Clinical Documentation
Update for Physicians
November 9 and 16, 2011
Dr. Karen Jerome
Kyle Jossi, RN
1
Which hospitals were recently recognized by
the Joint Commission as Top Performers on
Key Quality Measures?
s.
..
0%
ro
s
sp
...
C
ho
ol
y
er
y
H
.
D
.
Ev
er
y
Ev
.
B
0%
sp
...
ho
ho
er
y
Ev
.
A
0 of 30
0%
sp
...
0%
C
A. Every hospital in the
United States
B. Every hospital in the DC
metro area
C. Every hospital in the
state of Maryland
D. Holy Cross Hospital and
no other hospitals in
Maryland or the DC
Metro area or the Trinity
Health system
2
Top Performer Award from The Joint Commission
• In Sept. 2011, Holy Cross Hospital was the sole
hospital in Greater Washington and all of
Maryland to receive a "Top Performer on Key
Quality Measures" award from The Joint
Commission for 2010.
• Holy Cross Hospital was one of only 405 U.S.
hospitals selected out of a total 3,099
participating.
We were recognized for all four categories of
adult medicine that were rated: heart attack, heart
failure, pneumonia, and surgical care.
• This recognition indicates that we have made real
improvements in our many, many outside
measurements of quality. But more importantly, it
demonstrates our ongoing success in improving
the care we provide to our patients.
• This is the first year of this new Joint Commission
recognition program.
3
Agenda
• Clinical documentation significance
• Chart coding
– Case mix
– ICD-10
• Select documentation issues
• Sepsis
• Clinical Doc. Improvement Program
– Queries
4
The Importance of Your Documentation
•
•
•
•
•
Clinical information for patient care
Quality/Core measure adherence
Potentially Preventable Complication (PPC) performance
Tumor Registry data
Physician and hospital profiling
– Including mortality data
• Compliance for reimbursement/denial prevention
– Commercial payors
– RAC audits
• Protection in the event of litigation
5
Coding Definitions
• Principal diagnosis – the condition established,
after study, to be chiefly responsible for
occasioning the patient’s hospital admission
• Secondary diagnosis – anything that:
–
–
–
–
–
is diagnostically tested
is clinically evaluated
is treated
causes increased nursing care and/or monitoring
prolongs the patient’s length of stay
• ICD-9 is the current coding terminology.
6
Coders can code from which sources?
.
D
.
C
no
te
s
0%
RN
E.
ho
c
ec
ph
ys
.
B
A
0 of 30
0%
ar
di
...
...
0%
pa
th
ol
ic
i
an
...
0%
.
la
b
re
po
r..
.
0%
og
y
A. lab reports
B. physician progress
notes, H&P,
operative reports,
discharge summary
C. pathology reports
D. echocardiogram
reports
E. RN notes
7
Case Weight/Case Mix Index (CMI)
• Calculated by the coding software
• Case weight is assigned based on the principal
diagnosis and the severity of illness, determined
by the secondary diagnoses.
• The case weights for all coded cases are
combined to create the hospital’s CMI, on which
its reimbursement is based.
8
Case Weight Example - Pneumonia
•
•
Community Acquired Pneumonia
-with no secondary diagnosis
SOI 1
ROM 1
Case weight .40
-with 1 secondary dx – e.g. urinary incontinence
SOI 2
ROM 1
Case weight .54
-add acute renal failure (POA) a 2nd secondary diagnosis
SOI 3
ROM 3
Case weight .84
-add severe malnutrition, a 3rd secondary diagnosis
SOI 4
ROM 4
Case weight 1.46
If the pneumonia is documented more specifically, such as aspiration,
staphylococcus, TB, or H. influenza, the DRG changes. In that DRG, with
SOI 1
ROM 2
Case weight
.60
SOI 4
ROM 4
Case weight
1.96
9
The Future of Coding: ICD-10
• Will be implemented on 10/1/2013
• Applies to hospital and office coding
• Will require significantly more specificity
– Laterality
– Type of encounter (initial, subsequent)
• ICD-9: 14,300 diagnosis codes
4,000 procedure codes
• ICD-10: 68,000 diagnosis codes
87,000 procedure codes
10
Physician Support for ICD-10
• Holy Cross Hospital will help you to
improve your workflow efficiency.
• The following are being considered:
– At-the-elbow support for building customized
clinical documentation templates
– Front-end voice recognition software
– Computer-assisted coding—enables natural
language processing of charts
11
Select Documentation Issues
12
Which of the following diagnoses cannot be
coded as an active problem?
.
D
pn
U
e.
..
...
0%
ke
ly
Li
E.
Pr
ob
is
t
H
.
C
.
B
.
A
0 of 30
0%
ab
le
..
s.
ib
le
Po
ul
e
R
0%
of
...
0%
ss
ou
tm
...
0%
or
y
A. Rule out
myocardial
infarction
B. Possible sepsis
C. History of CHF
D. Probable UTI
E. Likely pneumonia
13
“History Of”
• H&P often cites the patient as having a
“history of” various conditions. These may
actually be currently active problems and,
if so, must be stated as such or the coder
cannot capture them as secondary
diagnoses.
14
Differential Diagnoses
• In the inpatient setting, coding guidelines
allow coders to pick up diagnoses that are
listed as rule out, possible, probable, or
likely. Unless you subsequently specify
that such diagnoses have been ruled out,
they may well be coded.
15
Laboratory/Diagnostic Results
• A diagnosis must be provided for every lab
value that is monitored and/or treated.
• Lab values and radiology reports that have
been merely copied and pasted cannot be
coded; the results must be commented
on/interpreted.
16
Clinical Connections
• Link the diagnosis to the underlying
condition, as coders can infer nothing.
• Example: A patient with diabetes is
admitted with vomiting and a history of
diabetic gastroparesis.
– If only vomiting is documented then vomiting
is the coded DRG, with a case weight of .32.
– If diabetic gastroparesis is documented and
thus coded, the case weight will be .48.
17
Signs and Symptoms
• Clarify their cause, once discovered.
• Don’t let the admitting symptom or lab finding be
your default final diagnosis, as this will result in
coding of a DRG with a lower case weight.
• Examples:
– Document acute respiratory failure (diagnosis)
instead of respiratory distress (symptom).
– Document sepsis (diagnosis) instead of bacteremia
(lab finding).
18
Signs and Symptoms (con’t)
• Symptom diagnoses often result in
medical necessity denials from insurers.
– Example
• Nausea, vomiting, chest pain, headache are often
deemed appropriate for “observation” status,
whereas diabetic gastroparesis with resultant
bowel obstruction, unstable angina, or concussion
with subdural hematoma likely qualify as inpatient
stays, even if brief.
19
What is the most common reason for
insurance companies to issue denials to
Holy Cross Hospital?
0%
is
s
...
...
ci
al
io
n
So
.
D
.
A
C
.
B
0%
dm
is
s
lt
o
on
su
ro
p
ap
p
In
.
A
0 of 30
0%
r..
.
ri.
..
0%
C
A. Inappropriate level of
care (tele vs. med/surg)
B. Consult or procedure
delays
C. Admission (i.e.
observation status
appropriate)
D. Social issues delaying
discharge
20
HCH Denial Data 10/2010-10/2011
Misc, 16%
Social Issues,
6%
Med.
Necessity,
18%
Admission,
29%
Clinical, 12%
LOC, 14%
Delay, 5%
21
Most Common HCH Admission Denials
•
•
•
•
•
•
•
•
•
Abdominal pain
Anemia
Asthma
Atrial fibrillation
Cellulitis
Chest pain and hypertension
DVT
Syncope
UTI
22
Present on Admission (POA) Flags:
Coders Choose Y, N, or W
• “Y” if condition present at the time that inpatient
admission is ordered
– Conditions that develop during an outpatient
encounter (i.e. in the ER, observation status, or
during outpatient surgery), prior to inpatient
admission, are POA.
• “N” if not present on admission
• “W” if physician clinically unable to determine
whether or not condition was POA
23
You obtain a first U/A on day #2 of a patient’s hospital
stay, diagnose and begin treatment for a UTI. You are
queried about the POA status of the UTI.
24
You are uncertain about whether or not the UTI
was actually present on admission, so you:
0%
en
t
th
e
...
t..
.
0%
um
oc
D
Ig
D
.
.
C
B
.
A
ns
w
er
ye
s
w
er
ns
A
.
0 of 30
0%
no
t..
.
...
0%
no
re
Answer yes, POA
Answer not POA
Ignore the query
Document that you
are clinically unable
to determine
whether or not the
UTI was POA
A
A.
B.
C.
D.
25
Diagnoses Frequently Requiring
Clarification of POA Status
• Decubitus or pressure ulcer
– Examine each patient’s skin at the time of
H&P performance and document ulcers.
•
•
•
•
UTI
Sepsis
Pneumonia
Acute renal failure
26
Potentially Preventable
Complications (PPCs)
• Maryland’s version of “never events”
– Financial penalties are possible if POA
flagging is not accurate and PPCs are
(incorrectly) assigned.
• Holy Cross was ranked in the top quartile
in the state for PPC performance in FY11.
27
Documentation Specificity
• Indicates increased resource utilization
and so justifies higher reimbursement.
– The more specific the diagnosis, the higher
the assigned case weight and risk of mortality.
• Specificity can provide exclusions for
some PPCs.
– e.g. Left sided heart failure—POA “Y”
excludes PPC assignment for acute
respiratory failure—POA “N”. Heart failure,
NOS does not.
28
Sepsis
29
Documentation of which of the following is sure to
make a CDS cry?
SIRS
Sepsis
Severe Sepsis
Septic Shock
Urosepsis
0 of 30
0%
ro
s
U
pt
ic
Se
ep
Sh
o
si
s
...
0%
.
D
C
.
Se
B
ve
.
re
Se
Se
ps
p.
..
S
SI
R
.
0%
E.
0%
is
0%
A
A.
B.
C.
D.
E.
30
Sepsis
• The thread of the sepsis diagnosis should be reflected
throughout the patient’s stay, as the diagnosis may not
be captured by the coder if just mentioned in the H&P or
early progress notes.
• If treated and resolved then document sepsis resolved.
• Include sepsis diagnosis in the discharge summary.
• Indicate whether or not sepsis was POA and also its
severity. (SIRS  Septic Shock)
• Urosepsis is not a codable diagnosis; it codes as UTI.
• Negative blood cultures do not preclude a diagnosis of
sepsis.
31
Clinical Documentation Improvement Program
• A combination of concurrent (CDS) and
retrospective (coder) chart review, with
documentation clarification querying as
necessary
• Common query triggers:
– POA status for
• pneumonia, UTI, decubitis/pressure ulcers, MI, CVA
– CHF specificity
• acute, chronic, or acute on chronic, diastolic or systolic
32
Query Essentials
• Where will you find queries?
– In your Message Center
• Need help to access/answer a query?
– Call CDS (x8641) or Physician Coach (x2348)
• Where should you document your
response?
– As an addendum to your H&P, progress note,
or discharge summary
– NOT ON THE QUERY ITSELF
33
The appropriate time frame to
answer a query is?
..
th
...
0%
a.
Be
f
or
e
so
on
D
.
.
.
B
0%
As
It
d
oe
s
im
e
So
m
et
.
A
0 of 30
0%
n’
...
...
0%
C
A. Sometime before
Christmas
B. It doesn’t matter
because no one will
notice if you answer it.
C. As soon as you receive
it, or when you next see
the patient, or within 48
hours
D. Before the end of the
month
34
Queries (con’t)
• When should you answer a query?
– ASAP
• If you disagree, click “refuse” and explain.
– Help us understand why you disagree with a
particular query so we can ask better queries.
• There will be follow up if query is
unanswered.
– Both CDS and coder queries will be followed
up by the CDS team.
35
Top Three Reasons For Prompt
Query Response
• #3 Charts are being coded 2-5 days after
discharge. If query response is not timely the
late documentation will require subsequent chart
recoding or might even be overlooked.
• #2 You will avoid phone calls from a CDS, and
your Message Center will be emptier.
• #1 It will ensure that the patient’s story has
been told and that the medical record accurately
reflects the severity of illness and complexity of
care provided to your patients.
36
Summary
• Accurate documentation is critical to
– tell the patient’s story
• details the patient’s diagnoses and describes how
they were determined and treated
– enable proper reimbursement of care
• correct DRG and SOI assignments result in case
weight that reflects resources used
– ensure hospital and physicians correctly rated
• public reporting
37
Public Reporting
• Core Measures
– Ever expanding—soon including CVA, VTE
• PPCs
• Publically accessible websites rating physicians
– Physician Compare – coming in 2012
• Outcomes based data for inpatient care
– www.HealthGrades.com – Independent source of
physician information and hospital quality outcomes
38
In Conclusion…
Thank you for the excellent care you
provide to patients at Holy Cross Hospital
and for the attention you pay to the
documentation of that care.
39