what is clinical documentation integrity? a daily scavenger hunt
TRANSCRIPT
What is Clinical Documentation Integrity?
A daily scavenger hunt
• More accurate documentation reflective of true acuity and services provided
• More accurate profiling data for both Hospital and medical staff
• More appropriate case mix and reimbursement• Reduced compliance risk• Potential reduction in denials• More appropriate patient severity, mortality,
outcomes and resource consumption data • Increased cooperation between physicians and
hospital
Benefits of Clinical Documentation
• A consulting group reviewed the appropriateness of the DRG assignment for a sample of inpatient Medicare cases at HPRHS based on the clinical documentation in the Medical Record.
• Based on their findings, there was a potential financial impact of approximately $1.8 million in missed opportunities, contributed to documentation.
• Documentation was the key factor, not the quality of care or service.
• We know that we deliver exceptional health care services to the people of our region!
• Many times the documentation doesn’t support the true severity of illness of our patients.
HPRHS Data Analysis: Why Does Data Matter?Hospital and physician profiling data is available
to the public
Research& ComparePhysicians
HPRHS Data Analysis: Why Does Data Matter?Hospital Report Cards
www.abouthealthtransparency.org
POA vs. Hospital-acquired Conditions
Present on admission (POA) is defined as present at time the order for inpatient admission occurs - - conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
Hospital-acquired conditions (HACs) are those that developed / occurred during an inpatient hospital stay.
Purpose of POA
• Intention of this new concept is to reduce increased payments for complications that occurred after admission / during the hospitalization.
• Hospitals have to submit data on all Medicare claims indicating whether the diagnoses were POA.
• Coders indicate (Y or N) beside the principal diagnosis and all secondary diagnoses.
The 10 categories of HACs include:
• Foreign Object Retained After Surgery • Air Embolism • Blood Incompatibility • Stage III and IV Pressure Ulcers • Falls and Trauma • Manifestations of Poor Glycemic Control • Catheter-Associated Urinary Tract Infection (UTI) • Vascular Catheter-Associated Infection • Surgical Site Infection Following
– Orthopedic Procedures • Spine Neck,Shoulder,Elbow
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)• Total Knee and Total Hip Replacement• Payment implications began October 1, 2008, for these 10
categories of HACs.
Medicare 101DRG (Diagnosis Related Groups) Basics
• How are DRGs used:– Calculating Hospital reimbursement– Evaluate quality of care– Evaluate utilization of resources
• Each DRG represents the average resources utilized to care for a patient within the grouping
• Every DRG has a relative weight (RW) assigned to it• The RW is used in the calculation of the Hospitals
Case Mix Index
www.hcup-us.ahrq.gov
Medicare 101DRG Basics
– Major enhancement is revision of the CC list and development of MCC list
– With the development of MS-DRGs, CMS reduced the CC capture rate from 77% to 40%
– CC’s are categorized:• MCC (Major complication/comorbidity)• CC (complication/comorbidity)• Non CC
www.hcup-us.ahrq.gov
MS-DRG’s
• Heart failure with no MCC/CC DRG 293 = RW 0.7220 = $3,699 CHF LOS 3.7days TX O2 and IV Lasix
• Heart Failure with CC DRG 292 = RW 1.0069 = $5,155 CHF LOS 5 days TX O2, IV Lasix, echo, med adjustment, Chronic obstructive bronchitis acute exacerbation
• Heart Failure with MCC DRG 291 = RW 1.4601 = $7,481 CHF LOS 6.5 days intubated ED, admit to ICU, In ICU 7 days, IV Dobutamine, multiple tests, multiple med adjustment, critical care, complicated by acute renal and respiratory failure
CMS DRGs vs. MS-DRGs
• The Goals of Clinical Documentation Integrity (CDI) Process are as follows:
– Drive appropriate coding for accurate reimbursement
– Reflect accurate patient acuity levels– Meet standards– Reduce compliance risks– Provide accurate data for quality indicators and
other hospital metrics– Reduce coding turnaround time– Decrease post-discharge queries to the physicians
by utilizing concurrent physician queries when indicated
Clinical Documentation Analysts
• Nita Campbell, RN ICU/CCU/OCU• Janice Davis, RN 6S/7N/PJC• Alletheia Fitzgerald, RN 6N/7N/5N• Tamika Jones, RN CPU/MTU• Elinore Poindexter, RN 5S/CTU
• Medical Records x 2938