Title: Is Clinical Documentation Improvement the Answer
1Is Clinical Documentation Improvement the Answer?
- MAPAM /MAHIMA Joint Meeting
- Thursday, November 19, 2009
- Thomas D. Sills, M.D.
- Lori Beaudry, CCS-P
- Clinical Financial Resource
2What are the Issues?
- Inpatient
- MS-DRGs
- AP-DRGs
- SOI
- ROM
- Quality rankings
- Health Grades
- US News WR
- CMS data
- Blue Cross
3Outpatient
- Emergency Department
- Levels, procedure capture, medical necessity
- Ancillary services lab, radiology, etc.
- Medical necessity
- Anesthesia/Pain Clinic
- Accurate coding
4Professional Services
- Emergency Department
- Hospitalists
- Clinics
- Anesthesia/Pain
5Audits
6 - A physician who heals for nothing is worth
nothing. - The Talmud
7All Billing Depends on Documentation
- Documentation
- Coding
- Billing
8Quality Measurement
- Documentation
- Coding Quality metrics
- Billing
9Inpatient CDI
10- Hospitals with Clinical Documentation Improvement
Program Report Increased Reimbursement... - Mon Aug 11, 2008 830am EDT
- -(Business Wire)--J.A. Thomas and Associates,
the leader in healthcare clinical documentation
improvement, published today a set of
benchmarking reports that show 188 hospitals
using its Compliant Documentation
11 - Management Program (CDMP(R)) have realized an
overall 5 improvement in CMI than projected by
the Centers for Medicare and Medicaid
Services/MEDPAR for hospitals adjusting to the
new MS-DRG coding system. To download the full
report, visit www.jathomas.com.
12Inpatient Example 1
- 77 y/o pt admitted from N.H. with documented
urosepsis, azotemia, and chronic sacral
decubitus. Treated with IV antibiotics seen by
plastic surgeon, who leaves illegible note.
Discharged after 8 days.
13 - Principal dx UTI, 599.0
- Secondary dx azotemia, 790.6 sacral
decubitus 707.03 - MS-DRG 690 Kidney and Urinary
Infections without MCC - Relative weight 0.7708
- Payment 4600
- ROM 2
14 - Principal dx UTI, 599.0
- Secondary dx azotemia, 790.6 sacral
decubitus 707.03 stage III decub - MS-DRG 689 Kidney and Urinary Infections
with MCC - Relative weight 1.2122
- Payment 7300
- ROM 3
15 - Principal dx Septicemia, 038.9,
- Secondary dx sepsis, 995.91 azotemia,
790.6 sacral decubitus 707.03 stage III
decub - MS-DRG 871 Septicemia w/o MV 96h w/
MCC - Relative weight 1.8437
- Payment 11,000
- ROM 3
16 - Principal dx Septicemia, 038.9,
- Secondary dx sepsis, 995.91 AKI, 584.9
sacral decubitus 707.03 stage III decub - Px Excisional Debridement, 86.22
- MS-DRG 853 Septicemia with MCC
with procedure
17 - Relative weight 5.4946
- Payment 33,000
- ROM 4
18Hospitalist - Example 2
- 77 y/o pt admitted to the ICU with urosepsis.
On hospital day 2, progress note documents,
Looks better. VS stable but rales 1/3 up. Will
decrease IVF and give IV lasix. BC for E Coli.
Cr down to 1.8. Continue Rocephin. Check CXR.
19 - Documentation as is supports assignment of
- Level 1 subsequent care, 99231
- RVU 1.03
- Payment 37
- Good documentation would support assignment of
Critical Care, 99291 - RVU 5.88
- Payment 212
20Radiology - Example 3
- 65 y/o sees his primary care physician with a
persistent headache, one day after falling and
striking his head. The only findings were
tenderness of scalp. Because pt was on Plavix, a
head CT was obtained.
21 - Contusion of head, 920, was documented on record
and requisition. Blue Cross denied payment due
to lack of Medical Necessity. - Head injury, 959.01, was documented on record and
requisition. Blue Cross paid the claim.
22 - In the midst of your illness you promise a goat,
but when you have recovered, a chicken will seem
sufficient. - African Proverb
23Causes of poor inpatient documentation
- Lack of education
- Lack motivation
- Lack of structure for documentation
- Lack of uniformity of medical semantics
- Mismatch between language of clinical medicine
and coding
24Approaches to CDI
- Multiple targets
- Multiple methodologies
- No one silver bullet
- Detail driven
- Look at each category
25Inpatient CDI
- Improve documentation to fully capture
complexity by coding. - Severity of Illness (SOI)
- Affects Case Mix
- Risk of Mortality (ROM)
- Quality measures
26Organizational Issues
- Potential conflict between
- Quality and Coding
- CDS and Coding
- Increased Staffing
- CDI
- Coding staff
27 Inpatient - Example 3
- 65 y/o admitted for elective hemicolectomy. On
post op day 1 post op patient has episode of
atrial fibrillation which resolves with
treatment. Pt had prior episode of a fib. 4
years before.
28 Principal dx Colon Cancer, 153.6 Secondary
dx a. fib, 427.31 Procedure rt hemicolectomy,
45.73 MS-DRG 331 Major bowel surgery
w/o cc/mcc Relative weight 1.8415 Payment 11,417
ROM 1
29 - Principal dx Colon Cancer, 153.6
- Secondary dx a. fib, 427.31 cardiac comp 997.1
- Procedure rt hemicolectomy, 45.73
- MS-DRG 330 Major bowel surgery w/o cc/mcc
- Relative weight 2.8935
- Payment 17,940
- ROM 1
30Inpatient - Example 4
- 69 y/o pt with widely metastatic breast CA is for
management of pain due to new bony mets. CT of
head showed 4 cm brain lesion in temporal lobe
with vasogenic edema and effacement of sulci and
compression of lateral ventricle. Neuro is
consulted because of question of focal seizures.
The pt is seen in consult and is started on anti
seizure medication. During her stay the pt also
received a Greenfield filter for recurrent DVT
and contraindication to anti coagulation.
31 - Principal dx bone mets 198.5
- Secondary dx seizure, 345.50 brain met,
198.3 DVT, 453.40 - Procedure Vena Cava filter, 38.7
- MS-DRGs 516 Other Musc/Skel proc with
cc - Relative weight 1.8083
- Payment 11,400
- ROM 3
32 - Principal dx bone mets 198.5
- Secondary dx seizure, 345.50 brain
met, 198.3 DVT, 453.40 brain edema
348.5 compression brain, 348.4 - Procedure Vena Cava filter , 38.7
- MS-DRG 515 Musc/Skel proc/ mcc
- Relative weight 3.0669
- Payment 18 ,800
- ROM 3
33Inpatient - Example 5
- 65 y/o male was admitted for surgical resection
of his pancreatic cancer. The patient had
obstructive jaundice and CAT scan showed dilated
biliary and pancreatic ducts. The patient had
surgical resection with mild post op ileus and
was discharged home after 7 days.
34 - Principal dx Pancreatic Cancer, 157.1
- Secondary dx post op ileus, 997.4
hypertension, 401.9 gout 274.9 - Px Radical Pancreatectomy, 57.2
- MS-DRG 406 Pancreas procedures w cc
- Relative Wt. 2.6729
- Payment 16,000
- ROM 2
35 The pt was admitted for surgical resection of his
pancreatic cancer. The patient presented with
obstructive jaundice and CAT scan showed dilated
biliary and pancreatic ducts. Did the pt have
1. obstruction of the biliary duct? 2.
obstruction of the pancreatic duct? 3.
other_____________?
36 - Principal dx Pancreatic Cancer, 157.1
- Secondary dx post op ileus, 997.4
hypertension, 401.9 gout 274.9
obstruction of bile duct, - 576.2
- Px Radical Pancreatectomy, 57.2
- MS-DRG 405 Pancreas procedures w MCC
- Relative Wt. 5.5911
- Payment 33,500
- ROM 3
37 - A physician is an angel when employed but a
devil when one must pay him. - Latin Proverb
38How to approach Inpt CDI
- Conventional approach
- Hire RNs train them in coding issues educate
physicians concurrent chart review on floor
prompt physicians for documentation communicate
with coders - Advantages Dedicated staff to CDI
- Increase CMI
-
39 - Disadvantages
- High cost
- Staffing
- Lack of coding expertise
- New level of bureaucracy
- Reporting relationship with HIM
- Compliance Issues
40Inpatient CDI
- Thorough Coding Back end validation with robust
physician query system - Front end review and back end queries
- Adding focused reviews of documentation with
ongoing feed back to medical staff -
41Inpatient CDI
- Separate but equally important issue of
documentation for medical necessity
42Impact of Documentation on E.D. Facility Coding
and Billing
- Assignment of levels
- Procedure coding
- Diagnostic coding (Medical Necessity)
43Assignment of E.D. levels
- "While awaiting the development of a national set
of facility-specific codes and guidelines, we
have advised hospitals - 1. Levels should reasonably relate to
intensity of services. - 2. Levels should be consistently applied.
44Assignment of E.D. levels
- Point systems
- Includes electronic records documentation and
coding can be problematic - ACEP guidelines (2004/2007)
- Documentation is not an issue
45E.D. Procedure Coding
- Documentation can be problematic
- Infusions and Injections
- Drug, dose, route of administration, time
started, time stopped - Splinting
- Explicit documentation of application
46E.D. Facility Documentation Improvement
- Direct organizational issue
- Pressure VP Nursing
- Nurse Manager of E.D.
- E.D. Staff Nurses
- Ongoing monitoring
-
47E.D. Diagnostic Coding
- Problematic diagnoses
- Normal exam
- Medical Clearance
- Odd diagnoses
48E.D. Diagnostic Coding
49Professional Coding and Billing
- Evaluation and Management (E/M)
- E.D. Physicians
- Hospitalists
- Clinic Physicians
50Physician documentation example
- 64 y/o male c/o chest pain for 2 days. Hx of
CAD with prior CABG 2004 and repeat CABG in
2007. Pt had done well until two months ago pt
underwent cardiac catheterization after episode
of chest pain Drug eluting stent was placed in
circumflex artery. Pt last saw own doctor last
week. - Two elements of HPI location and duration
51Physician documentation example
- 64 y/o male c/o mild, dull, constant chest pain
for 2 days, better after eating and associated
with dyspnea. NTG helped slightly. - Seven elements of HPI location, quality, timing,
duration, context, associated signs/symptoms,
modifying factors.
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56Hospitalist Documentation Example
- Called to see 75 y/o woman admitted by PMD
earlier today to ICU for pneumonia and COPD
exacerbation. Patient has hx of severe COPD and
was quite dyspneic on admission. Improved
initially with Solumedrol, nebs but increasing
dyspnea and confusion over last 20. Pulse ox
now 88. - Meds--
- Physical exam fully documented
57 - Labs, ABGs, repeat CXR done
- Pt placed on BiPAP, given pressors, diuretics,
watched closely for 90 minutes. - Consult or initial hospital visit
- 99252 to 99255, 99221-99223
- Critical Care 99291, 99292
58Documentation of Procedures
- Sutures
- Incision and Drainage
- Splinting
- Smoking cessation
- Central lines
59Documentation for Pain Clinic
- Facet joint injections of spine
- Trigger point injections
- Procedures under Fluoroscopic guidance
60Approach to CDI
- Identify all areas where improved documentation
will have significant impact - - inpatient coding
- - inpatient medical necessity
- - E.D. coding
- - Professional coding
- - Other services
61 - Obtain Administrative Support
- Educate Physicians
- Effective Feedback
- Never stop monitoring
62 - The doctor demands his fees whether he has
killed the illness or the patient. - Polish
Proverb