal/newborn aspiration, meconium aspiration, aspiration of amniotic fluid, blood, stomach contents, pneumothorax, pulmonary immaturity, pulmonary hemorrhage, respiratory failure (771.81) Sepsis of newborn (772*) Fetal blood loss, IVH/grade, SAH, GI hemorrhage

18 NICU (775*) Neonatal diabetes, hypocalcemia, hypomagnesemia, hypoglycemia, late metabolic acidosis (776.1) Neonatal thrombocytopenia (transient) (776.6) Anemia of prematurity (777.5*) Necrotizing enterocolitis (779) Convulsions (779.85) Cardiac arrest (285.1) Acute blood loss anemia (292) Drug withdrawal (377*) Papilledema complications (530.84) TE fistula

19 NICU CDIS staffing 2 NICU case managers 1.8 FTE Rotate CDI workload
Training—documentation software—Midas CDI module MDC 15 only Query process DRG reconciliation process Coding summaries Frequency of reviews CDS NOTES FROM ED SERVICES: Not sure I understand fourth dash bullet (Training—documentation software…)

20 NICU Physician/staff engagement/education
CDI presentation to neonatology Case scenarios Review of charts Physician education posters/lounge Laminated documentation hints pocket cards CDI presentation to NICU nursing management/staff CDI rounding

21 We’re Growing Up: PICU/Pediatrics
Payer source—DRG system Medicaid TRICARE Self-insured UHC

22 PICU/Pediatrics Top 5 MDCs
1 Nervous system—seizures, meningitis, migraines 4 Respiratory—pneumonia, asthma, respiratory arrest, cystic fibrosis, reactive airway disease, bronchiolitis, bronchitis 9 Skin—cellulitis, impetigo 10 Endocrine/nutritional/metabolic —diabetes, DKA, hypoglycemia 16 Blood—Sickle-cell anemia/crisis

23 PICU/Pediatrics Query opportunities Anoxic brain damage (348.1)cc
Postop wound infection (998.59)cc Severe/profound mental retardation (318*)cc Cellulitis and abscess (682*)cc Grand/petit mal status (345.3, 345.2)cc Thrush (112.0)cc Airway obstruction d/t tracheitis, epiglottitis, laryngitis (464.11, , )MCC Bacterial intestinal infection (008.5) Atelectasis (518.0)MCC Acute renal failure (584)cc Aspiration pneumonia (507)MCC Gram-negative pneumonia (482.83)MCC Malnutrition (263.9)cc Severe protein-calorie malnutrition (261)MCC Acute respiratory failure (518.81)MCC Acidosis/alkalosis (276.2,276.3)cc Septic shock (785.52)MCC Hypovolemic shock (785.59)MCC Shock (785.50)cc Hyponatremia (276.1)cc Sickle-cell crisis (282.42)MCC Sepsis (995.91)MCC Signs & symptoms (possible diagnosis?) NOTES FROM ED SERVICES: CC should be capped (same as MCC). Also, can we add spaces between the end parentheses and CC/MCC?

24 PICU/Pediatrics CDIS staffing Different combinations of staff
NICU case managers/CDS— trained on top 5 MDCs, then … OB case manager/CDS—trained on CDI and pregnancy DRGs, then … CDS (0.8 FTE)—experienced CDS trained on both neonatal and pregnancy DRGs WHEW! CDS

25 PICU/Pediatrics Physician/staff engagement and education
CDI presentation to pediatricians Case scenarios Review of charts Physician education posters/lounge Laminated documentation hints pocket cards CDI presentation to PICU/pediatrics nursing management/staff Documentation tips for nursing staff

26 We’re Having a Baby! Antepartum/Postpartum
Payer source—DRG system Medicaid 70% TRICARE 10% Self-insured UHC

27 Antepartum/Postpartum
Documentation tips—review prenatal record, anesthesia record Factors to consider: Lack of prenatal care Age Parity BMI Drug/alcohol dependence Diabetes Hypertension Anemia Thyroid disease Mental conditions Preexisting infections

28 Antepartum/Postpartum
Other considerations: - Pt admitted pregnant with ANY diagnosis codes to complication of pregnancy UNLESS provider documents that the pregnancy is incidental to the encounter! Pregnancy is Everything! NOTE FROM ED SERVICES: I don’t understand this.

29 Antepartum/Postpartum
Preterm labor Before 22 wks = threatened abortion After 22 wks but before 37 wks = threatened premature labor 5th digit codes Postpartum period = delivery to 6 weeks Postpartum complication = any complication during 6-week time frame

30 Antepartum DRG 781/782 Principal and secondary diagnoses
(641*) Placenta previa w/w/o hemorrhage, hemorrhage (642*) Severe pre-eclampsia, PreE, PIH, other HTN (643*) Hyperemesis, vomiting (644.2) Premature labor before 37 weeks (646.63) GI infections (648*) Maternal DM, thyroid, anemia, drug dependence (657.03) Polyhydramnios (658.03) Oligohydramnios (658.13) PROM NOTE FROM ED SERVICES: In first dash bullet, delete last “hemorrhage”? In second dash bullet, is PreE just repeating pre-eclampsia?

31 Antepartum (647*) Syphilis, gonorrhea, STDs, HIV, hep B/C
(648.63) Other maternal CV (MI) (648.93) Other conditions (pneumothorax, asthma, etc.) Once delivery occurs, some secondary diagnoses will not move the DRG!

32 Postpartum DRG—Vaginal or C-section delivery
Principal and/or secondary diagnosis (In addition to the antepartum diagnoses) (641.21) Abruptio (648.24) Acute blood loss anemia (659.21) Maternal fever during labor, delivered (659.31) Generalized infection (sepsis) during labor (666*) Postpartum hemorrhage (667.02) Retained placenta NOTES FROM ED SERVICES: Should be “Abruptio placentae”?

33 Postpartum (668*) Complications of anesthesia
(669*) Maternal shock, hypotension, ARF (670*) Major puerperal infections, sepsis, peritonitis (671*) DVTs (673*) Pulmonary air embolism, amniotic and blood clot embolism (674*) CVA (675*) Nipple infections, nonpurulent mastitis

34 Antepartum/Postpartum
CDIS staffing OB case manager/CDS— trained on CDI and pregnancy DRGs, then … CDS (0.8 FTE)— experienced CDS trained on both neonatal and pregnancy DRGs CDS

35 Antepartum/Postpartum
Physician/staff engagement and education CDI presentation to OB department Case scenarios Review of charts Physician education posters/lounge Laminated documentation hints pocket cards CDI presentation to OB nursing management/staff Documentation tips for nursing staff

36 Quality documentation!
Results So Far … Quality documentation! FY12 FY11 FY10 DRG 765 C-section w/ MCC/cc DRG 766 C-section w/o MCC/cc 45.4% 44% 42.1% DRG 774 Vag delivery w/ comp dx DRG 775 Vag delivery w/o comp dx 18.1% 18.5% DRG 791 Prematurity w/ major problem DRG 792 Prematurity w/o major problem 49.6% 53% 43% NOTE FROM ED SERVICES: Again, CC should be capped (complication and comorbidity)

37 Next Steps … SOI/ROM Continued physician education
Train additional CDS staff Prepare for ICD-10

38 ICD-10-CM Considerations
Pregnancy—categories O00-O9a O = Obstetrics O80 = full-term uncomplicated delivery New codes identify trimester when condition occurs New codes identify # fetuses when condition occurs Category Z37.x- Outcome of delivery New codes for multiple births beyond twins

39 ICD-10-CM Considerations
Diabetes in pregnancy Type 1 diabetes Type 2 diabetes & identify when patient is on long-term insulin Diabetes secondary to another condition & name the condition Gestational diabetes Identify peripheral manifestations of diabetes (e.g., retinopathy, nephropathy, neuropathy) Clarify trimester of each visit

40 ICD-10-CM Considerations
Obstetrical embolism Identify source Venous from leg vs. from pelvic veins Amniotic fluid embolism Septic embolism Air embolism Specify trimester that it occurred or childbirth Identify severity Acute respiratory failure ARDS when it occurs Identify when saddle embolism

41 ICD-10-CM Considerations
Newborns—category Z38 Identifies # births—single, twin, triplet Born in/outside of hospital Vaginal/C-section

42 ICD-10-CM Considerations
Newborn aspiration Clarify the substance aspirated: Meconium Blood Gastric content Amniotic fluid Clarify manifestations: w/o respiratory manifestations w/ hypoxia w/ atelectasis w/ acute respiratory failure w/ ARDS

43 ICD-10-PCS Considerations
Obstetrics—Section 1 Procedures performed on “products of conception” Procedures performed on mother—med-surg Body system = pregnancy Root operation Abortion: artificially terminating pregnancy Extraction: C-section Delivery: manual & vaginal delivery Body part—products of conception

44 Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.

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