CDI Using ME-PI Tools Anita G. Murthy, MD, Garpsa Solutions LLC Andrew R. Ganti, MBB, UHS of Delaware, Inc.
Topics Timing for CDI Role of Clinical Documentation Role of ME-PI Tools Our Focus Key ME-PI Tools and Assumptions CDI Details (Process steps, Key players/roles, Different current and desired states, 6Rs of documentation, Impact, Coding systems, ICD-9 & 10, Approaches, and Measures) Clinical Documentation Improvement Process Benefits of CDI Questions and Answers 2
Timing of CDI Clinical Documentation Improvement (CDI) is gaining momentum as EMRs and EHRs install base is increasing in the hospitals, health systems, physician offices, and free standing outpatient centers Transition from ICD-9 to ICD-10 Increased specific documentation requirements by third party payers and potential for decreased reimbursement due to higher claims denials when such requirements are not met 3
Role of Clinical Documentation Clinical documentation plays an important role in patient care delivery by providing Continuity between care givers Appropriate coding and abstracting by HIM Accurate billing for reimbursement by third party payers Tools for data analytics Improving the clinical documentation helps Improve the quality of care delivered Reduce denials for reimbursement Enhance population health management & clinical research 4
Role of ME-PI Tools ME-PI tools have proven track record to improve many healthcare processes in a variety of settings including but not limited to: Hospitals Multi-hospital systems Physician Offices Outpatient testing & treatment centers e.g. Lab, Img., Surgery Third Party payers Patient transport systems e.g. air and ground ambulance 5
Our Focus Application of ME-PI tools to CDI to ensure Clinical Documentation is Accurate Complete Concise Clear Patient centric Prompt 6
Key ME-PI Tools & Assumptions Key PI Tools Theory of Constraints Lean Six Sigma Change Management (from Current to Desired State) Statistical Tools A3 documentation of project results Key Assumptions Attendees have more knowledge in one or more of the above tools compared to CDI topic Attendees like to hear more CDI details than the ME-PI tools 7
CDI Details CD Process Steps CDI Key Players and their Roles Different Current States with different Desired States Six Rights of Documentation Impact of Coding Different Coding Systems ICD-9 to ICD-10 Conversion and Challenges CDI approaches CAC and AIM Measures of Success and Quality measures 8
CD Process Steps Coder assigns current or retrospective ICD-9-CM diagnosis code for the clinical presentation for which the patient sought treatment In case of a documentation gap due to physician documentation practices, the coder may or may not be able to correctly abstract a proper diagnosis from the chart A CDI specialist who is trained to understand the nuances of clinical documentation will ideally do a concurrent chart review to ensure completeness of documentation by the physician Attending physician can be queried for clarification regarding the stated diagnosis in the chart 9
CDI Key Players and Roles The four key players on the CDI team are Physicians the are the diagnosticians who witness clinical presentations of the patients and draw their conclusions based on clinical assessments, lab/imaging data, and acumen CD specialists- have a combination of clinical knowledge and coding skills that is used to review the chart and proactively assess gaps in physician documentation Coders possess the coding skills to accurately assign a diagnostic code from the clinical documentation using ICD-9 or ICD-10 and CPT codes CDI Physician Advisor serves as a liaison between medical staff, CD specialists, and coders 10
Different Current and Desired States Due to the changes in healthcare spurred by the ACA, Meaningful Use requirements, and transition from ICD-9 to ICD-10, there are several problems that have been encountered in Clinical Documentation i.e., manual to electronic, changing code sets etc. These changes are presenting several challenges to hospitals and providers alike in capturing the clinical encounter completely without information gaps By using a CDI team, these problems can be remedied and the outcome will be seamless coding leading accurate charge capture, timely reimbursements, and reduced denials 11
Six Rights of Documentation Right Patient Right Physician Right Diagnostic Codes Right Documentation Right Review Right Charge Capture 12
Impact of Coding When coding mistakes are made, the consequences are farreaching The inaccurate codes lead to wrong diagnoses, inaccurate charge capture, increased denials for necessary medical tests and claims, and decreased revenue just to name a few If the codes are accurate and they have appropriate supporting documentation, the aforementioned problems are likely to be eliminated 13
Different Coding Systems ICD-9 CM ICD-10 CM/PCS CPT DRG SNOMED CT 14
ICD-9 to ICD-10 Coding The code set has been expanded from five positions to seven positions. The codes use alphanumeric characters in all positions, not just the first position as in ICD-9. In ICD -10 there are 68,000 existing codes, as opposed to the 13,000 in ICD-9. The new code set provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code. The terminology has been modernized and has been made consistent throughout the code set. There are codes that are a combination of diagnoses and symptoms, so that fewer codes need to be reported to fully describe a condition. 15
CDI Approaches Two approaches CAC and AIM Not mutually exclusive CAC (Computer Aided Coding) Analysis of healthcare documents to produce accurate codes Uses binary patterns to produce human-readable documents Can reduce workload on coding staff and decrease errors AIM (Assess, Improve and Maintain) Conduct a full end to end assessment of all coding processes Identify and correct discrepancies in the coding and documentation methods using PI tools and other methods Sustain the improvements with dashboard metrics and support from the CDI team, HIM department, and medical staff 16
Measures Measures of Success Enhanced safety and quality of care provided to patients Savings of time and money Improved communication among providers and HIM staff Reduction in provider frustration for post-discharge queries Measures of Quality Better data quality for analytics, benchmarking, public health, and clinical research Improved scores on publicly reported quality health measures Ability to meet and exceed government mandated meaningful use reporting requirements 17
Clin. Doc. Improvement Process Assess to find the gap b/w current & future state relative to coding and supporting documentation using the following data sources VOC (Voice of the Customers) i.e. Third party payers and internal auditors Anecdotal comments by the providers and Utilization Review teams, Cursory and detail review of the documentation using the screening templates to determine deficiencies Historical performance, and bench marks to determine the performance gap 18
Clin. Doc. Improvement Process (Cont d) Improve the current state (using the Work-Out tool by first defining how much gap to be bridged per the customer specifications) to achieve the desired state Analyzing identifying/prioritizing the root causes or barriers with IS and IS NOT tool to find when, where, who, and how of the operating conditions; Developing/prioritizing alternate counter measures to remove the barriers Testing the top 3 solutions using simulation or pilot before selecting and rolling it out Maintain the gains using metrics with dashboard and well defined SOPs including remedial education and training to the key players 19
Benefits of CDI When the ME-PI tools are applied correctly, the following benefits can be achieved Increased accuracy of the medical record translating to enhanced patient quality measures Increased accuracy of charge capture leading to better reimbursement Decreased claim denials Decreased possibility of RAC audits Decreased time wasted on billing and administrative burdens associated with claim resubmission These benefits can be achieved whether you current CD process is electronic, manual or a combination 20
Questions and Answers 21
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