DEPARTMENT: Clinical Services
Group – Core Measures
PAGE: 1 of 6
EFFECTIVE DATE: April 1, 2010
POLICY DESCRIPTION: Core Measure
Clarification Process Documentation and Abstraction
Education
REPLACES POLICY DATED: 11/1/09
REFERENCE NUMBER: CSG.COM.001
(formerly QM.COM.001)
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All personnel responsible for performing, supervising or monitoring the Core Measure
abstraction and Inter-Rater Reliability (IRR) process within HCA affiliated facilities including, but
not limited to, hospitals, hospital-based outpatient surgery departments, and all Corporate
Departments, Groups and Divisions.
PURPOSE: The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission
require adherence to Core Measure specifications. This policy sets forth procedures to clarify
incomplete or ambiguous Core Measure documentation so that the medical record accurately reflects
the patient’s clinical condition, treatments, the physician’s medical-decision making process,
medication contraindications, and/or procedures that occurred during an inpatient hospitalization
and/or outpatient encounter.
POLICY:
1. Company-affiliated facilities must follow the appropriate processes to document and collect Core
Measure data elements. Documentation must not be added to the medical record outside of the
timeframe published in the current The Joint Commission/CMS Specification Manual to ensure
the passing of a Core Measure.
2. Each data element must be obtained within a specific time frame (e.g., within 30 days of
discharge, prior to discharge, and for Identified Pathogens within 24 hours of arrival) as set forth
in The Joint Commission/CMS Specification Manual.
3. Documentation must be obtained from specific sources (e.g., a progress note, discharge summary,
or the nursing history) as specified in The Joint Commission/CMS Specification Manual.
4. Individuals engaged in the Core Measure Clinical Clarification Process must utilize the
concurrent review screen in the Quality Management (QM) module in Meditech to initiate
clarification communication via the Core Measure Clinical Clarification Form with the physician
for the Core Measure data elements.
5. The Core Measure Clinical Clarification Form must be maintained in the body of the permanent
medical record and is considered to be a physician progress note.
6. The personnel responsible for reviewing and/or abstracting Core Measure documentation must
NOT initiate:
a. The Core Measure Clinical Clarification Process when the documentation does not reflect the
care provided to the patient.
b. Clinical clarifications cannot be construed as “leading” the physician. A leading clinical
clarification is one that appears to prompt the physician to make specific documentation,
regardless of its accuracy.
c. Repeated attempts to clarify documentation with the intent only to pass a Core Measure.
12/2010
DEPARTMENT: Clinical Services
Group – Core Measures
PAGE: 2 of 6
EFFECTIVE DATE: April 1, 2010
POLICY DESCRIPTION: Core Measure
Clarification Process Documentation and Abstraction
Education
REPLACES POLICY DATED: 11/1/09
REFERENCE NUMBER: CSG.COM.001
(formerly QM.COM.001)
APPROVED BY: Ethics and Compliance Policy Committee
DEFINITION:
Core Measure Clinical Clarification Process - An established mechanism of communication
between core measure abstractors and physicians to clarify incomplete and/or ambiguous
documentation in the medical record.
1. The Concurrent Core Measure Clinical Clarification Process is initiated before the patient is
discharged from the facility.
2. The Retrospective Core Measure Clinical Clarification Process applies to specific Core Measure
data elements that can only be documented and/or abstracted accurately at or after patient
discharge (i.e., discharge medications).
PROCEDURE: All efforts to clarify incomplete and/or ambiguous documentation as it relates to
Core Measure data elements and abstraction within the medical record must be done utilizing the QM
Module concurrent review screens in Meditech. The QM module screens will produce a Core
Measure Clinical Clarification Form for the physician to provide a response. The primary goal is to
obtain only documentation that is representative of the care provided and is acceptable within the
processes below.
1. Core Measure Clinical Clarification Process
The personnel responsible for supervising, reviewing and/or abstracting Core Measure
documentation must understand and adhere to the following requirements:
a.
Core Measure clinical clarifications can be initiated either concurrently or retrospectively
as an established mechanism of communication between a Core Measure abstractor and
physicians to clarify documentation in the medical record.
b.
Core Measure clinical clarifications must be sought when the documentation of the
clinical picture of the patient indicates a clinical core measure was considered or
addressed, or a condition was present, but the physician has not specifically documented
the clinical decision-making process within the medical record.
c.
The Core Measure Clinical Clarification Form must be maintained in the body of the
medical record. Once this form is signed, dated, and timed by the physician, this
information can be used in the Core Measure abstraction process.
d.
Utilization of the Core Measure Clinical Clarification Form in the QM module is required.
The Form is designed with specific parameters based on the specification manual that
ensures compliance for timeframes and source requirements for the data elements.
e.
The selection of the appropriate data element requiring clinical clarification via Meditech
will be determined based on the incomplete and/or ambiguous documentation. The
documentation of the approved and required clinical clarifications is available on the
Clinical Analytics website at: Clinical Analytics Website.
12/2010
DEPARTMENT: Clinical Services
Group – Core Measures
PAGE: 3 of 6
EFFECTIVE DATE: April 1, 2010
POLICY DESCRIPTION: Core Measure
Clarification Process Documentation and Abstraction
Education
REPLACES POLICY DATED: 11/1/09
REFERENCE NUMBER: CSG.COM.001
(formerly QM.COM.001)
APPROVED BY: Ethics and Compliance Policy Committee
2. Response from the Physician
a. The Core Measure Clinical Clarification Form used to clarify Core Measure documentation
during an inpatient hospitalization or outpatient encounter must be signed, dated, and timed
by the physician in order for it to be used as physician documentation for the purpose of Core
Measure abstraction.
b. It is not acceptable for a nurse to document a verbal response from the physician on a Core
Measure Clinical Clarification Form for the purpose of Core Measure abstraction.
c. If no additional documentation is provided by the physician in response to a Core Measure
Clinical Clarification Form, the Core Measure abstractor must abstract the record based on
the written documentation found in the medical record.
d. There may be instances when the physician response is received outside the specific
timeframes for utilization within the Core Measure abstraction process. However, the facility
personnel responsible for abstraction shall abstract the Core Measure data that exists at the
time the data is required to be abstracted.
e. Communication must clarify that the request, even if asked verbally, will be required in
writing and the physician response must be documented by the physician and included within
the medical record.
3. Medical Staff Approval Process
The facility must submit the Core Measure Clinical Clarification Form (e.g., progress note print
out) to its Forms Committee for approval following the process outlined in hospital policy,
medical staff bylaws, or rules and regulations for adding forms to the medical record, if
applicable.
4. Administration and Medical Staff Support
Administration and medical staff must support this processs to ensure its success. It is the
responsibility of each facility’s administration to ensure that this policy is applied by all
individuals involved in Core Measure abstraction, documentation and IRR testing.
5. Education
a. All facilities must educate their physicians and Core Measure abstraction staff on the
importance of concurrent documentation within the body of the medical record.
Communication must be provided to the medical staff that individuals responsible for Core
Measure abstraction or concurrent review will initiate requests to support accurate and
complete documentation in the medical record. Facilities should use educational materials
developed by the Clinical Analytics staff, which are available on the Clinical Analytics
Website on Atlas.
b. Specific training requirements for users of the Clinical Outcome Measures Evaluation and
Transmission (COMET) application are set forth on the CSG Atlas site. Clinical Analytics
12/2010
DEPARTMENT: Clinical Services
Group – Core Measures
PAGE: 4 of 6
EFFECTIVE DATE: April 1, 2010
POLICY DESCRIPTION: Core Measure
Clarification Process Documentation and Abstraction
Education
REPLACES POLICY DATED: 11/1/09
REFERENCE NUMBER: CSG.COM.001
(formerly QM.COM.001)
APPROVED BY: Ethics and Compliance Policy Committee
Website
c. Facility Responsibilities
i. The User Administrator is responsible for ensuring all COMET users review the policies,
educational content, and data quality tools and resources as required in the Health Stream
Leanring System (HLC).
ii. The User Administrator is responsible for holding his or her staff accountable for the
review and compliance with the policies, tools and resource documents.
iii. If the mandatory education requirement is not met within five business days of the
designated timeframe, the employee must not perform abstraction responsibilities until the
educational requirements are met.
d. Corporate Responsibilities
i. CSG will review the tools and resources as appropriate to include any regulatory
requirements on a quarterly basis.
ii. Any revisions to the mandatory education will be communicated via e-mail.
iii. CSG will monitor the participation and completion of the mandatory education.
iv. CSG will notify the User Administrator prior to removing a COMET users’ access.
Failure to complete the specified training requirements will result in the loss of COMET
access.
6. Facility Compliance Monitoring
Each facility must designate a Core Measure User Administrator (typically the Quality Director
or designee). The Core Measure User Administrator must complete an annual review to confirm
adherence with this policy. The number of Core Measure Clinical clarifications should be
tracked and trended by the Core Measure User Administrator in order to identify ongoing
educational and documentation needs of the medical/clinical staff.
7. Maintenance of the Meditech Core Measure Clinical Clarification Tool and Documentation
The CSG Clinical Analytics Department will update the Meditech Core Measure Clinical
Clarification Tool with each new Core Measure specification manual release.
8. Questions and Concerns
a. Core Measure-related issues or questions.
Individuals seeking clarification of Core Measure-related issues or questions should refer to
the COMET Resource Document.
b. Unresolved COMET application issues or questions.
Individuals with unresolved issues or questions related to COMET should contact COMET
Support via e-mail at COMETSupport@hcahealthcare.com.
12/2010
DEPARTMENT: Clinical Services
Group – Core Measures
PAGE: 5 of 6
EFFECTIVE DATE: April 1, 2010
POLICY DESCRIPTION: Core Measure
Clarification Process Documentation and Abstraction
Education
REPLACES POLICY DATED: 11/1/09
REFERENCE NUMBER: CSG.COM.001
(formerly QM.COM.001)
APPROVED BY: Ethics and Compliance Policy Committee
c. Unresolved Core Measure data definition related issues or questions.
Individuals with unresolved issues or questions related to Core Measure data definitions
should contact COMET Support via e-mail at COMETSupport@hcahealthcare.com.
d. Unresolved Coding issues or questions.
i. Individuals with unresolved coding issues should work within the facility to address such
issues or questions, including discussing the issue(s) with the coding supervisor and/or
HIM/HSC Coding Director.
ii. For technical coding questions, the HIM Department should contact the 3M Nosology
Helpline pursuant to the Coding Help Line Policy, REGS.COD 004.
iii. If after completing steps i. and ii. above there are still unresolved coding questions, the
individual should contact the Regs Help Line for additional assistance for coding
guidance, including application of coding policies and procedures.
e. Unresolved Core Measure operational issues or questions.
i. All day-to-day operational issues should be handled locally at the facility working
collaboratively with one’s direct supervisor and/or facility Ethics and Compliance Officer.
ii. For unresolved or unanswered general questions regarding operations or implementation
of the CSG.COM policies, please contact the CSG Manager of Clinical Operations
Clinical Analytics, or COMET Support.
iii. Each colleague has an individual responsibility for reporting any activity by any
colleague, physician, subcontractor, or vendor that appears to violate applicable laws,
rules, regulations, accreditation standards, standards of medical practice, Federal
healthcare conditions of participation, or the HCA Code of Conduct.
iv. If a matter that poses serious compliance risk to the organization is reported locally, and if
the reporting individual doubts that the issue has been given sufficient or appropriate
attention, the individual should report the matter to higher levels of management or the
Ethics Line (1-800-455-1996) until satisfied that the full importance of the matter has
been recognized.
REFERENCES:
1.
2.
3.
4.
5.
6.
Medicare Conditions of Participation, 42CFR482.24(c) (2) (viii)
CMS Medicare Bulletin - GR 2007-03
Q Net Quest Question Number 228360
The Joint Commission/CMS Specification Manual for National Hospital Quality Measures
The Joint Commission Data Quality Manual
COMET Resource Document
12/2010
DEPARTMENT: Clinical Services
Group – Core Measures
PAGE: 6 of 6
EFFECTIVE DATE: April 1, 2010
POLICY DESCRIPTION: Core Measure
Clarification Process Documentation and Abstraction
Education
REPLACES POLICY DATED: 11/1/09
REFERENCE NUMBER: CSG.COM.001
(formerly QM.COM.001)
APPROVED BY: Ethics and Compliance Policy Committee
7. Coding Help Line Policy, REGS.COD.004
8. Documentation Improvement (DI) – Compliance Requirements Policy, REGS.DOC.001
9. Query Documentation for Clinical Documentation Improvement (CDI) & Coding – Compliance
Requirements, REGS.DOC.002
10. Correction of Noneditable Core Measure Data Elments in COMET Policy. CSG.COM.002
11. Purging of COMET Core Measure Records Policy, CSG.COM.003
12/2010