1. Level II Training Clinical Documentation Improvement DoIM – Hospitalists 7/09/14 Presented by: Catherine Porto, MPA, RHIA, CHP Exec. Director HIM, UNMH ICD-10 Executive Project Lead & Erlinda Smith, CCS CDI Provider Education & Kayode Balogun CDI Program Development - Precyse 1

2. UNMMG Coding Staff – Current State UNMMG Professional Fee Coding: Assign ICD-9-CM diagnosis code (for that visit) Assign CPT procedure Codes (for that visit) – Evaluation & Management (E/M)codes for provider services – Procedure codes –for provider fees 2

3. UNMMG Provider Coding 4 Day Hospital Stay (Evaluation &Management) – Day 1 = Initial Hospital Care (CPT 99223) Charge = $514.00 wRVUs = 3.86 – Day 2 = Subsequent Hospital Care/Follow up (CPT 99233) Charge = $265.00 wRVUs = 2.00 – Day 3 = Subsequent Hospital Care/Follow up (CPT 99233) Charge = $265.00 wRVUs = 2.00 – Day 4 = Hospital Discharge (CPT 99239) Charge = $269.00 wRVUs = 1.90 Total Provider Charges = $1,313 Total Provider wRVUs = 9.86 3

4. UNMH Coding Staff Hospital (Facility) Coders are responsible for Facility Coding for the hospitals and clinics: Assignment of one DRG Code derived from: One Principle Diagnosis (ICD-9-CM) All Secondary Diagnoses (ICD-9 & capturing all present on admission (POA) diagnoses) One Principle Procedure (ICD-9-PC) All Secondary Procedures (ICD-9-PC) Any & all Co-morbidities & Complications (CC & MCCs) Assignment of the DRG 4

5. Assignment of the MS-DRG  DRG (Diagnosis Related Grouping)  One DRG is assigned for each Inpatient stay  Using all diagnoses and procedures codes  Includes codes for all complications & comorbidities (CCs and MCCs) DRGs are assigned a relative weight (RW)  RW is the calculation of resource consumption  Used to determine payment 5

6. MS-DRG Financial Impact Relative weight (RW): Number assigned to each account based on the DRG assigned. The higher the RW, the sicker the patient. – 1: Average – <1: Below average – >1: Above average Case Mix Index (CMI): The average of all relative weights for a patient population (Month, Year, etc.) for any given period of time. 6

7. Secondary Data Uses The role of the APR-DRGs APR-DRG (All-Payer Refined DRG-3M Software) Calculates Severity of Illness (SOI) Calculates Risk of Mortality (ROM) – Based on diagnoses, procedures and – Complications & Co-morbidities (CC and MCCs) SOI & ROM scales (APR-DRG & UHC scale) – 1. Minor – 2. Moderate – 3. Major – 4. Extreme 7

8. Impact of Complete Documentation MS DRG 195 w/o MCC/CC MS DRG 194 with CC MS DRG 193 with MCC MS DRG 177 with MCC PDX: Pneumonia, organism Unspecified PDx: Pneumonia, Organism Unspecified PDx: Pneumonia Organism Unspecified PDx: Pneumonia, Staphyloccus Aureus SDx COPD SDx: COPD with Exacerbation Malnutrition, protein calorie Malnutrition, severe protein calorie Malnutrition, severe protein-calorie (BMI<19) Decubitus UlcerPressure Ulcer Stage IV Pressure Ulcer, Stage IV, lower back (site needed for ICD-10) Acute Respiratory Failure with hypercapnia and/or hypoxemia SOI Level: 1SOI Level: 2 SOI Level: 3 SOI Level: 4 ROM level: 1 ROM level: 2 ROM level: 3 DRG Wt: 0.6997DRG Wt: 0.9771 DRG Wt: 1.4550 DRG Wt: 1.9934

9. POA and HAC There is a BIG difference in whether a condition was: POA: Present on Admission – documentation in the H&P or progress notes after a definitive diagnosis is made—whether each condition was present on admission (provider’s best clinical judgment) – Does this patient have a pressure ulcer (where)? OR HAC: Hospital Acquired Condition – For some selected conditions (diagnoses) that were not present on admission, but were acquired during hospitalization, the case may be paid as though the secondary diagnosis is not present Fracture occurring during the IP stay Diabetic Ketoacidosis (MCC) not present on admission Foreign object retained after surgery Vascular Catheter-Associated Infection Surgical Site Infection 9

10. Documenting Questionable Diagnoses Provider should document all possible, probable, or suspected conditions – this communicates what the provider is thinking. Example: – Professional fee Dx: Cannot code R/O-- rolls back to coding a symptom – IP - Possible Sepsis, r/o sepsis: Sepsis coded as though it exists – Sepsis ruled out: Sepsis would not be coded—IP remember to confirm prior to discharge or in the discharge summary – Pneumonia vs. CHF: Both can be coded (IP); pro fee-- codes to a symptom (i.e. chest pain, shortness of breath etc.) 10

11. Mission: Meaningful Clinical Process “Telling the Patient’s Story” Clinical Information is used by clinicians for “telling the story” for this episode of care. Primary uses of clinical documentation: – The Documentation story critical for patient care – The Medical Record is a communication tool among care providers – The Documentation should tell/demonstrate the clinical pathway to diagnoses Many times the story is lost in our current “cut and paste” or more forward world or documentation. 11

12. Secondary Uses of Clinical Information “As Documented in the EMR” Secondary Clinical Information/Data Uses: – Disease & Operative Indexing for research (ICD & CPT codes) – Validates the patient care provided – Serves as a legal document of the care provided – Drives Revenue/Reimbursement (Coding) – Permits accurate comparisons to other providers/institutions/national benchmarks – Identifies the quality and efficiency of the care we give. Computer extractions of: Quality Indicators (PQRS) Meaningful Use Data (MU) Compliance/Regulatory Standards (TJC, CMS, DOH) Metrics used for Value Based Purchasing

13.  Cost per patient  Resource utilization  Length of stay  Complication Rates  Morbidity Scores  Mortality Scores  Outcome Analysis  Payer Audits 13 Why does CDI Matter? Medicine is Under The Microscope

14.  Hospital Report cards  Healthgrades, Delta Group, Leapfrog  Medicare Physician Data (since 2007)  Federal and state regulatory agencies (e.g. OIG)  The Joint Commission (TJC)  Centers for Medicare and Medicaid Services (CMS)  Quality Improvement Organizations (QIO) 14 Physician Profiling

15. 15 Healthgrades.com

16. ICD-10: Advancing Healthcare… ICD-10 ( International Classification of Diseases version 10) The ICD is the international standard diagnostic classification for general epidemiological, health management purposes and clinical use. ICD-10 CM & PCS is an upgrade of the U.S. developed Clinical modification (ICD-9- CM) of Diagnosis and Procedure Codes, first adopted in 1979. Pervasive Impacts Diagnosis codes and procedure codes flow through mission critical operational systems and analytical tools Alignment of technology remediation with business and technology strategies Business process reengineering, training and change management is essential Comprehensive Benefits Quality Measurement Public Health Disease Surveillance Clinical Research Organizational Monitoring and Performance Reimbursement ICD-10 ChangesImplications Significant Increase in Clinical Granularity 5 digits > 4,000 unique codes 3-7 alphanumeric characters > 68,000 unique codes 7 alphanumeric characters > 72,000 unique codes ICD-9 CM (Procedure) ICD-10 CM (Diagnosis) ICD-10 CM (Procedure) 3-5 characters alphanumeric ICD-9 CM (Diagnosis) >14,000 unique codes ICD-9 CM (Procedure) 3-4 characters numeric > 4,000 unique codes The Federal Government through CMS is driving the healthcare industry to upgrade diagnosis and procedure coding standards (ICD-10) by October 1, 2015.

17. The Basics of the ICD-10-CM Change The ICD-10-CM diagnosis code set is a full replacement of the ICD-9 code set that will provide additional granularity for diagnosis and procedure codes. This additional granularity is the primary driver of value. XXXXX. ICD-9ICD-10-CM XXXXXXX Category Etiology, anatomic site, manifestation. Extension An Example of Structural Change Type 1 diabetes mellitus with diabetic neuropathy, unspecified E1040. Type 1 diabetes mellitus with diabetic mononeuropathy E1041. Type 1 diabetes mellitus with diabetic amyotrophy E1044. Type 1 diabetes mellitus with other diabetic neurological complication E1049. Diabetes mellitus with neurological manifestations type I not stated as uncontrolled 2506. 1 An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes One ICD-9 code is represented by multiple ICD- 10 codes The industry expects that mapping ICD-9 and ICD-10 codes will be a complex task

18. The Basics of the ICD-10-PCS Change The ICD-10-PCS is an American procedure coding system that represents a significant step toward building a health information infrastructure that functions optimally in the electronic age. XXXX. ICD-9ICD-10-PCS XXXX X XX Section An Example of Structural Change Total hip replacement 8151. An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes One ICD-9 code is represented by multiple ICD- 10 codes Body System Root Operation Body Part ApproachDeviceQualifier 0SRB07ZReplacement of Left Hip Joint with Autologous Tissue Substitute, Open Approach 0SRB0KZReplacement of Left Hip Joint with Nonautologous Tissue Substitute, Open Approach 0SRB0J7Replacement of Left Hip Joint with Synthetic Substitute, Ceramic on Ceramic, Open Approach 0SRB0J8Replacement of Left Hip Joint with Synthetic Substitute, Ceramic on Polyethylene, Open Approach 0SRB0J6Replacement of Left Hip Joint with Synthetic Substitute, Metal on Metal, Open Approach 0SRB0J5Replacement of Left Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach 0SRB0JZReplacement of Left Hip Joint with Synthetic Substitute, Open Approach 0SR907ZReplacement of Right Hip Joint with Autologous Tissue Substitute, Open Approach 0SR90KZReplacement of Right Hip Joint with Nonautologous Tissue Substitute, Open Approach 0SR90J7Replacement of Right Hip Joint with Synthetic Substitute, Ceramic on Ceramic, Open Approach 0SR90J8Replacement of Right Hip Joint with Synthetic Substitute, Ceramic on Polyethylene, Open Approach 0SR90J6Replacement of Right Hip Joint with Synthetic Substitute, Metal on Metal, Open Approach 0SR90J5Replacement of Right Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach 0SR90JZReplacement of Right Hip Joint with Synthetic Substitute, Open Approach

19. ICD-10 Coding Snapshot: Diabetes Scenario A 68 y/o male has type I diabetes with diabetic chronic kidney disease stage 3, is being seen for regulation of insulin dosage. The patient has an abscessed right molar, which was determined, in part, to be responsible for elevation of the patient’s blood sugar. ICD-10 codes: – E10.22 Diabetes type 1 with CKD – N18.3 CKD Stage 3 – K04.7 Abscess Tooth – Z79.4 Long term drug therapy, insulin

20.  Don’t need to turn doctors into coders  We Need good documentation habits  We Need specialty specific documentation education  We need to Begin the process of education now for ICD-9 and incorporate ICD-10 issues into the education as we prepare for Oct. 1, 2014 (Now 2015) ICD-10 Physician Education

21. UNMH & SRMC- CMI (Case Mix Indicator)

22. UNMH- Facility-Wide SOI (Severity of Illness Indicator

23. UNMH- Facility-Wide ROM (Risk of Mortality Indicator)

24. SRMC - SOI

25. SRMC - ROM

26. DoIM UNMH - CMI

27. DoIM UNMH - SOI

28. DoIM UNMH - ROM

29. DoIM – Hospitalists UNMH - SOI

30. DoIM – Hospitalists UNMH - ROM

31. April Discharges – Ortho Major Joint Replacement – Lower Extremity

32. Sepsis SIRS Criteria Assess for 2 or more (Fever) Temp > 38⁰C or < 36⁰C (Tachycardia) HR > 90 (Tachypnea) Resp rate > 20 or pa CO₂ < 32 (Leucocytosis/Leukopenia) WBC > 12K, 10% bands

33. SIRS: Suspected Infection If infection is known: Document organism and site Document whether infection is present on admission May document possible, probable, likely or suspected sepsis Complete Sepsis M-Page Determine Sepsis Severity

34. Sepsis Severity Sepsis Lactate levels documented No organ dysfunction No hypotension Severe Sepsis Lactate levels Organ failure – Organ dysfunction must be linked to the Sepsis * (Occult) Septic Shock (Written as Septic Shock) Lactate levels No hypotension Septic Shock Written as Septic Shock Hypotension Refractory to IV fluids *see organ reference pages

35. SMITE Bundle Basic SMITE Bundle 1.Lactate q 4h x2 2.Blood Culture 3. Antibiotics within 1 h 4. Fluids 5. Re-evaluate as needed Advanced SMITE Bundle Basic Bundle Plus: 5.Fluids bolus 6.CVP 7.Vasopressors

36. Severe Sepsis : Organ Dysfunction Documentation of (Encephalopathy) Altered mental status (Acute kidney injury) Creat levels/abnormal labs (Acute liver failure) Abnormal LFTs/Total Bili (Coagulopathy) INR level documented (Acute respiratory failure) Hypoxemia and/or hypercapnia * Please refer to organ reference for detailed documentation suggestions

37. Case Study #1 MS DRG –178 Respiratory Infections & Inflammations w CC PDX: Cystic Fibrosis with pulmonary manifestations SDX: protein-calorie malnutrition. GERD, several other dx SOI level: 3 ROM level: 2 DRG Wt. 1.4403 DRG Reimb: $13,091.09 Additional documentation in chart CDI Queries for: nutrition note documentation, malnutrition related to CF. Pt with BMI 15.9 on high calorie diet and clinimixi at 80 cc an hr for nutritional support. Malnutrition documented on PN. CDI query for the severity of the malnutrition. If provider agreed with query and documents severe protein calorie malnutrition. MD DRG-177 Respiratory Infections & Inflamations w MCC SOI level: 3 ROM level: 3 DRG WT. 2.0549 DRG Reimb: $18,677.24

38. Case Study # 2 MS DRG –872 Septicemia or Severe Sepsis w/o MCC PDX: Septicemia due to E coli SDX: protein calorie malnutrition, DM without complications type II, acute pancreatitis SOI level: 3 ROM level: 2 DRG Wt. 1.0687 DRG Reimb $8,120.74 Additional documentation in chart: Sepsis with AMS CDI Queries for: Specific type of Encephalopathy. If provider agrees and documents metabolic encephalopathy MS DRG-871 Septicemia or Severe Sepsis W MCC SOI level: 3 ROM level: 3 DRG WT. 1.8527 DRG Reimb: $14,078.15

39. Department Training Schedule Level I Training – Completed by April 30, 2014 Level II Training – Completed by June 1, 2014 Level III Training – Expectation: You are here – Dept Champion (s) Complete 1:1 training by June 1, 2014 – All Dept. Specialty Training to be completed in June/July 2014 for ICD-10: Date to be determined by UNM HSC (RFP Vender selection underway 6/1/14 – Metrics & Measures part of Monthly Department Meetings by June 2014 – Top Dx/Tip Sheets & All Staff Trained by Dept/Div Champions by June 30, 2014

40. Upcoming in Fall 2014: Dept./Div. Specialty-Specific CDI Training – Vendor Proposals for Level III Training chosen by RFP Committee. Next steps: – Top vendors on-site to demonstrate their sub-specialty training method & tools – week of July 21 – Encourage All Dept/Division Champions and anyone else interested to attend – Dept/Division – Specialty Specific ICD-10 Documentation Sessions to be scheduled in the Fall of 2014 (following UNM HSC approval of vendor and purchase)

41. Contacts UNMH Coding & Clinical Documentation Erlinda Smith, CCS UNMH Coding Educator (Inpatient) EVSmith@salud.unm.edu Kayode Balogun, MD, CCS CDI Program Manager, UNMH kbalogun@salud.unm.edu Catherine Porto, RHIA, MPA, CHP Exec. Director HIM cporto@salud.unm.edu CDI Information to be posted on the following web site: https://hospitals.health.unm.edu/int ranet/HIM Provider Documentation and ICD-10 Tab 41