How to Implement CDI in the NICU. This Santa Maria, is the CAFull Title of a Session

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1 How to Implement CDI in the NICU Rabia Jalal, MBBS, CCS, CDIP, CCDS Clinical Documentation Specialist Marian Regional Medical Center This Santa Maria, is the CAFull Title of a Session Loni Johnston, RN, BSN, CCDS Service Area Director, Clinical Documentation Improvement Optum 360 Central Coast & Bakersfield, CA 1

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3 Polling Question #1 Does your facility currently review NICU? Yes No 3

4 Learning Objectives At the completion of this educational activity, the learner will be able to: Identify the steps to determine the ROI of reviewing NICU at their facility Name three resources they can use to help implement a CDI program at their facility Explain neonatology terminology Describe coding guidelines to generate compliant queries relevant to neonates 4

5 Project Management 101 Initiating (assessment) Closing Planning (planning) Monitoring/ Controlling (evaluation) Executing (implementation) 5

6 Assessment Audit at least 10% of the NICU cases to determine opportunities If census is low, audit at least cases Know your payers and track changes in DRG, reimbursement, and SOI/ROM After analysis, present business case based on the data Explain the role of CDI and how it impacts NICU cases in accurately capturing the correct diagnoses, severity of illness, risk of mortality, effect on length of stay, and other secondary diagnoses as well as comorbid conditions (CC) and major comorbid conditions (MCC) 6

7 Assessment Monitor pre implementation metrics CMI SOI/ROM PSI/HAC Documentation opportunities Payers: Traditional CDI focuses on Medicare NICU payers are Medicaid, California Children s service and commercial Improved documentation can change APR DRG as well as support commercial contracts based on SOI/ROM 7

8 Planning Hire the right candidate NICU CDI CDI that can cross train Nurse with NICU/OB experience May need to think outside the box Contractor FMG Assess existing queries May need to develop or add to query database 8

9 Planning Suggested Queries NB Acid_Late NB Acid_Metabolic NB Anemia NB Congenital Anomaly NB CLD and BPD NB Electrolytes NB Glucose NB Hypoxic Ischemic Encephalopathy (HIE) NB IVH NB Nutritional Support NB Malnutrition NB Meconium NB Pneumonia NB POA NB Reflex Assessment NB Vitamin K NB Vomiting NB Respiratory NB Sepsis NB Thrombocytopenia 9

10 Planning Develop NICU specialty orientation plan Bootcamps Colleague (other NICU CDI and coding) Planning location If space allows, CDI should be physically in NICU Identify work space Set up dual monitors/desktop or laptop 10

11 Implementation Communicate with NICU staff and providers Kick off presentation to NICU providers, staff with introduction of CDI program at facility Present how CDI can improve SOI/ROM/reimbursement by accurately capturing diagnosis Present goals Introduce the CDI staff member who will be covering the unit Educate neonatologists proactively on frequent areas of opportunity Acute respiratory failure Sepsis/severe sepsis Congenital anomaly POA 11

12 Implementation CDI to NICU implementation Confirm workspace location is ready Confirm dual monitors/desktop or laptop ready Obtain physician contact information and preferences (no texting unless HIPAA compliant method available such as OnePass) Orient CDI to NICU workflow including rounding structure Begin reviewing charts on unit Introduce the CDI staff member who will be covering the unit 12

13 Evaluation Monitor post implementation metrics CMI SOI/ROM PSI/HAC Physician response rates Physician agreement rates Query rate Productivity 13

14 Evaluation DRG Pre implementation Post implementation* Medicaid Commercial *DRG weights have gone up, but the overall CMI improvement is greater than those RW increases 14

15 Closing/Maintenance Evaluate for need to create additional query templates Cross train all CDI staff to cover NICU to prevent single point failure Yearly assess queries for any ICD 10 changes that would requiring updates Ongoing education of providers at rounds or NICU meetings Yearly provider education regarding updates to documentation changes 15

16 Resource List Other directors Other facilities with active program Coding Staff neonatologist Current queries ACDIS HCPro s CDI Pocket Guide & other printed resources Contractors 16

17 Challenges Qualified staff Orientation of staff Resignations Technology interface challenges Silos 17

18 Polling Question #2 Does your facility anticipate implementing CDI in the NICU? Yes No 18

19 The Role of CDI in the NICU I will be discussing the role of CDI and how it impacts NICU cases in accurately capturing the correct diagnosis, severity of illness, risk of mortality, effect on length of stays, and other secondary diagnoses, CCs, and MCCs. 19

20 Neonatology As a NICU CDI professional, it is important to know some basic terminology pertaining to neonates. 20

21 Neonatal Terminology Extra/extreme immaturity: Less than 28 weeks of gestation completed Low birth weight: An infant born weighing less than 2,500 grams 21

22 Neonatal MS DRGs They fall in the 700 DRG category Normal Newborn: 795 Full Term: 794 (with other problem) Full Term: 793 (with major problem) Premature: 792 (with other problem) Premature: 791 (with major problem) Extreme Immaturity/RDS: 790 Expired/Transferred to Another Facility:

23 Neonatal MS DRGs For a newborn transferred from another facility, use the DX that necessitated the transfer as PDX rather than the Z38 code DXs that change DRG 795 to 794 Late acidosis of the newborn Meconium aspiration Hypomagnesemia Hypocalcemia Apnea Anemia of prematurity Respiratory distress syndrome 23

24 Query Compliance and Coding Guidelines In this section, I will discuss a critical part of any CDI program: Query compliance and coding guidelines related to the NICU, as set forth by CMS and AHIMA. 24

25 Neonatal Coding Guidelines Principal diagnosis When coding the birth episode in a newborn record, assign a code from category Z38, Liveborn infants according to place of birth and type of delivery, as the principal diagnosis. Do not code Z38 in the mother s chart. Code all clinically significant conditions Require evaluation, diagnostic tests, treatment, nursing care, and impact LOS, SOI, and ROM. 25

26 Neonatal Coding Guidelines Observation and evaluation of newborns for suspected conditions not found Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present *Z05.1 code should only be used with neonate with no symptoms Example: Sepsis ruled out use code Z05.1 If neonate was admitted or transferred for respiratory distress etc. then the sign or symptoms would be coded with the appropriate P code range 26

27 Neonatal Coding Guidelines Code all conditions documented in the neonate s chart including signs and symptoms if a diagnosis has not been determined Diagnosis from mother s chart should not be coded in the newborn s chart unless it affects the baby and vice versa Ex: Infant of a diabetic mother, meconium staining Perinatal/congenital conditions can be reported throughout the life of the patient if it persists Query/clarify from MD if a condition is not due to the birth process 27

28 Common Newborn CCs and MCCs CCs: Atelectasis (newborn) Coarctation of aorta Congenital anomaly (gallbladder, bile duct, liver, pancreas, ribs, sternum, spleen) Congenital atresia & stenosis of intestine Cyanotic attacks IVH grade I and II Marfan s syndrome Neonatal diabetes 28

29 Common Newborn CCs and MCCs CCs (cont.): Trisomy 13 Patent ductus arteriosus Polycystic kidney Spina bifida w/hydrocephalus MCCs: Congenital anomalies (brain, heart, cerebrovascular system, abdominal wall, diaphragm) Congenital cytomegalovirus infection Convulsions 29

30 Common Newborn CCs and MCCs MCCs (cont.): Hydrops fetalis due to isoimmunization IVH III & IV Meconium aspiration w/respiratory symptoms Persistent fetal circulation Prune belly syndrome Respiratory distress syndrome Sepsis Severe birth asphyxia Tetralogy of Fallot 30

31 Opportunities for Queries in the NICU Case Study: Sepsis Day 1: Term male; mother has GDM and is GBS positive. APGAR scores at birth are 8 at 1 minute and 9 at 5 minutes. At about 2 ½ hours of age, infant has dusky spells and brought to the NICU and placed on nasal cannula 30% at 1 L/minute with good saturations in high 90s (H&P). Day 2: On CXR, there is a non tension small pneumothorax on left side. 31

32 Case Study: Sepsis (cont.) Reviewed the x ray with pediatric radiologist. Lungs consistent with pattern of respiratory distress syndrome. The infant is on ABX ampicillin and gentamicin started this morning. Blood culture so far is negative (progress note). Day 3: The infant is on second day of ABX. Culture will be 48 hours this evening. WBC 12.6, CRP elevated at 28. Procalcitonin normal at 5.2. Blood culture today is negative. Infant is clinically ill with elevated CRP and a left shift. Attempted to treat at least 72 hours (progress note). 32

33 Case Study: Sepsis (cont.) Query clinical validation/criteria: Currently on gentamicin and ampicillin CRP elevated at 28 WBC elevated at 12.6 Hypotensive RR on O2 via nasal cannula Respiratory distress syndrome on CXR Maternal infection 33

34 Query Impact Patient A DRG 793 RW 3.79 SOI 2 ROM 1 GMLOS

35 Query Impact Patient B DRG 793 RW 3.79 SOI 3 ROM 1 GMLOS

36 Case Study: Sepsis (cont.) Final coding: DRG 793/SOI 3/ROM 1 PDX: Single liveborn infant, delivered by cesarean delivery SDX: Bacterial sepsis of newborn Resp distress unspecified Pneumothorax PDA 36

37 Case Study: Meconium Aspiration Case study: Day 1: Full term female infant at weeks of gestation is delivered vaginally. Mother was induced with Pitocin. GBS negative. Membranes artificially ruptured showed thick meconium no foul smell. Baby was suctioned on perineum; thick meconium noted. APGAR scores at birth are 5 at 8 minute and 6 at 5 minutes. At birth tracheal tube insertion and suction, meconium below the cords. At about 2 ½ hours of age, infant grunting respirations with desats noted. C xray ordered and transferred to NICU. 37

38 Case Study: Meconium Aspiration (cont.) Day 1: X ray showed hyperinflation, patchy infiltrates, and consolidation. O2 via hood started. Baby did well and was weaned within 24 hours. 38

39 Query Impact RW 1.34 SOI 1 ROM 1 GMLOS 3.4 RW SOI 1 ROM 1 GMLOS

40 Query Impact RW SOI 2 ROM 1 GMLOS

41 Case Study: Meconium Aspiration (cont.) Final Coding: DRG 793/SOI 2/ROM 1 Full term neonate w major problems PDX: Single liveborn infant, delivered vaginally SDX: Meconium aspiration Acute respiratory distress 41

42 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 program guide. 42