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The DRG Assurance Program creates a bridge between the gap.

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Presentation on theme: "The DRG Assurance Program creates a bridge between the gap."— Presentation transcript:

0 Clinical Documentation Update Cardiology Service Line
Name Title Role: ensure coding accurately reflects the clinical picture. - Each service line reviews their LOS, CMI, and Quality measurements. _ Lori Armstrong and DR. Dalton requested a review inpatient medical records in OB and MFM looking for any opportunities where documentation would impact the clinical Scores. Starting this past march I began to review the documentation for this service line and found there were opportunities. Lori Armstrong and Dr. Dalton wanted my department to give in-services to update the providers on the changes in coding. With most service lines, including this service line, there are not many changes. How ever there is an incredibly high volume of cases where clarification is needed thus affecting the scores.

1 The DRG Assurance Program creates a bridge between the gap.
The Challenge Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms. Physician documentation is received in CLINICAL terms Breakdown between the two. 2 separate languages The DRG Assurance Program creates a bridge between the gap.

2 Our Goal Accurately reflects the high quality of care provided
Clarify documentation in the medical record to reflect the true severity of the patient’s illness. Achieve and maintain an administrative database that: Accurately reflects the high quality of care provided Ensures compliance with regulatory guidelines Accurately reflects the complexity of our patient population Provides a complete medical record for communication among providers

3 Case Mix Index Case Mix Index (CMI)
Used for resource allocation such as nursing, PA/NP staffing levels Compare peer hospitals Calculate Medicare reimbursements Designate length of stay allowances A low CMI may result from DRG assignments that underestimate the patient acuity and the actual resources used in treatment

4 CMS Present on Admission Reporting Requirements
CMS defines POA: present at the time of order for inpatient admission Conditions that develop during an outpatient encounter, including ED, observation, or outpatient surgery, are considered present on admission POA indicator is assigned to the principal and secondary diagnoses Provider must resolve inconsistent, missing, conflicting or unclear documentation Conditions that occur during the inpatient stay are called “hospital Acquired Conditions” (HACs) Source: CMS Manual System Transmittal 1240, May 11, 2007 Subject: Present on Admission Indicator

5 Case Study 1: Specificity of Pulmonary Edema as Secondary Diagnosis
Before DRG 217 Cardiac valve procedure w/o MCC Severity Weight 6.8038 Principal Diagnosis Mechanical complication due to heart valve Secondary Diagnosis Severe MR COPD HTN Hypothyroidism Procedure S/P tMV Replacement SOI Level 2 Items to Query MD note stated- CXR shows increased pulmonary edema & R effusion POD 4 After DRG 216 Cardiac valve procedure with MCC Severity Weight Principal Diagnosis Mechanical complication due to heart valve Secondary Diagnosis Severe MR COPD HTN Hypothyroidism ADDED Post op acute pulmonary edema Procedure S/P tMV Replacement SOI Level Increased 3 Documentation to Impact SOI Post op acute pulmonary edema 74 y/o F Hx of AVR/MVR 1999; admitted with worsening SOB, Echo- severe MR. S/P tMVR. CXR- pulmonary edema treated with Lasix. No history of Heart Failure. Impact: Increased Severity Level and Service Weight with the documentation of Acute pulmonary edema.

6 Case Study 2 –Specificity for systolic CHF as Secondary Diagnosis
Before DRG 251 Perc Cardiovasc Proc w/o Corn Artery Stent w/o MCC Severity Weight 1.6038 Principal Diagnosis CAD Secondary Diagnosis USA Systolic CHF UTI- E.coli infection DM2 CKD Procedure PTCA SOI Level 2 After DRG 250 Perc Cardiovasc Proc w/o Corn Artery Stent with MCC Severity Weight 2.9914 Principal Diagnosis CAD Added Acute on chronic Systolic CHF Secondary Diagnosis USA Systolic CHF UTI- E.coli infection DM2 CKD Procedure PTCA SOI Level Increased 3 Items to Query Cath cancelled due to elevated BNP, pulm edema on CXR. CHF exacerbation treated with IV Lasix Documentation to Impact SOI Acute on chronic Systolic CHF 81yo F with HTN, hyperlipidemia, DM 2, transferred from OSH for cath /possible PTCA which was cancelled due to CHF exacerbation. Impact: Severity Weight and Severity Level Increased with documentation of Acute on chronic systolic CHF.

7 Documentation to Impact Reimbursement/ LOS
Case Study 3: Specificity of Congestive Heart Failure as Secondary Diagnosis After DRG 545 Cardiac Valve Proc with MCC Severity Weight Principal Diagnosis Mitral Valve Disorder Added Acute on chronic Diastolic CHF Secondary Diagnosis Congestive Heart Failure - unspecified CAD HTN UTI Post-op anemia Hyponatremia Procedure Replacement of Mitral Valve Mean LOS 17 Days SOI Level 3 Before DRG 104 Cardiac Valve Proc w/o MCC Severity Weight 8.3988 Principal Diagnosis Mitral Valve Disorder Secondary Diagnosis Congestive Heart Failure - unspecified CAD HTN UTI Post-op anemia Hyponatremia Procedure Replacement of Mitral Valve Mean LOS 11 Days SOI Level 3 Items to Query Can CHF be described with specificity. Patient treated with IV diuretics/ CXR- pulmonary congestion this admission. Documentation to Impact Reimbursement/ LOS Congestive Heart failure documented as Acute on chronic Diastolic CHF 59yo F adm. with dyspnea. S/P cath showing severe MR/ 3V CAD. Echo- impaired LV relaxation. S/P MV replacement & coronary bypass. Impact: Increased severity weight with documentation of specificity of CHF. Mean LOS 17 days vs. 11days

8 Case Study 4: Clinical Significance of Dissection
After DRG 175 Percutaneous Cardiovasc w/o AMI Severity Weight 2.2627 Principal Diagnosis CAD Added Dissection coronary artery Secondary Diagnosis USA Hyperlipidemia HTN Subendocardial infarction, subsequent episode of care Hx coronary angioplasty Procedure PTCA with DES Mean LOS 2 Days SOI Level 3 Before DRG 175 Percutaneous Cardiovasc w/o AMI Severity Weight 1.6232 Principal Diagnosis CAD Secondary Diagnosis USA Hyperlipidemia HTN Subendocardial infarction, subsequent episode of care Hx coronary angioplasty Procedure PTCA with DES Mean LOS 2 Days SOI Level 1 Items to Query Is dissection clinical significant? Dissection was documented by fellow in hand written cath report; however, no dissection documented in official cath report. Documentation to Impact Reimbursement/ SOI Dissection coronary artery, area stented. 39y/o male with HTN,hyperlipedemia, USA…NSTEMI on 3/18/11- S/P cath with PTCA/ xience stent x2; returns for staged PCI. Coronary artery dissection documented only in fellow’s proc. note. Impact: Increased severity weight with documentation of coronary artery Dissection.

9 Case Study 5 : Impact of Principal Diagnosis Change
Before DRG Circulatory Disor. W AMI Case Mix 1.6352 Expected LOS 4 days Principal Diagnosis NSTEMI Secondary Diagnosis DM type 2 -controlled Hx tobacco use Overweight HTN Cannabas (marijuana) abuse Procedure Lt heart Cath Severity 1 Query Pt with non-obstruc CAD on cath. Urine tox + for tetrahydro cannabinols (THC); is NSTEMI possibly due to THC? After DRG Injuries, Poisoning & Toxic effect of Drugs Case Mix 2.3338 Expected LOS 6 days Principal Diagnosis Poisoning by hallucinogen Secondary Diagnosis DM type 2 -controlled Hx tobacco use Overweight HTN Cannabas (marijuana) abuse NSTEMI Procedure Lt heart Cath Severity 3 Response NSTEMI probably due to marijuana use. 55yo male with 20yr hx of tobacco use, HTN..c/o severe chest pain radiating down Lt arm, fatigue, diaphoresis…urine tox positive for THC…troponin 0.67 to cardiac cath showed non-obstructive CAD. Query: Is NSTEMI possibly due to THC? Impact: Case mix index, Expected LOS, SOI increased

10 Clinical Documentation Update
Questions about this presentation? Please contact: Thenia Nesbeth-Blades,RN,MSN Documentation Improvement Specialist (212)

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