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CDI for Inpatient CodingMaterials by: Kimberly Cunningham CPC, CIC, CCS

Presented by: Rae Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CCS

No part of this presentation may be reproduced or transmitted in

any form or by any means (graphically, electronically, or

mechanically, including photocopying, recording, or taping)

without the expressed written permission of AAPC.

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• Clinical Documentation Improvement in an Inpatient setting

• Common inpatient conditions that often create documentation and coding problems

• Accurate physician documentation and tips on how to improve your physician’s

documentation

• Effective query writing and when it is appropriate to query the physician

• Clinical indicators and how they can help improve physician documentation

CDI for Inpatient Coding

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What does CDI look like in the for Inpatient Coders?

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CDI Professionals

• CDI Specialist

• Inpatient Coder

• Auditor

• Nurse Reviewer

• Physician Reviewer

• Quality Department


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Importance of Clinical Documentation

• The goal of Clinical Documentation Improvement initiatives in the inpatient setting are to

maximize the opportunity to obtain the most accurate account of the patients inpatient

hospital stay. CDI specialists work to review the documentation while the patient is still in

the hospital. This allows for real time interaction between CDI professionals and

Practitioners to capture the most accurate diagnoses.

• CDI professionals have important knowledge regarding documentation requirements for

various diseases and conditions that are often problematic for physicians. By reviewing the

documentation and data while the patient is still in house, the problematic documentation

can be reviewed and clarified by the physician before the patient is discharged from the

hospital.


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Importance of Clinical Documentation

• With the implementation of ICD 10 CM and PCS in October, 2015, and the specificity to

which to codes account for, physician documentation requires great detail with clear and

concise documentation. Many payers will not allow diagnoses to be submitted to an

unspecified category, so physicians are required to clearly define the patients condition.

• CDI professionals and CDI initiatives promote the best practice for the entire revenue

cycle. From the time the patient is admitted to the facility, CDI professionals analyze the

documentation and data, and work with the physician to ensure that the patient’s condition

is captured completely, prior to discharge. This helps to decrease the number of

retrospective queries to physicians post discharge.

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Emergency Department Admission

Labs and other

Diagnostic tests

performed

Inpatient Admission

Consult Specialist

Labs and other

Diagnostic test results reviewed

Physician MDM and

DD

Attending physician determines

diagnosis and treatment plan

Patient Discharged

Code and Submit

Claim or Bill for IP

Encounter

Each Triangle representsan

opportunity for CDI review and documentation improvement.


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Impact of CDI on Inpatient Reimbursement

• Clinical Documentation Improvement initiatives can directly impact reimbursement as well as facility quality

measures and data reporting.

• Beyond the ongoing CDI reviews that take place during the inpatient encounter, prebill audits or reviews can be

done to ensure accuracy of the documentation and coding before the bill is dropped.

• Ongoing Quality reviews of CDI specialist and Inpatient Coders to ensure accuracy help to maximize

reimbursement and insure that documentation reviews and coding are accurate.

• Audits of physician documentation, along with physician education can improve physician documentation and

ensure the accuracy of the codes assigned, and maximize reimbursement.

• The assignment of a diagnosis code is based on the provider’s diagnostic

statement that the condition exists. The provider’s statement that the patient

has a particular condition is sufficient. Code assignment is not based on

clinical criteria used by the provider to establish the diagnosis.

Code assignment and Clinical Criteria

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We will review the medical record documentation to ensure that it

supports the diagnoses that MA organizations submitted to CMS for use in

CMS’s risk-score calculations and determine whether the diagnoses

submitted complied with Federal requirements. Prior OIG reviews have shown

that medical record documentation does not always support the diagnoses

submitted to CMS by MA organizations. MA organizations are required to

submit risk adjustment data to CMS in accordance

2016 OIG Workplan

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Question 25: (new 08/18/2016)

Is Medicare going to phase in the requirement to code to the highest

level of specificity?

Answer 25:

No, providers should already be coding to the highest level of specificity. ICD-

10 flexibilities were solely for the purpose of contractors performing medical

review so that they would not deny claims solely for the specificity of the ICD-

10 code as long as there is no evidence of fraud. These ICD-10 medical

review flexibilities will end on October 1, 2016. As of October 1, 2016,

providers will be required to code to accurately reflect the clinical

documentation in as much specificity as possible, as per the required

coding guidelines.

CMS ICD-10-CM FAQ

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Common Inpatient Conditions in CDI

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Sepsis

• Septicemia is the most expensive condition treated in US hospitals

• Accounts for 5% of all hospitalizations in the United States

• 85% of patients with sepsis are admitted with the infection, the remainder acquire the condition as an inpatient

• Overall Inpatient death rate of 17.2% of those admitted with Sepsis

• Death rate climbs in those with hospital acquired sepsis

• 38.6% for medical admissions

• 29.2% for surgical cases

• Sepsis is more costly to treat in academic facilities


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Sepsis

• Common Documentation Errors with Sepsis

• Coding/CDI language of sepsis and physician language do not always match. Physicians will

often write statements like “urosepsis” or “sepsis like” among others to describe a patient that

may be septic.

• As coders and CDI specialist, there are very specific terms that indicate sepsis, or another

diagnosis such as bacteremia, SIRS, or another localized infection. It is often necessary to

query a physician to determine if sepsis was POA and treated during the inpatient hospital stay.

• CDI professionals should look for clinical indicators that coincide with a diagnosis of sepsis,

along with clear and concise documentation of sepsis in order to ensure proper code

assignment.


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Acute Respiratory Failure• There are Two Types of Respiratory Failure:

• Hypoxic: There is not enough oxygen in the blood.

• Respiratory Failure occurs when fluid builds up in the air sacs in the lungs and then oxygen cannot be released into the

blood.

• Hypercapnic: There is to much carbon dioxide in the blood.

• Respiratory failure occurs when the capillaries in the air sacs in the lungs cannot properly exchange carbon dioxide for

oxygen.

• There are many causes of Respiratory failure including, but not limited to:

• Injury

• Obstruction

• ARDS – Acute Respiratory Distress Syndrome – generally occurs with an additional underlying problem

• Drug and/or Alcohol abuse

• Chemical inhalation

• Stroke

• Patients most at risk for having respiratory failure generally smoke, or have a history of smoking, consume excessive amounts of

alcohol, have a family history or respiratory conditions or diseases, sustain an injury, or have a chronic lung disease such as cancer or

COPD.


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Respiratory Failure

• Common Documentation Errors with Respiratory Failure

• Physicians will often document respiratory failure or acute respiratory failure in instances when

the patient may be having respiratory symptoms due to another underlying condition or cause,

such as heart failure, COPD, lung injury, post surgical period etc.

• Depending on the origin of the respiratory failure, coding guidelines may provide sequencing

instruction that will require specific physician documentation of the cause of the patient

respiratory condition.

• CDI professionals should look for clinical indicators that coincide with a diagnosis of respiratory

failure, along with clear and concise documentation of the condition in order to ensure proper

code assignment.


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Pneumonia

• Pneumonia is a lung infection caused by a bacteria, virus or fungi.

• There were 1.1 million inpatient discharges for pneumonia in 2015.

• The average length of an inpatient hospital stay for a patient diagnosed with pneumonia is

5.2 days.

• Most healthy people recover from pneumonia, however the condition can be life

threatening.

• Around 1/3 of all pneumonia cases are caused by a virus, with the flu virus being the most

common viral cause.

• A chest x-ray is usually needed to diagnose pneumonia.

• Generally inpatient pneumonia treatment involves fluids, antibiotics and sometimes

respiratory therapies such as inhalers, nebulizers or oxygen.


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Pneumonia

• Common Documentation Errors with Pneumonia

• Physicians will often document a diagnosis of pneumonia, and they will also document any

bacterial findings that may be present on any diagnostic labs. Unless the physician documents

a relationship between the pneumonia and the organism, the pneumonia cannot be coded to

that type of bacterial pneumonia.

• Pneumonia is a common condition that can develop while a patient is receiving care in a hospital

or facility. Often physicians will document CAP or HAP which indicates, community or hospital

acquired pneumonia. It is important to determine if the pneumonia was present on admission,

or if it developed subsequently following admission to the hospital.

• CDI professionals should look for clinical indicators, including imaging that coincide with a

diagnosis of pneumonia, along with clear and concise documentation of the condition in order to

ensure proper code assignment.


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Heart Failure

• Congestive heart failure is the leading cause for admissions of adults 65 years of age and

older.

• There are greater than 1 million admissions annually with CHF as the principal diagnosis.

• There are nearly 6 million Americans living with Heart Failure.

• There are over 900,000 new diagnoses each year.

• In 2012, CHF accounted for $17 billion in Medicare expenditures.

• Most common comorbid conditions are coronary artery disease, high blood pressure and a

prior heart attack.

• Common tests done to diagnose Heart Failure include blood tests, chest x-rays, EKG,

ECHO, Stress tests, scans and cardiac catherization.


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Heart Failure

• Common Documentation Errors with Heart Failure

• Physicians will often document a diagnosis of heart failure, but they will neglect to document the type of heart

failure, either diastolic or systolic, and the acuity of the condition. This documentation is key to accurately

capturing a heart failure diagnosis.

• Another common documentation error that occurs with heart failure is the documentation of comorbid

complications associated with heart failure such as pleural effusions, edema and respiratory conditions. All of

these conditions are inherent, and are symptoms of a heart failure diagnosis. So they would not coded

separately unless there is specific treatment directed to that condition. For example a heart failure patient with

a pleural effusion that is treated with a chest tube placement. The pleural effusion can be coded as an

additional diagnosis.

• Heart failure patients often have many coexisting diagnoses, some of which, when documented by the

physician can be reported with relation to the patient’s heart failure, such as hypertension. It is important that

the physician clearly establishes a relationship between the both conditions for accurate code assignment.

Hypertension with Heart Disease

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The classification presumes a causal relationship between

hypertension and heart involvement and between hypertension and

kidney involvement, as the two conditions are linked by the term “with”

in the Alphabetic Index. These conditions should be coded as related

even in the absence of provider documentation explicitly linking them,

unless the documentation clearly states the conditions are unrelated.

For hypertension and conditions not specifically linked by relational

terms such as “with,” “associated with” or “due to” in the classification,

provider documentation must link the conditions in order to code them

as related.


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Encephalopathy

• Encephalopathy is a disease that affects the function or structure of the brain.

• There are many different types of encephalopathy. Below are a few types, certainly not all:

• Chronic Traumatic

• Hepatic

• Hypertensive

• Hypoxic

• Lyme

• Static

• Toxic Metabolic

• Patients with encephalopathy may present with altered mental status including severe confusion and

disorientation, and memory loss.

• Other symptoms include weakness, difficulty speaking, seizures, lethargy and even coma.


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Encephalopathy

• Common Documentation Errors with Encephalopathy

• Physicians will often document a diagnosis of encephalopathy, however within the medical

record the documentation does not clearly support the diagnosis of encephalopathy.

• Often encephalopathy will be reported, and the diagnosis is supported, however it is integral to

another reported condition, and therefore, not separately reported.

• Patients with encephalopathy often have many complicated additional diagnoses and conditions

that can make it difficult to determine if the condition was present and treated during the

inpatient hospital encounter, or if another diagnosis is responsible for the patients condition.


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Acute Kidney Failure (AKI)

• Acute Kidney Failure occurs when the suddenly lose the ability to eliminate salt, fluid and waste from the blood. This can cause electrolytes and waste materials to accumulate in the body which can be a life threatening condition.

• Also documented as acute kidney injury and acute renal failure.

• AKI is a common condition that often develops to patients that are in the hospital for other reasons, and can develop very quickly, however those that are critically ill are most at risk. AKI often occurs in patients that also have dehydration, urinary tract obstruction, injury, hemorrhage, burns, low blood pressure, serious injury or illness, are post surgical or have sepsis.

• AKI requires inpatient treatment and monitoring to effectively treat the condition.

• Labs tests of the blood and urine, along with imaging are used to diagnose and monitor AKI.


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Acute Kidney Injury (AKI)

• Common Documentation Errors with Acute Kidney Injury

• Physicians will often document kidney dysfunction with terminology of prerenal, intrarenal and

post renal. These terms alone are not enough to document acute renal failure or AKI. The

physician needs to clearly document that the patient has AKI for it to be reported.

• Often AKI will occur in patients that have Chronic Kidney Disease. It is important to carefully

review the documentation and confirm that patients baseline status, as it may differ from a

patient that does not have CKD and is suffering from AKI. If both conditions occur, both are

reportable diagnoses.

• Physicians will often diagnose a patient with renal insufficiency. This is different from AKI.

Renal insufficiency is the early stages of renal impairment that has not progressed to failure. If

this condition is documented it may be necessary to query to physician to determine the proper

diagnosis.


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Anemia

• Anemia is the most commonly found blood disorder and occurs in more than 3 million Americans.

• Patients with Anemia lack oxygen in their body. Symptoms of Anemia include weakness, shortness of breath, dizziness, fast or irregular heartbeat, headache, whooshing sound or pounding in the ears, cold hands or feet, pale or yellow skin and chest pain.

• There are many risk factors for anemia that make it a common condition among the inpatient population such as poor diet, intestinal disorders, chronic illness, infections and being postsurgical.

• Iron-deficiency anemia is the most common type of anemia and occurs when the body does not have enough iron in the body. This usually occurs due to blood loss, but can also be due to poor absorption of iron.

• Anemia also occurs in chronic diseases such as chronic kidney disease and neoplasms. Patients receiving chemotherapy for treatment of their neoplasm can develop Aplastic Anemia which is a rare type of anemia that occurs when the body stops making red blood cells.


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Anemia

• Common Documentation Errors with Anemia

• Patients that are having a surgical procedure are at risk for blood loss and anemia. These

patients often incur a post surgical drop in hemoglobin that is an expected occurrence following

some surgical procedures or childbirth. It is important to carefully review physician

documentation to determine the proper diagnosis of documented anemia in those instances.

• There are sequencing guidelines with reference to coding anemia with a neoplasm. It is

important to carefully review the documentation to determine the type of anemia present, and

the focus of care for the inpatient encounter.


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Complications of Care

• Complications of care range from Hospital Acquired Conditions (HAC) or Hospital Acquired Infections (HAI) to

post surgical and post traumatic complications, pressure ulcers and injuries while an inpatient, as well as adverse

effects and other complications of medical care.

• CMS publishes the list of HACs in the Final Rule each year.

• Many facilities track data as it relates to complications of care and have protocols in place to help prevent

complications from occurring.


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Complications of Care

• Common Documentation Errors with Complications of Care

• Physician documentation regarding the relationship between medical care and complications

needs to be clearly documented. If there is not a relationship established by they physician it

cannot be documented as such.

• There are sequencing guidelines with reference to coding complications and other conditions

that need to be accounted for when sequencing coding for cases of complications of care.

• Some outcomes are anticipated follow surgical procedures and medical care, and are not

reported as complications of care. Clear and concise physician documentation must be present,

or the physician must be queried when the documentation is unclear.


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Procedure Coding

• With the implementation of ICD 10 PCS, clear and accurate accounts of procedures is necessary for proper code

assignment.

• ICD 10 PCS requires a strong knowledge of Anatomy and Physiology, as well as surgical terminology in order to

effectively assign the proper procedure codes.

• CDI specialist and coders may not always use the same terminology with regard to procedure descriptions. It is

important to note that it is not the job of the physician to use the terminology that is used by ICD 10 PCS, but

rather it is the job of the coder to review the procedure and determine the proper code assignments based on the

physician account of the procedure.

• DRG assignment for Inpatient encounters is divided by surgical and non surgical DRG assignment. It is important

to accurately ensure the documentation matches the procedure code assignment to insure proper

reimbursement.

Common Inpatient Documentation Issues in CDI

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Importance of Accurate and Detailed Physician Documentation

The detail and accuracy of physician documentation is key to proper reimbursement and data

reporting.

• Common Inpatient Documentation Issues:

• Conflicting Documentation

• Diagnosis not confirmed on Discharge Summary

• Two or more Conditions exist on Admission

• Clinical indicators do not support a diagnosis or vice versa


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Conflicting Documentation

Conflicting Documentation:

• Principal or secondary diagnosis is confirmed on the discharge summary but not clearly and concisely document

in the body of the medical record, or the documentation in the record is vague or incomplete.

• Two physicians call the same condition two different things. A consulting physician may note one diagnosis, while

a different or attending physician refers to the same condition with a different diagnosis.

• Early workup, such as ED documents or History and Physical report document one conditions, however over the

course of evaluation, the condition may be an entirely different diagnosis.


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Diagnosis not confirmed on the Discharge Summary

• Principle of secondary diagnosis that are reported as having existed or established throughout the medical

record, but not confirmed at the time of discharge.

• Diagnosis described as probably, possible, suspected etc. must me documented as such at the time of discharge

in order to be reported. Initial workup may indicate a probably condition, but the continuing evaluation may

determine an entirely different diagnosis.


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Two or more conditions exist on admission

• When two or more conditions exist on admission but one condition requires treatment with surgical management.

• When two or more conditions exist on admission, but one condition requires more intensive treatment such as IV

medications, and monitoring that is only available as an inpatient.


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Clinical indicators do not support Physician documentation or vice versa

• Clinical indicators may support a diagnosis, however the physician may not document the diagnosis.

• A physician may report a diagnosis, however, clinically the documentation does not support that diagnosis.

• Clinical Indicators have become a large part of CDI and Inpatient coding. With the implementation of RAC audits,

and the continued scrutiny of physician documentation and coded data, it is important for CDI specialists and

Inpatient coders to have a strong working knowledge of clinical indicators and disease process. This helps

facilitate a collaborative documentation and reporting relationship between the physician and the HIM staff. It

allows for the most accurate account of the patient encounter to be captured, and optimizes reimbursement

potential.

• Many facilities adopt clinical indicator standards for reporting of commonly treated conditions.


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How to Improve Physician Documentation

• Physician Education

• Clinical Indicator Standards

• Documentation Standards

• Documentation and Coding Audits and Review


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Physician Queries

• A physician query is a method of communication used by coders and clinical documentation professionals to

request clarification of patient diagnoses or procedures from the physician. The physician query is used to clarify

documentation by clarifying conflicting, ambiguous, or incomplete information about significant conditions or

procedures in the medical record of the patient. In addition to obtaining clarification, the query may serve as an

educational tool to improve physician documentation and the coders’ understanding of clinical scenarios.

• Queries are often necessary for clarification. Queries can be done while the patient is still an inpatient in the

hospital to allow the physician an opportunity to clarify a diagnosis or procedure prior to the patient's discharge.

These are called concurrent reviews and queries. A query that is conducted after the patient has been

discharged is called a retrospective query. The facilities’ processes should include some manner of recording

the queries, such as an electronic database, or inclusion of the query in the medical record.


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Physician Queries

• Physician Queries should include:

• Patient name

• Admission date and/or date of service

• Health record number

• Account number

• Date query initiated

• Name and contact information of the individual initiating the query

• Statement of the issue in the form of a question along with clinical indicators specified from the chart


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Physician Queries

• The query should not be constructed in a manner that can be interpreted as leading the physician. Queries can

be open ended, and provide documentation from the medical record, along with clinical documentation to obtain

and a more concise diagnosis from the physician. Multiple choice or yes/no queries can also be utilized, however

it is important when providing choices for physicians to include the option of other, or if the diagnosis was

uncertain, or could not be determined.

• When responding to a query, the physician may document the response to the query in the body of the patient

medical record, such as on the progress notes, or in an addendum to other documentation. The physician query

can also be made part of the medical record.

Questions?

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• American Heart Association – Akshay S. Desai, MD, MPH; Lynne W. Stevenson, MD 2012

• http://circ.ahajournals.org/content/126/4/501.full

• National Kidney Foundation

• https://www.kidney.org/kidneydisease/aboutckd

• Centers for Disease Control and Prevention

• http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm

• Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4751740/

• World J Urol. 2014 Jun;32(3):813-9. doi: 10.1007/s00345-013-1167-3. Epub 2013 Sep 27.

• Pneumonia Fastats

• http://www.cdc.gov/nchs/fastats/pneumonia.htm

• Hospital-Acquired Condition Reduction Program (HACRP)

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html

• Diabetes Fastsats

• http://www.cdc.gov/nchs/fastats/diabetes.htm

• Management of diabetes mellitus in hospitalized patients

• http://www.uptodate.com/contents/management-of-diabetes-mellitus-in-hospitalized-patients

• Acute Respiratory Failure Written by Brindles Lee Macon and Winnie Yu Medically Reviewed by Deborah Weatherspoon, Ph.D, RN, CRNA, COI on October 13, 2015

• http://www.healthline.com/health/acute-respiratory-failure#Causes3

• Encephalopathy Written by Rose Kivi | Published on August 20, 2012 Medically Reviewed by Peter Rudd, MD

• http://www.healthline.com/health/hepatic-encephalopathy#Overview1

• Acute Kidney Failure Written by Bree Normandin and Winnie Yu Medically Reviewed by Steven Kim, MD on November 4, 2015

• http://www.healthline.com/health/acute-kidney-failure#Overview1

• American Society of Hematology

• http://www.hematology.org/Patients/Anemia/

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References:

http://circ.ahajournals.org/content/126/4/501.full

https://www.kidney.org/kidneydisease/aboutckd

http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4751740/

http://www.cdc.gov/nchs/fastats/pneumonia.htm

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html

http://www.cdc.gov/nchs/fastats/diabetes.htm

http://www.uptodate.com/contents/management-of-diabetes-mellitus-in-hospitalized-patients

http://www.healthline.com/health/acute-respiratory-failure#Causes3

http://www.healthline.com/health/hepatic-encephalopathy#Overview1

http://www.healthline.com/health/acute-kidney-failure#Overview1

http://www.hematology.org/Patients/Anemia/

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