3M Health Information Systems, Inc.
Advocate
Thomas C Kravis MD
Innovating
Innovating
the
the
Language
Language
of
Health
of
Health
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from 3M.
3M Health Information Systems
Clinical Documentation Improvement
Goals and Objectives
 Clear concise accurate documentation
 Across the continuum of care: inpatient and outpatient
 Capture the severity of illness (SOI) and the Risk of Mortality (ROM)
 Improve quality report cards and clinical outcomes
 Reduce denials and queries
 Comply with ICD-10
2
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Value of Accurate and Complete Documentation
Physician and
Hospital Quality Reports
Core
Measures
ICD-9-CM
ICD-10
Preventable
Readmissions
Complications
PSIs
Compliance
Fraud Abuse
RAC
Value
Base
Purchasing
2 MIDNIGHT
RULE
Care
Coordination
Medical
Necessity
3
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POA
HAC
E&M Pro Fees
Denial related
claims
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3M Health Information Systems
3M Value Based Payment solutions across the continuum
Hospital
Out of Hospital
Plan
Payer
ACO
Population at
Risk
Ambulatory
Outpatient
Inpatient
ASC
Hospital Outpatient
Psych
Urgent Care
• Day Surgeries
• Emergency
• Clinic visits
Physician
Office
Clinic
Physician FFS E&M, Patient
4
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Post Acute Care
MedSurg
ICU
• Observation
• Ancillary
services
Hospice
SNF
LTACH
HOME
HOSPICE
Physician
Office
Clinic
Value and risk/gain sharing
3M Health Information Systems
Opportunities Across Continuum of Care
Financial Opportunity by Payer
Financial Opportunity by Quality Indicator
Financial Opportunity in Outpatient
$23,564
$2,100,000
$193,720
$207,371 $268,871
$123,190
$91,088
$785,469
$3,210,367
$1,390,269
$2,800,450
$2,128,644
$1,374,080
Reduced Cost of Readmissions
MedPAR (2013)
Medicaid (3M Compare)
Payer
All Payer (3M Compare)
Financial
Opportunity @ 75%
Realization
SOI variance
Increased revenue due to better PSI scores
Reduced Cost of HACs
Increased revenue due to better SOI/ROM
ROM
variance
ROI Type
Reduced Cost of Readmissions
$
23,564
Reduced Cost of HACs
$
1,390,269
ROI Amount
$3,210,367
-5.80%
19.40%
Medicaid (3M Compare)
$2,800,450
14%
-24%
Increased revenue due to better PSI scores
All Payer (3M Compare)
Payer Financial
Opportunity
$2,100,000
-10%
-14%
$
1,374,080
Increased revenue due to better SOI/ROM
$
785,469
Quality Indicators Financial Opportunity
$
3,573,382
Total Opportunity: $14,697,083
5
Inpatient Only Edits
CCI Edits
Medically Unlikely Edits
Missing Modifier Revenue
Observation to Inpatient
Number
Financial
Opportunity
11.026
$268,871
6
$123,190
984
$91.088
Medically Unlikely Edits
Edit Financial Opp
Ineffective Modifiers
(no change in outcome)
1,077
$2,128,644
$2,611,793
Inappropriate Modifiers
3223
Possible Missing Modifiers
4897
Issue
MedPAR (2013)
$8,110,817
Medical Necessity Edits
Medical Necessity Edits
IP Only Procedure Edits
CCI Edits
Modifier Financial Opp
Observation to IP Opp
Outpatient Financial Opp
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$193,720
29
$207,371
$3,012,884
3M Health Information Systems
Documentation & Coding Issues
Physician
Document in
CLINICAL terms
Two separate
languages
Documentation for
coding, profiling &
compliance requires
specificity in
DIAGNOSITIC terms
This gap will be increased with ICD-10
Documentation
Improvement can help bridge the gap
6
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3M Health Information Systems
E&M
Physician pro fee
Elements
Chief
Complaint
7
•
•
•
•
Chief Complaint
History
Examination
Medical Decision
Making
• Symptom
DRG Assurance
Inpatient
DIAGNOSTIC
TERMS
problem, condition,
diagnosis reason for
the encounter
Two Midnight Rule
Signs Symptoms Expectation of 2 Midnight
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Risk of Adverse Event
requires prior approval from 3M.
8
Unable to Code
Able to Code
Clinical Term
Diagnostic Term
Multi System Organ Failure
Liver failure, renal failure, heart failure
Severe respiratory distress
Respiratory failure : acute, acute on chronic
Hemodynamically unstable
Hypotension: Shock : cardiac, septic
Will rehydrate
Dehydration, hypovolemia
“Urosepsis”
Simple UTI
↓ K = 2.0, will give KCL
Hypokalemia
LLL infiltrate
LLL pneumonia
↓ Hgb 5.2, Transfuse
Acute. Acute/Chronic Blood Loss Anemia
Emaciated ↓ Albumin ↓BMI
Protein Calorie Malnutrition
Altered Mental Status
Coma (Glasgow Coma Scale); Encephalopathy
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General and Internal Medicine
Clinical Terms
Diagnostic Statement
(Documentation needs clarification)
(Accurate code may be assigned)
Continue home medications such as
furosemide, HCTZ, ACE inhibitor
Document specific diagnosis such as chronic systolic/diastolic heart
failure, CAD, atrial fibrillation, angina, HTN
History of CHF, will continue home
meds
Specify acuity (chronic, acute, acute on chronic); specify type (systolic,
diastolic, combined systolic and diastolic)
Cardiac enzymes elevated, elevated
troponin, EKG positive
Acute myocardial infarction STEMI or NSTEMI; specific artery LAD,
age> 4 weeks and exact date)
Acute coronary syndrome (ACS)
Intermediate/insufficiency syndrome, unstable angina, coronary
slow flow syndrome, myocardial infarction
Cardiac history
Document specific diagnoses such as CAD, angina, old MI (document
date when MI occurred)
Atrial fibrillation
Specify type (e.g., paroxysmal, permanent, persistent, chronic)
Atrial flutter
Typical (type I) or atypical (type II)
BP 70/40, ordered norepinephrine or
dopamine for support
Shock ( specify type cardiogenic hypovolemic septic,
A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician
must document the corresponding diagnosis in the body of the medical record.
9
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Orthopedics
Clinical Terms
Diagnostic Statement
(Documentation needs clarification)
(Accurate code may be assigned)
Intervertebral disc disorders
Document site (cervical, thoracic, lumbar, sacral); document any
associated myelopathy, radiculopathy, sciatica
Gout
Document acuity (acute, chronic); document type (idiopathic, lead induced,
drug induced, due to renal impairment)
Osteomyelitis
Document acuity (acute, chronic, subacute); document type (hematogenous,
multifocal, with draining sinus); specify location and laterality; indicate
causative organism if known
Right calf swollen, reddened and
tender
Phlebitis, thrombophlebitis, deep venous thrombosis :site, acuity
laterality : “acute venous thrombosis of right greater saphenous”
Wound red and indurated, IV
antibiotics given
Cellulitis (document location, laterality and organism; document any open
wound, ulcer or traumatic wound associated with cellulitis; specify underlying
cause)
Diabetes, blood sugar ↑360, will start
insulin drip, history of neuropathy
Specify type (type 1, type 2, drug or chemical induced, other underlying
condition), document any associated complications (diabetic neuropathy,
diabetic foot ulcer, osteomyelitis due to diabetes – must document a cause
and effect link), document insulin control status as controlled, out of control,
with hyperglycemia
A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician
must document the corresponding diagnosis in the body of the medical record.
10
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General Surgery
11
Clinical Terms
Diagnostic Statement
(Documentation needs clarification)
(Accurate code may be assigned)
POD #3, lack of bowel sounds, abdominal
distention, remains NPO, re-insertion of NG
tube, ordered Reglan, delayed discharge
Ileus (document if condition is a complication of
the prior surgery or is an expected outcome)
Right calf swollen, reddened and tender
Phlebitis, thrombophlebitis, deep venous
thrombosis (document site, acuity and laterality –
e.g., acute venous thrombosis of right greater
saphenous)
S/P hemicolectomy, temp ↑, ↓breath sounds,
ordered ↑ambulation, CXR, and incentive
spirometry
Atelectasis, pneumonia (document if condition is a
complication of the prior surgery or is an expected
outcome)
Dysuria, abnormal urinalysis, urine culture
>100,000, will treat with antibiotics
UTI (specify site of UTI such as bladder, urethra,
kidney; specify if UTI is related to device such as
Foley catheter; document causative organism
such as E. Coli)
Fever to 102° F, s/p cholecystectomy, left shift
in differential, AMS, patient pancultured, IV
antibiotics given
Sepsis, acute peritonitis, wound infection
(document if condition is a complication of the
prior surgery)
Urosepsis
Be clear on intended diagnosis such as UTI,
sepsis or severe sepsis. Document any organ
dysfunction and presence of shock. (Urosepsis is
not a codeable diagnosis in ICD-10-CM)
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Emergency Medicine
Clinical Terms
Diagnostic Statement
(Documentation needs clarification)
(Accurate code may be assigned)
SOB ↑ RR,cyanosis ↑ HR pO2 55, pCO2 64,
pH 7.32, O2 sat 88%,
Respiratory failure: acute, chronic or acute on chronic; hypoxia (Type I) ,
hypercapnia (Type II); respiratory acidosis
LUL infiltrate + sputum culture, productive
cough
Pneumonia: type, organism, known suspected; link pathogen e.g. “Pneumonia
due to Klebsiella”
Pleuritic chest pain, SOB, O2 sat 65%
Pulmonary embolism (specify type, if known or suspected, such as saddle, septic;
specify acuity such as acute or chronic, specify source such as DVT; healed/old;
document presence of cor pulmonale if applicable)
Asthma
Severity and type (mild intermittent, mild persistent, moderate persistent, severe
persistent): status (uncomplicated, with acute exacerbation, or with status
asthmaticus)
CT scan/MRI of brain indicative of infarction
CVA/stroke/cerebral infarction (specify if due to embolism, thrombosis, occlusion,
stenosis – document the clinical significance from the diagnostic findings to the current
condition; document artery involved such as carotid, middle cerebral, vertebral;
document laterality such as left or right; document any associated cerebral edema)
A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician
must document the corresponding diagnosis in the body of the medical record.
12
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Spinal Cord Injury documentation
Type of injury:
Specific Level
•
•
•
•
•
•
Anterior cord syndrome
Brown-Séquard syndrome
Central cord syndrome
Complete lesion
Spinal concussion
Spinal edema
Example:
“C4 and C5 spinal cord injury with closed nondisplaced
fracture of C4 & C5 vertebrae initial encounter”
13
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Present on Admission and Hospital-Acquired Conditions (HAC)
 Foreign Object Retained after Surgery
 Air Embolism
 Blood Incompatibility
 Pressure Ulcer Stage III and IV
 Falls and Trauma
― Fracture
― Dislocation
― Intracranial Injury
― Crushing Injury
― Burn
― Electric Shock
 Catheter-Associated Urinary Tract Infection (UTI)
 Vascular Catheter-Associated Infection
 Manifestations of Poor Glycemic Control
 Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)
 Surgical Site Infection Following Certain Orthopedic Procedures
14
 Surgical Site Infection Following Bariatric Surgery for Obesity
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 Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures
Anesthesiology
Clinical Terms
Diagnostic Statement
(Documentation needs clarification)
(Accurate code may be assigned)
History of previous heart problems
Specific diagnoses : CAD, angina, old MI (document date, atrial
fibrillation, heart failure (acuity and type)
Will give prophylactic IV antibiotics
Document specific diagnosis such as mitral valve regurgitation, mitral
prolapse, rheumatic heart disease
Difficulty breathing, will re-intubate
Laryngeal spasm, respiratory failure (specify acuity and underlying
cause), macroglossia, stridor, bronchospasm
Will hydrate with 500 ml bolus fluid
Dehydration
Will postpone surgery until patient is
hemodynamically stable
Dehydration, hypovolemia, hypotension, shock (specify type such as
cardiogenic, septic, hypovolemic)
H/H ↓, will transfuse 2 units PRBCs
Anemia (specify type, if known or suspected, such as acute or chronic
blood loss anemia, anemia of chronic disease, hemolytic anemia, iron
deficiency anemia, pernicious anemia)
Bleeding from puncture sites, prolonged
bleeding time, oliguria, will give FFP
and platelets
Disseminated intravascular coagulation (DIC)
A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician
must document the corresponding diagnosis in the body of the medical record.
16
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Documentation of Comorbid Conditions
Johns Hopkins
Ochsner Clinic
17,649 patients
J Stonemetz et al ,J Clin Outcomes
Mgmt 2007; 14 (9): 499-50
17
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•
•
•
•
•
•
Inpatient elective
ASA Physical Status II III or IV
Comorbid conditions
Conditions identified
Increase comorbid conditions
Increase (predicted)
8.3
13.6
5.3
$15.2M
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Cardiology
Clinical Terms
Diagnostic Statement
(Documentation needs clarification)
(Accurate code may be assigned)
Pulmonary insufficiency
Document acuity (acute or chronic), document cause (due to shock, surgery, trauma)
SOB, paCO2 60 mmHg, pH 7.32, O2 sat 88%, BiPAP
Respiratory failure (specify acuity, if known or suspected: acute, chronic or acute on chronic;
document hypoxia, hypercapnia, if present)
CT scan/ MRI of brain infarction
Cerebral Infarction: etiology embolism, thrombosis, occlusion, stenosis, or hemorrhage;
presence of cerebral edema and clinical significance from the diagnostic findings to the current
condition; artery :carotid, middle cerebral, vertebral; laterality ; cause-and-effect between
medical intervention and the Cerebral Infraction and if related to intraoperative or postprocedural either cardiac or other type of surgery
Diabetes, blood sugar ↑360, will start insulin drip, history
of PVD
Specify type (type 1, type 2, drug or chemical induced, other underlying condition), document any
associated complications (diabetic autonomic neuropathy, diabetic foot ulcer, PVD due to diabetes –
must document a cause and effect link), document insulin control status as controlled, out of control,
with hyperglycemia
CXR shows chronic lung changes. Nurses’ notes
indicate COPD. Home meds of inhalers noted
COPD (document if with acute exacerbation or decompensated and document if oxygen dependent);
Emphysema (document type such as unilateral, panlobular, centrilobular)
Chronic kidney disease (CKD)
Document stage (stage 1-5, ESRD) and etiology such as due to diabetes or polycystic kidney disease
Acute kidney failure
Document etiology, if known or suspected (acute tubular, cortical or medullary necrosis; postprocedural;
post-traumatic or drug-induced)
A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician
must document the corresponding diagnosis in the body of the medical record.
18
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Risk-Adjusted Mortality: Actual versus Expected
Advocate
Medical Specialty
Behavioral
Cardiology
CT Surgery
Medicine
Neurology
Neurosurgery
Ophthalmology
Orthopedics
Pulmonary
Renal
Surgery
Transplant
Vascular
Women's Health
Total
Medicare
Volume
14
568
105
1,265
224
31
9
626
539
273
263
0
53
18
3,988
Actual
Deaths
0
15
3
51
7
1
0
3
28
1
9
0
0
0
118
Actual
Death
Rate
0.00%
2.64%
2.86%
4.03%
3.13%
3.23%
0.00%
0.48%
5.19%
0.37%
3.42%
0.00%
0.00%
0.00%
2.96%
Expected
Deaths
0.0
17.3
2.4
50.4
10.5
0.1
0.0
7.2
31.6
3.5
9.8
0.0
1.2
0.1
134.1
Expected Variance,
Variance,
Death
In
As A %
Rate
Deaths
Of Expected
0.00%
0.0
0.0%
3.05%
-2.3
-13.3%
2.29%
0.6
25.0%
3.98%
0.6
1.2%
4.69%
-3.5
-33.3%
0.32%
0.9
900.0%
0.00%
0.0
0.0%
1.15%
-4.2
-58.3%
5.86%
-3.6
-11.4%
1.28%
-2.5
-71.4%
3.73%
-0.8
-8.2%
0.00%
0.0
0.0%
2.26%
-1.2
-100.0%
0.56%
-0.1
-100.0%
3.36%
-16.1
-12.0%
Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of
actual to expected mortality variance without further study.
19
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3M APR DRG Classification System
Risk-Adjusted Mortality Example
APR-DRG 194
,
HEART FAILURE
Illinois Average
APR DRG
Subclass
1
2
3
4
Total
Actual
Cases Deaths Mortality Rate
1,549
5
0.3%
9,812
46
0.5%
10,792
239
2.2%
2,856
390
13.7%
25,009
680
2.7%
Advocate
Actual
Cases
9
89
90
34
222
Actual
Expected Actual Mortality
Deaths Deaths Rate
0.0
0
0.0%
0.4
2
2.2%
2.0
1
1.1%
4.6
4
11.8%
7.0
7
3.2%
Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013
Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of
actual to expected mortality variance without further study.
20
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ICD-10 Documentation Specificity for Heart Failure
Specify
• Acuity – acute, chronic, acute on
chronic/exacerbation
• Type – systolic and/or diastolic
heart failure
• Etiology known or suspected:
• Anemia
• Supraventricular tachycardia
• Myocarditis
• Cardiomyopathy (dilated,
hypertrophic (obstructive vs.
nonobstructive), restrictive
• Structural heart disease
• Hypertension
• Renal failure
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Training objective:
Heart Failure
 Respond to query
SAMPLE PHYSICIAN: SOI LESS THAN
PEERS
 Document the drivers of SOI
TARGET FOR TRAINING/GUIDANCE
 Treat underlying cause: clinical
Top 10 secondary diagnoses from National Norms driving SOI subclass 3 and 4
effectiveness
194 - Heart Failure
SOI
Subclass
1
2
3
4
Overall
Cases
Actual Days
1
10
3
0
14
1
40
19
0
60
ALOS
1.0
4.0
6.3
0.0
4.29
Peer Comparison
Sample Physician
Peer Group 1 - Cardiology
Peer Group 2 - Physician Practice Group
Peer Group 3 -National
Distribution
7%
71%
21%
0%
100%
Actual
Weight
0.4868
Total
Weight
0.4868
0.6127
0.9591
2.0096
6.1270
2.8773
0.0000
9.4911
Severity
Index
0.6779
Variance
0.7311
0.7982
0.8695
--7.3%
-15.1%
-22.0%
Subclass 3
Subclass 4
Dx Code
Description
Dx Code
Description
5849
486
42833
42823
4271
5119
42831
42821
2639
51883
Acute Kidney Failure Nos
Pneumonia, Organism Nos
Ac On Chr Diast Hrt Fail
Ac On Chr Syst Hrt Fail
Parox Ventric Tachycard
Pleural Effusion Nos
Ac Diastolic Hrt Failure
Ac Systolic Hrt Failure
Protein-cal Malnutr Nos
Chronic Respiratory Fail
51881
41071
5070
51884
5845
4275
78551
262
99592
570
Acute Respiratry Failure
Subendo Infarct, Initial
Food/vomit Pneumonitis
Acute & Chronc Resp Fail
Ac Kidny Fail, Tubr Necr
Cardiac Arrest
Cardiogenic Shock
Oth Severe Malnutrition
Severe Sepsis
Acute Necrosis Of Liver

Lower SOI
22
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“Drivers” of Severity and Mortality
Depends on Principal Diagnosis and Other Issues
Gastrointestinal
hemorrhage
(acuity, link to site
of bleed)
End stage renal
disease (cause)
Encephalopathy
(type, acuity and
cause)
23
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Acute renal
failure and
cause
Atrial
fibrillation/flutter
(type and etiology)
Principal
Diagnosis
COPD
acute
exacerbation
Electrolyte imbalances
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CDI Program
Concurrent Real Time
All conditions documented in the medical record
Capture Severity Of Illness (SOI)
Capture Risk Of Mortality (ROM)
360
Assign DRG and APR-DRG
Physicians
CMS Medicaid private payer rules
25
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Concurrent Query Process
Query
Opportunity
Physician
Responds
Query
Yes
No
Clarify
EMR
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No Response
Respond
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3M Health Information Systems
When should a physician be queried
regarding clinical documentation?
“Whenever there is conflicting, ambiguous, or
incomplete information in the health record regarding
any significant reportable condition or procedure”
AHIMA Practice Brief
“Managing an Effective Query
Process” October 2008
27
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requires prior approval from 3M.
3M Health Information Systems
Documentation of Comorbid Conditions
Johns Hopkins
Ochsner Clinic
17,649 patients
J Stonemetz et al ,J Clin Outcomes Mgmt
2007; 14 (9): 499-50
28
•
•
•
•
•
•
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requires prior approval from 3M.
Inpatient elective
ASA Physical Status II III or IV
Comorbid conditions
8.3
Conditions identified
13.6
Increase comorbid conditions
5.3
Increase (predicted)
$15.2M
Physician Role
Focus on patient care
Respond to queries
No need to learn coding
CDI nurse is a resource
to the physician
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Example: Impact of Surgeon Response to Query
“The magnesium level is 1.6 and the patient is
receiving magnesium sulfate.”
“Please provide a corresponding diagnosis”
Query:
Documents “hypomagnesemia”
Orthopedic Procedure
IMPACT W/O RESPONSE TO QUERY
RW = 1.5344
GLOS = 3.25
SOI = 1 MINOR
ROM = 1 MINOR
30
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IMPACT W/ RESPONSE TO QUERY
RW = 1.6994
GLOS = 3.50
SOI = 2 MODERATE
ROM = 1 MINOR
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General Documentation Guidelines
All treatments diagnoses and procedures
Hands-on treating practitioner : EMR and discharge summary
Cannot code from lab x-ray symbols (↑, ↓)
Cut and paste risk of Fraud and Abuse
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General Documentation Guidelines
Inpatient condition must meet at least one of the following criteria
•
•
•
•
•
32
Clinical evaluation
Therapeutic treatment
Diagnostic procedures
Extended length of hospital stay
Increased nursing care and/or monitoring
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Quality Scorecards
APR DRG
3M™
Subclasses
33
Severity of Illness
Risk of Mortality
1. Minor
1. Minor
2. Moderate
2. Moderate
3. Major
3. Major
4. Extreme
4. Extreme
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Quality
Documentation
Coding
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3M APR DRG Classification System
Risk-Adjusted Mortality Example
APR-DRG 134 – PULMONARY EMBOLISM
State Average
APR DRG
Subclass
1
2
3
4
Total
Cases
321
624
397
114
1,456
Actual
Deaths Mortality Rate
0
0.0%
5
0.8%
15
3.8%
38
33.3%
58
4.0%
XYZ Example
Actual
Cases
5
4
2
3
14
Actual
Expected Actual Mortality
Deaths Deaths Rate
0.0
0
0.0%
0.0
1
25.0%
0.1
1
50.0%
1.0
0
0.0%
1.1
2
14.3%
Mortality
Rate %
Variance
0%
―
900%
-100%
82%
Patients expiring at levels <4
Data Source: 3M APR DRG Classification System utilizing
MEDPAR 2014 data
Data based on all cases using selection criteria. No inference is made or conclusion can be
drawn about the significance of actual to expected mortality variance without further study.
34
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SOI and ROM: Dependent on all of the patient’s underlying conditions
Principal
Diagnosis
Serious
Multiple
Comorbid
Diseases
Interaction
35
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Principal Diagnosis "XYZ"
Impact of Secondary Diagnosis
36
1
2
3
4
Severity of Illness
Minor
Moderate
Major
Extreme
1
2
3
4
Risk of Mortality
Minor
Moderate
Major
Extreme
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Secondary Diagnosis-Diabetes Mellitus
Uncomplicated Diabetes
Diabetes w Neuropathy
Diabetes w Ketoacidosis
Diabetes w Hyperosmolar Coma
Secondary Diagnosis-Cardiac Dysrhythmias
Premature Beats
Sinoatrial Node Dysfunction
Paroxysmal Ventricular Tachycardia
Ventricular Fibrillation
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Diabetic “Neuropathy” is Nonspecific in ICD-10
Diabetic Neuropathy is a nonspecific code in ICD-10.

If known or suspected, document:
 Diabetic mononeuropathy
 Diabetic polyneuropathy
 Diabetic autonomic neuropathy
 Diabetic amyotrophy
 Type of diabetes: Type 1 or Type 2
 Control status
• Document with or without hyperglycemia
 In ICD-10, the following are classified as “with hyperglycemia”



37
“Inadequately controlled”
“Out-of-control”
“Poorly controlled”
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ICD-10 Documentation Tips
Use adjectives
Indicate cause and
effect
Be specific about
aspects of the
disease
Identify specific
anatomical site and
laterality
Use exact dates
38
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• Acute, chronic, acute on chronic, mild, moderate, severe,
persistent
• “ Severe persistent asthma with acute exacerbation”
• Use “due to” or “secondary to”
• “ Pneumonia due to Pseudomonas pneumonia”
• Current terminology
• “ Atypical or type II atrial flutter; Persistent atrial
fibrillation
• “ Pressure ulcer of right heel, stage 3”
• Acute Myocardial Infarction 7/10/2015
© 3M 2015 All Rights Reserved
“Probable" “Possible" "Suspected" Diagnosis
Inpatient application only:
Coded as though they exist
If condition is ruled out, it may not be coded
Outpatient application:
Must code signs/symptoms, not the suspected condition
Supports appropriate E&M professional component
39
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Chest Pain Alternatives
Biliary Colic
MS-DRGs
444/445/446
RW = 1.5055
Anxiety
MS-DRG 880
RW = 0.6191
Cardiac Cath
MS-DRGs
286/287
RW = 1.9634
GERD
Gastritis
MS-DRGs 391/392
RW = 1.0958
Anterior CP
Pleuritic CP
Chest Wall Pain
MS-DRG 204
RW = 0.6472
Psychogenic
Angina Pericarditis
MS-DRGs
314/315/316
RW = 1.7589
Costochondritis
Tietze’s Disease
MS-DRGs 205/206
RW = 1.2566
Chest Pain
MS-DRG 313
RW = 0.5404
Pleurisy
MS-DRGs
193/194/195
RW = 1.4378
Pulmonary
Embolism
MS-DRGs 175/176
RW = 1.6121
Psychogenic
Chest Pain
MS-DRG 882 RW =
0.6676
Shingles
MS-DRGs
595/596
RW = 1.7691
Note: In Quick Reference Guide
40
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© 3Mreview
2011.only.
All Rights
Further use or disclosure requires prior
approval
Reserved. from 3M.
CAD
MS-DRGs
302/303
RW = 0.9999
Angina
MS-DRG 311
RW = 0.5128
Cardiac
Arrhythmia
MS-DRGs
308/309/310
RW = 1.2188
© 3M 2015 All Rights Reserved
Documentation for Pulmonary Embolism
Document acuity:
Specify if related to any other
condition such as:
•Acute
•Chronic
•Atrial fibrillation
•Healed/old
Specify meaning of “history of PE”
•Patient has chronic PE continuing to be
•Hypercoagulable state
treated, is being prophylactically treated or
patient no longer has the condition
•Documentation of “chronic pulmonary
embolism” vs. “healed PE” or “old PE” makes
a clear distinction
•Malignancy
Specify type:
Document presence of cor
pulmonale (specify acute or
chronic)
•Saddle
•Septic
•Postprocedural or due to a vascular
41
•DVT (specify site and laterality)
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device
•Orthopedic surgery
•Sepsis
•Trauma
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Acute Myocardial Infarction ICD-10
Type : STEMI or NSTEMI
Specific site of myocardium :anterior/inferior wall
Coronary artery involved :LMCA, LAD, RCA, LCx
Age of new MI within 4 weeks; specify date
42
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Documentation of Pancreatitis
66 year old male
admitted nausea,
vomiting, abdominal
pain; history of
elevated triglycerides
and daily alcohol use.
Lab:
Elevated lipase and
amylase
Current Documentation
Pancreatitis, alcohol use
ICD-10 Documentation
Acute pancreatitis due to alcohol dependence
•
•
•
•
43
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Treatment:
IVF, NPO, pain
control, electrolyte
correction.
Intoxication
Blood alcohol
Psychotic disorders :delusions hallucinations
In remission withdrawal : delirium perceptual disturbances
© 3M 2015 All Rights Reserved
3M APR DRG Classification System
Risk-Adjusted Mortality Example
APR-DRG 720,
SEPTICEMIA & DISSEMINATED INFECTIONS
Illinois Average
APR DRG
Subclass
1
2
3
4
Total
Advocate
Actual
Cases Deaths Mortality Rate
880
1
0.1%
3,680
50
1.4%
10,539
518
4.9%
11,594 3,067
26.5%
26,693 3,636
13.6%
Actual
Cases
9
26
72
120
227
Actual
Expected Actual Mortality
Deaths Deaths Rate
0.0
0
0.0%
0.4
3
11.5%
3.5
4
5.6%
31.7
28
23.3%
35.6
35
15.4%
Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013
Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of
actual to expected mortality variance without further study.
44
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Sepsis and Severe Sepsis
Sepsis
• Streptococcal sepsis (group
A, group B, Streptococcus
pneumoniae, other
streptococcal) or
• Other sepsis (e.g., MRSA,
pseudomonas)
45
Severe sepsis
associated with organ
dysfunction
• Specific associated
organ dysfunction (not
MOD) and
• Presence of septic
shock
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Documentation of Acute Kidney Failure
Specify the
etiology known or
suspected
46
• Postprocedural
• Posttraumatic
• Other condition (e.g., dehydration, rhabdomyolysis)
Specify the Type
• Acute renal “insufficiency”
• Acute kidney injury (AKI)
• Acute kidney failure
SOI 1; ROM 1
SOI 3; ROM 3
SOI 3; ROM 3
Acute kidney
failure
“ due to”
• Acute tubular necrosis
• Cortical necrosis
• Medullary (papillary) necrosis
SOI 4; ROM 4
SOI 4; ROM 3
SOI 4; ROM 3
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Respiratory Failure Documentation
Acuity
• Acute
• Chronic
• Acute on chronic
• SOB labored breathing
Findings
Etiology
or cause
47
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• With hypoxia Type I
• With hypercapnia Type II
• pH, pO2 pC02
“Acute respiratory failure due to Klebsiella
Pneumonia treated and resolved”
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Complications
Clinical definition
“A condition occurring
in the postoperative period”.
Coder definition
“A diagnosis related to the surgical
procedure”
Complication-900 code
48
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Cerebral Infarction
49
Document
etiology of
cerebral
infarction
•
•
•
•
Embolism
Thrombosis
Occlusion
Stenosis
Specify
artery
involved
•
•
•
•
•
•
•
Anterior cerebral artery
Basilar artery
Carotid artery
Cerebellar artery
Middle cerebral artery
Posterior cerebral artery
Vertebral artery
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Link the occluded vessel to the infarct
and laterality
Intraoperative or Postprocedural cerebral Infarction
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Postoperative Respiratory Failure
POSTSURGICAL PATIENT
• Surgery caused the failure
• Patient failed weaning off vent
• Underlying respiratory condition that could have been the cause of the failure
QUALITY CONCEPTS
• Respiratory failure not present on admission (POA)
and occurs after an operative episode: patient safety indicator (PSI 11)
• Document:
• POA status vs. occurs after admission
• Confirmation of diagnosis if condition documented without corresponding clinical picture
• Cause of the respiratory failure following surgery (related or unrelated to surgery)
50
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ICD-9 vs. ICD-10
Structural Changes
ICD-9 DIAGNOSIS CODES
#
#
#
#
#
3-5 characters
Category
etiology, site,
manifestation
 ICD-10 Diagnosis code
a
#
a/#
a/# a/# a/# a/#
3-7 characters
Category
51
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etiology, site,
manifestation
extension
© 3M 2015 All Rights Reserved
Building an ICD-10 Diagnosis Code
EXAMPLE: FRACTURE FEMUR
S
Fracture
Femur
52
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7
Head &
Neck Femur
2
0
Base of
Neck Femur
4
2
Displaced
fx left Femur
K
Subsequent encounter
closed fx with nonunion
© 3M 2015 All Rights Reserved
Total Joint Replacement
Joint and
laterality
Device
inserted
Synthetic
substitute
Qualifier
53
• Autologous tissue substitute
• Nonautologous tissue substitute
• Synthetic substitute
• Metal
• Metal on polyethylene
• Ceramic
• Ceramic on polyethylene
• Cemented
• Uncemented
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Documentation Requirements for Fractures
ENCOUNTER SPECIFICITY
INITIAL – PATIENT IS RECEIVING ACTIVE TREATMENT FOR THE CONDITION:
• Surgical treatment
• Emergency department encounter, and
• Evaluation and treatment by a new physician
SUBSEQUENT – PATIENT HAS RECEIVED ACTIVE TREATMENT OF THE
CONDITION AND IS CURRENTLY RECEIVING ROUTINE CARE FOR THE
CONDITION DURING THE HEALING OR RECOVERY PHASE.
• Cast change or removal
• Removal of external or internal fixation device
• Adjustment of medication
• Other aftercare and follow-up visits following treatment of the injury or condition
SEQUELA – USED FOR COMPLICATIONS OR CONDITIONS – LATE EFFECTS
THAT ARISE AS A DIRECT RESULT OF A CONDITION.
54
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ICD-10 Documentation Requirements for Procedures
LATERALITY OF SITE
•
Left
•
Right
•
Bilateral
SPECIFICITY OF APPROACH
55
•
Open
•
Percutaneous
•
Percutaneous endoscopic
•
Via natural or artificial opening
•
Via natural or artificial opening- endoscopic
•
Open with percutaneous endoscopic assistance
•
External
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Building an ICD-10 Procedural Code
PTCA WITH 1 DES
0
Medical
and
Surgical
Heart &
Great
Vessels
PTCAs are always:
Section 0:
Medical & Surgical
Body System 2:
Heart & Great Vessels
Root Operation 7:
Dilation
56
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2
7
Dilation
0
3
Coronary
Artery,
One Site
Body Part
0: one site
1: (2) sites
2: (3) sites
3: (4+) sites
4
Z
Perc
Intraluminal
Drug-eluting
device
Approach
0: open
3: perc
4: perc
endoscopic
Device
4: drug-elut
D: non-elut
T: radioactive
Z: no device
No
Qualifier
Qualifier
6: bifurcating
Z: no qualifier
© 3M 2015 All Rights Reserved
Impact of Documentation
57
MS-DRG 330
2.4981
MS-DRG 329
5.1396
MS-DRG 329
5.1396
Bowel Procedure
with CC
Bowel Procedure
with MCC
Bowel Procedure
with MCC
PDx: Colon cancer
PDx: Colon cancer
PDx: Colon cancer
SDx:
SDx:
SDx:
Dehydration
Acute Renal Failure – ATN
Acute Renal Failure – ATN
Post-op ileus
(codes to 997.4 + 560.1)
Expected ileus
(560.1)
Expected ileus
(560.1)
“Ulcer/Wound” noted by
RN
Pressure Ulcer, site
unspecific
Pressure Ulcer Stage IV
on Sacrum
PPx: Left hemicolectomy
PPx: Left hemicolectomy
PPx: Left hemicolectomy
APR DRG:
SOI Level:
APR Weight:
ROM Level:
Peer Group
APR DRG:
SOI Level:
APR Weight:
ROM Level:
Peer Group
APR DRG:
SOI Level:
APR Weight:
ROM Level:
Peer Group
221
2
1.7681
1
0.0%
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221
3
2.9531
3
2.5%
221
4
6.3732
4
24.2%
© 3M 2015 All Rights Reserved
3M Health Information Systems
3M™ APR DRGs
MDC/APR MDC
314 APR DRGs
Subdivide each APR DRG
into subclasses
Four Severity of Illness Subclasses
Four Risk of Mortality Subclasses
1.
Minor
1.
Minor
2.
Moderate
2.
Moderate
3.
Major
3.
Major
4.
Extreme
4.
Extreme
1,256 Subclass Cells
58
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1,256Subclass Cells
3M Health Information Systems
Clinical Term
1. Status post CABG doing well
2. Chest pain probable ACS
3. Acute myocardial infarction with ST
elevation
4. Acute STEMI of LMCA
5. Congestive heart failure
6. EKG shows atrial fibrillation
7. Pleuritic chest pain, SOB O2 sat
70%
8. Excessive bleeding noted following
surgery
9. Status post CABG doing well
59
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Diagnostic Term I-10
1.
Atherosclerosis of autologous vein (or artery)(non
autologous biological) CABG with unstable angina pectoris
(or with spasm)
2.
Intermediate or insufficiency coronary syndrome ( or
unstable angina; or coronary slow flow syndrome; or
myocardial infarction;
3.
Myocardial infraction (STEMI) involving the anterior wall and
left main coronary artery LMCA; ( or LAD,diagonal/or right
coronary or left circumflex oblique marginal (NSTEM I no
additional specificity required)
4.
Subsequent STEMI Myocardial infarction inferior wall (<
four weeks) e.g.10/13/12 acute S TEM I of L MCA status
post STEM I on 9/23/2012
5.
Acute systolic heart failure: ( acute, chronic/acute on
chronic systolic/diastolic/both; specific etiology known or
suspected)
6.
Atrial fibrillation: paroxysmal ( persistent/chronic; or atrial
flutter Typical/Type I; atypical or Type II)
7.
Acute pulmonary embolism (saddle /septic ) with acute Cor
Pulmonale
8.
Acute blood loss anemia ,intra operative (or post operative)
cardiac/other
9.
Coronary angioplasty coronary artery one site(or more )
autologous venous tissue, open; drug eluting versus nondrug eluting device)
3M Health Information Systems
Complication
Postop ileus
Non-Complication
Ileus
(997.4 + 560.1)
Ileus
secondary to
surgery
(997.4 + 560.1)
Post op
atelectasis
Prolonged
ileus
Expected
ileus
Incidental
atelectasis
(997.39 + 518.0)
Atelectasis
Post op
anemia
(998.11 + 285.1)
60
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Acute blood
loss anemia
3M Health Information Systems
ICD-10 Pulmonary Embolism (PE) and Cor Pulmonale
Unchanged
New
Embolism with cor
pulmonale and
acute or chronic
61
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requires prior approval from 3M.
:Acute or chronic versus healed or “old pulmonary
embolism
History of PE - Still present Healed/old?
3M Health Information Systems
ICD-10 Transient Ischemic Attack
“TIA” = unspecified code
If known or suspected,
document:
•
•
•
•
•
•
62
Vertebro-basilar artery syndrome
Carotid artery syndrome
Precerebral artery syndrome
Amaurosis fugax
Transient global amnesia
Other cerebral ischemic attacks and
syndromes
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requires prior approval from 3M.