acdis day1-5 track4-1 pres 0515 ciccarelli-west-haynes f · ©2015 hcpro, a division of blr. all...

©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.

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Utilization Review and CDI: A Physician Advisor’s Perspective

Stephanie Ciccarelli, MD, FACP

Physician Advisor

Rhonda West‐Haynes, MHA, BSN, RHIA, CCDS

Manager, Clinical Documentation Specialists

Penn Medicine – Chester County Hospital

West Chester, Pennsylvania

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Describe the importance of information technology in achieving a successful CDI program as well as satisfying compliance initiatives

– Define strategies on how to incorporate medical necessity, CDI, and the 2‐midnight rule initiatives in an organized, efficient fashion while utilizing the electronic health record

– Explain ways to engage medical staff/CDI/case management in education and increase their use of technology

– Identify ways to measure the success of initiatives

– Identify ways the processes discussed in this presentation can be incorporated and adapted at your facility


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Hospital Goals

Initiatives

CDI

Medical necessity

Meaningful use

LOS

Readmissions

Compliance

Profiles

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• HIMD

• CDIS

• Clinicians

• Administrators

• Nursing

• Utilization review – case management

• IT staff

Who Are the Players?

What or who is the common

factor?

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You Need the Doctor to Buy In

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SWITCH: How to Change Things When Change Is Hard

Chip Heath & Dan Heath


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Emotions Willpower

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Even though I have performed a carotid endarterectomy, you mean to tell me that CMS can refuse to reimburse us if I don’t have an attestation documented that this is a CMS IP‐only surgery even though it is listed on the list they created? This just sounds WRONG!

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You mean to tell me that if I write the inpatient order after my elective surgery (as I have been doing for the last 30 years), CMS won’t pay because technically, this CMS IP‐only surgery was performed before the patient was an inpatient? What kind of moronic world do we live in?!


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This patient has a diverticular hemorrhage. Of course they have “acute blood loss anemia”—everyone with a hemorrhage does. Why should I document it again? And why would insurance reimburse more for writing “acute blood loss anemia?” Insurance underpays everything else; why would they be willing to pay us more for the same problem? Isn't this double dipping? This just sounds WRONG! Why should I believe this, and why should I believe you?

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Insurance companies are so unfair and don't pay us for the services really provided (in situations involving technicalities like the 2‐midnight rule). Do you really expect me to believe that they will reimburse thousands of dollars extra for a single diagnosis? This sounds like insurance fraud.

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I already wrote “acute COPD flare.” Why is “acute COPD flare” not the same as “acute COPD exacerbation?” Do you know what a synonym is?!


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I already wrote “anemia from blood loss.” Why are you asking me to write it again? How is “acute blood loss anemia” different from “anemia of blood loss?” Why do you keep asking me the same question? Don’t you have anything better to do? Do they pay you to do this?

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You want me to write that my morbidly obese patient with a SBO who has been NPO for seven days has severe protein‐calorie malnutrition?!

The doctor has a defensive reaction that this somehow means they

were a bad doctor because they let this occur; they think they are being told that they should have started TPN earlier and prevented this from

occurring.

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A patient is three weeks postop and is now admitted with a wound infection. The doctor answers "not a complication" to a coding query.

The doctor thinks that if they admit it was a

complication, it implies they provided poor care or did

something wrong.


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I did not go to medical school to learn this crap!

What’s in it for me?

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5 Rules of Success for Doc Engagement

1. Keep it super simple!

2. Educate and remind doctors every chance you get.

3. Make sure that your information is accurate. Once they don’t trust you … you’re DONE!

– It’s okay to say, “Let me check on that or confirm that.” It’s better than being caught saying something inaccurate.

4. Remind docs every chance you get that you are on the same team.

– NEVER argue with the doctor!

– Make yourself SUPER available.

5. Support and partnerwith others.

– Nurses and CM staff.

– Physician advisor or physician champion.

– Ancillary departments.

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5 Rules of Success for Doc Engagement

S Simple

E Educate and remind

A Accurate

T Teamwork

S Support and partner


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2‐Midnight Rule

• Attestation of two‐midnight expectation and why

• Since January 2, 2015, this is no longer a critical need, BUT you will still need this to help justify medical necessity and to help use the “quicker recovery” exemption to still receive inpatient DRG if less than two midnights

• Since January 1, 2015, 20‐day and every‐30‐day recerts are now critical to reimbursement

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2‐Midnight Rule

• Form (moving away from paper).

• Include in H&P or note. “Buried” and difficult to track.

• Order.

Order Easy to track

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! = Alert• CDI query• CMS two‐midnight attestation• CMS IP‐only surgery• VTE prophylaxis • Pressure ulcer • Foley catheter• Malnutrition alert

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XXXX


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We chase down the attendings to complete the

orders and certs

98%–100%16 months


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SIMPLIFY

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Dear Dr. X,

Na=130 on 1.31 (admitted 1.31).

Pt is on IVF (NS).

Diagnosis:

Hyponatremia

Clinically insignificant below normal sodium value

Other

Clinically unable to determine

AND:

POA (present on admission)

HAC (hospital acquired)

(Inpatient coders cannot code from lab reports w/o clinical physician confirmation.)

Thank you.

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Dear Dr. X,

The patient was admitted 1/17/2015.

1/17/15 NA 132.

1/18/15 NA 131.

Treatment: IVF.

Please clarify below and in your progress notes which, if any, of the following are being monitored or treated this admission:

Hyponatremia

Clinically insignificant below normal sodium value

Other

Unable to determine

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Dear Dr. X,

Documentation in the medical record indicates the following: The patient has anemia that is worse due to blood loss during ORIF. Hgb 11.7 on admit with drop to 7.3 with patient receiving 2 units PRBC.

Based on your medical judgment, can you further clarify below which, if any, of the following conditions are responsible for these findings:

Acute blood loss anemia

Chronic blood loss anemia

Acute postoperative blood loss anemia

Iron deficiency anemia

Acute on chronic blood loss anemia

Other anemia

Other/unable to determine

Thank you.

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Dear Dr. X.

Dx: Anemia.

• s/p ORIF

• Hgb: 11.7 7.3

• 2u pRBC given

** Looking for more specificity in the dx of anemia: **

(Some examples)

Acute blood loss anemia

Chronic blood loss anemia

Acute postoperative blood loss anemia

Iron deficiency anemia

Acute on chronic blood loss anemia

Other anemia

Other/unable to determine

Please base your answer on your best medical judgment.

Thank you.


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Dear Dr. X,

Inpatient coders cannot code diagnoses from path reports without physician confirmation somewhere in the chart. In the impression of the pathology report, metastatic ductal ca to 1/19 lymph nodes is documented.

Do you agree with the path report specifying metastatic ductal ca to 1/19 lymph nodes? Please document your response below as:

Yes

No

Other

Clinically undetermined

Thank you.

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Dear Dr. X,

Pathology report:

• Metastatic ductal cancer to lymph node

Do you agree that “Metastatic ductal cancer to lymph node” has clinical significance?

Yes

No

Other

Clinically unable to determine

(Inpatient coders cannot code from path reports w/o clinical physician confirmation.)

Thank you.

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Dear Dr. X,

Malnutrition documentation clarification.

“Malnutrition” is documented in your progress note. The record notes a serum albumin of 2.3, BMI=33.66, and nutrition assessment notes patient at risk, 9.3% of weight loss in past month with a diagnosis of rectal cancer w/oral intake of < 75% of energy intake, severe peripheral edema. If you agree with the addition of the diagnosis, and in order to accurately reflect patient severity, please document the severity (mild, moderate, severe, or other) of malnutrition this patient is thought to have.

Thank you.


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Dear Dr. X,

“Malnutrition” is in your progress note.

Nutritionist: “Pt met ASPEN criteria for severe protein‐calorie malnutrition.”• Serum albumin=2.3• BMI=33.66 • 9.3% of weight loss in past month w/diagnosis of rectal cancer • Oral intake of < 75% of energy intake• Severe peripheral edema • Muscle wasting

Do you agree with dx of “severe protein‐calorie malnutrition?” Yes No Other Clinically unable to determine

Thank you.

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Top 20 Most Common Queries

• Acute blood loss anemia

• Sepsis or SIRS

• Underweight, morbid obesity

• CHF, specificity

• Shock

• AKI and ATN

• Demand ischemia vs. NSTEMI

• Acute respiratory failure

• Cardiorenal syndrome

• Encephalopathy

• Hemiparesis

• Protein‐calorie malnut, degr

• HCAP = GNR pneumonia

• Hyponatremia

• Hypercoagulable state

• Pathologic fracture

• Transbronch bx lung tissue

• Complication

• Path report

• Excisional debridement

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Focus on Just a Handful of CDI Terms

• OB‐GYN – ABLA (acute blood loss anemia)

• Cards – asystole, atrial flutter, bifascicular block, V‐tach, CHF, cardiorenal syndrome, CKD, accelerated hypertension

• Ortho – pathologic fx, complication?

• Gen surg – sepsis, peritonitis, debridement

• Heme – pancytopenia, hypercoagulable state


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Physician Champions

Recruit your physician champions and especially specialists to help educate

other doctors on definitions and clinical appropriateness of these diagnoses.

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Thank you. Questions?

[email protected]@cchosp.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

acdis day1-5 track4-1 pres 0515 ciccarelli-west-haynes f · ©2015 hcpro, a division of blr. all...

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