Terri Adell, RN, MS, CNRN, CCM

Clinical Documentation Specialist Supervisor

Stony Brook University Medical Center

Catherine Morris, RN, MS, CCM, CMAC

Executive Director of Care Management

Stony Brook University Medical Center

"Stayin' Alive" in today's healthcare market: Bettering your observed to expected mortality rates

Stony Brook University Medical Center

591-bed academic medical centerLevel 1 trauma center

Regional stroke center, neuroscience institutePediatric emergency room

Comprehensive psychiatric emergency room Burn center

Located in Stony Brook, Long Island, NY> 30,000 inpatient discharges/year

Objectives

• Define severity of illness and risk of mortality

• Discuss the risks and benefits of the current public reporting systems

• Describe how to develop a mortality review program

• Understand the benefits of using a risk-adjusted system

• Describe some of the intricacies of coding certain patient types

Current Issues in Healthcare

• High cost of services, push for reform and cost containment

• Change to severity-based reimbursement

• Decreased revenues due to MS-DRGs and RAC initiatives

• Public access to physician/hospital report cards/outcomes

• Change to ICD-10

New Focus: Risk Adjustment/Quality

• Clinical documentation improvement programs initially focused on capturing major complications and comorbidities (MCC) and complicating conditions (CC) that impacted the DRG and that resulted in higher utilization of resources and higher reimbursement

• SBUMC now uses a four-level subclass of APR-DRG data, which more accurately defines a patient’s severity of illness and risk of mortality:– Level 1: Minor– Level 2: Moderate– Level 3: Major – Level 4: Extreme

Benefits of Using a Risk-Adjusted System

• Provides a higher level of specificity about the patients’ condition and the care/treatment provided

• Improve facilities’ quality data

• Improve physicians’ and hospitals’ public report cards

• Enhance revenue, impact LOS

• Ensure regulatory compliance

• Avoid retrospective audit “money recovery” and penalties

CMS Severity Levels

• MS-DRGs introduced October 1, 2007, to better account for severity of illness and resource consumption of Medicare beneficiaries

• There are 3 levels of severity based on secondary diagnosis codes:1. MCC (major complication/comorbidity), highest level

of severity

2. CC (complication/comorbidity)

3. Non-CC does not significantly affect severity of illness and resource use

Definitions of SOI/ROM

• Severity of illness:

The “extent of physiologic decompensation or organ system loss of function experienced by the patient” (HCPro)

• Risk of mortality:

Likelihood patient will die from this illness

The ratio of the SOI to the ROM = Mortality index

SOI ≠ ROM

• Although severity of illness and risk of mortality are highly correlated for many conditions, they often differ because they relate to distinct patient attributes

Acute choledocholithiasis (acute gallstone attack)

Severity of illness is major (level 2)(because of organ system dysfunction)

Risk of mortality is minor (level 1)

• If a more serious diagnosis presents, severity of illness and risk of mortality may increase – e.g., patient develops peritonitis as a complication of choledocholithiasis:

Extreme (level 4) severity of illnessMajor (level 3) risk of mortality

Reasons for Mortality Reviews

• Identify adverse events, errors

• Prevention and process improvement

• Documentation of core measure elements

• Improve O/E severity of illness & risk of mortality

• Revenue capture

• Public reporting

Public Reporting Sites

CMS’ Hospital Comparewww.hospitalcompare.hhs.govU.S. News & World Reportwww.healthgrades.comThomson-Reuterswww.100tophospitals.comLeapfrog Grouphttps://www.leapfroghospitalsurvey.org

UHC (University Healthsystem Consortium)https://www.uhc.com

Premier, Inc.www.premierinc.com/quality-safety/tools-services/performance-suite/clinical-

advisor.jspState governments/DOH _______.govIn New York state:Myhealthfinders.com or NYSDOH.gov

Problems With Public Reporting

• No standard data collection methods

• Diverse data sources

• Provider editing ability

• Timeliness

• Intent

• Relevance, methodological rigor

• Different measures of quality, inconsistent definitions used, different reporting periods

• Institutional variability in the definitions

Improving Standardization

Error- Prone Collection Methodology

• Because mortality measures are obtained through claims rather than clinical data, we must work to improve the standardization of documentation and coding that drives mortality rates

Potential Problem

Overcoding• There is always the risk of hospitals

overcoding, either intentionally or unintentionally, and skewing results

• Disclaimer: The information, techniques, situations, and references in this presentation are for information purposes only. They are not communicated with reference to any specific issue, do not constitute legal or clinical advice, and are not in any way a substitute for such due diligence inquiries and investigations as otherwise may be required by law or clinical standards. Laws, regulations, clinical standards, and other professional due diligence requirements vary from state to state. It is your responsibility to check with your compliance department before using any of the information/techniques from this presentation.

Our Mortality Review Processand Documents

Initially

• Estimated yearly mortalities: 600

• Estimated reviewed records: 50 per month

• One documentation specialist assigned to mortality review per week

• Project length: Three months

Mortality Review Process– Documentation Improvement

• Mortalities coded by HIM• Record “GROUPED” for severity and mortality risk by

coder and second attestation printed and given to coding supervisor

• Each mortality record placed on “MQ” bill hold (if it is a SMART chart, it will be placed on “MR” bill hold as usual until the record is reviewed by the coding supervisor and will then be changed to “MQ”)

• Chart sent to tech park for scanning by coder• Report on mortalities run by coding supervisor daily to

be picked up by CDS with attached attestations• Assigned CDS reviews records daily (Mon–Fri)• No query identified, coding supervisor notified to

removeMQ bill hold by CDS

Mortality Review Process– Documentation Improvement

• Queries identified, physician contacted regarding query by CDS

• If physician does not agree, coding supervisor notified to remove MQ bill hold by CDS

• If he or she agrees, physician documents on HIM retro query form

• CDS brings retro query form to coding supervisor• Appropriate coding changes are made by coding supervisor

and an attestation is sent as a priority scan to tech park • Chart regrouped for severity and mortality risk• Bill hold removed• CDS maintains database to be sent to coding supervisor by

e-mail by close of business every Thursday for reconciliation• Report run every month on changes to severity and mortality

Patient name

Patient enc #        

Age        

Admitting dx        

Attending        

Service        

Unit        

Readmit within 30 days        

Admit date        

Date of death        

LOS        

Day of week of death        

Time of death        

Rapid response        

Date/time of code blue        

Cause of death        

Palliative care        

Hospice        

DNR/DNI        

MCC already coded        

CC already coded        

New MCC        

New CC        

Coder DRG        

CDS DRG        

ROM        

Comments        

Identified Opportunities

• Data collection

• Neonates

• Short-stay deaths

• Palliative care/“V” code

• Assigning an attending

PATIENT NAME

ENCOUNTER NUMBER

AGE 81 89 92 70 86

ADMITTING DX subdural hematoma chf Intracerebral hemorrhage breast cancer copd

ATTENDING Alpa Desai William Lawson Riyaz Kamadoli Ostrow Stavola, Thomas

SERVICE MCU CAD GMX MOL CAD

UNIT MICU 17s CCU 16n 19N CCU

READMIT WITHIN 30 DAYS no no no yes no

ADMIT DATE 3/21/2010 3/31/2010 3/31/2010 4/2/2010 3/17/2010

DATE OF DEATH 3/24/2010 4/12/2010 4/3/2010 4/8/2010 3/27/2010

LOS 3 days 2 3 6 10

DAY OF WEEK OF DEATH Wednesday Monday Sat Thursday Saturday

TIME OF DEATH 2127 0220 1PM 0309 2220

RAPID RESPONSE no no no no no

DATE/TIME OF CODE BLUE 3/21 & 3/24 (2105)   na na no

CAUSE OF DEATH cardio pulm arrest/sepsis Septic shock Intracerebral hemorrhage metastic breast ca anoxic brain injury

PALLIATIVE CARE no no yes yes yes

HOSPICE no no no yes no

DNR/DNI no yes yes yes yes

MCC ALREADY CODED yes no no yes yes

CC ALREADY CODED yes no no yes yes

NEW MCC acute resp failure multiple no acute resp failure  

NEW CC chronic sys. Chf see comments no no  

CODER DRG 85 293 64 374 246

CDS DRG   280 64 374 246

ROM 3 2 4 3 4COMMENTS Retro query acute resp

failure with agreement. Review of chart revealed multiple mccs not capture because no attending cosign. Retroqueried Dr Lawson in person who wrote on retroquery: "Non STEMI, cardiogenic shock w multiorgan system failure, renal, respiratory, gastrointestinal, cerebral"

  Retroquery for acute resp. Failure based on freq documentation of

resp distress w sats low 80s. Retroquery signed

by attending

 

Financial impactnone $5,102.00   none  

New ROM 4 4   4  

Neonates

New York State Law

• If there is documentation that the infant “drew a breath,” then the child must be encountered as a live birth and considered an inpatient mortality..

Definition of Stillbirth

• A stillbirth is when a fetus that was expected to survive dies during birth or during the last half of pregnancy*

*In the United States, the term stillbirth or fetal demise does not have a standard definition.

For statistical purposes, fetal losses are classified according to gestational age.

A death that occurs prior to 20 weeks' gestation is usually classified as a spontaneous abortion; those occurring after 20 weeks constitute a fetal demise or stillbirth.

Many states use a fetal weight of 350 g or more to define a fetal demise.

More Confusion

New York

vs.

California

• However, not all states interpret the weeks of gestation in the same manner.

• In California, 20 weeks' gestation is worded "twenty utero gestational weeks" and has therefore been interpreted to be 23 weeks from the last menstrual period. (Implantation in the uterus does not occur until 1 week after fertilization.)

• In New York state, intrauterine fetal death (IUFD) includes a death at a gestational age of 20 completed weeks or greater, or if fetal weight is 300 g or more.

Neonates

• When are neonatologists/pediatricians involved?

• Under what week gestational age are they coded solely from the obstetrician's notes?

• Neonatologist language– Apnea vs. acute respiratory failure

Short-Stay Patient Deaths

• There are many difficulties to address:– Medical history

– Assessment is focused on the problem

– Etiology

– No/incomplete diagnosis

– “Unresponsive”

– Lack of studies or clinical findings

– Lack of indication for procedures

– Who is the attending of record?

Short-Stay Patient Deaths

• A 57 y/o patient was brought in as a Code H from an outside hospital s/p cardiac arrest and intubation. He underwent emergent stenting upon arrival. He was clearly extremely ill, and his death in the CCU within 24 hours of arrival was not unexpected.

• This patient was coded as having a ROM of 1 (the lowest risk in a scale from 1–4).

Short-Stay Patient Deaths

• The sickest patients who arrive as a code H and expire rapidly and only have a slim chart may end up with the lowest ROM if the right verbiage is not stated by an attending physician or NP. – Cardiac arrest should be queried for cardiogenic

shock

– Intubation as acute respiratory failure

– Renal insufficiency as acute renal failure

– Glasgow coma scale of 5 must be stated as coma  

MORTALITY REVIEW QUICK REFERENCE

DX OR INFO PRESENT DX INCREASING RISK OF MORTALITY

Renal insufficiency, elevated creatinine    Acute renal failureSOB, increases respirations, respiratory distress, increases O2 demand    Acute respiratory failure

Obtunded, unconscious    ComaUnresponsive to verbal or tactile stimuli, pupils & dilated    Coma

Positive tropinins, no EKG changes, demand ischemia    NSTEMI

Ascites, pleural effusion   Ascites, pleural effusion secondary to…malignancy

Cardiac arrest Cardiogenic shock, acute respiratory failure

Cardiac arrestPulmonary insufficiency secondary to shock/trauma

Increases ammonia levels with ams in liver dz Hepatic encephalopathyIncreasing liver enzymes in pt with cirrhosis, liver mets, etc. Liver failure

SAH, SDH, ICH, CVA, head trauma Cerebral edema, brain edema

Pneumonia Aspiration pna, gm neg pna, fungalIncreased WBC, hypotensive on vasopressors, bacteremia Septic shock

Cath Notes

Palliative Care

• Comorbidities

• Lack of specific treatment

• Palliative care – V667

• Top 9 diagnoses

• DNR code – V49.86

V66.7 Code

• Effective October 1, 1996• Terminally ill patient receiving palliative care• Palliative care is an alternative to aggressive

treatment – the focus is toward management of pain and symptoms

• Care provided is dependent on the terminal illness• Always a secondary code – terminal condition is

always the principal diagnosis• Comfort care, end-of-life care, and hospice care are

synonymous terms• MD documentation must include these or similar

terms

Hospice or Palliative Care Code Usage

UHC CMS Hospital Compare

U.S. News & World Report America’s Best Hospitals

Thomson-Reuters 100 Top Hospitals

HealthGrades

Admitted from a hospice

No Yes, if Medicare benefit used in last 12 months

No No No

Palliative care code v66.7 excluded?

No No No Yes Excluded in 12 dx-based cohorts

Risk adjusted

Yes No Yes NA/No NA/No

Necessary position to be applied

Any Top 9 (within top 25 this year)

Top 9 Top 9 Top 9

Assign anAttending Physician

Mortality Progress Note

• Improve documentation

• Clarify cause of death

• Include other diagnoses

• Ensure attending is identified

MortalityNote

Case Study

Attestation

Clinical documentation specialist queried for further clarification of primary diagnosis based on documentation of unresponsiveness and GCS of 5.

Physician documented that the patient was in a coma secondary to large intracranial hemorrhage and cerebral edema. This increased the SOI and the ROM to 4.

Case Study

This patient underwent CPR in the ED with futile outcome. Because of documentation of prior cardiac interventions et al., the SOI/ROM increased to 4/4.

Results

MonthSBUMC % observed

SBUMC % expected SBUMC index NYS index UHC index

January 2.55 2.76 0.92 1.03 0.91February 2.43 2.75 0.88 1.00 0.83March 2.30 2.80 0.82 0.93 0.80April 2.43 2.75 0.88 0.87 0.79May 1.83 2.56 0.72 0.91 0.81June 2.62 2.76 0.95 0.93 0.79July 2.33 2.65 0.88 0.94 0.80August 1.95 2.56 0.76 0.92 0.80September 3.14 3.04 1.04 0.94 0.80October 2.07 2.68 0.77 0.98 0.82November 2.49 3.07 0.81 0.96 0.79December          

Excludes implant of heart assist system; heart, liver, and lung transplants; neonatology; normal newborn; obstetrics; psychiatry; and rehabilitation product lines. 

         

Discharge month% deaths (observed) % deaths (expected)  Mortality index

2010-012.01 2.29

0.88

2010-021.86 2.22 0.84

2010-03 1.68 2.29 0.73

2010-041.81 2.41 0.75

2010-05 1.41 2.03 0.69

Mortality Observed and Expected

O/E Index

Severity of illness andrisk of mortality are highly dependent on the patient's underlying clinical problems

Terri Adell tadell@notes.cc.sunysb.eduCatherine Morris cemorris@notes.cc.sunysb.edu

Hughes J. 3M Health Information Systems (HIS) APR™-DRG Classification Software—Overview. In Mortality Measurement. February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/mortality/Hughessumm.htmThe History of Medical Coding

John Landers, eHow Contributor. Mortality Rates as a Measure of Quality and Safety, “Caveat Emptor” Robert Klugman, MD,1, Lisa Allen, PhD,2, Evan M. Benjamin, MD,3, Janice Fitzgerald, MS,4, and Walter Ettinger, Jr., MD, MBA1 American Journal of Medical Quality OnlineFirst, published on January 21, 2010 as doi:10.1177/1062860609357467

Evaluation of Fetal Death Author: James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of MedicineCoauthor(s): Sultana L Sultani, MD, Resident Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical CenterContributor Information and Disclosures Updated: Jan 18, 2011

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Choosing The Best Hospital: The Limitations Of Public Quality Reporting Health Aff (Millwood). 2008;27(6):1680-1687

OB and Newborn Coding Guidelines Differ Patricia Maccariella-Hafey, RHIA, CCS, CCS-P Posted on: April 15, 2002

Review of Newborn Coding Guidelines Prepared by Ingenix staff Posted on: December 8, 2010

July 2009 Clinical and Health Affairs, Price and Quality Transparency - How Effective for Health Care Reform? By John A. Nyman, Ph.D., and Chia-hsuan W. Li, B.S.P.H.

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