clinical documentation improvement - lee health documentation... · clinical documentation...

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Clinical Documentation

Improvement

Precise Terminology is the Key to

Supporting the Integrity of Documentation

Specific Documentation

• Support medical necessity

• Capture severity and complexity of illness

• Validate the length of stay

• Support CMI (case mix index) compensation

• Withstand auditing

• Accurately reflect quality indicators and publicly published outcome measures

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Coding the Medical Record

• The primary diagnosis, responsible for

occasioning the admission, must be noted by the

attending Physician.

• Any diagnosis that is clinically supported and

currently being treated, monitored or evaluated

can be coded.

• Diagnoses discovered by diagnostic testing must

be validated as clinically significant in progress

notes by an actively involved practitioner.

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Codes For Capture

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Documents to code from Supporting evidence

ER Physicians note Nursing note

H & P PT/OT/RT/Dietary note

MD, PA, ARNP progress note Lab results

MD Consultation X-ray/CT/MRI/ECHO

Operative or Procedure report Pathology report

Discharge Summary Flow sheet

CDIs Role in Chart Completion

• Concurrently review the entire in-patient

chart, usually by day 3-4 of hospital

admission

• Seek to clarify any documentation that is

unspecified, unclear, conflicting or missing

• Send Queries to providers to obtain any

additional clarifying documentation

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The Query Process • A Query is an electronic question posed to

a provider by a CDI RN or MD

• Most queries are derived from a template

bank and are always in a multiple choice

format

• All queries are meant to be non-leading

and the best judgment of the practitioner

is advised

• Once answered, the query becomes a

permanent part of the medical record

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Answering The Query

• If a query is sent it will populate in the

Epic in-basket for chart completion

• A query that is sent on a template can be

answered in just a few clicks

• Select a response from the drop down

menu of options or manually fill in the

appropriate response as needed

• A signed query becomes a progress note

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What if I Don’t Answer?

• CDI personnel are required to follow-up on any query sent after 24 hours and every 24 hours thereafter. This can be done through email, text, page, office messages or personally

• After 72 hours an escalation process is initiated to facilitate compliance

• CDI personnel are located on each campus M-F to provide assistance or answer questions

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Hospital Acquired Conditions (HAC) and Patient Safety Indicators ( PSI)

– Foreign object retained after surgery

– Air embolism

– Blood incompatibility

– Pressure ulcers

– Falls

– Manifestations of poor glycemic control

– Catheter-associated urinary tract infection

– Vascular catheter-associated infection

– DVT/ pulmonary embolism after lower extremity procedures

– Surgical site infection

– Post operative DVT/PE, Respiratory Failure & Sepsis

– If you are not able to determine present on admission status- “unable to determine” choice does not code to a HAC

COPD Observer A Observer B Observer C

Principal

Diagnosis COPD

Exacerbation

COPD

Exacerbation

COPD

Exacerbation

Secondary

Diagnoses w/o CC/MCC w/CC Chronic

Diastolic/Systolic

CHF Oral Lasix -chronic

home medication

w/MCC Acute

Diastolic/Systolic

CHF IV Lasix

Medicare DRG 192 191 190

MS-DRG AMLOS 3.3 4.0 4.9

Relative Weights 0.7313 0.9321 1.1578

Severity of Illness

Risk of Mortality Level 1/minor

Level 1/minor

Level 2/moderate

Level 2/moderate

Level 2/moderate

Level 2/moderate

Reimbursement $5,143.20 $6,322.03 $7,647.09

Pneumonia Specificity

• Pneumonia can be specified based on the

treatment. Negative or inconclusive sputum cultures

do not preclude a diagnosis of a specific bacterial

pneumonia in patients with the clinical evidence of

this condition. (per: AHA Coding Clinic). If you

are/were treating a suspected, possible or probable

gram negative or other resistant pneumonia or

Sepsis, please document as such.

• CAP and HCAP are not specified

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Pneumonia

Observer A Observer B Observer C Observer D

Principal Diagnosis

Simple

Pneumonia,

unspecified

Simple

Pneumonia,

unspecified

Simple

Pneumonia,

unspecified

Complex

Pneumonia: Treating Gram

Negative

Secondary

Diagnoses

w/o CC/MCC w/CC AKI w/MCC ARF w/MCC ARF

Medicare DRG 195 194 193 177

MS-DRG

AMLOS

3.3 4.4 5.8 8.2

Relative

Weights

0.7111 .9695 1.4261 2.0549

Severity of

Illness

Risk of

Mortality

Level 1/minor

Level 1/minor

Level 2/mod

Level 1/minor

Level 3/major

Level 3/major

Level 3/major

Level 3/major

Reimbursement $5,024.61 $6,541.63 $9,222.24 $12,023.79

Diagnoses Impact Metrics

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Diagnosis CMI SOI/ROM ALOS

Weakness Glioblastoma grade 4 AKI

0.9207 2/3 3.2

Glioblastoma grade 4 AKI Cerebral edema

1.4680 4/4 4.4

Hierarchical Condition Category

For Risk Adjustment

• Reimbursement model implemented by CMS

• HCC diagnoses are considered excellent predictors of risk for future healthcare needs

• Documenting the entire disease burden during every 12-month period is essential for capturing resource consumption

• Common HCC diagnoses include: • Protein Calorie Malnutrition

• Specified Bacterial Pneumonia

• Diabetes with complications

• Drug and Alcohol Dependence

• Specified (Systolic/Diastolic) CHF

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Navigating Change • CDI is a resource team that works in

collaboration with providers to ensure that the documentation accurately encompasses all aspects of the medical picture and captures the level of care needed to help each patient

• Quality measures that affect population health, risk of mortality and morbidity are becoming a vital part of the health record. Diagnoses such as Malnutrition and Obesity are sought out to help define appropriate medical care in compliance with CMS guidelines..

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What has changed since the implementation of ICD-10:

Section

Body System

Root Operation

Body Part

Approach

Device

Qualifier

Diagnoses Codes: 14,025 71,486

Procedure Codes: 3,824 75,625

Injury codes increased from 2,600 to 43,000

Top 5 Most Bizarre ICD-10 codes of 2015

1.W55.21 Bitten by a cow

2. Z63.1 Problems in relationship with in-laws

3.W56.22 Struck by Orca, initial encounter

4.V97.33 Sucked into jet engine

5.V91.07 Burn due to water-skis on fire

Any Questions?

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