the impact physician documentation on hospital reimbursement and metrics
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The Impact Physician Documentation on Hospital Reimbursement and
Metrics
Integration of CDIPhysician documentation
Clinical Documentation Improvement (CDI)/Concurrent Review
Coding
(identify/validate principal and secondary diagnoses & procedures)May refer back to CDI as needed or may query provider
ICD-9 codes
Grouping of ICD-9 diagnosis codes
(APR-DRG, MS-DRG, or DRG)
Submission of hospital bill
Disclaimer
The following information is educational and based on estimates of MS-DRG distribution against current practicesThis organization has a policy against DRG creeping
and/or DRG “upcoding”Physicians have the freedom to disagree with
CDI/coding recommendations without concern for any reprisal
Important Terms
• Principal Diagnosis • Secondary Diagnoses• Diagnostic Related Group (DRG)• Medicare Severity - Diagnostic Related Group
(MS-DRG)• Concurrent/Complicating Condition• Major Concurrent/Complicating Condition• GLOS – geometric/global length of stay
How Do Hospitals Get Paid by Medicare?
Each MS-DRG has a unique RELATIVE WEIGHT (RW)
XThe hospital’s annual BASE RATE
=Hospital Payment ($)
Ensuring the Highest RW
The principal diagnosis and the principal procedure (if applicable) establishes the base MS-DRGCo-morbidities (a.k.a. complicating or concurrent
conditions) can adjust the MS-DRG to a higher relative weight = $
THEREFORE, a systemic, full body approach is more effective than a focused assessment, which requires a comprehensive H & P, identifying all body systems impacted by the disease process
Principal Diagnosis
Establishes the base MS-DRGThe condition, after study, which occasioned the
inpatient admission to the hospital – Not necessarily what brought the person to the
hospital• ER c/o abdominal pain• Admitted for SIRS 2/2 chronic pancreatitis (principal dx)
– Should be a disease process or condition rather than a symptom i.e., CAD vs. chest pain
Principal Diagnosis
Coders can’t infer a cause/effect relationship– The physician doesn’t have to state the condition in the
H&P for it to be the principal dx HOWEVER– The presenting symptomology necessitating the
admission MUST be linked to the final disease process diagnosis by the physician • Usually this occurs in the discharge summary; therefore,
discharge summaries should be completed as soon as possible following discharge for accurate coding• The provider needs to clearly state the diagnosis was
present on admission (POA) as evidence by the presenting symptoms of . . .
Co-morbidities (CC/MCC)
Additional conditions that affect patient care in terms of requiring:• Clinical evaluation AND/OR• Therapeutic treatment AND/OR
– Continuation or adjustment of home medications– Initiation of new medications or IVF
• Diagnostic procedures AND/OR• Extended length of hospital stay AND/OR
– Focus on GLOS – global length of stay• Increased nursing care and/or monitoring
Co-morbiditiesCC = concurrent condition
Patients who are more ill than a “healthy” person with the same principal condition i.e., many chronic conditions add a CC
MCC = major concurrent conditionRepresent the highest severity of illness to identify the
“sickest of the sick” i.e., acute episodes (exacerbation) of chronic conditions e.g., acute on chronic systolic or diastolic HF and/or potentially lethal conditions i.e., acute respiratory failure, shock, encephalopathy, ESRD, open fracture of a major bone, etc.
Secondary ConditionsSome DRGs differentiate between “ill” and
“sickest of the sick” patients – One tier• no differentiation among patients
– Two tier• With a CC/MCC or without a CC/MCC
Differentiate between ill and more ill/sickest of the sick Easiest to move the MS-DRG
• With a MCC or without a MCCDifferentiate between ill and sickest of the sickMost difficult to move the MS-DRG
– Three tier • Without a CC or MCC (ill)
– Medicare estimates 41% of total patient population• With a CC (more ill)
– Medicare estimates 37% of total patient population• With a MCC (sickest of the sick)
– Medicare estimates 22% of total patient population
MS-DRGs GroupingsSubgroups
# base MS-DRGs
# of MS-DRGs
Single no CC/MCC option 53 53
Two tiered
w/CC/MCC43 86
w/o CC/MCC
w/MCC63 126
w/o MCC
Three tiered
w/MCC
152 456w/CC
w/o CC or MCC
RecommendationsProvide more extensive H & P
• CCs and MCCs are based on the secondary conditions that occur with the principal dx
• Many problematic cases are elective admissions• Specify which “history of” conditions are being treated
compared to those that are resolved• Note when a chronic condition is exacerbated
Assign a diagnosis to abnormal lab values i.e., “acute blood loss anemia” or “posthemorrhagic anemia” when transfused due to low H&H
Document identified or suspected organism leading to antibiotic selection for all infections, especially pneumonia
Documentation Hints
• Chronic conditions: – Last 12 months or longer AND– Places limitations on self-care, independent living, &
social interactions– Results in the need for ongoing intervention w/medical
products, services, and special conditions• Always note when the patient is experiencing an
acute exacerbation of a chronic condition• Describe how the patient’s current condition
differs from their normal baseline
Weight Issues
Add BMI to your H & P– BMI > 40 + morbid obesity = CC• Provider must document the BMI and the diagnosis of
obesity or morbid obesity– Protein-calorie malnutrition = CC– BMI < 16 + severe malnutrition = MCC– Cachexia = CC• Note under general impressions
– Emaciated = MCC• Note under general impressions
Substance Dependence• Substance dependence is not the same as
substance abuse and can occur with prescription medications
• Document any withdrawal symptoms associated with substance use i.e., alcohol or drugs (specify substance if known).– Alcohol or drug withdrawal = CC– Toxic encephalopathy = MCC
• Link the treatment of a “banana bag” with the diagnosis of thiamine deficiency in alcoholics– Thiamine deficiency = CC
Mental Status
Altered Mental Status (AMS) does not convey severity in ICD-9Consider acute delirium – confusion accompanied
by agitation or other behavioral disturbances rather than “confusion,” or “altered mental status” secondary to Alzheimer’s, late effect of stroke, Lewy body dementia, vascular dementia, anoxic encephalopathy, alcohol withdrawal, etc. = CC
Consider encephalopathy (toxic or metabolic) especially with acid/base or electrolyte imbalances
Renal Function
Be sure to distinguish between acute and chronic Renal Failure and specify Acute Tubular Necrosis (ATN) when applicable:–Acute Renal Failure (A.K.A. non-traumatic
Acute Kidney Injury or AKI) = CC–ATN = MCC
Renal Function
Chronic Kidney Disease (Chronic Renal Failure)• Always specify the applicable stage• Use the National Kidney Foundation’s
standardized staging of progressive kidney disease – add a CC–CKD stage IV (severe) • GFR = 15-29 SCr = 2.5 – 4.5
–CKD stage V (cardiovascular disease) • GFR = <15 SCr = > 4.5
Renal Failure
Chronic Renal Failure (CKD IV & V) = CC
End Stage Renal Failure = MCC • specify the known or suspected underlying
cause of ESRD i.e., HTN, DM, renal cystic disease, systemic lupus erythematosus, glomerulomephritis, etc.
Renal Failure
• The known or suspected etiology of kidney disease should be specified
• Coding assumes a casual relationship b/t HTN and CKD – The presence of essential hypertension and CRF is
classified as “Hypertensive Kidney Disease” which is not inclusive of renal manifestations due to secondary HTN – so add the documentation/diagnoses
Renal Insufficiency
• Codes to “unspecified disorders of the kidney and ureter” and is considered by coding as an early stage of renal impairment
• Chronic renal insufficiency codes to “CKD, unspecified”
• AVOID using renal insufficiency and renal failure interchangeably
Fluid Volume Overload
Determine the cause of Fluid Volume Overload• Fluid volume overload is always attributed to
CHF if it is listed as a secondary diagnosis unless another cause is clearly specified e.g., ESRD, as the cause of the fluid volume overload– This can lead to failures on CMS Quality Measures
for HF as the provider does not realize the principal diagnosis will be HF on these patients
– Remember to have heart failure, the heart must have pathology
Heart Failure
Avoid the use of term “CHF” (congestive heart failure) – Classify to the type of heart failure whenever
possible• Systolic • Acute• Diastolic • Chronic• Combined • Acute on chronic
(exacerbation or decompensated)
– Use presenting symptomology when ECHO results are not available
Heart Failure
Systolic – most common type of HFEF < 40% Dilated on Echo Cardiomegaly on CXR S3 gallop
DiastolicEF usually normal LVH on EKGS4 gallop Often hypertensiveAbnormal relax on ECHO
Acute Heart Failure
SymptomsRales CVP > 16 cmNeck vein distensionParoxysmal nocturnal dyspneaAcute pulmonary edema or BNPWeight loss => 4.5 kg in 5 days in response to CHF
treatment
Electrolyte Imbalances
Interpret abnormal lab valueshyponatremia/ hyposmolality = CC
SIADH = CCMetabolic encephalopathy = MCC
Hyperkalemia (not a CC)Hypoaldosteronism = CC
ACE-Inhibitors, Angiotensin Receptor Blockers, Spironolactone
Hypercalcemia (not a CC) Metabolic encephalopathy = MCC
Electrolyte Imbalances
Are there acid/base imbalance?Acidosis = CC
HCO3<18
Alkalosis = CCHCO3 >28
Rather than Altered Mental Status or Confusion - consider Metabolic encephalopathy = MCC
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