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Is Clinical Documentation Improvement the Answer

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Hospitals with Clinical Documentation Improvement Program Report ... Px: Radical Pancreatectomy, 57.2. MS-DRG 405 Pancreas procedures w MCC. Relative Wt. ... – PowerPoint PPT presentation

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Title: Is Clinical Documentation Improvement the Answer


1
Is 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

2
What are the Issues?
  • Inpatient
  • MS-DRGs
  • AP-DRGs
  • SOI
  • ROM
  • Quality rankings
  • Health Grades
  • US News WR
  • CMS data
  • Blue Cross

3
Outpatient
  • Emergency Department
  • Levels, procedure capture, medical necessity
  • Ancillary services lab, radiology, etc.
  • Medical necessity
  • Anesthesia/Pain Clinic
  • Accurate coding

4
Professional Services
  • Emergency Department
  • Hospitalists
  • Clinics
  • Anesthesia/Pain

5
Audits
  • RAC
  • MIC
  • BC
  • Other payors

6
  • A physician who heals for nothing is worth
    nothing. - The Talmud

7
All Billing Depends on Documentation
  • Documentation
  • Coding
  • Billing

8
Quality Measurement
  • Documentation
  • Coding Quality metrics
  • Billing


9
Inpatient 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.

12
Inpatient 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

18
Hospitalist - 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

20
Radiology - 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

23
Causes 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

24
Approaches to CDI
  • Multiple targets
  • Multiple methodologies
  • No one silver bullet
  • Detail driven
  • Look at each category

25
Inpatient CDI
  • Improve documentation to fully capture
    complexity by coding.
  • Severity of Illness (SOI)
  • Affects Case Mix
  • Risk of Mortality (ROM)
  • Quality measures

26
Organizational 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

30
Inpatient - 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

33
Inpatient - 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

38
How 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

40
Inpatient 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

41
Inpatient CDI
  • Separate but equally important issue of
    documentation for medical necessity

42
Impact of Documentation on E.D. Facility Coding
and Billing
  • Assignment of levels
  • Procedure coding
  • Diagnostic coding (Medical Necessity)

43
Assignment 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.

44
Assignment of E.D. levels
  • Point systems
  • Includes electronic records documentation and
    coding can be problematic
  • ACEP guidelines (2004/2007)
  • Documentation is not an issue

45
E.D. Procedure Coding
  • Documentation can be problematic
  • Infusions and Injections
  • Drug, dose, route of administration, time
    started, time stopped
  • Splinting
  • Explicit documentation of application

46
E.D. Facility Documentation Improvement
  • Direct organizational issue
  • Pressure VP Nursing
  • Nurse Manager of E.D.
  • E.D. Staff Nurses
  • Ongoing monitoring

47
E.D. Diagnostic Coding
  • Problematic diagnoses
  • Normal exam
  • Medical Clearance
  • Odd diagnoses

48
E.D. Diagnostic Coding
49
Professional Coding and Billing
  • Evaluation and Management (E/M)
  • E.D. Physicians
  • Hospitalists
  • Clinic Physicians

50
Physician 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

51
Physician 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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Hospitalist 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

58
Documentation of Procedures
  • Sutures
  • Incision and Drainage
  • Splinting
  • Smoking cessation
  • Central lines

59
Documentation for Pain Clinic
  • Facet joint injections of spine
  • Trigger point injections
  • Procedures under Fluoroscopic guidance

60
Approach 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
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