3 rd Annual Association of Clinical Documentation Improvement

3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

CDI Physician Education Catch Them and Hold Them

By: Monica Dancu, RN, BSN Sylvia Hoffman, RN Darlene Shelffo, RN, CCDS, CDI Manager Tampa General Hospital Tampa, FL

Tampa General Hospital • Academic Medical Center: 929 -bed teaching facility affiliated with The University of South Florida College of Medicine (USF) • USF affiliation: 1, 200 community and university affiliated attending physicians, 285 resident physicians, and 400+ medical students

Physician education • Educating physicians can be quite a challenge. They may be: – Busy – Bored – Resistant – Confused – Angry – Tired

Creativity is a must Doctors are bombarded with information on a daily basis. If you want them to remember, you must make it memorable!

Presentation tips • State the facts • Make it relative • Keep it simple • Use physician “speak” • Make it interesting • Provide buy–in

Keep your audience interested • Quote specific physicians • Show documentation examples • Include personal progress notes or forms • Insert physician pictures • Break up boredom with humor • Involve your audience; ask questions • Provide CMEs

Say, “Cheese!”

Alert physicians about public profiling • Health. Grades. com • Disclosure Project • Delta Group • Leapfrog • Medicare Physician Data • Etc.

Explain how profiles are derived • Take into account: – Principal diagnosis – All other diagnoses (CCs and MCCs) – Principal procedure – All other procedures Give a more accurate reflection of mortality risk by reflecting all severity elements.

Provide physician-specific data • • • Documentation examples Case studies Severity-adjusted statistics for specialties Mortality rates Missed opportunities for individual practices • E/M billing documentation

Give rationale for accurate documentation • Each note must: – Support what will be coded and billed – Be legible – Show medical necessity Example: Urosepsis = UTI Is this what you mean?

Point out missed opportunities Pulmonary Embolism w MCC Pulmonary Embolism w/o MC 3 cases COPD w MCC COPD w/o CC/MCC 21 cases 39 cases 42 cases 20. 6% of cases 38. 2% of cases 41. 2% of cases Pneumothorax w MCC Pneumothorax w/o CC/MCC 3 cases 10 cases 9 cases 13. 6% of cases 45. 5% of cases 40. 9% of cases Resp System Diagnosis w MCC Resp System Diagnosis w/o MCC 8 cases 19 cases 29. 6% of cases 70. 4% of cases MCC = Major comorbidities 13% of cases 20 cases 87% of cases CC = Comorbidities

Explain case-mix index (CMI) Case-mix index is the sum of all MS-DRG relative weights (RW) divided by the number of discharges. Factors that can positively affect the CMI include: • Admitting and treating a more resource intensive patient mix • Improvement of documentation in the medical record

Give real-life examples • Lack of complete documentation can skew mortality and morbidity data, case-mix index scores, and possibly reimbursement • Low CMI and high mortality scores influence physician and hospital profiles • Poor profiles can mean lower patient volumes and possible higher malpractice rates

Describe how wording affects data • Patient with respiratory insufficiency – Has a low mortality score • Patient with acute respiratory failure – Has a 30% mortality score • Patient with pneumonia due to pseudomonas – Has a 40%– 70% mortality rate

Use physician language • Good documentation can serve as a benefit to your practice • Proper documentation supports the severity of the presenting problem and the complexity of your decision-making • The clinical documentation team is your ally in providing the precise terms needed to capture the best representation of your patients’ needs and services

Explain what’s in it for them • Show documentation affects billing. • Give real life examples.

Give them the tools • Brochures • Pocket cards • Query forms • Signs

Make It Unforgettable YEEEEEAAAAAAHHHHHHH!!!!!!

CDI-CSI DOCUMENTATION INVESTIGATION Avoiding a Documentation Felony !

Medical documentation is not what it used to be !

Physician performance and documentation are under scrutiny • • • Cost per patient Morbidity scores Mortality scores Length of stay Utilization Audits

Statistics are being collected Severity of illness (SOI) Risk of mortality (ROM) Length of stay (LOS) Case-mix index (CMI)

Documentation impacts data • Lack of complete documentation may alter • mortality and morbidity (M&M) data and casemix index scores Low CMI and high mortality scores influence physician and hospital profiles Did the patient die from a UTI ?

Medical data sources are growing • Physician profiles • Hospital report cards • Medicare physician data • Health. Grades, Delta Group, Leapfrog “Medicine is under the microscope. ”

Health. Grades. com Example of Web sites

Disclosure project

But that’s not all, now a new danger threatens

Centers for Medicare & Medicaid Services The Centers for Medicare & Medicaid Services adds or changes ICD-9 codes each year. This requires adjustments in how physicians must document in the medical record. It can make you crazy !

Must obey the law Specificity is vital; a definitive diagnosis must be documented New Golden Rule: If it is not written in the correct language, it didn’t happen.

The CMS word game • Specificity is paramount • Certain diagnoses should be linked • Diagnostic medical/coding language only • Remember: Lab, pathology, and radiology reports cannot be used for coding

Wording must be specific Nonspecific Anemia Hypoalbuminemia U/A abnormal Urosepsis Altered mental status COPD CHF Specific Blood loss anemia Malnutrition UTI Sepsis Encephalopathy COPD exacerbation Acute diastolic HF

Specific terms are necessary for documenting severity of illness Acute Chronic Unstable Exacerbated Postoperative Secondary to Due to Severe She had acute aspiration pneumonia!

Examples Severe sepsis Severe malnutrition Acute diastolic CHF Acute respiratory failure Acute confusional state Acute renal failure Unstable angina Exacerbated COPD She died from severe sepsis!

What do you mean? Unless a condition is given a diagnosis and documented by a physician, the diagnosis cannot be captured. (Remember, lab results and pathology reports cannot be used. ) This was a major skin disorder, according to the path report!

Point out missed opportunities Pulmonary Embolism w MCC Pulmonary Embolism w/o MC 3 cases 20 cases 13% of cases 87% of cases COPD w MCC COPD w/o CC/MCC Pneumothorax w/o CC/MCC Resp System Diagnosis w/o MCC 21 cases 39 cases 42 cases 3 cases 10 cases 9 cases 8 cases 19 cases 20. 6% of cases 38. 2% of cases 41. 2% of cases 13. 6% of cases 45. 5% of cases 40. 9% of cases 29. 6% of cases 70. 4% of cases MCC = Major comorbidities CC = Comorbidities

Why is this important? Hypotension Low mortality score Shock 50%– 70% mortality rate Simple pneumonia 2. 5% mortality rate Complex pneumonia 20% mortality rate Respiratory insufficiency Low mortality score Acute respiratory failure 30% mortality rate UTI (urosepsis) 1. 5% mortality rate Sepsis 20% mortality rate

Give a diagnosis, not a symptom

No use of symbols Symbols and numbers do not translate into a diagnosis. Na 124 U/A + Hgb Albumin 1. 5 Troponins Symbols = nothing = nothing No more use of symbols.

Example This cannot be coded *comorbidites will not be counted in patient’s diagnosis

Legibility Make sure what you write is legible. If your coworkers can’t read it, your patient may be at risk. I can’t make it out. It either says patient released or patient deceased.

Legibility? Illegible ! ! Signature illegible? This is a true crime scene !

Recognize POA clues

Present on admission (POA) • Any condition present at the time the order for inpatient admission occurs • Any condition that develops during an outpatient encounter She had a vascular catheter-associated infection present on admission.

Hospital-acquired conditions (HAC) Any condition that could reasonably have been prevented through the use of evidence-based guidelines. They gave me the wrong blood and I almost died!

Most common HACs resulting in decreased reimbursement • Urinary catheter-associated urinary tract infection • • Vascular catheter-associated infection • DVT or PE following total knee and hip replacement Surgical site infection following orthopedic procedures, bariatric procedures, and CABG 11 total HACs for FY 2010

E/M billing Don’t gamble on your documentation.

Elements of E/M services (evaluation and management) Seven elements of E/M services (physician billing) 1. History 2. Examination 3. Medical decision-making 4. Counseling 5. Coordination of care 6. Nature of problem 7. Time spent

Time element Time spent with patient or family Time spent checking labs or reports Coordinating services or consults *If more than 50% of time is spent with counseling and/or coordination of care, the code should be selected on the basis of time.

Example Initial hospital care Subsequent inpatient care Level 1 $86 $35 Level 2 $117 $64 Level 3 $172 $91 Documentation supports billing

Show your work The sicker your patient is … the lengthier your workup would be, affecting your level of service: History Exam Decision-making Risk Time spent … Documentation must support the billing level!

Who needs help with documentation ? Don’t let these smiles fool you!

Deadly documentation excuses Already written Takes too long Don’t have time Doesn’t help me Too hard to remember

What can be done to help? Let the CDI department shed some light on your documentation needs!

Tools/weapons Pocket cards Handouts Clarification forms Newsletters CDI specialists

Pocket cards

Helpful documentation words • • • Acute Blood Loss Anemia 2 nd to GI Bleed Acute Confusional State Acute MI Acute Postop Respiratory Insufficiency Acute Renal Failure Acute Respiratory Failure AIDS Alzheimer’s Dementia with Behavior Disturbance Anorexia Aspiration Pneumonia/Bronchitis • • • Dementia w/ Delirium Drug Dependence Ongoing/ Continuous Encephalopathy End-Stage Renal Disease Heart Failure: Acute/Chronic, Systolic/Diastolic Hypo-/Hypernatremia Malnutrition Pneumonia 2 ndary to … Pressure Ulcer Stage 3 or 4 Present on Admission Severe Malnutrition Sepsis, Severe Sepsis, or Septic Shock Use of these words in your documentation helps support the severity of the presenting problem and the complexity of your decision-making. This has a direct effect on your severity of illness (SOI) and risk of mortality (ROM) scores.

Etiology form Date _______________________ Pt Name _____________________ Acct # ______________________ Dear Dr. and/or Associates: Please document the Etiology of _____________ in the Progress Notes, Consult Notes, or Discharge Summary when and if able to determine. This form will NOT be maintained as part of the legal permanent medical record. Your patient’s severity of illness (SOI) and risk of mortality (ROM) scores are affected by what you document in the medical record. Take credit for the severity of your patient by using the correct and thorough medical terminology in your documentation. Thank You! _______________________________ Coding/Clinical Documentation Specialist _______________________________ Phone #

Date: ____________________ Patient Name: ________________ Acct#: ____________________ Documentation Clarification Request Dr. ______________ Findings in chart: _______________________________________________________________________ ________________________________________________________________ q q q Noted clarification request, no response documentation Clarification response documented in the medical record Comments_________________________________________ Thank You! ________________________________________ Please document your response in the PROGRESS NOTES section of the patient’s chart. ________________________ Coding/Clinical Documentation Specialist Phone #____________________ This form will NOT be maintained as part of the legal permanent medical record. Your patient’s severity of illness (SOI) and risk of mortality (ROM) scores are affected by what you document in the medical record. Take credit for the severity of your patient by using the correct and thorough medical terminology in your documentation.

Clarification response Document your response using the current date and time in one of the following areas: • • Progress note Consult note Discharge summary Addendum note Get the evidence!

Summary • Use appropriate documentation verbiage • Document pathology results • Document whether present on admission • Document legibly • Give a diagnosis, not a symbol or a symptom • Answer clarification requests for specificity • Use your tools

CSI Crime Scene Investigation Tampa Thank You

Questions?