Essentials for Clinical Documentation Integrity 2017
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1 Essentials for Clinical Documentation Integrity 2017 Prepared and Published By: MedLearn Publishing A Division of Panacea Healthcare Solutions, Inc. 287 East Sixth Street, Suite 400 St. Paul, MN
2 TABLE OF CONTENTS Foundations of Clinical Documentation Integrity... 1 What is CDI?... 2 Symptoms vs. Diagnoses... 3 MDCs and MS-DRGs... 4 The Grouper... 6 Principal and Secondary Diagnoses... 6 Defining SOI and ROM... 8 Case-Mix Index (CMI) and Base Reimbursement Rate... 9 Whose Documentation Counts? Daily Documentation Diagnosis Guidelines Principal Diagnosis Guidelines Secondary Diagnoses Guidelines ICD-10 Guidelines ICD-9 and the Transition to ICD Identifying the Differences Understanding Coding and Your Coding Resources Building ICD-10 Codes Performing New Patient and Follow-Up Reviews New Patient Reviews Prioritizing New Patient Reviews Follow-Up Reviews or Additional Reviews Queries: A Tool for CDI Success Who Should Send queries? What is a Query? A Three-Step Approach What s the Best Practice for Sending Queries? What Should You Include in the Query? Diagnostic Options of a Query What is the Impact of Your Query? iii
3 What are Possible Query Impacts? Examples of Compliant Queries INTRODUCTION TO CDI Metrics TYPES OF METRICS Connecting with Physicians and Providers Introducing Yourself Education, Education, Education Physician Champion or Advisor Pepper Report How Can the PEPPER Report Assist You with RAC Activity? FY 2016 Final Hospital-Acquired Conditions (HACs) Introduction to MDCs and MS-DRGs MDC 1: Diseases and Disorders of the Nervous System MDC 1: Severity Drivers, CCs, and MCCs MDC 1: Case Studies MDC 4: Diseases and Disorders of the Respiratory System Pneumonia Respiratory Failure Postoperative Respiratory Failure Obesity Hypoventilation Syndrome Pleural Effusion Pulmonary Embolus Cystic Fibrosis Asthma MDC 4: Severity Drivers, CCs, and MCCs MDC 4: Case Studies MDC 5: Diseases and Disorders of the Cardiovascular System Chest Pain Angina Acute Myocardial Infarction iv
4 Cardiorenal Syndrome Arrhythmias Deep Vein Thrombosis Pericarditis Acute Cor Pulmonale Shock (Specified) Cardiac Catheterization MDC 5: Severity Drivers, CCs, and MCCs MDC 5: Case Studies MDC 6: Diseases and Disorders of the Digestive System Abdominal Pain GI Bleed GI Malignancy Gastroparesis Intestinal Obstruction and Lysis of Adhesions MDC 6: Severity Drivers, CCs, and MCCs MDC 6 Case Studies MDC 7: Diseases and Disorders of the Hepatobiliary System and Pancreas Defining Underlying Cause Cirrhosis Hepatic Encephalopathy Shock Liver MDC 7: Severity Drivers, CCs, and MCCs MDC 7 Case Studies MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue ( Ortho ) Back Pain Fractures Pathologic Fractures Hungry Bone Syndrome Rhabdomyolysis Orthopedic Procedures In ICD MDC 8: Severity Drivers, CCs, and MCCs MDC 8 Case Studies v
5 MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast Pressure Ulcers Cellulitis and Complex Wounds Debridement Documentation MDC 9: Severity Drivers, CCs, and MCCs MDC 9 Case Study MDC 10: Endocrine, Nutritional and Metabolic Diseases and Disorders Diabetes Body Mass Index (BMI): Underweight and Obesity Malnutrition MDC 10: Severity Drivers, CCs, and MCCs MDC 10 Case Studies MDC 11: Diseases and Disorders of the Kidney and Urinary Tract Understanding the Kidneys Urinary Tract Infection MDC 11: Severity Drivers, CCs, and MCCs MDC 11 Case Studies MDCs 12 and 13: Diseases and Disorders of the Male and Female Reproductive Systems MDCs 12 and 13: Severity Drivers, CCs, and MCCs MDC 16: Diseases and Disorders of the Blood and Blood-Forming Organs and Immunological Disorders Anemia Pancytopenia Neutropenic Fever Coagulopathy and DIC MDC 16: Severity Drivers, CCs, and MCCs MDC 16 Case Studies MDC 17: Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms (Cancer) Cancer Coding Guidelines vi
6 Query Opportunity Cancer Patients MDC 17: Severity Drivers, CCs, and MCCs MDC 17 Case Study MDC 18: Infectious and Parasitic Diseases, Systemic or Unspecified Sites Sepsis MDC 18: Severity Drivers, CCs, and MCCs MDC 18 Case Studies MDC 19: Mental Diseases and Disorders MDC 20: Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders MDC 19 and 20: Severity Drivers, CCs, and MCCs MDC 19 and 20 Case Studies MDC 21: Injuries, Poisonings, and Toxic Effects of Drugs (frequently called The Complications Chapter ) Complications of Treatment Poisonings/Adverse Reactions MDC 21: Severity Drivers, CCs, and MCCs MDC 21 Case Study MDC 22: Burns Burns MDC 22: Severity Drivers, CCs, and MCCs MDC 22 Case Study MDC 24: Multiple Significant Trauma MDC 24: Severity Drivers, CCs, and MCCs MDC 24 Case Study MDC 25: HIV Infections HIV and AIDS MDC 25: Severity Drivers, CCs, and MCCs MDC 25 Case Studies vii
7 High-Risk MS-DRGs Table Lab Value Breakdown Understanding the Significance of Lab Values Documented Lab Values with Clinical Significance Final Test and Comprehensive Case Studies Comprehensive Case Studies Answers to Final Test and Comprehensive Case Studies References viii
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Welcome and Instructions
Welcome and Instructions For audio, join by telephone at 877-594-8353, participant code 56350822# Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6.
During the hospital medicine rotation, residents will focus on the following procedures as permitted by case mix:
Educational Goals & Objectives The Inpatient Family Medicine rotation will provide the resident with an opportunity to evaluate and manage patients with common acute medical conditions. Training will focus
COURSE NAME: PNE237 Pathophysiology I COURSE DESCRIPTION PLAR INFORMATION COURSE LEARNING OUTCOMES
COURSE NAME: PNE237 Pathophysiology I Credit Value: 4 Total Course Hours: 56 Prerequisite Course(s): IAP100, IAP120 Corequisite Course(s): none COURSE DESCRIPTION This course provides the learner with
RE: Two-Midnight Policy and Potential Short Stay Payment Solutions
Sean Cavanaugh Deputy Administrator & Director Centers for Medicare & Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W., Room 445-G Washington, DC 20201 RE: Two-Midnight Policy