Clinical Documentation Improvement

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1 Clinical Documentation Improvement Precise Terminology is the Key to Supporting the Integrity of Documentation # Rev. 10/16

2 Specific Documentation Support medical necessity Capture severity and complexity of illness Validate the length of stay Support CMI (case mix index) compensation Withstand auditing Accurately reflect quality indicators and publicly published outcome measures 2

3 Coding the Medical Record The primary diagnosis, responsible for occasioning the admission, must be noted by the attending Physician. Any diagnosis that is clinically supported and currently being treated, monitored or evaluated can be coded. Diagnoses discovered by diagnostic testing must be validated as clinically significant in progress notes by an actively involved practitioner. 3

4 Codes For Capture Documents to code from ER Physicians note H & P MD, PA, ARNP progress note MD Consultation Operative or Procedure report Discharge Summary Supporting evidence Nursing note PT/OT/RT/Dietary note Lab results X-ray/CT/MRI/ECHO Pathology report Flow sheet 4

5 CDIs Role in Chart Completion Concurrently review the entire in-patient chart, usually by day 3-4 of hospital admission Seek to clarify any documentation that is unspecified, unclear, conflicting or missing Send Queries to providers to obtain any additional clarifying documentation 5

6 The Query Process A Query is an electronic question posed to a provider by a CDI RN or MD Most queries are derived from a template bank and are always in a multiple choice format All queries are meant to be non-leading and the best judgment of the practitioner is advised Once answered, the query becomes a permanent part of the medical record 6

7 Answering The Query If a query is sent it will populate in the Epic in-basket for chart completion A query that is sent on a template can be answered in just a few clicks Select a response from the drop down menu of options or manually fill in the appropriate response as needed A signed query becomes a progress note 7

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9 What if I Don t Answer? CDI personnel are required to follow-up on any query sent after 24 hours and every 24 hours thereafter. This can be done through , text, page, office messages or personally After 72 hours an escalation process is initiated to facilitate compliance CDI personnel are located on each campus M-F to provide assistance or answer questions 9

10 Hospital Acquired Conditions (HAC) and Patient Safety Indicators ( PSI) Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcers Falls Manifestations of poor glycemic control Catheter-associated urinary tract infection Vascular catheter-associated infection DVT/ pulmonary embolism after lower extremity procedures Surgical site infection Post operative DVT/PE, Respiratory Failure & Sepsis If you are not able to determine present on admission status- unable to determine choice does not code to a HAC

11 Principal Diagnosis Secondary Diagnoses COPD Observer A Observer B Observer C COPD Exacerbation w/o CC/MCC COPD Exacerbation w/cc Chronic Diastolic/Systolic CHF Oral Lasix -chronic home medication Medicare DRG MS-DRG AMLOS COPD Exacerbation Relative Weights Severity of Illness Risk of Mortality Level 1/minor Level 1/minor Level 2/moderate Level 2/moderate w/mcc Acute Diastolic/Systolic CHF IV Lasix Level 2/moderate Level 2/moderate Reimbursement $5, $6, $7,647.09

12 Pneumonia Specificity Pneumonia can be specified based on the treatment. Negative or inconclusive sputum cultures do not preclude a diagnosis of a specific bacterial pneumonia in patients with the clinical evidence of this condition. (per: AHA Coding Clinic). If you are/were treating a suspected, possible or probable gram negative or other resistant pneumonia or Sepsis, please document as such. CAP and HCAP are not specified 12

13 Pneumonia Principal Diagnosis Secondary Diagnoses Observer A Observer B Observer C Observer D Simple Pneumonia, unspecified Simple Pneumonia, unspecified Simple Pneumonia, unspecified Complex Pneumonia: Treating Gram Negative w/o CC/MCC w/cc AKI w/mcc ARF w/mcc ARF Medicare DRG MS-DRG AMLOS Relative Weights Severity of Illness Risk of Mortality Level 1/minor Level 1/minor Level 2/mod Level 1/minor Level 3/major Level 3/major Level 3/major Level 3/major Reimbursement $5, $6, $9, $12,023.79

14 Diagnoses Impact Metrics Diagnosis CMI SOI/ROM ALOS Weakness Glioblastoma grade 4 AKI Glioblastoma grade 4 AKI Cerebral edema / /

15 Hierarchical Condition Category For Risk Adjustment Reimbursement model implemented by CMS HCC diagnoses are considered excellent predictors of risk for future healthcare needs Documenting the entire disease burden during every 12-month period is essential for capturing resource consumption Common HCC diagnoses include: Protein Calorie Malnutrition Specified Bacterial Pneumonia Diabetes with complications Drug and Alcohol Dependence Specified (Systolic/Diastolic) CHF 15

16 Navigating Change CDI is a resource team that works in collaboration with providers to ensure that the documentation accurately encompasses all aspects of the medical picture and captures the level of care needed to help each patient Quality measures that affect population health, risk of mortality and morbidity are becoming a vital part of the health record. Diagnoses such as Malnutrition and Obesity are sought out to help define appropriate medical care in compliance with CMS guidelines.. 16

17 What has changed since the implementation of ICD-10: Diagnoses Codes: 14,025 71,486 Procedure Codes: 3,824 75,625 Body System Body Part Device Section Root Operation Approach Qualifier

18 Injury codes increased from 2,600 to 43,000 Top 5 Most Bizarre ICD-10 codes of W55.21 Bitten by a cow 2. Z63.1 Problems in relationship with in-laws 3.W56.22 Struck by Orca, initial encounter 4.V97.33 Sucked into jet engine 5.V91.07 Burn due to water-skis on fire Any Questions? 18

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