3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
Bridging the CDI gap: Bringing
the clinical/coding
reconciliation process
together
Margi Brown, RHIA, CCS, CCS-P,
CPC, CCDS
Lynne Spryszak, RN, CCDS, CPC-A
Objectives of this presentation:
• Identify successful CDI infrastructure
models
• Learn how to use each other’s strengths to
build a strong process
• Use differences to “close the gap”
• Develop a “full-circle” reconciliation
process
Program
Foundation/Infrastructure
Who needs to be involved?
• Build a solid foundation of support
– Administrative support/Steering Committee
•
•
•
•
CEO
CFO
CMO/VP Medical Affairs/Chief of Staff
VP Nursing
– HIM Director
– Director of CDI
Who has responsibility?
• CDI Program Reporting structure
– HIM and CDI reporting to same level of
administration
•
•
•
•
•
•
•
Facilitates decision-making
Eliminates barriers d/t differing facility goals
Understands global effect of program
Support for change
Champions growth – invested in success
Promotes program within organization
Ability to approve program changes
– Staffing
– Focus of program
Importance of program leaders
• CFO (Chief Financial Officer)
– Understands:
• Financial impact of program
– Payer benefits
– Impact on operating budget
» DNFB, A/R
• How improved profiling affects business
– Fiscal responsibility
• Approves budget/spending
– CDI FTEs
Importance of program leaders
• CEO (Chief Executive Officer)
– Hospital’s “top dog”
• Top level of Administrative Tree
– Influence
•
•
•
•
Medical Staff
Nursing
HIM
All other departments
Importance of program leaders
• CMO (Chief Medical Officer)/VPMA (Vice
President of Medical Affairs)/Chief of Medical
Staff
– Responsibilities:
• Support/facilitate physician education
• Support physician participation
– Access to staff meetings
• Support CDI Process
– Medical staff involvement
» Inclusion on medical staff agendas
» Physician compliance
– Final medical authority in query follow-up process
Importance of program leaders
• CNO (Chief Nursing Officer)/VP of Nursing/
Director of Nursing
– May have responsibility for CDS
– Understanding of CDI goals
• Documentation drives data
– Nursing documentation
• Impacts data
• Patient care
• Ability to effect change
– Required documentation: forms, templates, EMR fields, etc.
– Participation of Nurse Practitioners, other second
level providers with documentation privileges
– Support goals of documentation improvement
Importance of program leaders
• HIM Director
– Approves CDI/Coding policies and
procedures
– May have responsibility for CDS as well as
coders (overall program administrator)
– Approves procedural changes
– Final responsibility for actions of HIM
department
• Coder participation
• Coding turnaround time
• Compliance
Importance of program leaders
• CDI Director
– Provides guidance
– Access to resources
– Liaison between CDS and upper
management
– Responsible for
•
•
•
•
Program outcomes
Meeting goals
Staffing
Training
Importance of program leaders
Importance of program leaders
• Key Points
– Success depends upon involvement of the
executive committee
– Collaboration within and between
administrative levels essential
– Program organizational structure not as
important as strong leadership at each level
– Ongoing communication is pivotal to success
The blended model
The “Blended” Model:
HIM and RN teams
The blended model
What each profession brings to the team
The blended model
• HIM Strengths
– Knowledge of coding rules and regulations
– Training/Education 2 - 4 (or >) years of formal learning
including:
•
•
•
•
Anatomy & Physiology
Pharmacology
Medical Terminology
Health Information Management
–
–
–
–
–
Inpatient coding/billing
Physician (Professional) coding/billing
Specialty training
Legal/Ethical Issues in Healthcare
Reimbursement Methodology
•
•
•
•
•
Outpatient coding/billing
ED coding/billing
Health Data Management
Computer Systems
Clinical Data Management
The blended model
• RN Strengths
– Clinical (hands-on) assessment experience
– Training/Education 2 – 4 (or >) years of formal
learning including:






Anatomy & Physiology
Pharmacology
Medical Terminology
Pathophysiology
Nutrition
Microbiology
 Pediatric/Adult Growth and
Development
 Psychology
 Ethics
 Clinical Practice
 Chemistry
The blended model
HIM
50%
RN
50%
100 % Success = 50% + 50% Effort!
The blended model
• Teams
– Respect differing values & viewpoints
– Share the “load”
– Define goals
– Develop processes
– Avoid blame/shame
– Focus on the problem, not the people
– Persistent
– Work together…
The blended model
Success depends on everyone knowing their
job and then doing it!
The blended model
• Responsibilities of the Coder:
–
–
–
–
–
–
Ethical behavior
Accurate code assignment
Productivity benchmarks
Data management
Confidentiality
Adherence to internal policies and procedures
• Facility
• Coding
• Employee
– Adherence to rules and regulations
•
•
•
•
AHIMA Code of Ethics
“Official Coding Guidelines for ICD-9”
Coding Clinic
State regulations
– Continuing education
– Training and development
The blended model
• Responsibilities of the CDS
– Ethical behavior
– Facilitate improvements in provider diagnostic documentation
– Collaborate in data reporting (diagnoses)
•
•
•
•
Specificity
Clinically appropriate
Supported by medical record
Ensure “complete” record
– Adherence to internal policies and procedures
• Coding
• CDI
• Employee
– Adherence to external rules and regulations
• AHIMA?
• ???? Are there any?
The blended model
While CDI team members may be subject to the same internal
policies (employee, safety, body mechanics, etc.), determining
whether the CDS’ are governed by coding rules and regulations
and whether their goals are the same as the coders’ has been
much disputed and the subject of controversy.
• This “double standard” creates an “us” versus “them”
mentality.
– Impedes or eliminates trust
– Creates conflict
– Prevents collaboration
– Diminishes credibility
– Team working as individuals rather
than partners
Perspective: Do you see what I see?
Case study
The patient is a 78-year-old female who presented with a 2-day history of
black tarry stools. This patient denied any abdominal pain, nausea, vomiting
or diarrhea, also, no chest pain, no fevers or chills. The patient denied any
recent trauma or change in medication. The patient had a significant history
of use of aspirin, Plavix, and Coumadin. The patient denied any gross blood
in stool or history of any ulcers in her GI tract or cancers of the GI tract.
Initial laboratory work revealed hemoglobin level of 8.1 and hematocrit of
24.8, which was down from a baseline level of 10.4 hemoglobin in August
2009. Her INR was 4.4 as well. Troponins were negative x3 sets and chest
x-ray was clear. Upon admission, warfarin, Plavix, and aspirin were held
and she was transfused 2 units of packed red blood cells followed by H and
H q.6 hours. She was also given IV fluids and placed on a Nexium drip.
Case study
On April 3rd, she was again found to be weak, tired, and
also experienced a bowel movement that was positive for
blood. Her hemoglobin had initially responded to the first 2
units of blood to a level of 9.6 but had again decreased to
8.6. She was given 1 more unit of packed red blood cells
and GI was consulted for endoscopy.
EGD was performed, which revealed no active source of
bleeding. Also, colonoscopy was performed which
revealed no source of bleeding as well.
Case study
• DISCHARGE DIAGNOSES:
1. Osteoporosis
2. Dementia
3. Osteoarthritis (OA)
4. Coronary artery disease (CAD)
5. Type 2 diabetes
6. Gastroesophageal reflux disease (GERD)
7. Peripheral vascular disease (PVD)
8. Depression
9. Hyperlipidemia
10. Hypertension
11. Acute gastrointestinal (GI) bleed
How good are your ‘eyes’?
Through a coder’s
eyes:
1. Acute GI bleed
–
Due to ?
2. H/H low –
–
–
–
–
Query needed for
?anemia & type
?blood loss
?acute on chronic
3. GERD
4. Hx aspirin use
5. (Code the rest of discharge
diagnoses listed)
–
–
–
EDG
Colonoscopy
Transfusion
How good are your eyes?
Through a nurse’s eyes:
1. Why was the patient on Plavix and
Coumadin?
2. Was patient taking her medication
appropriately – she has dementia
a) Was this then a “poisoning” or is it an
“averse effect”?
3. Pt placed on Nexium drip – did the doctor
suspect an upper GI bleed?
4. Should I ask the GI guy if he suspects a
cause of bleeding even though the scopes
were negative?
5. Did the patient have blood loss anemia or
was it a combination – blood loss, iron
deficiency, other?
The medical record
• Coders:
– Identify documented conditions (diagnoses)
• Focus on what IS documented, not what isn’t
– Focus on “who” documented
– Identify and interpret conflicting information
– Interpret operative reports
– Understand the difference between what is
apparent and what is “code-able”
– Process records efficiently and within defined
time frames (can’t get bogged down in one
record)
The medical record
• Nurses:
– Synthesize random bits of information into a diagnosis
• Pulmonary infiltrates + Levaquin = Pneumonia
• Absent bowel sounds = Ileus
• Increased pulse, edema, and “wet” breath sounds = CHF
– “Leap to conclusions”
– Don’t need to see the word to know it exists
– Aren’t necessarily concerned with specificity
• Bronchitis or COPD – what’s the difference – it’s all SOB
• Altered mental status = more work!
• Why do I care if it’s systolic heart failure? They all get Lasix!
• I can’t read the progress notes either - when in doubt, I guess!
The medical record
• Coders typically
– Review thousands of records each year
– Look at all the documentation, while thinking coding, guidelines, and is it
all supported?
• All clinician documentation, all reports, progress notes, orders …
– Are happy to have a discharge summary at the time of coding.
• Compares the discharge summary to the body in the chart to make
sure all is consistent.
– Have the “whole enchilada” available for coding
• Well, maybe half an enchilada if there’s no d/c summary…
– Reviews all other information and digs into the nursing notes when
searching for a missing link…
– Generally don’t place a lot of emphasis on the ED notes, (for coding
purposes), but use for the introduction (framework of the patient – what
occasioned the admission to the hospital)
– Take pride in their work
The medical record
• Nurses typically
– Focus on the abnormals: lab results, vital signs,
mental status, x-rays
– Focus on the clinical, not the record
– Don’t see things as contradictions
• Renal failure = renal insufficiency
– Rarely “challenge” a physician’s diagnosis
– Only use the progress notes if there’s no “check box”
– Are task-oriented
•
•
•
•
Assess patient
Pass medications
Sign-off orders
Document by exception
– Take pride in their work
What’s the answer?
•
•
•
•
Respect our similarities
Appreciate our differences
Share what we know
Be willing to admit what we don’t know and
ask for help
• Appreciate each other’s limitations
– Time
– Opportunity
– Expertise
• Keep our “eyes on the prize” – accurate data!
• Collaborate in devising solutions
Comprehensive approach
• CDS perform concurrent reviews and Coders perform
retrospective reviews to:
– Identify opportunities
• Diagnosis specificity/accuracy
– Request clarification as needed
• Priorities – align, but the scope or focus may be a little
different
– CDS
•
•
•
•
Physician documentation: accurate, specific, clinically supported
HACs
CORE measures
Medical Necessity
– Coders
• Coding the record: accurate, specific, clinically supported,
also meeting the above (to an extent)
Observations
• Neither group can do it alone –
– or should have to
• What one person misses, another one
may catch – “have each others’ backs”
• Wearing different “glasses” makes us see
things differently
• One group can help the other – “many
hands make light work”
One solution?
• Never only one solution
• Process is dynamic
• Enlist support:
– Medical staff
– Nursing
– Ancillary care
– Quality
– Finance
– Managers
• Be willing to compromise on the small issues
and collaborate on the big issues
Drawing the circle
Assigning the DRG
DRG/MS-DRG assignment
Aiming for the most accurate …
40
The driver = The principal diagnosis
• The principal
diagnosis (PDx) is the
initial “driver” to the
(one) MDC….
• Then driving on to the
most specific
DRG/MS-DRG
• With of course several
factors involved
PDx: Principal diagnosis
• Coding guideline for inpatient hospital cases
for the Principal diagnosis =
“that condition established after study to be chiefly
responsible for occasioning the admission of the
patient to the hospital for care.”
• How does the term “principal” dx differ from
the clinician’s definition? (Most severe? most
acute?)
MDC listing
The bucket list
Medical
Diagnosis
Start with medical first
• The starting point is always the medical
diagnosis.
– Determines the correct MDC
• Medical diagnoses are grouped to DRGs
within that MDC
• MDC assignment does not change d/t
surgical procedure
• Correct starting point “drives” the DRG
assignment
⇒Incorrect starting point, incorrect ending point
45
DRG bucket options
Post-
MS- Acute
DRG DRG
Special
Pay DRG MDC
TYPE
FY 2010 MS-DRG Title
Weights
Geo
metric
mean
LOS
Arith
metic
mean
LOS
186
187
188
Yes
Yes
Yes
No
No
No
04
04
04
MED
MED
MED
PLEURAL EFFUSION W MCC
PLEURAL EFFUSION W CC
PLEURAL EFFUSION W/O CC/MCC
1.5917
1.0620
0.7612
5.5
3.9
2.9
7.1
5.0
3.6
189
No
No
04
MED
1.3455
4.7
6.0
190
Yes
No
04
MED
1.2076
4.7
5.8
191
Yes
No
04
MED
0.9622
4.0
4.8
192
193
194
195
Yes
Yes
Yes
Yes
No
No
No
No
04
04
04
04
MED
MED
MED
MED
PULMONARY EDEMA & RESPIRATORY FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
W MCC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
W CC
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
W/O CC/MCC
SIMPLE PNEUMONIA & PLEURISY W MCC
SIMPLE PNEUMONIA & PLEURISY W CC
SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC
0.7175
1.4378
0.9976
0.7095
3.2
5.3
4.3
3.3
3.8
6.6
5.1
3.9
291
292
293
304
305
Yes
Yes
Yes
No
No
No
No
No
No
No
05
05
05
05
05
MED
MED
MED
MED
MED
HEART FAILURE & SHOCK W MCC
HEART FAILURE & SHOCK W CC
HEART FAILURE & SHOCK W/O CC/MCC
HYPERTENSION W MCC
HYPERTENSION W/O MCC
1.4609
0.9740
0.6940
1.0242
0.5959
5.0
3.9
2.9
3.7
2.2
6.4
4.7
3.4
4.8
2.8
1.2188
4.0
5.3
0.8207
3.0
3.8
0.5710
0.5128
0.7215
0.5404
2.1
1.9
2.5
1.7
2.6
2.3
3.1
2.1
308
No
No
05
MED
309
No
No
05
MED
310
311
312
313
No
No
No
No
No
No
No
No
05
05
05
05
MED
MED
MED
MED
CARDIAC ARRHYTHMIA & CONDUCTION
DISORDERS W MCC
CARDIAC ARRHYTHMIA & CONDUCTION
DISORDERS W CC
CARDIAC ARRHYTHMIA & CONDUCTION
DISORDERS W/O CC/MCC
ANGINA PECTORIS
SYNCOPE & COLLAPSE
CHEST PAIN
Procedures
Surgical
Procedure
Is there a surgical procedure?
• If a procedure is done, you then drive from
medical to the surgical side of the MDC.
• However; not in all cases.
– Not all procedures will drive to the surgical
side:
• Example: Biopsy
• Closed, percutaneous, open …
Non-surgical procedures
CMS non -surgical procedures are coded, but does not
impact the DRG assignment
•
•
•
•
•
•
•
•
Chest tube
Cystoscopy
Defibrillation
EGD
Electroshock therapy
Endotracheal intubation
ERCP
Foley catheter
•
•
•
•
•
•
•
•
Gastric tube
I&D
Intrathecal catheter
Lumbar puncture
Paracentesis
Peritoneal dialysis
Spinal tap
Subclavian line
• Swan-Ganz
catheter
• Temporary
pacemaker
• Thoracentesis
49
Procedures: One too many
• The PDx as the driver is still the determining
factor in many cases for a surgical DRG/MSDRG.
• There are procedures common for multiple
diagnoses in many MDCs.
– IVC or Greenfield filter placement
– Excisional debridement
• While these procedures are included in several
surgical DRGs/MS-DRGS, the PDx will drive to
the most specific choice.
50
Unrelated mix
• For procedures “unrelated to the principal
diagnosis”
– these cases are not defined in one MDC, but
listed as “DRGs Associated with all MDCs”
– MS-DRG 981 – 989 and further categorized by
• The type of OR procedure
– Extensive
– Non-extensive
– Prostatic
• Severity with or without MCC or CC
– With MCC
– With CC
– Without CC/MCC
52
Driver pathway
1. The PDx drives the assignment of the medical
DRG.
2. A surgical procedure will drive the final surgical
DRG assignment (determine “surgical”).
•
•
•
•
One too many: diagnosis to procedure
Unrelated
OR vs. bedside
Multiple surgical procedures
3. Check the surgical hierarchy
• Variables = PDx, surgical class, complications & comorbidities
4. Review for those significant secondary diagnoses
that may affect the severity of the patient
53
Driving points
• “Birds of a feather …”
– DRGs are sometimes like close “flocks”
• the medical PDx and the (valid OR) surgical
procedure usually stick together in the same MDC
flock when they can
54
55
The driver(s)
• Who is the driver of
the documentation
and can it be
coded?
“Medical record documentation
from any provider (a physician or
any qualified healthcare practitioner
who is legally accountable for
establishing the patient’s diagnosis)
involved in the patient’s care and
treatment may be used to support
the determination of whether a
condition was present on admission
or not; and the importance of
consistent, complete documentation
in the medical record cannot be
overemphasized”
Source: MLN Matters Number: MM5499 Related Change Request
Number: 5499, 091107 update and Transmittal #289 071707
update
56
The passenger(s)?
• Not the licensed “treating” physician for an
inpatient case:
• Radiologist interpreting an x-ray
• Pathologist examining tissue
• Roles for clarification:
– Residents
• Are all residents licensed in your organization?
– Nurse Practitioner/Physician Assistants
• Check the state and/or hospital bylaws
57
HAC: Yes or no, and why?
Indicator
Definition
How a HAC will be treated
with this indicator
Yes; POA
Will assign to higher
weighted DRG
No; Not POA
Will NOT assign to higher
weighted DRG
U
Unknown: insufficient
documentation
Will NOT assign to higher
weighted DRG
W
Clinically Undetermined:
Unable to determine
based on clinical picture
Will assign to higher
weighted DRG
Y
N
It’s a go!
59
Reconciliation process
Tightening the
reconciliation process
•
•
•
•
Many variables
Start to finish review
Coding rules
Procedure –
– It is what it is
• Setting the bar too
high
– % matching
• Final outcome
Reconciliation goals
• Back to basics
– Goal(s) of the program
– Top priorities
– Communication front to back and in-between
– Stats reported
•
•
•
•
Purpose
Method
Outcome
Baseline and opportunities
– Remembering the different “lens”
Bottom line
• Hospitals as well as each physician need
the most accurate and specific
documentation that translates into correct
and compliant coding to reflect the true
complexity of care and severity of illness
of their patients.
Evolvement of the MS-DRG
Admitting
DRG
• Starting Point; does not count
• As currently documented
Working
DRG
Presumptive
DRG
• Pending query
• After query resolved and final coded
Final DRG
63
Reconciliation mismatches
The majority of the original sample of mismatches involved the principal
diagnosis from the CDS to final coding .
Reason
Medical
#
Surgical
%
#
Total
%
#
%
PDx
27
54%
4
8%
31
62%
MCC
3
6%
2
4%
5
10%
CC
1
2%
0
0%
1
2%
SDx
0
0%
0
0%
0
0%
PP
6
12%
1
2%
7
14%
SPx
0
0%
0
0%
0
0%
Multiple
3
6%
3
6%
6
12%
Total
40
80%
10
20%
50
100%
Reconciliation mismatches
The final coded MS-DRG
averaged a higher relative
weight compared to the
initial (working) MS-DRG
assigned by the CDS.
• RW ↑
36
• RW ↓
13
• No Change 1
72%
• Total Sample
50
26%
2%
Reconciliation mismatches
Auditor’s review of the MS-DRGs assigned:
Total Sample
50 cases
• Agreed
with Coding 40
• Changes
– RW ↑
5
– RW ↓
5
80%
10%
10%
• The 10 cases that differ from
the final MS-DRGs:
– 8 cases agreed to the
working CDS assignment
– 2 cases with different MSDRGs, compared to the
initial CDS and the final
coded assignments
Reconciliation mismatches
• In many cases, the final MS-DRG assigned was the
most accurate due to different reasons such as:
– The Coders have the entire chart at the time of coding for
review, instead of reviewing the chart as a snapshot point
during the hospitalization.
– The Coders are trained in coding, take the coding
guidelines into consideration and since each case is
different, multiple coding rules may apply.
– The CDS however may not be as well versed in the
guidelines.
– The discharge summary in some of the sample cases
“pulled” the information together, supporting the final
coded MS-DRG.
Reconciliation mismatches
• The majority of the mismatched MS-DRGs assigned
were due to principal diagnosis selection:
– Multiple diagnoses that meet the definition for the principal
diagnosis
– PDx as a complication diagnosis/code
– Adverse effects versus poisoning
– Contradictory terms
• There were also several cases with a “multiple” reason
for the change.
– These include a combination of topics including the principal
diagnosis, and/or the secondary diagnosis at a higher
weighted code - CC/MCC, and/or the procedure.
Multiple PDxs? Which one is it?
69
Reconciliation mismatches
• There were several cases where a
mismatched MS-DRG was due to the
procedure(s).
– The majority of these changes involved incorrect
MS-DRGs assigned by the CDS due to actual
coding of the procedure itself and/or reviewing
the case prior to the procedure date.
– As a note, with these cases, the documentation
was present in the chart where the Coders were
able to accurately code the chart.
Reconciliation mismatches
• Factors
– Knowledge and skill level of staff
– The complexity of the cases
• The focus of this review was complex cases that
involved high level understanding of coding guidelines.
– Process of concurrent reviews
• Root cause(s)
• In most cases, the inability to follow-up on cases and
the application of coding guidelines for the principal
diagnosis led to the MS-DRG mismatch.
RAC – one more reason to work
together…
RAC: Top errors
• Medically Unnecessary Service or Setting
– 62%
• All Other Inpatient Overpayments
– 11%
• Incorrect Discharge Status
– 1%
• DRG Change Due to Wrong Diagnosis Code or Principal
Assignment
– 14%
• DRG Change Due to Wrong Procedure Code(s)
– 12%
Source: Appendix F
Audit Areas and Top Errors by Provider Type
Figure F1. Audit Areas and Top Errors by Provider Type, Net of Appeals:
Cumulative Through 3/27/08, Claim RACs Only (Percent of Overpayment Amount)
http://www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf
RAC: Debridement
Table P1. Excisional Debridements (Complex Review, Incorrect Coding)
•
Claim Facts
–
–
–
The hospital coder assigned a procedure code of 86.22.
In the medical record, the physician writes “debridement was performed.”
Coding Clinic 1991Q3 states “Unless the attending physician documents in the medical record that
an excisional debridement was performed (definite cutting away of tissue, not the minor scissors
removal of loose fragments), debridement of the skin should be coded to 86.26, non excisional
debridement of skin… Any debridement of the skin that does not meet the criteria noted above or is
described in the medical record as debridement and no other information is available should be
coded as 82.26.”
•
The RAC determined that the claim was INCORRECTLY CODED and issued a repayment
request letter for the difference between the payment amount for the incorrectly correctly
coded procedure and the payment amount for the correctly coded procedure.
•
Corrective Actions
–
Hospitals can be more careful when submitting claims for excisional debridement. Medicare claims
processing contractors can remind hospitals about the importance of following the coding clinic
guidelines when submitting claims for excisional debridement.
Source: http://www.cms.hhs.gov/RAC/Downloads/RAC_Demonstration_Evaluation_Report.pdf
Summing it all up
Set it up
• Set your key goals
involving:
– Complete clinical
documentation
– Coding Quality
– Medical Necessity
– RAC or denial
vulnerabilities
• Set your table
– Who is involved
– Who is the “key” point
person
– Determine the level of
involvement
– Responsibility and
authority
– Map the process
– Agree on the road
map
Reconciliation internally
incorporating KEY
members and
“interdepartmental”
involvement: CM, quality,
core measures,
departments
• Developing and
maintaining the full circle
program
• Bringing it all together
Audits and RAC
• Starting the program and
Documentation
Working together
– Team and
Relationship
Building
– Development of
“partnerships”
within and outside
the facility
– Dancing to the
“same” tune
Driving the distance
• Develop a current
state process and
map to your common
goal – destination
• Keep going no matter
what the barriers may
be
Audience questions
?