Clinical Documentation Update Cardiology Service Line

1. Clinical Documentation Update Cardiology Service Line

2. 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.

3. Our Goal • 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

4. 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

5. 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

11. Clinical Documentation Update Questions about this presentation? Please contact: • Thenia Nesbeth-Blades,RN,MSN Documentation Improvement Specialist thn9003@nyp.org (212) 305-0337