1. What is Clinical Documentation Integrity?
A daily scavenger hunt
You may have seen us looking at charts on the nursing units and wondered what we were doing and why. We review the medical record. Labs, radiology, progress notes, nurse’s notes, ED notes, H&P, consults, op reports & even prior admissions to ensure all appropriate clinical diagnoses are documented to reflect the true severity of illness for each patient.

2. Benefits of Clinical Documentation
More accurate documentation reflective of true acuity and services provided
More accurate profiling data for both Hospital and medical staff
More appropriate case mix and reimbursement
Reduced compliance risk
Potential reduction in denials
More appropriate patient severity, mortality, outcomes and resource consumption data
Increased cooperation between physicians and hospital
Refer to slide.

3. A consulting group reviewed the appropriateness of the DRG assignment for a sample of inpatient Medicare cases at HPRHS based on the clinical documentation in the Medical Record.
Based on their findings, there was a potential financial impact of approximately $1.8 million in missed opportunities, contributed to documentation.
An outside consulting group reviewed a sample of inpatient Medicare charts from HPRHS and found that we had 1.8 million dollars in missed opportunities based on documentation or lack of appropriate documentation.

4. Documentation was the key factor, not the quality of care or service.
We know that we deliver exceptional health care services to the people of our region!
Many times the documentation doesn’t support the true severity of illness of our patients.
Refer to slide

5. HPRHS Data Analysis: Why Does Data Matter
HPRHS Data Analysis: Why Does Data Matter? Hospital and physician profiling data is available to the public
These are just a few of the available online resources for the public to use as a reference when they’re considering where to go for care, or “shopping around.” Elderly patients may not surf the internet for this information, but more and more family members will.
Research & Compare Physicians

6. HPRHS Data Analysis: Why Does Data Matter? Hospital Report Cards
About Health Transparency is a website available that gives information related to comparative costs to treat specific illnesses. Here is an example of how patients can choose a specific city and compare the costs for common diagnoses and procedures with the national average.

7. Healthgrades is another website available that is set up in a “report card” format and grades hospitals using 1,3,or 5 stars and is based on mortality. Look at HPRHS…survival rate in hosp.=1 star, survival rate 30 days post D/C=1 star, survival rate 180 days post D/C=3 stars. So, it looks like our patients w/respiratory failure don’t do well in the hospital or are likely to die 30 days post D/C. But if they can make it 180 days post D/C they do okay. Look at Randolph Hospital…their resp. failure patients have a really great survival rate and do well across the board. What we try to capture as Clinical Documentation Analysts is the true clinical picture of how severely ill the patient is. For example, did the patient possibly also have morbid obesity, acute renal failure, and CHF that could have contributed to his demise? And were those conditions documented in the medical record? We try to capture those conditions in the documentation.

8. But the good news is the current data shows we have improved to 3 stars ,which is as expected

9. Another reason to ensure clear, accurate documentation is the RAC which stands for Recovery Audit Contractors. The RAC looks at consistency in documentation throughout the hospital stay. They can come in and recoup payment. Then the hospital would have to undergo a lengthy appeals process to attempt to get the money back. The 3-year RAC demonstration program in California , Florida , New York , Massachusetts , South Carolina and Arizona collected over $900 million in overpayments compared to nearly $38 million in underpayments returned to health care providers.  The RACs are reimbursed based on a percentage of what they find in overpayments to hospitals so they are in the money making business. NC is one of the states in RAC review is scheduled to begin Aug. 1, The RAC is allowed to look back at cases As far back as those discharged on Oct 1, 2007.

10. POA vs. Hospital-acquired Conditions
Present on admission (POA) is defined as present at time the order for inpatient admission occurs - - conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
Hospital-acquired conditions (HACs) are those that developed / occurred during an inpatient hospital stay.
Another focus of Medicare through the RAC reviews is identifying conditions that developed during the hospital stay which were not present on admission. Determining those which were POA vs those acquired in hospital. Why do you think Medicare is focusing on this?

11. Purpose of POA
Intention of this new concept is to reduce increased payments for complications that occurred after admission / during the hospitalization.
Hospitals have to submit data on all Medicare claims indicating whether the diagnoses were POA.
Coders indicate (Y or N) beside the principal diagnosis and all secondary diagnoses.
Refer to slide

12. The 10 categories of HACs include:
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Stage III and IV Pressure Ulcers
Falls and Trauma
Manifestations of Poor Glycemic Control
Catheter-Associated Urinary Tract Infection          (UTI)
Vascular Catheter-Associated Infection
Surgical Site Infection Following
Orthopedic Procedures
Spine Neck,Shoulder,Elbow
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
 Total Knee and Total Hip Replacement
Payment implications began October 1, 2008, for these 10 categories of HACs.
These HAC (hospital acquired conditions) usually cost more to treat and extend the LOS, but now the hospital will not receive additional reimbursement for these extra costs associated with HAC.

13. Medicare 101 DRG (Diagnosis Related Groups) Basics
How are DRGs used:
Calculating Hospital reimbursement
Evaluate quality of care
Evaluate utilization of resources
Each DRG represents the average resources utilized to care for a patient within the grouping
Every DRG has a relative weight (RW) assigned to it
The RW is used in the calculation of the Hospitals Case Mix Index
All diagnoses and procedures (if any) must be documented by the attending MD in the patients medical record. After discharge all cases are coded by hospital personnel based on the documentation & a DRG (diagnosis related group) is assigned (drgs range from 001 to 999). Each DRG has a RW assigned to it & the RW is used in calculating the hospitals Case Mix Index as well as the hospitals reimbursement from Medicare. The higher the RW the greater the severity level / case mix index as well as the higher the payment.

14. Medicare 101 DRG Basics
Major enhancement is revision of the CC list and development of MCC list
With the development of MS-DRGs, CMS reduced the CC capture rate from 77% to 40%
CC’s are categorized:
MCC (Major complication/comorbidity)
CC (complication/comorbidity)
Non CC
In Oct the DRG system changed to the MS-DRG system (Medicare Severity – DRG). With this change came the introduction of MCC and reduction of the number of CC’s available. If a cc or MCC is documented as a secondary diagnosis it affects the amount of our reimbursement (see next slide)

15. CMS DRGs vs. MS-DRGs
MS-DRG’s
Heart failure with no MCC/CC DRG 293 = RW = $3,699 CHF LOS 3.7days TX O2 and IV Lasix
Heart Failure with CC DRG 292 = RW = $5,155 CHF LOS 5 days TX O2, IV Lasix, echo, med adjustment, Chronic obstructive bronchitis acute exacerbation
Heart Failure with MCC DRG 291 = RW = $7,481 CHF LOS 6.5 days intubated ED, admit to ICU, In ICU 7 days, IV Dobutamine, multiple tests, multiple med adjustment, critical care, complicated by acute renal and respiratory failure
You can see how MCCs and CCs impact the reimbursement as well as the severity of illness for these patients.

16. The Goals of Clinical Documentation Integrity (CDI) Process are as follows:
Drive appropriate coding for accurate reimbursement
Reflect accurate patient acuity levels
Meet standards
Reduce compliance risks
Provide accurate data for quality indicators and other hospital metrics
Reduce coding turnaround time
Decrease post-discharge queries to the physicians by utilizing concurrent physician queries when indicated
Refer to slide.

17. Clinical Documentation Analysts
Nita Campbell, RN ICU/CCU/OCU
Janice Davis, RN S/7N/PJC
Alletheia Fitzgerald, RN 6N/7N/5N
Tamika Jones, RN CPU/MTU
Elinore Poindexter, RN S/CTU
Medical Records x 2938
These are our current unit assignments. Thank you for your time today.