Transcript Document

PMMC
PHYSICIAN ORIENTATION
2008
Teaming for
Documentation
Integrity
What is TDI?
 A process designed to
 Provide education for complete, compliant
documentation to achieve an accurate reflection of
resource utilization for the care of patients admitted.
 Address documentation and coding connection.
 Bridge the gap between clinical documentation and
technical coding.
 A concurrent review process to clarify documentation
in order to achieve clinical accuracy in the medical
record during the hospitalization
 A process to eliminate the need for retrospective
Medical Records queries after discharge because
TDI clarifies documentation prior to discharge.
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Benefits That Can Be
Gained From TDI
 Complete, accurate and timely medical
record documentation.
 Improved quality of care.
 Accurate Hospital and Physician profiles.
 Enhanced teamwork between the Hospital
and Medical Staff.
 Hospital’s Case Mix Index (CMI) is more
reflective of the types of patients treated by
the facility.
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Why incorporate TDI into current
operations?
 Improve data accuracy
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Case Mix Index does not accurately reflect
intensity of service and resource utilization.
Publicly available data increasingly scrutinized
to measure hospital performance.
 Coding language and requirements often
differ from the clinical thought processes and
documentation.
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Better Quality Information (BQI)
 Medicare announced its Better Quality Information (BQI) project
to improve care for Medicare beneficiaries.
In a February 15 press release, CMS stated the following:
The results of the BQI Project will be used for two primary
purposes: first, to provide performance information to physicians
that will assist them in improving the quality of care they are
delivering to Medicare beneficiaries; and second, to give
physician performance information to Medicare beneficiaries in
order to help them with physician selection.
The objective of the Initiative is to provide the public and
providers with reliable and consistent measures of quality care.
http://www.justcoding.com/premium/content.cfm?content_id=67915
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Documentation Querys
 Diabetes:
 Type I or Type II
 Controlled or uncontrolled (even temporarily)
 Complicating conditions (i.e. diabetic neuropathy)
 Please do not use arrows to indicate hyper or hypo.
 Patient admitted with signs & symptoms (S&S) as
diagnosis:

Please link S&S to an etiology, if known

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“Syncope due to hypovolemia”
“Abdominal pain due to diverticulitis”
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Documentation Querys

Debridement:
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Urosepsis = “UTI unspecified” in the Coding World

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If clinically applicable please document “sepsis due
to urinary tract source”
Post Op Anemia:

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“Excisional” or “Non excisional”
“Post op blood loss anemia”
CHF:

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Acute, Acute on Chronic or Chronic?
Systolic, Diastolic or both?
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TDI Awareness
 Scheduled lunch/ breakfast meetings
 Initiated a TDI information/education board
 Share pertinent literature regarding TDI
 Implementation of TDI Steering Committee
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Questions?
 Dr. N. Dodhia
TDI Physician Advisor
 Mary Ellen Totzke R.N
Quality Documentation Coordinator
(630) 801-5861
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