3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
The Power of Case Studies:
Death Review and SOI/ROM
Cheryl Ericson, MS, RN
Manager of Clinical Documentation
Integrity & Utilization Review
Medical University of South Carolina (MUSC)
Medical University of
South Carolina
• Academic medical center
• Located in Charleston, SC
• Licensed for 709 beds
– Ashley River Tower
– Main Hospital
– Children’s Hospital
• Approximately 40,000 discharges in 2009
Clinical documentation program
• Initiated in 2005
– Three staff including the manager
– Used consultants through 2007
• Current staffing
– Eight FTE and one manager
– Registered nurses without coding credentials
– Split between two buildings
• Ashley River Tower
• Main Hospital
Clinical documentation program
• Primary duty is revenue capture
• Only department that queries physicians
– Coding does not query physicians
• No additional duties related to quality
measures, case management, etc.
• Follow records to billing
– Primarily conduct concurrent reviews
– Discharge reviews
– Few retro-reviews
Reporting structure
• CDI reports to the director of health
information services (HIS) and patient
access services (PAS)
– HIS manager is over the coding department
• One coding supervisor
– CDI manager and HIS manager of equal
status
• Director of HIS/PAS reports to the chief
financial officer (CFO)
Challenge: Take CDI to the
next level
• New management, May 2008
– Tasked with taking CDI to the next level
– CDI processes were unchanged since the
department was established
• MS-DRGs introduced October 2007
– Limited physician support and little physician
education outreach
– Focused on diagnosis clarification
• Urosepsis, CHF, anemia, etc.
Challenge: Physician engagement
• Administrative physicians are interested in
the financial impact of the CDI program;
however, because hospital reimbursement
doesn’t directly affect the medical staff,
hospital revenue enhancement may not be
enough incentive to elicit the cooperation
of the medical staff in CDI activities.
Physicians: What’s in it for me?
• How did the medical staff view CDI at
MUSC?
– Many physicians viewed CDI activities/
documentation as a distraction from patient
care
– Many physicians thought CDI was a
documentation “game”
– Reimbursement was a dirty word
Making the link
• Historically, the CDI department at MUSC only
focused on revenue enhancement
– CC and MCC capture
• Under new management, the focus of the CDI
department was changed to a focus on
improving the overall quality of the
documentation regardless of the impact on
CC/MCC capture
– Introduced the significance of SOI/ROM
Making the link
• It was important to understand the link
between CC and MCC capture rates and
the expected mortality index
– MS-DRG is a severity-adjusted DRG system,
MS = Medicare Severity
• MUSC uses the APR Grouper so the
severity of illness (SOI) and risk of
mortality (ROM) are calculated as part of
the coding process
APR grouper
• Assigns a severity of illness (SOI) score
on a scale of 1–4
•
•
•
•
1 = minor
2 = moderate
3 = major
4 = extreme
•
•
•
•
1 = minor
2 = moderate
3 = major
4 = extreme
• Assigns a risk of mortality (ROM) score on
a scale of 1–4
Recognizing the
importance of SOI/ROM
• The mortality index is the ratio of actual deaths
to expected deaths
– CC/MCC capture impacts the expected mortality rate
• The SOI/ROM scores are a key component in
the algorithm used by the University Health
Consortium (UHC) to calculate the expected
mortality rate
– MUSC uses UHC data for comparison with other
academic medical centers
How is the SOI/ROM determined?
• Each diagnosis has its own intrinsic SOI/ROM
value of 1–4
• A complex formula is used to calculate the SOI/
ROM of the DRG/case
• Basically, in order for the DRG/case to be a 4/4,
at least two diagnoses used to calculate the
DRG must have a value of 4/4
– In other words, multiple major complicating
conditions (MCC) are need to reach a 4/4
Making the link
• The strategy for physician education was
changed from CC/MCC capture and
revenue enhancement to accurately
representing their patient’s severity of
illness and risk of mortality.
• Basically, we challenged the assertion that
MUSC physicians treat the “sickest of the
sick”
Making the link
• CDI shifted focus from revenue to quality,
with revenue enhancement as a byproduct
– SOI/ROM scores were included on working
DRG documentation
– CDI staff began issuing “educational” queries
• Queries that could result in an additional CC or
MCC that may impact SOI/ROM but would not
impact the current level of reimbursement
Why focus on the mortality index
• MUSC is a Studer® hospital
• Studer® hospitals use five pillar goals to
measure the success of the facility
• The Quality Pillar at MUSC is measured
by the mortality index
– This pillar goal was unmet in 2008 and
2009
Mortality index prior to education
Comparison data 4th Quarter 2008
MUSC data 4th Quarter 2008
• At the UHC median – middle of the pack in
comparison to other academic medical
centers
• Significantly below the benchmark (0.83
for the year), which represents top quartile
• Just barely below 1.0 for the mortality
index – want to be as much below 1.0 as
possible
Implementing the strategy
• The CDI staff at MUSC was successful at
identifying diagnoses that required
additional specificity to capture a CC or
MCC (i.e., incomplete diagnoses such as
CHF, anemia, urosepsis, etc.), but a
successful CDI program also identifies
missing diagnoses.
The next step
• Find a way to identify missing diagnoses
• How do you know if/which records are
potentially missing diagnoses?
Assumption
• Deaths should have a severity of illness
(SOI) of extreme/4 and a risk of mortality
(ROM) of extreme/4
• A focused review was conducted on
deaths that occurred over the past year
without a SOI/ROM  7
– Where the SOI/ROM was not 3/4 or 4/3 or 4/4
Outcome
• Reviewing deaths that aren’t 4/4 revealed
certain trends in physician documentation
at MUSC
– Identified many opportunities for CC/MCC
capture
– Identified types of patients that negatively
impacted the mortality index
• Hospice patients
• Short-stay deaths
• Nonviable neonates
Outcome
The CDI program was able to:
• Generate a list of diagnoses that were
supported by medical evidence but
undocumented by the medical staff
• “Translate” terms used by physicians into
diagnoses that could be captured by
coding
Educational tools
Initial phase
• Educate the CDI and coding staff regarding
the importance of reviewing all deaths without
a SOI/ROM of 4/4
– We found that 3/4 and 4/3 were not strict enough
criteria
• Implemented a process where all deaths
without a 4/4 are reviewed by CDI staff upon
discharge
– Non-DRG payers are referred to CDI by coding
Education
• Develop educational tools
• Presentations are requested by the
individual service lines or departments and
are tailored to that particular service line to
emphasize relevance to the medical staff
– Neurosciences
– Heart and vascular
– Digestive disease center
Sample of Physician
Educations
Short-stay death
Diagnoses: Etiology of stated
symptoms?
Respiratory diagnoses?
Encoder demonstration
Added ABLA – no change
Added hemorrhagic shock
ROM is  to 4
SOI is  to 4
Added hemorrhagic shock &
respiratory failure due to shock
ROM is  to 4
SOI is  to 4
Added coma =  Mental status?
ROM is  to 4
SOI is  to 4
Key discussion points
There are several diagnoses that were
supported by medical evidence but not
documented in the medical record that could
have moved the SOI/ROM
•Emphasize a body system review
– Avoid focusing only on specialty area
•Provide a rationale/diagnosis for all
procedures
Short-stay death
SOI= 3 ROM = 2
Short-stay death
– Suspected location of bleed?
– Evidence of hypovolemic/hemorrhagic shock secondary to
GI bleed?
– Level of consciousness?
– Respiratory status?
Potential diagnoses?
– Translate these findings into diagnoses
•
•
•
•
•
“Not having any spontaneous respirations”
“Unresponsive”
Hemoglobin 6.7, hematocrit 9/7
ABG results
Totality of the symptoms
Diagnoses?
Encoder demonstration
Revised w/ hemorrhagic shock
ROM is  to 3
Revised w/ acute respiratory failure
ROM is  to 4
SOI is  to 4
Translation of ‘unresponsive’
Revised w/ coma
ROM is  to 4
SOI is  to 4
The value of physician
documentation
• When presenting death cases, especially
those with a long length of stay, ask how
much documentation occurs on these
patients (e.g., how many pages of
progress notes). Physicians are often
surprised to learn that pages and pages of
documentation may result in only a few
diagnoses that can be coded.
Service Line Education
Mortality index
• The goal is for the expected mortality rate
(yellow line) to ALWAYS be higher than
the observed mortality rate with increasing
separation
• The observed mortality rate should be on
a steadily rising incline as physician
documentation improves
Potential problem DRG
Base MS-DRG 84
Major cardiovascular procedures – adults
MS-DRG 238 (w/o MCC)
It is important to note the cases we will be
discussing occurred in a MS-DRG associated with
“healthy” patients – those without a major
complication and comorbidity (MCC) rather than in
the MS-DRG assigned to the “sickest of the sick”
(i.e., those with an MCC).
Therefore, deaths are not expected to occur within
this MS-DRG.
Distribution by procedure
Problematic procedures
One death occurred in seven cases = 14%
One death occurred in 11 cases = 9%
Non-deaths need to be maximized to offset the deaths, but
it is always problematic when deaths occur in “healthy”
tiers (i.e., w/o MCC)
Actual case from UHC
Encoder results
APR-DRG grouper
• The SOI of major/3 is captured because
two diagnoses have a value of SOI = 3
• Because there is only one diagnosis
with an ROM value of 3, the ROM of
major/3 cannot be captured for the
diagnosis
Discharge summary
Evidence of additional diagnoses:
Cardiogenic shock
The 4/4 of
cardiogenic shock
is not sufficient to
move it to 4/4
Review of systems
• No documentation regarding respiratory
function
• No documentation regarding level of
consciousness/neurological status
Maximized SOI/ROM
The Impact of Physician
Cooperation
Change in mortality ranking
• In 4th Quarter 2008, MUSC was at the
median compared to other academic
medical centers in the University Health
Consortium (UHC) database
• MUSC uses pillar goals to monitor our
success, and the mortality index was an
unmet pillar goal in 2009
– The goal was a ratio of 0.80; our value was
0.98 for the year
Current mortality index
Current medical mortality index
Current surgical mortality index
Comparison data 3rd Quarter 2009
Change in mortality ranking
• In less than a year, MUSC has improved
its annual comparison ranking from 57th
to 35th
– It will take up to four quarters for the impact
of process changes to be realized
– The current quarterly ranking for MUSC is
22nd, so the annual ranking is expected to
continue to rise
Change in mortality ranking
• In less than a year, MUSC has
dramatically reduced its annual mortality
rate from 0.98 to 0.83
– It will take up to four quarters for the impact
of process changes to be realized
– The current quarterly rate for MUSC is 0.74,
so the annual value is expected to continue
to decrease
Risk of mortality distribution
Percentage
ROM Distribution
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
1st 08 2nd 08 3rd 08 4th 08
1st 09 2nd 09 3rd 09
4th 09
Quarter
ROM Minor = 1
ROM Moderate = 2
ROM Major = 3
ROM Extreme =4
A closer look
Percentage
ROM Distribution
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
78%
76%
74%
72%
70%
68%
66%
64%
62%
60%
58%
56%
54%
52%
50%
1st 08 2nd 08 3rd 08 4th 08
1st 09 2nd 09 3rd 09
4th 09
Quarter
ROM Minor = 1
ROM Moderate = 2
ROM Major = 3
ROM Extreme =4
MUSC ROM = Extreme
Risk of Mortality = Extreme
Percent
7.00
6.50
6.00
5.50
5.00
4.50
4.00
1st
2008
2nd
2008
3rd
2008
4th
2008
1st
2009
2nd
2009
Quarter
ROM=4
Benchmark
3rd
2009
Severity of illness distribution
SOI Distribution
100%
90%
80%
Percentage
70%
60%
50%
40%
30%
20%
10%
0%
1st 08
2nd 08
3rd 08
4th 08
1st 09
2nd 09
3rd 09
4th 09
Quarter
SOI Minor =1
SOI Moderate = 2
SOI Major = 3
SOI Extreme = 4
A closer look
SOI Distribution
100%
95%
90%
85%
80%
Percentage
75%
70%
65%
60%
55%
50%
45%
40%
35%
30%
25%
20%
1st 08 2nd 08 3rd 08 4th 08 1st 09 2nd 09 3rd 09 4th 09
Quarter
SOI Minor =1
SOI Moderate = 2
SOI Major = 3
SOI Extreme = 4
Revenue capture
CMI Value
Case Mix Index by Quarter
2.15
2.10
2.05
2.00
1.95
1.90
1.85
1.80
1.75
1.70
1.65
1.60
1.55
1.50
1.45
1.40
1.35
2008-1
2008-2
2008-3
2008-4
2009-1
2009-2
2009-3
Quarter
Total CMI
Medicare CMI
Non-Medicare CMI
2009-4
CMI comparison with UHC data
CMI
Case Mix Index by Quarter
2
1.95
1.9
1.85
1.8
1.75
1.7
1.65
1.6
1.55
1.5
1st 2008
2nd
2008
3rd 2008 4th 2008 1st 2009
MUSC CMI
2nd
2009
UHC Benchmark CMI
3rd 2009
Second phase initiated 1/10
• Ensuring all deaths are 4/4 is only part of
the equation; the extremely ill patients who
survive have the greatest impact on the
expected mortality index
• When more patients with 4/4 survive it
raises the expected mortality rate and
lowers the mortality index
Second phase initiated 1/10
• The “sickest of the sick” patients are
usually in the ICU
– CDI staff perform concurrent review on ICU
patients with DRG payers until the SOI/ROM
is maximized or transfer out of the ICU
– CDI staff round with ICU medical teams
• CDI staff also follow hospice patients of
DRG payers for SOI/ROM regardless of
their location in the hospital
The future
We anxiously await each quarter of data as
it is released by UHC to track our progress
and hope we can continue to sustain this
growth in CC/MCC capture and
decreasing mortality index
The goal of the CDI department is to reach
the top 10 among academic medical
centers
Questions?
• Questions?