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Level II TrainingClinical Documentation Improvement

DoIM – Hospitalists 7/09/14

Presented by:Catherine Porto, MPA, RHIA, CHP

Exec. Director HIM, UNMHICD-10 Executive Project Lead

&Erlinda Smith, CCS

CDI Provider Education& Kayode Balogun

CDI Program Development - Precyse

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UNMMG Coding Staff – Current State

UNMMG Professional Fee Coding:• Assign ICD-9-CM diagnosis code (for that visit)• Assign CPT procedure Codes (for that visit)

– Evaluation & Management (E/M)codes for provider services

– Procedure codes –for provider fees

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UNMMG Provider Coding

• 4 Day Hospital Stay (Evaluation &Management)– Day 1 = Initial Hospital Care (CPT 99223)

• Charge = $514.00• wRVUs = 3.86

– Day 2 = Subsequent Hospital Care/Follow up (CPT 99233)• Charge = $265.00• wRVUs = 2.00

– Day 3 = Subsequent Hospital Care/Follow up (CPT 99233)• Charge = $265.00• wRVUs = 2.00

– Day 4 = Hospital Discharge (CPT 99239)• Charge = $269.00• wRVUs = 1.90

• Total Provider Charges = $1,313• Total Provider wRVUs = 9.86

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UNMH Coding Staff

• Hospital (Facility) Coders are responsible for Facility Coding for the hospitals and clinics:

• Assignment of one DRG Code derived from:• One Principle Diagnosis (ICD-9-CM)• All Secondary Diagnoses (ICD-9 & capturing all present

on admission (POA) diagnoses)• One Principle Procedure (ICD-9-PC)• All Secondary Procedures (ICD-9-PC)• Any & all Co-morbidities & Complications (CC & MCCs)• Assignment of the DRG

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Assignment of the MS-DRG

DRG (Diagnosis Related Grouping) One DRG is assigned for each Inpatient stay

Using all diagnoses and procedures codesIncludes codes for all complications &

comorbidities (CCs and MCCs)• DRGs are assigned a relative weight (RW)

RW is the calculation of resource consumptionUsed to determine payment

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MS-DRG Financial Impact

• Relative weight (RW): Number assigned to each account based on the DRG assigned. The higher the RW, the sicker the patient.– 1: Average– <1: Below average– >1: Above average

• Case Mix Index (CMI): The average of all relative weights for a patient population (Month, Year, etc.) for any given period of time.

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Secondary Data UsesThe role of the APR-DRGs

• APR-DRG (All-Payer Refined DRG-3M Software)• Calculates Severity of Illness (SOI)• Calculates Risk of Mortality (ROM)

– Based on diagnoses, procedures and– Complications & Co-morbidities (CC and MCCs)

• SOI & ROM scales (APR-DRG & UHC scale)– 1. Minor– 2. Moderate– 3. Major– 4. Extreme

Impact of Complete DocumentationMS DRG 195 w/o MCC/CC

MS DRG 194 with CC

MS DRG 194 with CC

MS DRG 193 with MCC

MS DRG 193 with MCC

MS DRG 177 with MCC

PDX: Pneumonia, organism Unspecified

PDx: Pneumonia, Organism Unspecified

PDx: Pneumonia Organism Unspecified

PDx: Pneumonia Organism Unspecified

PDx: Pneumonia Organism Unspecified

PDx: Pneumonia, Staphyloccus Aureus

SDx COPDSDx: COPD with Exacerbation

SDx: COPD with Exacerbation

SDx: COPD with Exacerbation

SDx: COPD with Exacerbation

SDx: COPD with Exacerbation

Malnutrition, protein calorie

Malnutrition, protein calorie

Malnutrition, severe protein calorie

Malnutrition, severe protein-calorie (BMI<19)

Decubitus Ulcer Pressure Ulcer Stage IV

Pressure Ulcer, Stage IV, lower back (site needed for ICD-10)

Acute Respiratory Failure with hypercapnia and/or hypoxemia

SOI Level: 1 SOI Level: 2 SOI Level: 2 SOI Level: 3 SOI Level: 3 SOI Level: 4

ROM level: 1 ROM level: 1 ROM level: 2 ROM level: 2 ROM level: 3 ROM level: 3

DRG Wt: 0.6997 DRG Wt: 0.9771 DRG Wt: 0.9771 DRG Wt: 1.4550 DRG Wt: 1.4550 DRG Wt: 1.9934

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POA and HAC

There is a BIG difference in whether a condition was:• POA: Present on Admission – documentation in the H&P or progress notes

after a definitive diagnosis is made—whether each condition was present on admission (provider’s best clinical judgment)– Does this patient have a pressure ulcer (where)?

OR• HAC: Hospital Acquired Condition

– For some selected conditions (diagnoses) that were not present on admission, but were acquired during hospitalization, the case may be paid as though the secondary diagnosis is not present

• Fracture occurring during the IP stay• Diabetic Ketoacidosis (MCC) not present on admission• Foreign object retained after surgery• Vascular Catheter-Associated Infection • Surgical Site Infection

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Documenting Questionable Diagnoses

Provider should document all possible, probable, or suspected conditions – this communicates what the provider is thinking.• Example:

– Professional fee Dx: Cannot code R/O-- rolls back to coding a symptom

– IP - Possible Sepsis, r/o sepsis: Sepsis coded as though it exists – Sepsis ruled out: Sepsis would not be coded—IP remember to

confirm prior to discharge or in the discharge summary– Pneumonia vs. CHF: Both can be coded (IP); pro fee-- codes to

a symptom (i.e. chest pain, shortness of breath etc.)

Mission: Meaningful Clinical Process “Telling the Patient’s Story”

Clinical Information is used by clinicians for “telling the story” for this episode of care. Primary uses of clinical documentation:

– The Documentation story critical for patient care – The Medical Record is a communication tool among

care providers– The Documentation should tell/demonstrate the clinical

pathway to diagnoses

Many times the story is lost in our current “cut and paste” or more forward world or documentation.

Secondary Uses of Clinical Information “As Documented in the EMR”

Secondary Clinical Information/Data Uses: – Disease & Operative Indexing for research (ICD & CPT codes)– Validates the patient care provided– Serves as a legal document of the care provided– Drives Revenue/Reimbursement (Coding)– Permits accurate comparisons to other

providers/institutions/national benchmarks– Identifies the quality and efficiency of the care we give. Computer

extractions of:• Quality Indicators (PQRS) • Meaningful Use Data (MU)• Compliance/Regulatory Standards (TJC, CMS, DOH)• Metrics used for Value Based Purchasing

Cost per patientResource utilizationLength of stayComplication RatesMorbidity ScoresMortality ScoresOutcome AnalysisPayer Audits

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Why does CDI Matter?Medicine is Under The Microscope

Hospital Report cardsHealthgrades, Delta Group, Leapfrog Medicare Physician Data (since 2007)Federal and state regulatory agencies (e.g.

OIG)The Joint Commission (TJC)Centers for Medicare and Medicaid Services

(CMS)Quality Improvement Organizations (QIO)

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Physician Profiling

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Healthgrades.com

ICD-10: Advancing Healthcare…

ICD-10(International Classification

of Diseases version 10)

• The ICD is the international standard diagnostic classification for general epidemiological, health management purposes and clinical use.

• ICD-10 CM & PCS is an upgrade of the U.S. developed Clinical modification (ICD-9-CM) of Diagnosis and Procedure Codes, first adopted in 1979.

Pervasive Impacts• Diagnosis codes and procedure

codes flow through mission critical operational systems and analytical tools

• Alignment of technology remediation with business and technology strategies

• Business process reengineering, training and change management is essential

Comprehensive Benefits• Quality Measurement• Public Health Disease Surveillance• Clinical Research • Organizational Monitoring and

Performance• Reimbursement

ICD-10 Changes Implications

Significant Increase in Clinical Granularity

5 digits

> 4,000 unique codes

3-7 alphanumeric characters

> 68,000 unique codes

7 alphanumeric characters

> 72,000 unique codes

ICD-9 CM (Procedure)

ICD-10 CM (Diagnosis)

ICD-10 CM (Procedure)

3-5 characters alphanumeric

ICD-9 CM (Diagnosis)

>14,000 unique codes

ICD-9 CM (Procedure)

3-4 characters numeric

> 4,000 unique codes

The Federal Government through CMS is driving the healthcare industry to upgrade diagnosis and procedure coding standards (ICD-10) by October 1, 2015.

The Basics of the ICD-10-CM Change

The ICD-10-CM diagnosis code set is a full replacement of the ICD-9 code set that will provide additional granularity for diagnosis and procedure codes. This additional granularity is the primary driver of value.

X X X X X.ICD-9 ICD-10-CM

X X X X X X XCategory CategoryEtiology, anatomic

site, manifestationEtiology, anatomic site, manifestation

.Extension

An Example of Structural Change

Type 1 diabetes mellitus with diabetic neuropathy, unspecified

E 1 0 4 0.

Type 1 diabetes mellitus with diabetic mononeuropathy

E 1 0 4 1.

Type 1 diabetes mellitus with diabetic amyotrophy

E 1 0 4 4.

Type 1 diabetes mellitus with other diabetic neurological complication

E 1 0 4 9.

Diabetes mellitus with neurological manifestations type I not stated as

uncontrolled

2 5 0 6. 1

An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes

One ICD-9 code is

represented by multiple ICD-

10 codes

The industry expects that mapping ICD-9 and ICD-10 codes will be a complex task

The Basics of the ICD-10-PCS Change

The ICD-10-PCS is an American procedure coding system that represents a significant step toward building a health information infrastructure that functions optimally in the electronic age.

X X X X.ICD-9 ICD-10-PCS

X X X X X X XSection

An Example of Structural Change

Total hip replacement

8 1 5 1.

An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes

One ICD-9 code is

represented by multiple ICD-

10 codes

Body System

Root Operation

Body Part Approach Device Qualifier

0SRB07Z Replacement of Left Hip Joint with Autologous Tissue Substitute, Open Approach

0SRB0KZ Replacement of Left Hip Joint with Nonautologous Tissue Substitute, Open Approach

0SRB0J7 Replacement of Left Hip Joint with Synthetic Substitute, Ceramic on Ceramic, Open Approach

0SRB0J8 Replacement of Left Hip Joint with Synthetic Substitute, Ceramic on Polyethylene, Open Approach

0SRB0J6 Replacement of Left Hip Joint with Synthetic Substitute, Metal on Metal, Open Approach

0SRB0J5 Replacement of Left Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach

0SRB0JZ Replacement of Left Hip Joint with Synthetic Substitute, Open Approach

0SR907Z Replacement of Right Hip Joint with Autologous Tissue Substitute, Open Approach

0SR90KZ Replacement of Right Hip Joint with Nonautologous Tissue Substitute, Open Approach

0SR90J7 Replacement of Right Hip Joint with Synthetic Substitute, Ceramic on Ceramic, Open Approach

0SR90J8 Replacement of Right Hip Joint with Synthetic Substitute, Ceramic on Polyethylene, Open Approach

0SR90J6 Replacement of Right Hip Joint with Synthetic Substitute, Metal on Metal, Open Approach

0SR90J5 Replacement of Right Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach

0SR90JZ Replacement of Right Hip Joint with Synthetic Substitute, Open Approach

ICD-10 Coding Snapshot: Diabetes Scenario

• A 68 y/o male has type I diabetes with diabetic chronic kidney disease stage 3, is being seen for regulation of insulin dosage. The patient has an abscessed right molar, which was determined, in part, to be responsible for elevation of the patient’s blood sugar.

• ICD-10 codes:– E10.22 Diabetes type 1 with CKD– N18.3 CKD Stage 3– K04.7 Abscess Tooth– Z79.4 Long term drug therapy, insulin

Don’t need to turn doctors into codersWe Need good documentation habitsWe Need specialty specific documentation

educationWe need to Begin the process of education

now for ICD-9 and incorporate ICD-10 issues into the education as we prepare for Oct. 1, 2014 (Now 2015)

ICD-10 Physician Education

UNMH & SRMC- CMI(Case Mix Indicator)

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-141.3000

1.3500

1.4000

1.4500

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1.5500

1.6000

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1.7000

1.7500

SRMCUNMH Overall

UNMH- Facility-Wide SOI(Severity of Illness Indicator

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140

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UNMH- Facility-Wide ROM(Risk of Mortality Indicator)

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140

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SRMC - SOI

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SRMC - ROM

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DoIM UNMH - CMI

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-141.2000

1.4000

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3.4000

DoIM CardiologyMedicine - HospitalistsMICUUNMH Overall

DoIM UNMH - SOI

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140

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DoIM UNMH - ROM

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140

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DoIM – Hospitalists UNMH - SOI

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140

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DoIM – Hospitalists UNMH - ROM

Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140

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April Discharges – OrthoMajor Joint Replacement – Lower Extremity

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ROMSOI

Sepsis

• SIRS Criteria• Assess for 2 or more• (Fever) Temp > 38⁰C or < 36⁰C• (Tachycardia) HR > 90• (Tachypnea) Resp rate > 20 or pa CO₂ < 32• (Leucocytosis/Leukopenia) WBC > 12K, < 4K, or

> 10% bands

SIRS: Suspected Infection

If infection is known:• Document organism and site• Document whether infection is present on

admission• May document possible, probable, likely or

suspected sepsis • Complete Sepsis M-Page• Determine Sepsis Severity

Sepsis Severity

Sepsis• Lactate levels

documented• No organ dysfunction• No hypotensionSevere Sepsis• Lactate levels• Organ failure

– Organ dysfunction must be linked to the Sepsis *

(Occult) Septic Shock(Written as Septic Shock)• Lactate levels• No hypotension

Septic ShockWritten as Septic Shock• Hypotension• Refractory to IV fluids

*see organ reference pages

SMITE Bundle

Basic SMITE Bundle1. Lactate q 4h x22. Blood Culture3. Antibiotics within 1 h 4. Fluids5. Re-evaluate as needed

Advanced SMITE BundleBasic Bundle Plus:5. Fluids bolus6. CVP7. Vasopressors

Severe Sepsis : Organ Dysfunction

Documentation of • (Encephalopathy) Altered mental status• (Acute kidney injury) Creat levels/abnormal labs• (Acute liver failure) Abnormal LFTs/Total Bili • (Coagulopathy) INR level documented• (Acute respiratory failure) Hypoxemia and/or

hypercapnia

*Please refer to organ reference for detailed documentation suggestions

Case Study #1MS DRG –178 Respiratory Infections & Inflammations w CCPDX: Cystic Fibrosis with pulmonary manifestationsSDX: protein-calorie malnutrition. GERD, several other dxSOI level: 3ROM level: 2DRG Wt. 1.4403DRG Reimb: $13,091.09

Additional documentation in chart CDI Queries for: nutrition note documentation, malnutrition related to CF. Pt with BMI 15.9 on high calorie diet and clinimixi at 80 cc an hr for nutritional support. Malnutrition documented on PN. CDI query for the severity of the malnutrition. If provider agreed with query and documents severe protein calorie malnutrition.MD DRG-177 Respiratory Infections & Inflamations w MCCSOI level: 3ROM level: 3DRG WT. 2.0549DRG Reimb: $18,677.24

Case Study # 2MS DRG –872 Septicemia or Severe Sepsis w/o MCCPDX: Septicemia due to E coliSDX: protein calorie malnutrition, DM without complications type II, acute pancreatitisSOI level: 3ROM level: 2DRG Wt. 1.0687DRG Reimb $8,120.74

Additional documentation in chart: Sepsis with AMSCDI Queries for: Specific type of Encephalopathy . If provider agrees and documents metabolic encephalopathyMS DRG-871 Septicemia or Severe Sepsis W MCCSOI level: 3ROM level: 3DRG WT. 1.8527DRG Reimb: $14,078.15

Department Training Schedule

• Level I Training – Completed by April 30, 2014• Level II Training – Completed by June 1, 2014• Level III Training – Expectation: You are here

– Dept Champion (s) Complete 1:1 training by June 1, 2014– All Dept. Specialty Training to be completed in June/July

2014 for ICD-10: Date to be determined by UNM HSC (RFP Vender selection underway 6/1/14

– Metrics & Measures part of Monthly Department Meetings by June 2014

– Top Dx/Tip Sheets & All Staff Trained by Dept/Div Champions by June 30, 2014

Upcoming in Fall 2014:

• Dept./Div. Specialty-Specific CDI Training– Vendor Proposals for Level III Training chosen by

RFP Committee. Next steps:– Top vendors on-site to demonstrate their sub-specialty

training method & tools – week of July 21– Encourage All Dept/Division Champions and anyone else

interested to attend– Dept/Division – Specialty Specific ICD-10 Documentation

Sessions to be scheduled in the Fall of 2014 (following UNM HSC approval of vendor and purchase)

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Contacts

UNMH Coding & Clinical Documentation

Erlinda Smith, CCSUNMH Coding Educator (Inpatient)EVSmith@salud.unm.edu

Kayode Balogun, MD, CCSCDI Program Manager, UNMHkbalogun@salud.unm.edu

Catherine Porto, RHIA, MPA, CHPExec. Director HIMcporto@salud.unm.edu

CDI Information to be posted on the following web site:

https://hospitals.health.unm.edu/intranet/HIM Provider Documentation and ICD-10 Tab