CMS proposes IPPS changes for 2012 Agency continues coding adjustment, changes HAC list

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1 cdijournal July 2011 Vol. 5 No. 3 Director s note 4 n Advisory board qualifications/ expectations revamped, new elections process developed. LTACs explore CDI opportunities 5 n The complicated level of care required for LTAC patients makes the role of the CDI specialist even more important. Learn more about how CDI specialists perform reviews in this setting. Ask ACDIS 11 n James S. Kennedy, MD, CCS, discusses clinical criteria and documentation requirements for coding SIRS. Value-based purchasing 13 n CMS plans to reimburse facilities based on quality measures. Find out how CDI programs can help improve facility outcomes. CDI efforts in the ED 15 n Hear how some programs aim to expand efforts to the ED. ICD-10 implementation timeline 18 n Incorporate CDI efforts into ICD-10 preparation. CMS proposes IPPS changes for 2012 Agency continues coding adjustment, changes HAC list CMS plans limited changes to CCs in fiscal year (FY) 2012, but proposes new MS-DRGs for excisional debridement as well as an additional hospital-acquired condition (HAC). These and other changes are part of the inpatient prospective payment system (IPPS) proposed rule posted April 19. The proposals posted in April, however, did not contain a complete list of coding changes. Additional codes were not released until June 10. Comments on the proposed changes were due to CMS by June 20. As of press time, the ACDIS advisory board was in the process of reviewing the changes and providing comment to the agency. CMS did not list associated CC/MCC designations, nor did it list DRG assignments for the newly proposed codes. The bulk of ACDIS planned comments concern the collective opinion of the board as to where those new codes should fall. ACDIS generally supports the DRG designations for the new codes published in the proposed rule, the draft comments state. However, ACDIS would also like to offer its own opinions of what the DRG designations should be for codes that were not published in the proposed rule. (Read the final version of ACDIS comments under the CDI Journal tab on the ACDIS website.) Changes reflect healthcare reform trends The IPPS proposals would make adjustments to existing IPPS policies and pave the way for future changes as a result of the Patient Protection and Affordable Care Act (PPACA). Overall, CMS expects a year-over-year reduction of 0.5% in payments to acute care hospitals under the FY 2012 IPPS. The reduction includes a documentation and coding adjustment of -3.15%, eliciting disappointment from the hospital community. We re very concerned that CMS continues to move forward with the inpatient coding offset, says Joanna Kim, senior associate director for policy for the American Hospital Association in Washington, DC. We feel that it s excessive and wrongly assumes [that] spending on inpatient hospital care has increased solely due to changes in coding. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, regional managing director of HIM, NCAL Revenue Cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, CA, agrees. We believe that our efforts to improve documentation and coding actually do reflect patient severity, and we challenge CMS to look at other methodologies they re using. continued on p. 2

2 CMS proposes IPPS changes continued from p. 1 CC/MCC changes Stakeholders should watch for CC/MCC implications for new codes, including the stages of acute kidney injury or druginduced pancytopenia, says James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Brentwood, TN. One surprise is the continued inclusion of encephalopathy as an MCC, says Kennedy. Encephalopathy is such a generic word, he explains. I... had thought that encephalopathy, nonspecified, would be lowered to a CC... much like [congestive heart failure], nonspecified, is not a CC. The cost analysis that CMS used to reach this conclusion makes sense, Kennedy adds; however, from a physician documentation perspective, there is a need for increased specificity and guidance on this topic. CMS also proposed removing pressure ulcer diagnosis codes (stage III) and (stage IV) from the CC exclusion list when listed with a principal diagnosis code from to This allows the stage III and IV pressure ulcer codes to be MCCs when reported with the pressure ulcer codes as principal diagnosis, explains Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. The move is a response to commenters who contended that a patient admitted for treatment of a stage III or IV pressure ulcer likely requires resources that would qualify the case as a diagnosis with an MCC. McCall notes that the stage III or IV pressure ulcer present-on-admission reporting requirement still applies, so hospitals will need to identify that the pressure ulcer is not a HAC. Excisional debridement CMS proposed to create three new MS-DRGs for excisional debridement of skin and subcutaneous tissue and revise existing MS-DRGs to include skin grafts only, to account for cost differences. CMS resisted Editorial Board ACDIS Director: Brian J. Murphy, CPC bmurphy@cdiassociation.com Associate Director: Melissa Varnavas, CPC mvarnavas@cdiassociation.com Editorial Director: Lauren McLeod Shelia Bullock, RN, MBA, CCM, CCDS Manager, Clinical Documentation Services University of Mississippi Medical Center Jackson, MS sabullock@patacct.umsmed.edu Cheryl Ericson, MS, RN Manager of Clinical Documentation Integrity Medical University of South Carolina ericsonc@musc.edu Garri Garrison, RN, CPUR, CPC, CMC Director, Consulting Services 3M Health Information Services Atlanta, GA glgarrison@mmm.com Robert S. Gold, MD CEO DCBA, Inc. Atlanta, GA DCBAInc@cs.com Robin R. Holmes, RN, MSN Manager, Clinical Documentation Improvement DCH Health System Tuscaloosa, AL rholmes@dchsystem.com James S. Kennedy, MD, CCS Managing Director FTI Healthcare Brentwood, TN james.kennedy@ftihealthcare.com Glenn Krauss, BBA, RHIA, CCS, CCS- P, CPUR, FCS, PCS, C-CDIS, CCDS Independent Consultant Madison, WI glennkrauss@earthlink.net Trey La Charité, MD Physician Advisor University of Tennessee at Knoxville Knoxville, TN Clachari@UTMCK.edu Gail B. Marini, RN, MM, CCS, LNC Manager, Clinical Documentation South Shore Hospital Weymouth, MA Gail_Marini@sshosp.org Lynne Spryszak, RN, CPC-A, CCDS CDI Education Director HCPro, Inc. Danvers, MA lspryszak@hcpro.com Colleen Stukenberg, MSN, RN, CMSRN, CCDS Clinical Documentation Management Professional FHN Memorial Hospital Freeport, IL cstukenberg@fhn.org Donna D. Wilson, RHIA, CCS, CCDS Senior Director Compliance Concepts, Inc. dwilson@ccius.com Lena N. Wilson, MHI, RHIA, CCS, CCDS HIM Operations Manager Clarian Health Indianapolis, IN lwilson9@clarian.org Previous ACDIS board members: Cindy Basham, MHA, MSCCS, BSN, CPC, CCS ( ) Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS ( ) Jean S. Clark, RHIA ( ) Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS ( ) Colleen Garry, RN, BS ( ) Robert Gold, MD ( ) William E. Haik, MD ( ) Tamara Hicks, RN, BSN, CCS, CCDS ( ) Pam Lovell, MBA, RN ( ) Shannon McCall, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS ( ) Heather Taillon, RHIA ( ) CDI Journal (ISSN: ) is published quarterly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $129/year for membership to the Association of Clinical Documentation Improvement Specialists. Postmaster: Send address changes to CDI Journal, P.O. Box 3049, Peabody, MA Copyright 2011 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CDI Journal. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. 2 July HCPro, Inc.

3 classifying procedure code (excisional debridement of wound, infection, or burn) as a nonoperative procedure, stating that inpatient facilities would be under-reimbursed if it were to do so. The new debridement DRGs would still be classified as operating room procedures but would result in lower payment to reflect what CMS says is the lower cost of delivering these services. We examined MedPAR claims data on all excisional debridement cases and found that these debridement cases use appreciably fewer resources than other cases in their current surgical DRGs, CMS stated in the proposed rule. The change is a reasonable one and it may help hospitals that perform many skin graft procedures, as their reimbursement may have been skewed downward by the inclusion of excisional debridement in the same MS-DRGs, says Kennedy. However, because there are no changes to any of the underlying coding or documentation guidance for excisional debridement, coders will still face difficulty differentiating documentation of excision, removal, debridement, and excisional debridement. The fact that CMS maintained excisional debridement as an operating room procedure means that it will continue to generate interest from external reviewers such as the Recovery Audit Contractors, says McCall. New HAC: Contrast-induced acute kidney injury CMS proposed adding contrast-induced acute kidney injury to the list of HACs subject to reduced payment provisions under the IPPS. Although CMS states that there is no unique code that identifies the varying stages of acute kidney injury, the agency would identify it as a subset of discharges with ICD-9-CM diagnosis code (acute kidney failure, unspecified), which currently qualifies as a CC. CMS contends that it can accurately identify contrastinduced kidney injury when code is listed in combination with specified procedure codes from the 88.xx code series. CMS lists these codes starting on p. 113 of the proposed rule display copy. All the more reason that providers must be attentive to the release of new codes, what impact they may have in gauging contrast-induced nephropathy, and what impact it may have with the other acute renal failure codes, especially 584.5, acute kidney failure with lesion of tubular necrosis, Kennedy says. Although CMS considered the use of E codes to identify contrast-induced acute kidney injury, it ultimately scrapped the idea because E codes are not required on IPPS claims. Readmissions provisions CMS is also using the proposed rule to lay the foundation for the coming Hospital Readmission Reduction Program mandated by PPACA. The agency proposes to include acute myocardial infarction, heart failure, and pneumonia based on the current inpatient quality reporting measures as applicable conditions under the readmissions program, starting in FY This should encourage providers to analyze a full range of readmissions, says Bryant. I recommend hospitals look at readmission rates to determine what their top three to five readmissions conditions are, she advises. It s clear that readmissions are a topic of concern for the federal government. Even though we in the industry have talked about readmissions for years, this federal mandate means we need to look at it even more closely. CMS would adopt the National Quality Forum definition of readmission:... as occurring when a patient is discharged from the applicable hospital to a non-acute setting (for example, home health, skilled nursing, rehabilitation or home) and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization. For the three proposed applicable conditions, the specified time period would be 30 days. Editor s note: CMS accepted comments on the proposed rule until June 20. The final rule is expected to be issued by August 1. This article was ed to ACDIS members, courtesy of HCPro, Inc., and published on the HCPro website April HCPro, Inc. July

4 Director s note Advisory board qualifications and expectations revamped, new elections process developed In last quarter s director s note, Laying down the (by)laws, I spoke about a newly formed bylaws committee and the work it is charged with. This included examining which professionals should constitute our advisory board and expectations for their role as association leaders, as well as developing a new process that included more membership input and greater transparency in how we select our new board members. I m pleased to say that we ve made some tremendous progress. On our advisory board Web pages you can now find new documents describing qualifications and expectations of advisory board members, as well as our brand-new elections process. They are located here: Frequently asked questions: ACDIS advisory board qualifications, responsibilities: Nomination and election process: To sum up, new advisory board members will be elected using a two-step process. A nomination committee will conduct an initial review of applications and then follow up with candidates via phone. The final applicants who emerge from this process will be voted on by you, the ACDIS membership. In addition, our CCDS certification board is in the final stages of developing its own set of bylaws to govern the day-to-day operations of that group s vital work. We plan to publish these bylaws, along with policies on examination appeals and a disciplinary policy, in the coming weeks on the ACDIS certification pages. This is part of a long-term coordinated effort to obtain national accreditation for the CCDS credential. I want to thank these committees for their hard work and their dedication in making ACDIS a stronger and more transparent organization. I hope it encourages future leaders to apply for positions on our advisory board, our certification board, or one of our other important committees within ACDIS (e.g., CDI recogni tion committee, conference committee). If you have any other suggestions on how we can make ACDIS a better association, please let me know. My direct extension and address (as always) appear below. Take care, Brian J. Murphy, CPC bmurphy@cdiassociation.com 781/ , Ext July HCPro, Inc.

5 LTACs explore CDI opportunities for the long term When Jennifer Love, RN, BA, CCDS, accepted a CDI position in Texas, she d planned the move to be closer to her family. When her husband received a promotion, however, plans changed. They decided to stay in North Carolina. Although Love remained in the area, she found a brandnew opportunity to reenter the workforce in the long-term acute care (LTAC) space for Kindred Healthcare, one of the nation s largest LTAC providers. As a registered nurse I knew I d find another position, so it was an easy decision to stay where we are. When the opportunity at Kindred came up, I was thrilled at the prospect, says Love, an area director of CDI for Kindred in Greensboro, NC, and Richmond, VA. Most CDI specialists (97% according to the 2010 CDI Specialist s Salary Survey) work in short-term acute care (STAC) facilities. So Love saw the LTAC opening as a chance to broaden her CDI horizons. It is exciting to see CDI expand out like this, she says. I feel like I dove into the future. LTAC basics As its name implies, LTACs provide care for patients with serious (acute) medical needs over a long period of time, usually between 20 and 30 days. The payment system is essentially the same as that of STAC facilities LTACs use ICD-9 codes and MS-DRGs for Medicare patients, for example. But whereas STACs look to reduce a patient s geometric length of stay (GLOS), an LTAC patient is expected to require a longer treatment period. If a patient leaves the LTAC sooner (or longer) than expected, a number of questions need to be asked and answered, says Becky Slagell, BA, MHA, RHIT, CPHQ, regional senior director of case management for the Central Region Long-Term Acute Hospital Division at Kindred Healthcare. (Read her column on p. 8.) We need to ask ourselves why that patient was discharged earlier than patients with similar concerns. Was [he/ she] truly safe for discharge? Was [he/she] able to go home earlier than normally expected for that type of patient? Did [he/she] transfer back to a STAC? If so, why?...[w]e need to ask the questions to be sure we provided the best-quality care possible, Slagell says. It has got to be all about quality first, and the reimbursement will follow as appropriate. It is exciting to see CDI expand out like this. I feel like I dove into the future. Jennifer Love, RN, BA, CCDS LTACs treat a very specific type of patient, says Love. Patients typically are morbidly obese, suffer from bed sores and acute renal failure, and have often undergone tracheostomies. This isn t a nursing home. This isn t assisted care. This is an acute facility for long-term illnesses, she says. The top DRGs at Love s facilities include the following: 207: respiratory system diagnosis with ventilator support 96+ hours 189: pulmonary edema and respiratory failure 592 and 593: skin ulcers with CC/MCC 870 and 871: septicemia or severe sepsis with mechanical ventilation 96+ hours; and with MCC There shouldn t be a high rate of COPD in a LTAC setting, Slagell says. That is a chronic condition that by itself does not require our level of care. When a CDI specialist sees that, they ll look further in the record and see what the situation is. Is there an acute exacerbation of the COPD such as aspiration pneumonia or respiratory failure? This complicated level of care makes the role of the CDI specialist very important for this particular setting, says Slagell. CDI in the LTAC setting Pamela Phillips, CCS, is regional HIM director at Fundamental Clinical Consulting, LLC, in Dallas. She started her career as a coder and then moved into a compliance role as an auditor in a STAC. She moved to the LTAC setting 10 years ago. continued on p HCPro, Inc. July

6 LTACs explore CDI opportunities continued from p. 5 Today, working primarily from her home base in Dallas, she oversees CDI efforts at eight facilities, from Albuquerque, NM, to Las Vegas, to Overland Park, KS, each with between 25 and 60 beds. Every day, Phillips combs through facility medical records looking for something the coder overlooked, looking for signs and symptoms documentation with specific diagnoses. Certainly, given the number of facilities and patients, she cannot look at every record every day, but Phillips estimates that she reviews each patient every three to four days. The CDI specialist makes sure that everyone knows what is happening with a given patient s care. Becky Slagell, BA, MHA, RHIT, CPHQ In addition to the typical CDI role of record reviews, Phillips fields questions from coders, physicians, and case managers at each facility regarding documentation improvement. She also joins each facility s case manager for regular meetings with physicians and other clinical care team members to discuss specific cases, catch potential documentation errors, and identify possible educational opportunities. Kindred follows a similar process, says Slagell, who oversees facilities in Kentucky, Missouri, Illinois, Indiana, Ohio, Pennsylvania, Michigan, Wisconsin, and North Dakota. Reporting to the executive vice president for her region, Slagell is responsible for three districts. Each district has eight to 12 LTACs and employs a case management director and a CDI director. Each facility also has a case management director or manager, but the CDI specialists are only employed at the district level, she says. Kindred s electronic health record system allows its CDI specialists to review medical records off-site. The coders also work remotely. At Kindred, CDI staff constantly communicate with coders and case managers via a secure system just one of the many electronic tools available to the team, Slagell says. For example, the software can search for atypical focus DRGs, allowing the CDI specialists to hone their reviews. Due to the expected GLOS in a LTAC, coders regularly review the medical record and assign codes concurrently on what Kindred calls a coding face sheet. It is similar to a printed 3M grouper page, says Love, who sets the face sheet in front of her as she reviews the record for inconsistencies and missing information. CDI rounds Like Phillips, the CDI staff at Kindred also meets regularly with case managers and other care team members. The case manager at each LTAC arranges what Kindred dubs interdisciplinary team (IDT) meetings for each patient. During these sessions, all the members of the patient s care team are present, as appropriate, from the CDI specialist to the dietitian. The CDI specialist makes sure that everyone in that IDT meeting knows what is happening with a given patient s care, says Slagell. Where the discussion around the table doesn t match the information in the medical record or what appears on the coding face sheet, the CDI specialist raises the concern and queries the appropriate caregiver. Furthermore, all of Slagell s CDI staff meet regularly via teleconference to discuss common concerns pertaining to their CDI roles. (Read the related article on p. 7.) It is very important for all the various healthcare stakeholders to regularly come together to talk about each patient s case, says Slagell. At Kindred, it is very clear that there is equal ownership of the record and [that] ensuring quality care supported with clear, concise, and thorough documentation, is everyone s responsibility, Slagell says. Slagell s story Back in 1984, when CMS first implemented the prospective payment system, Slagell was fresh out of HIM school and went to work at a STAC. I was teaching the physicians the difference between the terms mass versus lesion and failure versus insufficiency back then, she jokes. Even then, I remember the [utilization review coordinator] coming up with the idea to look at DRGs concurrently so we could see how long the patient should be with us and then we could work to get the appropriate documentation. 6 July HCPro, Inc.

7 In 1996, Slagell switched to the LTAC setting and worked as the director of quality management. That s when she became truly enamored with the important link between medical record documentation and the quality of care provided to the patient. She fell in love with the idea that information in the medical record constitutes the story of patient care. Documentation is so important to tell the patient story, says Slagell. Once you ve been in a quality role, you don t take that hat off. I know through this process that the Kindred team can make a difference to Mrs. Smith s life by communicating together and documenting her story... with less of a risk of her becoming a poor outcome statistic. Now that is something to strive for. That is a reason to get up in the morning. Kindred CDI staff share their stories The following Kindred Healthcare district CDI specialists took time from their regular teleconference meeting to speak with ACDIS about their roles: Dianna Branigan, RHIA, CHP, district CDI specialist for the DFW/OKC region. Branigan came to Kindred from an acute care facility where she worked as the director of HIM and helped the organization implement its CDI program. She began work at Kindred a little more than a year ago. Tony Ekwo, MBBS, MPH, CCDS, district CDI specialist for the Illinois/Wisconsin region. Ekwo was a surgeon in Nigeria and has been working as a CDI specialist while awaiting approval to begin his residency as a surgeon. Sylvia Ramirez, RHIT, district CDI specialist for the South Texas/New Orleans region. She has a background in HIM and has worked at Kindred for 15 years. Carol Towson, RN, MSN, district CDI specialist for the Midwest region. Towson was the director of quality management at a short-term acute care (STAC) facility where she had worked for 25 years. She began her career as a floor nurse and worked her way to nurse supervisor before moving to quality and starting the facility s CDI program 11 years ago. She has been at Kindred for the past two years. ACDIS: Can you describe what your typical day is like? Ekwo: CDI efforts in the STAC setting and the long-term acute care (LTAC) setting are pretty much the same. The difference comes with the length of stay. LTAC patients need additional care, so they stay in the facility longer. What this means is that CDI specialists need to be sure that they have the most accurate documentation in the medical record as early as possible so that information can be continued as additional care is provided. Typically, I pull the census and reports for all the buildings, then begin my reviews using our electronic tools. I also run a CDI steering committee for all the executive directors and CEOs from the facilities in my district to examine how CDI functions affect their data. Ramirez: To piggyback on what Tony mentioned, we have an electronic health record, so we can perform much of our record reviews remotely. We also receive a filtered report from our support center to help us look for typically troublesome DRGs. We attend our facility weekly interdisciplinary team (IDT) conferences for each patient to offer our input and apply the latest CDI best practices to our reviews. Branigan: Kindred really places CDI responsibility on the entire care team. In a typical day in a facility, I print out all my coding face sheets, compare them with the medical record documentation, and when I find information in the record that isn t reflected on the face sheet, I bring the concern to the IDT members to help them understand the CDI process. We want all the IDT members to understand the coding face sheet. They know what conditions they are treating and can see how the documentation is being translated by the coders. It tells the patients story. ACDIS: You each seem to cover a fairly large geographic area. Tell me how that influences your daily duties. Ramirez: There is a lot of time on the road since we have facilities all over the place. I look at the reports remotely and determine which facilities need the most help and then schedule time with them. continued on p HCPro, Inc. July

8 Kindred CDI staff share their stories (cont.) Conversely, if I m slated to visit a particular facility, I ll look through the records and see what topics or which patient needs the most assistance. Of the six facilities under my charge, three are in the Houston area. I try to make it to each building at least twice a month. ACDIS: What types of tasks do you perform when you do visit a facility? Ekwo: I try to give a presentation on documentation improvement every week. There is a lot of education and communication that needs to happen. Branigan: Sometimes we go in and supplement the staff in their chart reviews, if someone is off, or there s an open position. We also attend IDT meetings to evaluate the process and participation by the team members. Ramirez: I do an IDT evaluation when I m in the building. I also review open and closed charts for any possible DRG migrations or educational opportunities. ACDIS: Can you give me an example of what constitutes a good day for you? Branigan: A good day would be one in which I review records and find hints and clues for potentially missing or incomplete documentation and speak with the physicians to help them understand the need for better documentation. I really enjoy finding diagnoses that were missed, but treatment was given. A good day is a day where I feel like my work had an impact. Towson: A good day? Those are the days when I see a light bulb go on when someone in the care team suddenly illustrates that they get why CDI efforts are important. It makes you feel good. Ramirez: Even getting the physician to say admit to LTAC and not rehab is a success story. Admit to rehab is not the same thing as admit to long-term acute care. They are two vastly different types of facilities, with differing care capabilities and differing payment systems. We think of the LTAC as a new chapter in the story of a patient s care plan, but it is a continuing story that needs to be brought over in the medical record. When the rest of the care team understands that underlying importance of the information in the medical record, to me, that s a good day; to me, that s a good job done well. CDI staff help LTAC clinical team tell the patient care story by Becky Slagell, BA, MHA, RHIT, CPHQ How can we provide quality care for our patients if we do not have a clear picture of their clinical story? That has been a core question of mine for as long as I can remember, even before I heard the term clinical documentation improvement. I started my quest to link quality of care concerns with documentation in 1984 the year CMS shifted short-term acute care (STAC) facilities to the prospective payment system for all Medicare patients. I worked in a STAC in a variety of roles from DRG coordinator to performance improvement director for more than 12 years. In that time, I always worked in tandem with the utilization review coordinators, physicians, HIM, and administration. I have an HIM education and the Certified Professional in Healthcare Quality (CPHQ) credential, so I take the idea that we need to consistently document what we do and do what we document very seriously. From a legal standpoint, the old adage If it wasn t documented, it wasn t done is as true as ever. (And surely no one wants to document care that wasn t provided, either.) We need to push these ideals further. If we do not connect the clinical dots to specify an actual diagnosis, then appropriate, timely care may not be provided and the care necessary to provide the best possible outcome for the patient may be missed. 8 July HCPro, Inc.

9 Outlining the book Throughout the years, my focus has always been the same: to get everyone to work together to connect the documentation dots so the medical record clearly tells the clinical story of the care provided to the patient. The medical record is the book of the patient s healthcare life. Capturing the appropriate details in that book ensures that every individual involved fully understands why the patient requires our care and what the facility needs to do to provide the best care possible for each patient. So after those 12-plus years at the STAC, I started to wonder about the rest of the patients stories, to wonder what happens when the sickest individuals shift from the STAC to a long-term acute care (LTAC) hospital. No healthcare organization needs to have an interdisciplinary team (IDT) connection more than an LTAC. They take on the sickest of the sick, the patients still considered to be in the acute phase of their care needs. I wanted to learn more about the care of patients whom I refer to as having Book Two: The LTAC Story. I found my way to a position at Kindred Healthcare where I have seen how my earlier vision of the medical record as a continuous story lives and breathes. Kindred believes so strongly in the importance of the IDT that it added an extra C to its CDI program acronym, which stands for clinical coordination and documentation improvement. Incorporating interdisciplinary input Kindred s CCDI process focuses on quality by first exhausting the reasons for a patient s LTAC care. This involves input from all the various healthcare stakeholders at the weekly IDT meetings. During these meetings, caregivers might discuss a number of questions such as: Why is the patient experiencing increased confusion? Is it from the narcotics the patient is on? Why does the patient need such medications? If the patient needs the medication for pain, where is the pain coming from? What is the cause of the pain? How is our treatment positioned to resolve the concern? The team addresses quality care and efficiency in real time and therefore seeks to accomplish the following two objectives: 1. Make a difference in the quality of care for the patient here and now instead of committing to get it right the next time with a future patient 2. Avoid labor-intensive retrospective reviews and duplication of efforts During my time at Kindred I have seen the IDTs grow increasingly more sophisticated. Now team members keenly watch for quality issues and, even more importantly, look to prevent any adverse outcomes. We more frequently observe and discuss risk factors for skin breakdown to avoid a pressure ulcer, for example. During our IDT meetings the CCDI specialist might ask whether the patient needs to be placed on a special mattress or the case manager might inquire whether the patient has been left sitting in a chair too long. Another risk for an LTAC patient is acquiring an infection. The IDTs include in their discussions how long the patient has had a central line, PICC, or Foley catheter, and collectively review documentation to determine when a line may need to be replaced. The IDT may even consider if the lines are necessary, or whether their removal could help improve the patient s overall condition, thus eliminating the risk of line infection. As a healthcare organization, we do not benefit from keeping a patient in the hospital for a few more days if those days are due to our error. Even if payment should be offered for such care, the cost of the treatment negates any financial benefit not to mention the inconvenience and dissatisfaction patients and families experience. Our goal is to provide the best care possible as we help patients recover and transition back to their home. In addition, we want our physicians and employees to take pride in what they do. Detailing the second book of care At Kindred, we examine how to improve the quality and efficiency of our patient care services by clearly documenting everything we do in real time. Kindred s philosophy is that we must deliver the right care to the right patient, at the right time in the right setting, with the right documentation yielding the right reimbursement. continued on p HCPro, Inc. July

10 LTAC clinical team continued from p. 9 We all want to see positive outcomes. But how do the healthcare providers from the bedside nurses to the dietitians to supporting physicians know what that care is if it was not clearly documented? Identifying the principal diagnosis at an LTAC is not easy. LTAC patients present with myriad diagnoses, which makes it a challenge for an LTAC physician to complete a patient history and physical (H&P) report within 24 hours of admission a challenge not typically faced in STACs. For example, a patient may present in the ER of an STAC with severe chest pain. The physician orders tests to rule out acute myocardial infarction. Although the patient is critically ill, the physical assessment piece is less complex. With the completion of the H&P, the STAC s Book One of that patient s care story is also complete. Consider, however, if at the STAC, this same patient has bypass surgery and develops postop respiratory failure and wound dehiscence. Later, he acquires decubitus wounds and becomes septic. His nutritional status is adversely affected as evidenced by the albumin level, body mass index, and oral intake. The physician determines that the patient needs LTAC care and he is admitted. Now the LTAC facility is responsible for generating the documentation for the next book of the patient care story. That is why Kindred incorporates CCDI staff into its IDT meetings to work not only with the physicians, but with the entire clinical care team tell the clinical story. At the meetings, the CCDI staff can clarify the types and severity level of the patient s wounds by facilitating conversation with the wound care nurse, an individual who wants to ensure the best possible care in his or her area of expertise. And if the dietitian notes that the patient is on total parenteral nutrition, doesn t it make sense to ask the why behind this treatment modality to the individual best suited to respond to a particular question? This querying for specificity by the expert is what makes Kindred live and breathe quality care. When all of us approach these opportunities for improvement concurrently, we identify signs, symptoms, even lab values that, if unaddressed, could negatively affect the patient s condition. For example, if the patient becomes febrile, experiences a rise in white blood cell count, or there is a notable increase in the suctioning of sputum or a positive culture of Klebsiella pneumonia, this can all be discussed, documented, and care can be adjusted to better meet patient needs. Here is an example of what an engaged IDT meeting can uncover: The nurse notes a rise in the patient s white blood cell count and the patient has become febrile. The respiratory therapist notes an increase sputum. The infectious disease nurse notes a positive culture of Klebsiella Pneumonia. But the pharmacist notes that the patient is not on antibiotics. An antibiotic order can save that patient s life. Answering important questions We have found that two questions often lead to aha moments for the entire IDT: What is it? (diagnosis) and What are we doing about it? (treatment). Anecdotally, someone inevitably says: No wonder the patient cannot wean off the ventilator, he has a new pneumonia! Let s concentrate on resolving the infection and then try to wean the patient again. The CCDI staff must also acknowledge all the risk factors identified in the medical record to ensure that the appropriate care and treatment for these clinical dots were provided. This, in turn, helps the team avoid a new complication or hospital-acquired condition. A common scenario is IDT discussion leading to the discovery of several risks for skin breakdown, such as the presence of contractures, brittle diabetes, peripheral vascular disease, and severe malnutrition. Of course we will care for all wounds, but we certainly do not want to be the cause of them. Once the risks are identified, the team can adjust their care to help prevent those risks from becoming a reality. The extra C is the key to Kindred s success in linking quality with CDI. The organization s culture promotes patient and family satisfaction because of the high-quality care outcomes. This in turn leads to high employee/physician satisfaction because they can take pride in these positive results. Editor s note: Slagell is regional senior director of case management for the Central Region Long-Term Acute Hospital Division at Kindred Healthcare. Contact her at Becky.Slagell@kindredhealthcare.com. 10 July HCPro, Inc.

11 Ask ACDIS Coding Clinic clarifies SIRS query questions How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes to sepsis? I want to correctly query and obtain the proper supporting information in the medical record in the event of an audit. Any discussion on this topic is appreciated. This question raises two issues. First, SIRS does not code to sepsis. SIRS by itself codes to , Systemic inflammatory response syndrome, unspecified. SIRS codes to sepsis only when it is linked to an infection. While the ICD-9-CM Official Guidelines for Coding and Reporting allow for pneumonia and urinary tract infection to be designated as infections (which, for pneumonia, is not always the case), other conditions that end with the suffix -itis that many assume to be infections, such as cellulitis, diverticulitis, orchitis, cholangitis, and the like, are not infections unless the physician explicitly states that these are infections. Coding Clinic, First Quarter 2010, p. 10, states the following: Question: Please clarify the Official Guideline for Coding and Reporting SIRS due to noninfectious process. The guideline states that systemic inflammatory response syndrome (SIRS) can develop as a result of certain noninfectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. A physician at our hospital stated that acute pancreatitis is an inflammation of the pancreas that can occur with infection. Acute pancreatitis is usually caused by gallstones or by drinking too much alcohol, but these aren t the only causes. If the guideline is accurate, could it be applied to other inflammatory conditions, such as diverticulitis, cholangitis, orchitis, et cetera? Answer: Yes, the guideline for noninfectious SIRS can be applied to other types of inflammatory conditions as well as pancreatitis. Therefore it would be appropriate to report code , Systemic inflammatory response syndrome due tononinfectious process without acute organ dysfunction, or code , Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction, for SIRS due to any noninfectious condition. A more recent answer reaffirming this appears in Coding Clinic, First Quarter 2011, p. 22: Question: We are requesting clarification of the advice published in First Quarter 2010, page 10, in which coders were instructed to assign code , Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction for SIRS due to a noninfectious condition, such as pancreatitis. Since the etiology of pancreatitis can either be infectious or noninfectious, shouldn t the provider be queried? Could Coding Clinic clarify this issue further? Answer: Pancreatitis can have various etiologies; however, the majority of cases of pancreatitis are noninfectious. In 10-30% of cases, the cause is unknown, although studies have suggested that approximately 70% of idiopathic pancreatitis may be due to biliary microlithiasis. In those rare circumstances where the provider documents SIRS due to infectious pancreatitis, use the infectious SIRS code rather than the noninfectious one. Query the provider regarding the cause of pancreatitis, if the health record documentation is not clear. This advice is consistent with previously published information. Therefore, SIRS due to any condition that is not explicitly documented to be an infection garners code (a CC) or (an MCC), depending on whether an acute organ dysfunction is linked to the SIRS. If it was the physician s intention to state that SIRS was due to infection, the word sepsis, defined as SIRS due to infection, is preferred. The physician should use the term SIRS only if the intent is to communicate that the SIRS phenomenon is due to a noninfectious disease process. The second issue addresses how to survive an audit. Sadly, the definition of the term SIRS has evolved over the years. Some still hold to the 1992 definition where only two out of four SIRS criteria primarily representing abnormal vital signs and/or a high or low white count must be met. This definition and associated criteria are currently not in vogue, given that the inflammatory mediators in SIRS have myriad manifestations and consequences and that each indicator by itself is not specific for the disease. continued on p HCPro, Inc. July

12 Coding Clinic continued from p. 11 I agree with Robert Gold, MD, who stated during the May 26 ACDIS quarterly conference call that a combination of abnormal vital signs does not constitute SIRS. One must remember that a SIRS score does not mean that the patient has SIRS or sepsis (SIRS due to infection). What must be present are the clinical findings that would lead a seasoned clinician to deduce that the patient is septic (has sepsis) or is systemically ill from his or her noninfectious inflammation. A list of these are available on the following websites: Sepsis: SIRS: If it was the physician s intention to state that SIRS was due to infection, the word sepsis is preferred. The physician should use the term SIRS only if the intent is to communicate that the SIRS phenomenon is due to a noninfectious disease process. I like what is published in the 2001 International Sepsis Definitions Conference. This references a table similar to that outlined in definition above. It states the following: It is important to emphasize that none of the findings in Table 1 [in the Definitions document] is specific for sepsis. A high cardiac output is commonly observed following major surgical procedures or multiple traumas. Arterial hypotension can be caused by many conditions other than sepsis, such as acute left ventricular failure secondary to acute myocardial infarction (AMI) or hemorrhage. Coagulopathy can be drug-induced and is associated with many different diseases, in addition to sepsis. It is important that as a practitioner checks off the boxes to establish the diagnosis of sepsis; only findings that cannot be easily explained by other causes should be included... We have not chosen thresholds for each of the criteria that are consistently abnormal in degree. The question is whether thresholds similar in degree of abnormality confer similar prediction in sepsis. During the deliberations on the signs and symptoms that characterize sepsis, the group turned toward the day-to-day reality for bedside clinicians. The group concluded that few, if any, patients in the early stages of the inflammatory response to infection are diagnosed with sepsis via four arbitrary criteria. Instead, the clinician goes to the bedside, identifies a myriad of symptoms, and regardless of an evident infection declares the patient to look septic. If no obvious source of infection exists, the clinician then initiates a search for an infectious origin of the signs and symptoms associated with sepsis. The use of the word some (Table 1) reflects the clinical reality at the bedside rather than an arbitrary list invented for the purpose of clinical trial entry criteria. Should the definition of sepsis reflect reality as seen at the bedside, thereby facilitating a clinical diagnosis, or should the definition enable investigators to develop clear and simple entry criteria for clinical trials? It was the opinion of the group that facilitating bedside diagnosis should have primacy over research entry criteria. Therefore, if a patient has sepsis (SIRS due to infection) or SIRS due to a noninfectious localized inflammation or cause, in order to survive an audit, I believe the following must be true: To have sepsis (SIRS due to infection), the following must exist: --Evidence that the patient has an infection (e.g., positive culture, prolonged antibiotic use) --The physician describes the patient as toxic in appearance or septic appearing -- Some (preferably three, or two with a severe organ dysfunction) of the SIRS criteria published in 2008 are met, provided that they are not due to another condition To have sepsis (SIRS due to noninfection), the following must exist: --Evidence of an underlying cause (Note: Drugs can cause SIRS; however, I would prefer that it be some sort of inflammation, trauma, burn, malignancy, and the like.) --At least two (preferably three) of the SIRS score are met, provided that they are not due to another condition --The patient appears to be very ill Editor s note: James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Brentwood, TN, and a member of the ACDIS advisory board, answered this question. He can be reached at james. kennedy@ftihealthcare.com or 615/ July HCPro, Inc.

13 Value-based purchasing presents new CDI opportunities Starting October 2012, Medicare will begin paying hospitals for quality measures, according to a CMS fact sheet released April 29. The new Hospital Value-Based Purchasing (VBP) program adopts performance measures under two domains : 1. Clinical process, composed of 12 measures (read the list of measures at right) 2. Patient experience, composed of the Hospital Consumer Assessment of Healthcare Providers and Systems survey Furthermore, beginning in 2013 hospitals with excess 30-day readmissions for patients admitted with heart attacks, heart failure, and pneumonia will see a reduction in payments. By 2015, a portion of Medicare payments will be linked to effective implementation of electronic health records and payment reductions will be punishment for certain hospital-acquired conditions (HAC). We are moving in a very interesting direction here, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK. Facilities are going to have to have a mechanism to collect this information concurrently, and that s going to draw in CDI and case management and quality team members the whole team. The pressure is on to make this happen. Common measures Most facilities will already be familiar with the VBP measures since CMS has collected data on them for some time. The Hospital Inpatient Quality Reporting Program is now known as QualityNet, but some know it better as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). Many CDI programs incorporate RHQDAPU items on physician documentation improvement tip sheets. (See the Physician Documentation Improvement Pocket Guide, by Pamela P. Bensen, MD, MS, FACEP.) But until now CMS hadn t tied payment to a facility s performance. Instead, hospitals were paid to participate in the program and simply reported the requested conditions. Since 2005, CMS has published each RHQDAPU participating hospital s measure rates on the Hospital Compare website. List of VBP measures Acute myocardial infarction 1. AMI-7a: Fibrinolytic therapy received within 30 minutes of hospital arrival 2. AMI-8a: Primary PCI received within 90 minutes of hospital arrival Heart failure 3. HF-1: Discharge instructions Pneumonia 4. PN-3b: Blood cultures performed in the emergency department prior to initial antibiotic received in the hospital 5. PN-6: Initial antibiotic selection for CAP in immunocompetent patient Healthcare-associated infections 6. SCIP-Inf-1: Prophylactic antibiotic received within one hour prior to surgical incision 7. SCIP-Inf-2: Prophylactic antibiotic selection for surgery patients 8. SCIP-Inf-3: Prophylactic antibiotics discontinued within 24 hours after the end of surgery 9. SCIP-Inf-4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose Surgical Care Improvement Project 10. SCIP-Card-2: Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period 11. SCIP-VTE-1: Surgery patients with recommended venous thromboembolism prophylaxis ordered 12. SCIP-VTE-2: Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery continued on p HCPro, Inc. July