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Clinical Documentation Update for Physicians

Clinical Documentation Update for Physicians

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Clinical Documentation Update for Physicians

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  1. Clinical Documentation Update for Physicians November 9 and 16, 2011 Dr. Karen Jerome Kyle Jossi, RN

  2. 0 of 30 Which hospitals were recently recognized by the Joint Commission as Top Performers on Key Quality Measures? A. Every hospital in the United States B. Every hospital in the DC metro area C. Every hospital in the state of Maryland D. Holy Cross Hospital and no other hospitals in Maryland or the DC Metro area or the Trinity Health system

  3. Top Performer Award from The Joint Commission • In Sept. 2011, Holy Cross Hospital was the sole hospital in Greater Washington and all of Maryland to receive a"Top Performer on Key Quality Measures" award from The Joint Commission for 2010. • Holy Cross Hospital was one of only 405 U.S. hospitals selected out of a total 3,099 participating. We were recognized for all four categories of adult medicine that were rated: heart attack, heart failure, pneumonia, and surgical care. • This recognition indicates that we have made real improvements in our many, many outside measurements of quality. But more importantly, it demonstrates our ongoing success in improving the care we provide to our patients. • This is the first year of this new Joint Commission recognition program.

  4. Agenda • Clinical documentation significance • Chart coding • Case mix • ICD-10 • Select documentation issues • Sepsis • Clinical Doc. Improvement Program • Queries

  5. The Importance of Your Documentation • Clinical information for patient care • Quality/Core measure adherence • Potentially Preventable Complication (PPC) performance • Tumor Registry data • Physician and hospital profiling • Including mortality data • Compliance for reimbursement/denial prevention • Commercial payors • RAC audits • Protection in the event of litigation

  6. Coding Definitions • Principal diagnosis – the condition established, after study, to be chiefly responsible for occasioning the patient’s hospital admission • Secondary diagnosis – anything that: • is diagnostically tested • is clinically evaluated • is treated • causes increased nursing care and/or monitoring • prolongs the patient’s length of stay • ICD-9 is the current coding terminology.

  7. 0 of 30 Coders can code from which sources? A. lab reports B. physician progress notes, H&P, operative reports, discharge summary C. pathology reports D. echocardiogram reports E. RN notes

  8. Case Weight/Case Mix Index (CMI) • Calculated by the coding software • Case weight is assigned based on the principal diagnosis and the severity of illness, determined by the secondary diagnoses. • The case weights for all coded cases are combined to create the hospital’s CMI, on which its reimbursement is based.

  9. Case Weight Example - Pneumonia • Community Acquired Pneumonia -with no secondary diagnosis SOI 1 ROM 1 Case weight .40 -with 1 secondary dx – e.g. urinary incontinence SOI 2 ROM 1 Case weight .54 -add acute renal failure (POA) a 2nd secondary diagnosis SOI 3 ROM 3 Case weight .84 -add severe malnutrition, a 3rd secondary diagnosis SOI 4 ROM 4 Case weight 1.46 • If the pneumonia is documented more specifically, such as aspiration, staphylococcus, TB, or H. influenza, the DRG changes. In that DRG, with SOI 1 ROM 2 Case weight.60 SOI 4 ROM 4 Case weight1.96

  10. The Future of Coding: ICD-10 • Will be implemented on 10/1/2013 • Applies to hospital and office coding • Will require significantly more specificity • Laterality • Type of encounter (initial, subsequent) • ICD-9: 14,300 diagnosis codes 4,000 procedure codes • ICD-10: 68,000 diagnosis codes 87,000 procedure codes

  11. Physician Support for ICD-10 • Holy Cross Hospital will help you to improve your workflow efficiency. • The following are being considered: • At-the-elbow support for building customized clinical documentation templates • Front-end voice recognition software • Computer-assisted coding—enables natural language processing of charts

  12. Select Documentation Issues

  13. 0 of 30 Which of the following diagnoses cannot be coded as an active problem? A. Rule out myocardial infarction B. Possible sepsis C. History of CHF D. Probable UTI E. Likely pneumonia

  14. “History Of” • H&P often cites the patient as having a “history of” various conditions. These may actually be currently active problems and, if so, must be stated as such or the coder cannot capture them as secondary diagnoses.

  15. Differential Diagnoses • In the inpatient setting, coding guidelines allow coders to pick up diagnoses that are listed as rule out, possible, probable, or likely. Unless you subsequently specify that such diagnoses have been ruled out, they may well be coded.

  16. Laboratory/Diagnostic Results • A diagnosis must be provided for every lab value that is monitored and/or treated. • Lab values and radiology reports that have been merely copied and pasted cannot be coded; the results must be commented on/interpreted.

  17. Clinical Connections • Link the diagnosis to the underlying condition, as coders can infer nothing. • Example: A patient with diabetes is admitted with vomiting and a history of diabetic gastroparesis. • If only vomiting is documented then vomiting is the coded DRG, with a case weight of .32. • If diabetic gastroparesis is documented and thus coded, the case weight will be .48.

  18. Signs and Symptoms • Clarify their cause, once discovered. • Don’t let the admitting symptom or lab finding be your default final diagnosis, as this will result in coding of a DRG with a lower case weight. • Examples: • Document acute respiratory failure (diagnosis) instead of respiratory distress (symptom). • Document sepsis (diagnosis) instead of bacteremia (lab finding).

  19. Signs and Symptoms (con’t) • Symptom diagnoses often result in medical necessity denials from insurers. • Example • Nausea, vomiting, chest pain, headache are often deemed appropriate for “observation” status, whereas diabetic gastroparesis with resultant bowel obstruction, unstable angina, or concussion with subdural hematoma likely qualify as inpatient stays, even if brief.

  20. 0 of 30 What is the most common reason for insurance companies to issue denials to Holy Cross Hospital? A. Inappropriate level of care (tele vs. med/surg) B. Consult or procedure delays C. Admission (i.e. observation status appropriate) D. Social issues delaying discharge

  21. HCH Denial Data 10/2010-10/2011

  22. Most Common HCH Admission Denials • Abdominal pain • Anemia • Asthma • Atrial fibrillation • Cellulitis • Chest pain and hypertension • DVT • Syncope • UTI

  23. Present on Admission (POA) Flags:Coders Choose Y, N, or W • “Y” if condition present at the time that inpatient admission is ordered • Conditions that develop during an outpatient encounter (i.e. in the ER, observation status, or during outpatient surgery), prior to inpatient admission, are POA. • “N” if not present on admission • “W” if physician clinically unable to determine whether or not condition was POA

  24. You obtain a first U/A on day #2 of a patient’s hospital stay, diagnose and begin treatment for a UTI. You are queried about the POA status of the UTI.

  25. 0 of 30 You are uncertain about whether or not the UTI was actually present on admission, so you: A. Answer yes, POA B. Answer not POA C. Ignore the query D. Document that you are clinically unable to determine whether or not the UTI was POA

  26. Diagnoses Frequently Requiring Clarification of POA Status • Decubitus or pressure ulcer • Examine each patient’s skin at the time of H&P performance and document ulcers. • UTI • Sepsis • Pneumonia • Acute renal failure

  27. Potentially Preventable Complications (PPCs) • Maryland’s version of “never events” • Financial penalties are possible if POA flagging is not accurate and PPCs are (incorrectly) assigned. • Holy Cross was ranked in the top quartile in the state for PPC performance in FY11.

  28. Documentation Specificity • Indicates increased resource utilization and so justifies higher reimbursement. • The more specific the diagnosis, the higher the assigned case weight and risk of mortality. • Specificity can provide exclusions for some PPCs. • e.g. Left sided heart failure—POA “Y” excludes PPC assignment for acute respiratory failure—POA “N”. Heart failure, NOS does not.

  29. Sepsis

  30. 0 of 30 Documentation of which of the following is sure to make a CDS cry? A. SIRS B. Sepsis C. Severe Sepsis D. Septic Shock E. Urosepsis

  31. Sepsis • The thread of the sepsis diagnosis should be reflected throughout the patient’s stay, as the diagnosis may not be captured by the coder if just mentioned in the H&P or early progress notes. • If treated and resolved then document sepsis resolved. • Include sepsis diagnosis in the discharge summary. • Indicate whether or not sepsis was POA and also its severity. (SIRS  Septic Shock) • Urosepsis is not a codable diagnosis; it codes as UTI. • Negative blood cultures do not preclude a diagnosis of sepsis.

  32. Clinical Documentation Improvement Program • A combination of concurrent (CDS) and retrospective (coder) chart review, with documentation clarification querying as necessary • Common query triggers: • POA status for • pneumonia, UTI, decubitis/pressure ulcers, MI, CVA • CHF specificity • acute, chronic, or acute on chronic, diastolic or systolic

  33. Query Essentials • Where will you find queries? • In your Message Center • Need help to access/answer a query? • Call CDS (x8641) or Physician Coach (x2348) • Where should you document your response? • As an addendum to your H&P, progress note, or discharge summary • NOT ON THE QUERY ITSELF

  34. 0 of 30 The appropriate time frame to answer a query is? A. Sometime before Christmas B. It doesn’t matter because no one will notice if you answer it. C. As soon as you receive it, or when you next see the patient, or within 48 hours D. Before the end of the month

  35. Queries (con’t) • When should you answer a query? • ASAP • If you disagree, click “refuse” and explain. • Help us understand why you disagree with a particular query so we can ask better queries. • There will be follow up if query is unanswered. • Both CDS and coder queries will be followed up by the CDS team.

  36. Top Three Reasons For Prompt Query Response • #3 Charts are being coded 2-5 days after discharge. If query response is not timely the late documentation will require subsequent chart recoding or might even be overlooked. • #2 You will avoid phone calls from a CDS, and your Message Center will be emptier. • #1 It will ensure that the patient’s story has been told and that the medical record accurately reflects the severity of illness and complexity of care provided to your patients.

  37. Summary • Accurate documentation is critical to • tell the patient’s story • details the patient’s diagnoses and describes how they were determined and treated • enable proper reimbursement of care • correct DRG and SOI assignments result in case weight that reflects resources used • ensure hospital and physicians correctly rated • public reporting

  38. Public Reporting • Core Measures • Ever expanding—soon including CVA, VTE • PPCs • Publically accessible websites rating physicians • Physician Compare – coming in 2012 • Outcomes based data for inpatient care • – Independent source of physician information and hospital quality outcomes

  39. In Conclusion… Thank you for the excellent care you provide to patients at Holy Cross Hospital and for the attention you pay to the documentation of that care.