The Impact Physician Documentation
on Hospital Reimbursement and
Metrics
Integration of CDI
Physician documentation

Clinical Documentation Improvement (CDI)/Concurrent Review

Coding
(identify/validate principal and secondary diagnoses & procedures)
May refer back to CDI as needed or may query provider

ICD-9 codes

Grouping of ICD-9 diagnosis codes
(APR-DRG, MS-DRG, or DRG)

Submission of hospital bill
Disclaimer
The following information is educational and
based on estimates of MS-DRG distribution
against current practices
This organization has a policy against DRG creeping
and/or DRG “upcoding”
Physicians have the freedom to disagree with
CDI/coding recommendations without concern
for any reprisal
Important Terms
•
•
•
•
Principal Diagnosis
Secondary Diagnoses
Diagnostic Related Group (DRG)
Medicare Severity - Diagnostic Related Group
(MS-DRG)
• Concurrent/Complicating Condition
• Major Concurrent/Complicating Condition
• GLOS – geometric/global length of stay
How Do Hospitals Get Paid by
Medicare?
Each MS-DRG has a unique
RELATIVE WEIGHT (RW)
X
The hospital’s annual BASE RATE
=
Hospital Payment ($)
Ensuring the Highest RW
The principal diagnosis and the principal procedure
(if applicable) establishes the base MS-DRG
Co-morbidities (a.k.a. complicating or concurrent
conditions) can adjust the MS-DRG to a higher
relative weight = $
THEREFORE, a systemic, full body approach is more
effective than a focused assessment, which requires a
comprehensive H & P, identifying all body systems
impacted by the disease process
Principal Diagnosis
Establishes the base MS-DRG
The condition, after study, which occasioned the
inpatient admission to the hospital
– Not necessarily what brought the person to the
hospital
• ER c/o abdominal pain
• Admitted for SIRS 2/2 chronic pancreatitis (principal dx)
– Should be a disease process or condition rather
than a symptom i.e., CAD vs. chest pain
Principal Diagnosis
Coders can’t infer a cause/effect relationship
– The physician doesn’t have to state the condition in the
H&P for it to be the principal dx
HOWEVER
– The presenting symptomology necessitating the
admission MUST be linked to the final disease process
diagnosis by the physician
• Usually this occurs in the discharge summary; therefore,
discharge summaries should be completed as soon as
possible following discharge for accurate coding
• The provider needs to clearly state the diagnosis was
present on admission (POA) as evidence by the presenting
symptoms of . . .
Co-morbidities (CC/MCC)
Additional conditions that affect patient care in
terms of requiring:
• Clinical evaluation AND/OR
• Therapeutic treatment AND/OR
– Continuation or adjustment of home medications
– Initiation of new medications or IVF
• Diagnostic procedures AND/OR
• Extended length of hospital stay AND/OR
– Focus on GLOS – global length of stay
• Increased nursing care and/or monitoring
Co-morbidities
CC = concurrent condition
Patients who are more ill than a “healthy” person with
the same principal condition i.e., many chronic
conditions add a CC
MCC = major concurrent condition
Represent the highest severity of illness to identify the
“sickest of the sick” i.e., acute episodes (exacerbation)
of chronic conditions e.g., acute on chronic systolic or
diastolic HF and/or potentially lethal conditions i.e.,
acute respiratory failure, shock, encephalopathy,
ESRD, open fracture of a major bone, etc.
Secondary Conditions
Some DRGs differentiate between “ill” and
“sickest of the sick” patients
– One tier
• no differentiation among patients
– Two tier
• With a CC/MCC or without a CC/MCC
Differentiate between ill and more ill/sickest of the sick
Easiest to move the MS-DRG
• With a MCC or without a MCC
Differentiate between ill and sickest of the sick
Most difficult to move the MS-DRG
– Three tier
• Without a CC or MCC (ill)
– Medicare estimates 41% of total patient population
• With a CC (more ill)
– Medicare estimates 37% of total patient population
• With a MCC (sickest of the sick)
– Medicare estimates 22% of total patient population
MS-DRGs Groupings
Subgroups
Single
no CC/MCC option
w/CC/MCC
Two tiered
w/o CC/MCC
w/MCC
w/o MCC
# base
MS-DRGs
# of
MS-DRGs
53
53
43
86
63
126
152
456
w/MCC
Three tiered
w/CC
w/o CC or MCC
Recommendations
Provide more extensive H & P
• CCs and MCCs are based on the secondary conditions that
occur with the principal dx
• Many problematic cases are elective admissions
• Specify which “history of” conditions are being treated
compared to those that are resolved
• Note when a chronic condition is exacerbated
Assign a diagnosis to abnormal lab values i.e.,
“acute blood loss anemia” or “posthemorrhagic anemia” when
transfused due to low H&H
Document identified or suspected organism leading to
antibiotic selection for all infections, especially
pneumonia
Documentation Hints
• Chronic conditions:
– Last 12 months or longer
AND
– Places limitations on self-care, independent living, &
social interactions
– Results in the need for ongoing intervention w/medical
products, services, and special conditions
• Always note when the patient is experiencing an
acute exacerbation of a chronic condition
• Describe how the patient’s current condition
differs from their normal baseline
Weight Issues
Add BMI to your H & P
– BMI > 40 + morbid obesity = CC
• Provider must document the BMI and the diagnosis of
obesity or morbid obesity
– Protein-calorie malnutrition = CC
– BMI < 16 + severe malnutrition = MCC
– Cachexia = CC
• Note under general impressions
– Emaciated = MCC
• Note under general impressions
Substance Dependence
• Substance dependence is not the same as
substance abuse and can occur with prescription
medications
• Document any withdrawal symptoms associated
with substance use i.e., alcohol or drugs (specify
substance if known).
– Alcohol or drug withdrawal = CC
– Toxic encephalopathy = MCC
• Link the treatment of a “banana bag” with the
diagnosis of thiamine deficiency in alcoholics
– Thiamine deficiency = CC
Mental Status
Altered Mental Status (AMS) does not convey
severity in ICD-9
Consider acute delirium – confusion accompanied
by agitation or other behavioral disturbances
rather than “confusion,” or “altered mental status”
secondary to Alzheimer’s, late effect of stroke,
Lewy body dementia, vascular dementia, anoxic
encephalopathy, alcohol withdrawal, etc. = CC
Consider encephalopathy (toxic or metabolic)
especially with acid/base or electrolyte
imbalances
Renal Function
Be sure to distinguish between acute
and chronic Renal Failure and specify
Acute Tubular Necrosis (ATN) when
applicable:
– Acute Renal Failure (A.K.A. non-traumatic Acute
Kidney Injury or AKI) = CC
– ATN = MCC
Renal Function
Chronic Kidney Disease (Chronic Renal Failure)
• Always specify the applicable stage
• Use the National Kidney Foundation’s
standardized staging of progressive kidney
disease – add a CC
– CKD stage IV (severe)
• GFR = 15-29 SCr = 2.5 – 4.5
– CKD stage V (cardiovascular disease)
• GFR = <15 SCr = > 4.5
Renal Failure
Chronic Renal Failure
(CKD IV & V) = CC
End Stage Renal Failure = MCC
• specify the known or suspected underlying
cause of ESRD i.e., HTN, DM, renal cystic
disease, systemic lupus erythematosus,
glomerulomephritis, etc.
Renal Failure
• The known or suspected etiology of kidney
disease should be specified
• Coding assumes a casual relationship b/t HTN
and CKD
– The presence of essential hypertension and CRF is
classified as “Hypertensive Kidney Disease” which is
not inclusive of renal manifestations due to
secondary HTN – so add the
documentation/diagnoses
Renal Insufficiency
• Codes to “unspecified disorders of the kidney
and ureter” and is considered by coding as an
early stage of renal impairment
• Chronic renal insufficiency codes to “CKD,
unspecified”
• AVOID using renal insufficiency and renal
failure interchangeably
Fluid Volume Overload
Determine the cause of Fluid Volume Overload
• Fluid volume overload is always attributed to
CHF if it is listed as a secondary diagnosis
unless another cause is clearly specified e.g.,
ESRD, as the cause of the fluid volume
overload
– This can lead to failures on CMS Quality Measures
for HF as the provider does not realize the
principal diagnosis will be HF on these patients
– Remember to have heart failure, the heart must
have pathology
Heart Failure
Avoid the use of term “CHF” (congestive heart
failure)
– Classify to the type of heart failure whenever
possible
• Systolic
• Diastolic
• Combined
• Acute
• Chronic
• Acute on chronic
(exacerbation or decompensated)
– Use presenting symptomology when ECHO results
are not available
Heart Failure
Systolic – most common type of HF
EF < 40%
Cardiomegaly on CXR
Dilated on Echo
S3 gallop
Diastolic
EF usually normal
LVH on EKG
S4 gallop
Often hypertensive
Abnormal relax on ECHO
Acute Heart Failure
Symptoms
Rales
 CVP > 16 cm
Neck vein distension
Paroxysmal nocturnal dyspnea
Acute pulmonary edema or  BNP
Weight loss => 4.5 kg in 5 days in response to CHF
treatment
Electrolyte Imbalances
Interpret abnormal lab values
hyponatremia/ hyposmolality = CC
SIADH = CC
Metabolic encephalopathy = MCC
Hyperkalemia (not a CC)
Hypoaldosteronism = CC
ACE-Inhibitors, Angiotensin Receptor Blockers, Spironolactone
Hypercalcemia (not a CC)
Metabolic encephalopathy = MCC
Electrolyte Imbalances
Are there acid/base imbalance?
Acidosis = CC
HCO3<18
Alkalosis = CC
HCO3 >28
Rather than Altered Mental Status or Confusion consider
Metabolic encephalopathy = MCC