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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