1. Clinical Documentation Improvement Langley Provider Group Colleen Garry RN, BS Mary Beth Genovese RN, BS, CCS, CCDS

2. JAMA: April 26, 2006 p. 1918 • “The era of accountability defined as measured performance with consequences, is rapidly arriving in the US for medical practitioners and health care facilities. Soon, both reputations and incomes of practitioners and health care facilities may well be altered depending on how one scores on a limited set of performance metrics”

3. Hospital Life Today • Affordable Care ACT Changes • Decreased reimbursement • Bundled payments • Pay for Performance/VBP • EMR Implementation • ICD 10 • Pay for Outcomes

4. Deficit Reduction Act of 2005SECTION 501 c of PL 109-71 • Congress authorizes CMS to adjust for Medicare IPPS hospital payments to encourage the prevention of certain conditions (VBP) • Requires CMS to choose at two conditions; • High volume high cost or both • Condition is a cc or MCC • Reasonably preventable thru evidenced based guidelines • No addition payment when these conditions develop after admission (when condition is the only one to bring to the higher RW tier)

5. Who’s Profiling Physicians? • Federal State and Regulatory agencies • Joint Commission • CMS • Peer Review Organizations • Managed Care organizations/Profiling Agencies • Prospective Payment Systems • Hospitals • (one of the major indices is based on SOI)

6. Is your profile accurate? • How complex is the care being delivered? • What overall severity is being reported and collected? • What risk of mortality is being reflected? • How do secondary diagnoses affect reflection of severity and risk? • Do I have any control over my profile?

7. WIKIPEDIA DEFINITIONS • Severity of illness (SOI) is defined as the extent of organ system derangement or physiologic decompensation for a patient. It gives a medical classification into minor, moderate, major, and extreme. The SOI class is meant to provide a basis for evaluating hospital resource use or to establish patient care guidelines. • The risk of mortality (ROM) provides a medical classification to estimate the likeli-hoodof in-hospital death for a patient. The ROM classes are minor, moderate, major, and extreme. The ROM class is used for the evaluation of patient mortality.

14. Flow of Documentation FEDERAL GOVT. RANKING REIMBURSEMENT MD DOCUMENTATION Converts into ICD 9 Codes NOW And ICD 10 codes OCTOBER 1, 2014 RACS OVERSIGHT RECOVERY TIER STATUS CREDENTIALING INSURANCE COMPANIES INTERNET PATIENT BALTIMORE SUN HEALTHGRADES LEAPFROG

15. Governmental AUDITS

16. RAC’s: YOUR BEST DEFENSE: A GOOD OFFENSE (CDI) • To Assess: • Level of Acuity • Severity of Illness • Clinical Indicators • Utilization of resources

17. LANGUAGE INCOMPATABILITIES

18. Clinical Language vs. Diagnostic Statements

20. ACCOMPLISHED BY: • CDI team fully trained in CDI (clinical, coding, compliance) • Concurrent “real” time record reviews • Ensure proper assignment of: DRG/CC/MCC/POA Status/ HAC’s • Tracking tool to report on vital data • Scheduled reports to CDI Steering Committee with regularly scheduled meetings • Continuous feedback to Mid Level Providers and Physicians

21. Benefits of CDI: • Regulatory Compliance • Improved outcome indicators • Thorough documentation enhances accurate hospital and physician profiles • Enhanced support for the patient’s treatment plan • LOS and medical necessity are supported by SOI • Fewer Denials • Added support for E&M coding levels • Risk management tool

22. What are the drivers for change? • Accurate and Comprehensive clinical documentation is essential for: • Safe, high quality patient care • Accurate performance data • Appropriate reimbursement revenue • Regulatory compliance e.g., MS DRG . POA, HAC’s, Core Measures, PSI’s, RAC ????

23. Critical Success Factors • To ensure accurate comprehensive clinical documentation: • Provide Strong Medical and Administrative Leadership Support • Communicate and Collaborate • Perform Robust Data Tracking • Offer ongoing education • Implement an effective CDI program

24. Improvement Activities Benchmarking

25. COUNTDOWN TO ICD 10 502 DAYS 71 WEEKS + 5 days OCTOBER 1, 2014 MAY 17, 2013

26. CHANGES TO VOLUME

29. Thank you QUESTIONS ? • mgenovese@langleyprov.com • cgarry@langleyprov.com