Physician Partners for CDI: Strategies for Goal Alignment. 7th Annual Association for Clinical Documentation Improvement Specialists Conference

Transcription

1 7th Annual Association for Clinical Documentation Improvement Specialists Conference Physician Partners for CDI: Strategies for Goal Alignment Larry Weems II, MD Medical Director Novant Health Huntersville Medical Center Charlotte, N.C. Abby Steelhammer, MBA/MHA, RN Manager, Clinical Documentation Improvement Novant Health Charlotte, N.C. 2

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Describe key strategies for physician involvement in CDI Define E/M goals and illustrate how these goals align with CDI Develop a physician education project plan Measure physician engagement in your organization through CDI metrics, CMI and LOS 3 Novant Health Integrated not-for-profit health system servicing four states: NC, SC, VA, and GA $3.4 billion in revenue (2010) 25,600 employees 15 medical centers 158 ambulatory centers 2,712 licensed beds 120,000 admissions 122,000 surgeries (inpatient and outpatient) 189,000 births 520,000 ED visits 3,750,000 physician encounters Approximately 5,000 medical staff 4

3 5 Who We Are Our mission: Novant Health exists to improve the health of communities, one person at a time Our vision: We, the employees of Novant Health and our physician partners, will deliver the most remarkable patient experience, in every dimension, every time Remarkable patient care the heart of our vision: Patient-centric care that creates an excellent patient experience and superior clinical quality Addresses every patient interaction with our healthcare system, from a simple outpatient test, to communicating the results of that test, to scheduling surgery and participating in rehabilitation 6

4 Clinical Documentation Improvement Program implementation in 2008 Aligned under clinical improvement Collaborative approach with HIM, finance, and physician champions Process improvement methodology to sustain impact across multiple payers and patient populations Complete chart review to identify areas for concern Prompt reconciliation process to recognize improvement opportunities and provide timely feedback Integration and cooperation with clinical and operational improvement, HIM, case management, compliance, and best practice teams 7 Physician Involvement/Engagement CDI Queries Need a RESPONSE to Be Effective! 8

5 Physician Involvement Aligned under clinical improvement and supported by VPMAs Quality focus Facility-based physician champions and NICS (Novant Inpatient Care Specialists) executive support Standardized orientation and new physician onboarding process Physician-facilitated practice teams Query escalation to physician champions ICD-10 clinical services team 9 Physician Involvement Best practice team involvement and service line relationship building (TAVR example) Collaborative workgroups for corporate goals (D/C metric) Workflow partnership for EHR integration and query process Alignment and shared resources for ICD-10 training 10

6 Aligning Goals We All Want Quality Care for Our Patients! 11 Aligning Goals Finance and quality Most people went into healthcare or a service industry for honorable intentions To help people To make a difference Emphasize values and a common thread Focus on the patient Focus on the organization 12

7 Aligning Goals Incentivize hospitalist teams to RESPOND to queries Piloted program at NH HMC 2010 and rolled program out corporatewide in % response rate at NH HMC for four years and counting Elevates importance attributed to documentation clarification to level of quality It s all about an accurate and complete record that clearly depicts the acuity/severity and quality of services rendered 13 Aligning Goals Evaluation and management documentation There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. (DHHS, CMS, E/M Guide, December 2010) 14

8 Aligning Goals The medical record should be complete and legible The documentation of each patient encounter should include: Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results Assessment, clinical impression, or diagnosis Medical plan of care Date and legible identity of the observer If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified The patient s progress, response to and changes in treatment, and revision of diagnosis should be documented The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record (DHHS, CMS, E/M Guide, December 2010) 15 Aligning Goals Medical decision-making Risk of complication and/or mortality Number of diagnoses or treatment options Amount and/or complexity of data to be reviewed History Detailed versus comprehensive Chief complaint, HPI indicators Past medical/surgical, family, social Review of systems, examination 16

9 Aligning Goals Documentation specialists educated in quality measures can provide support and resources to ensure and promote organizational compliance to patient safety initiatives Conditions or events are reportable via claims data (ICD-9 and procedure coding) and the present on admission (POA) indicator An astute documentation team can help facilitate continued education and awareness Accurate discharge documentation and disposition are key elements to attain successful aftercare and disease management Preventing unnecessary readmissions Health literacy is an ongoing challenge The record should be clear and concise for practitioners providing follow-up support 17 Aligning Goals Clinical documentation improvement is a systemwide approach: 70% of nurses time is spent documenting Novant Health s goal is to position nurses to spend 70% of their time in direct patient care Novant s clinical documentation improvement program supports this goal by streamlining clinician documentation to increase overall efficiency and effectiveness, thereby reducing need for duplicity and wasted effort The story of how we cared for the patient is clear, concise, and easily translated by coding and aftercare professionals 18

10 Aligning Goals Perhaps the best thing about the future is that it comes just one day at a time. Author Unknown 19 Education Plan Vision without execution is a hallucination. Albert Einstein 20

11 Education Plan Include the why Clinical documentation improvement rooted in the advent of medical severity diagnosis-related group system Accurately document the patient s condition Helps coders assign the correct diagnosis-related group (DRG) Benchmarks estimated length of stay (ELOS) Uses a patient s principal diagnosis that was present on admission to assign the patient s case to one of several appropriate DRGs for payment Uses patient s secondary diagnoses to assign the patient s case to a final DRG without, with a complication/comorbidity (CC#), or with a major complication/comorbidity (MCC*) Uses the DRG weight as a multiplier with a base charge to determine the allowed payment 21 Education Plan Case Studies Case 1: 72 y/o presents with a red left lower leg, subjective fever, and a hx of heart failure with an EF of 35% 40%, and hypertension. On exam, HR 76, +1 BLE edema, erythematous, indurated, LLE, WBC 10.7, NT-proBNP 20,770. Pt was given IV lasix and started on IV antibiotics. Option 1 Cellulitis of leg, congestive heart failure, HTN Option 2 better option Cellulitis of leg, acute on chronic syst heart failure*, HTN DRG 603 cellulitis w/o MCC Weight: Reimbursement: $4,474 ELOS: 3.8 days The diagnosis of only heart failure is presumed as chronic, which does not support the DRG. This is a minimally documented example. DRG 602 cellulitis w/mcc* Weight: Reimbursement: $7,877 ELOS: 5.3 days Documentation of the acute nature of the heart failure gives a MCC and supports the DRG more accurately reflecting the patient s condition. 22

12 Education Plan Case Studies Case 2: 70 y/o SNF resident with hx of dementia, and DM2 presents with cough, confusion, subjective fever. HR 102, temp 99.3, WBC 10.5 with bands 7%, Na 125, glucose 121, CXR with LLL infiltrate. Meropenem and Cipro started. Option 1 PNA HCAP, Na, AMS changes, DM2 DRG 195 simple PNA w/o CC/MCC Weight: Reimbursement: $3,790 ELOS: 3.1 days PNA, HCAP, CAP all code to simple pneumonia. Symbols like cannot be coded, and symptom diagnoses like AMS changes do not support the DRG and should be documented more accurately. Option 2 PNA HCAP, hyponatremia#, AMS changes, DM2 DRG 194 simple PNA w/cc# Weight: Hospital: $5,422 ELOS: 4.2 days Documentation of hyponatremia provides a CC and supports the DRG with higher CMI, reimbursement, and ELOS. 23 Education Plan Case Studies Case 2: 70 y/o SNF resident with hx of dementia, and DM2 presents with cough, confusion, subjective fever. HR 102, temp 99.3, WBC 10.5 with bands 7%, Na 125, glucose 121, CXR with LLL infiltrate. Meropenem and Cipro started. Option 3 best option PNA-HCAP probably Gram negative, hyponatremia#, metabolic encephalopathy*, DM2 controlled DRG 177 resp infections w/mcc* Weight: Reimbursement: $11,038 ELOS: 6.8 days By documenting the probable Gramnegative PNA (which is what is being treated), you move to a different DRG that more accurately reflects the treatment being rendered Recognition of the encephalopathy instead of the symptom (AMS changes) provides a MCC and supports the DRG The improved documentation provides for a DRG with higher CMI, reimbursement, and ELOS and accurately reflects the severity of the patient being treated 24

13 Education Plan Case Studies Case 3: 69 y/o with hx of DM, COPD not on chronic O2 presents with SOB and cough with green sputum. HR 85, RR 32, RA sat 86% on 3L O2 sat of 95%, glucose of 270, Na 127, and CXR without infiltrate. Option 1 COPD exac, DM, Na, hypoxemia DRG 192 COPD w/o CC or MCC Weight: Hospital: $3,856 ELOS: 3.1 days The use of symbols and symptom diagnoses (hypoxemia) does not support the DRG. This is an example of minimal documentation. Option 2 COPD exac w/acute bronchitis, hyponatremia#, DM2 uncontrolled, hypoxemia DRG 191 COPD w/cc# Weight: Hospital: $5,200 ELOS: 3.8 days Accurately documenting the hyponatremia supports the DRG with a CC and improves the CMI, reimbursement, and ELOS. 25 Education Plan Case Studies Case 3: 69 y/o with hx of DM2, COPD not on chronic O2 presents with SOB and cough with green sputum. HR 85, RR 32, RA sat 86% on 3L O2 sat of 95%, glucose of 270, Na 127, and CXR without infiltrate. Option 3 best option Acute hypoxemic respiratory failure, COPD exacerbation with acute bronchitis, hyponatremia, DM2 uncontrolled DRG 189 pulmonary edema & respiratory failure Weight: Hospital: $6,842 ELOS: 4.3 days Documenting the acute respiratory failure changes to a more correct DRG and more accurately reflects the conditions being treated. This DRG does not have CCs or MCCs. Continue to document this initial diagnosis even as it resolves throughout the hospital stay to support it as the primary reason for hospitalization. Remember that we generally wouldn t have admitted someone with no tachypnea and normal oxygen saturations. 26

14 Education Plan Practice Cases Case 1: The ED physician calls you to admit a 68 y/o with confusion, subjective fever, and UTI. The patient has a history of hypertension but no dementia. The patient is very confused and doesn t recognize family members who state this is all new over the last 24 hours. HR 98, temp 99.3, WBC 10.5 with bands 18%, U/A with TNTC WBCs, +4 bacteria, Cr 2.0 with a baseline Cr of 0.9 and a sodium 151. Given this information, list your best top 4 diagnoses. 27 Education Plan Practice Cases Case 1 best option and why Dx: sepsis due to UTI Dx: toxic &/or metabolic encephalopathy* Dx: hypernatremia Dx: acute renal failure These diagnoses document for: DRG: 871 sepsis w/o MV w/mcc* Weight: ELOS: 5.4 Reimbursement: $10,187 Not recognizing the sepsis and using UTI, acute renal failure, or hypernatremia document for lower-weighted DRGs with lower ELOS. DRG: 689 UTI w/mcc* Wt: ELOS: 4.5 Reimb: $6,266 DRG: 682 acute renal failure w/mcc* Wt: ELOS: 4.9 Reimb: $8,434 DRG: 640 hypernatremia w/mcc* Wt: ELOS: 3.4 Reimb: $5,890 Recognition of toxic &/or metabolic encephalopathy* instead of acute mental status changes documents for a MCC for the DRGs. Without the MCC*, all the DRG parameters drop by as much as half their value. Documentation of hypernatremia and acute renal failure instead of Na or acute renal insufficiency code for a CC for the DRG. Together, these diagnoses more accurately reflect the severity of the patient, the increased ELOS, and the level of care needed to manage this patient. 28

15 Education Plan Practice Cases Case 2: 72 y/o presents with shortness of breath and cough developing quickly after 24 hours of nausea and vomiting. The patient has hypertension and takes HCTZ & Lisinopril. She lives at home and has no hospitalizations in the last year. VS: HR 76 RR 22 BP 110/72 sats 86% RA and 94% on 3L O2 NC. On exam, lungs: decreased breath sounds right base with rales. Labs: WBC 8.8, H/H 15.1/45.4, Cr 2.4 (baseline 1.3 from an office note). You admit the patient, treat with Clindamycin IV, IVF, and O2. 29 Education Plan Practice Cases Case 2 best option and why Dx: probable aspiration pneumonia Dx: acute respiratory failure* Dx: acute renal failure Dx: benign essential hypertension controlled or nausea and vomiting These diagnoses document for: DRG: 177 respiratory infections and inflammations w/mcc (identified PNAs other than CAP) Weight: ELOS: 6.8 Reimbursement: $11,038 Not recognizing the probable aspiration pneumonia and using PNA or CAP, acute renal failure, or acute respiratory failure document for lower-weighted DRGs with lower ELOS. DRG: 193 simple pneumonia w/mcc* Wt: ELOS: 5.1 Reimb: $7,919 DRG: 682 acute renal failure w/mcc* Wt: ELOS: 4.9 Reimb: $8,434 DRG: 189 acute respiratory failure Wt: ELOS: 4.1 Reimb: $6,626 Recognition of acute respiratory failure* and acute renal failure instead of hypoxemia/hypoxia, Cr, or acute renal insufficiency code for a MCC* or a CC for the DRG. Without the MCC*, all the DRG parameters drop by as much as half their value. Together, these diagnoses more accurately reflect the severity of the patient, the increased ELOS, and the level of care needed to manage this patient. 30

16 Education Plan practice cases Case 3: 33 y/o with hx of alcoholic cirrhosis with esophageal varices presents with sudden onset of vomiting bright red blood. She denies any alcohol use in over 4 weeks. She has HR 124, temp 98.4, BP 90/47, WBC 9.5, H/H 7.2/22, Na 125, Cr 1.3. You admit the patient, consult GI, and order octreotide drip, PPI drip, and transfuse 2 units of PRBCs. Over the next 6 hours, the patient s BP drops to 70/40, H/H after transfusion is 6.8/19 and Cr rises to 2.6. After additional resuscitation with blood, the patient stabilizes. 31 Education Plan Practice Cases Case 3 best option and why Dx: esophageal variceal hemorrhage due to alcoholic cirrhosis Dx: hemorrhagic shock* Dx: acute renal failure Dx: acute blood loss anemia or hyponatremia These diagnoses document for: DRG: 368 major esophageal disorder w/mcc* Weight: ELOS: 5.1 Reimbursement: $9,389 Not documenting the hemorrhagic shock* and using only the acute renal failure and acute blood loss anemia document for a lowerweighted DRG with lower ELOS. DRG: 369 major esophageal disorder w/cc Wt: ELOS: 3.5 Reimb: $5,670 Recognition of hyponatremia, acute renal failure, and acute blood loss anemia instead of Na, acute renal insufficiency, or anemia code for a CC for the DRG. Together, these diagnoses more accurately reflect the severity of the patient, the increased ELOS, and the level of care needed to manage this patient. 32

17 Education Plan Be as complete and thorough as possible with diagnoses Document conditions you are treating that are probably present based on data and your judgment Continue to document conditions as they resolve (i.e., sepsis resolved) Document if something is present on admission if not mentioned in the original H&P Utilize your CDI partners as a resource 33 Education Plan Utilize Your CDI Partners as a Resource! 34

18 Metrics for Success Hit the ball over the fence and you can take your time going around the bases. John W. Raper 35 Metrics for Success CDI outcomes: Response rate Hospitalists rates Financial impact/program viability Review rate Staff productivity Query rate CMI SOI/ROM 36

19 Metrics for Success CDI monitors: PEPPER Audit feedback: payers, consultants, peers Revenue cycle Complication reports LOS reports Key Performance Indicators (KPI) for ongoing EHR integration Mortality index Specialty/service line focus 37 Metrics for Success Facility Highlight Hospitalist example: Novant Health Huntersville Medical Center Simple pneumonia (DRG 193, 194, and 195) 2012 Expected ALOS 4.8 days Actual ALOS 3.78 days Payer Neutral Revenue (PNR) 55.25% Simple pneumonia February 2013 Expected LOS of 5.6 days ALOS of 7.0 days PNR 93.78% 38

20 Metrics for Success Work Smarter Not Harder! 39 References Department of Health and Human Services, Centers for Medicare and Medicaid Services (December 2010), Evaluation and Management Services Guide, Medicare Learning Network. Online. Available: Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide- ICN pdf 40

21 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook. 41