Transcript Document
Indiana Association for Healthcare Quality
Denise Tinkel, RRT, MHA, CPHQ Manager, Clinical Documentation Improvement Huron Healthcare Carol Huffman, RN, MSN Associate, Clinical Documentation Improvement Huron Healthcare
Clinical Documentation Improvement
Clinical Documentation Improvement Program
Clinical Documentation Improvement (CDI) “bridges the gap” between clinical language and technical language
CDI Goals
Accurately reflect the severity of illness Improve physician and hospital profiles Increase case mix index Appreciate maximum compliant reimbursement
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Documentation Effects Documentation Effects
Severity of Illness Reimbursement RAC Audits & Compliance Medical Necessity & Length of Stay
Documentation
Profiling Hospital & Physicians POA 4
Accurate Documentation
Risk
Violate Regulatory Guidelines
Accurate Severity of illness
Loss
Financial Loss Inaccurate Physician/Hospital Profiling 5
Accurate Documentation
Key indicators that trigger a need for a CDI program: MS-DRG implementation October 2007 – (Severity Adjusted) Decreasing/low case mix index (CMI) High length of stay (LOS) Denials for lack of medical necessity Present on admission (POA) indicator requirement Increasing number of core measure reporting requirements Recovery Act Contractors (RAC) Medicare Administrative Contractors (MAC) High Mortality Index
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Phases of CDI
Assessment Implementation Continuing Support
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Concurrent, Multi-Disciplinary TEAM Approach
Patient Admitted Concurrent Medical Patient Discharged Coder Receives Record Review Complete Record
• • •
Reflects the appropriate severity of illness Supports CMS, OIG, Joint Commission Standards RAC Readiness
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Clinical Documentation Improvement Process
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Sustaining the Program
Quarterly monitoring of the program to ensure the long-term success Clinical Record Review Compliance Evaluation Analysis of data Communication with the leadership team Monitoring of CMI and MS-DRG trends Educational sessions Coding guideline updates Clinical and technological reviews
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Documentation Improvement
Poor quality documentation in a patient’s record has been linked to both excessive health care costs and poor quality of care” 1 1- National Coalition for Health Care, Charting the Cost of Inaction 2003
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Physician Profiling
Data utilized for physician profiling:
Length of stay DRG Assignment E & M Levels of physician service Mortality and Morbidity
Documentation improvement assists with creating accurate profiles
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HEALTHGRADES: Pneumonia
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Coding Guidelines
For reporting purposes the documentation that must be followed are those by the 4 cooperating parties: American Hospital Association (AHA) American Health Information Management (AHIMA) National Center for Health Statistics (NCHS) Centers for Medicare and Medicaid Services (CMS)
Clinical Documentation Improvement (CDI) follows all coding guidelines identified by the 4 cooperating parties. 14
It’s Not Just Semantics
1.
2.
3.
4.
5.
6.
7.
8.
Sepsis Renal Failure ESRD Aspiration Pneumonia Pneumonia CVA Acute MI Encephalopathy 1.
2.
3.
4.
5.
6.
7.
8.
Bacteremia Renal Insufficiency CKD V ECF Pneumonia Infiltrate TIA Acute Coronary Syndrome Altered Mental Status
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Sepsis versus UTI
DRG DRG RW Expected LOS
UTI w/o MCC .7864
3.4
1
SOI
1
ROM Expected Cost*
$4061
Documentation
UTI, death unlikely UTI w/MCC 1.2185
4.8
Sepsis w/o 96 MV, w/o MCC Sepsis w/o 96 MV w/MCC 1.1545
1.9074
Sepsis w/96+ MV 5.8305
4.6
5.4
12.9
3 1 3 3 3 1 3 4 $6292 $5962 $9850 UTI, encephalopathy Sepsis due to UTI Sepsis due to UTI, shock, death likely $30,109 Sepsis, Acute Respiratory Failure
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The Development of ICD-9-CM Coding • • • • Developed by the World Health Organization (WHO) Refined by the US Department of Health and Human Services (DHHS) for use in the United States Designed to be mutually exclusive and reliable – There is only one correct code for each diagnosis and procedure – Every coder should arrive at the same codes using this system The coding system uses “cataloging” concepts: – Main term (example: noun » pneumonia) – Sub terms (example: adjective » viral)
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The Development of ICD-9-CM Coding
• • • • • • ICD-9-CM Codes (17,000) are assigned to specific diagnoses and procedures.
ICD-9-CM Codes group to Diagnostic Related Groups (DRG) based upon similar resource consumption and care provided Coding Conventions that include complex and detailed information on how to use the system appear in the front of each ICD-9-CM Coding book.
Most HIM departments use an automated version, called an encoder.
Official Guidelines are composed and updated regularly by DHHS’ Centers for Disease Control and Prevention (CDC).
ICD-10-CM Codes (155,000) have a projected target start date of October 1, 2013.
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The Development of Diagnostic Related Groups (DRGs)
• • • • In 1982, the Tax Equity and Fiscal Responsibility Act (TEFRA) modified Medicare hospital reimbursement limits to include a case mix adjustment based on DRGs.
In 1983, Congress amended the Social Security Act to include a national DRG-based hospital prospective payment system for all Medicare patients. The design and development of the DRGs began in the late 1960’s at Yale University. The initial motivation for developing the DRGs was to create a system for monitoring the quality of care and the utilization of clinical resources in the inpatient setting. DRGs are a patient classification system that provides a methodology of relating the type of patients a hospital treats (i.e. the case mix) to the costs incurred by the hospital.
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Medicare Severity DRGs (MS-DRGs)
• • • • • Began October 1, 2007 and are planned to be the system used permanently for IPPS payment.
Revised to more effectively capture severity of illness and use of resources based on the complexity of the patient’s illness.
– Decrease the amount of cost variation within DRGs Change the outlier threshold, the transfer DRGs, and Case Mix Index (CMI).
Improve accuracy of payment rates in the IPPS and decrease financial incentives to create specialty hospitals due to changes in relative weights based on hospital costs vs. hospital charges.
Eliminate age-specific DRGs and incorporate those DRGs into the closest matching DRG categories to reduce the number of low-volume DRGs and improve the stability of DRG relative weights.
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MS-DRGs (continued) • • • Improve the ability to place patients in proper DRG assignments with severity levels.
Mandated a review of the Complications and Co-Morbidity (CC) list originally created in 1980 -1981 that assigned patients to a DRG if they had a CC on the list or if they were > 70 years old. The age requirement was dropped with the 1988 CC list revision.
CMS revisited the CC list and reviewed all secondary diagnoses that originally qualified as a CC. The list has been revised now to include only those conditions clearly demonstrated to require a substantial amount of hospital resources.
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MS-DRGs (continued) • • • Prior to FY 2008, approximately 78% of patients had a CC assigned. With the advent of the MS-DRG system, only 40% of patients will have a CC/MCC. Many chronic conditions have been eliminated from the CC list because most chronic conditions do not consume significant amounts of hospital resources unless there is an acute exacerbation of the disease or condition. Exceptions to this rule are conditions such as advanced stages of chronic diseases like end-stage renal disease or extreme obesity. There are now three different CC categories: – MCCs represent the highest level of severity – CCs represent a diminished level of severity – Non-CC/MCCs are those diagnosis codes that do not require significant additional amounts of hospital resources and are not reflective of increased severity CMS expects to make revisions to the MCC and CC lists each year.
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MS-DRGs (continued) • • • A primary purpose of going to the 3 different levels of severity categories is to encourage complete and accurate documentation in the medical record by providing financial incentives to do so.
There is an exclusion list for CCs and MCCs. Each diagnosis on this list is excluded from being a MCC or CC if coded with certain Principle Diagnoses. Exclusions are conditions that are closely related, chronic and acute manifestations of the same disease process. These conditions co-exist or are anatomically proximal sites of the same diseases. – An example of a co-existing condition is cardiomyopathy with congestive heart failure.
There are DRGs that do not change with the presence of a CC or MCC.
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MS-DRGs (continued)
• Examples of Major Severity Complications and Co-morbidities that increase risk of mortality: – Sepsis – Severe sepsis (septic shock or sepsis with identified organ failure) – Systemic inflammatory response syndrome in non infectious cases with or without organ failure – Acute systolic congestive heart failure – Acute on chronic respiratory failure – Toxic/metabolic encephalopathy ** Risk of mortality increases by 60%
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Severity of Illness & Risk of Mortality
∙ The severity of illness (SOI) and risk of mortality (ROM) system provides a higher level of detail about a patient's condition and the care provided. Improving SOI and ROM indicators strengthens hospital quality data and physician report cards by more accurately detailing the nature of the patient’s illness and expected outcome. And while those numbers are crucial to a hospital's success, an SOI/ROM focused program can also have a positive effect on revenue and help reduce compliance risk.
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DRG Grouping
• Factors that impact DRG assignment: – Principal diagnosis – Secondary diagnosis – Procedure – Gender – Discharge status – Birth weight for Neonate
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Reporting Secondary Diagnoses
• Additional and secondary diagnoses should be reported when they affect patient care in terms of requiring the following: – Clinical evaluation – Therapeutic treatment – Diagnostic procedures – Extended length of hospital stay – Increased nursing care and monitoring
NOTE: The above is based on Coding Clinic, Second Quarter 1990, p.13.
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Major Diagnostic Categories
• • • • There are currently 747 DRGs that are divided into 25 Major Diagnostic Categories (MDCs). Each MDC was developed to correspond to a particular organ system or is associated with a particular medical specialty.
Each MDC is then further divided into Medical and Surgical DRGs.
A patient’s stay is defined based on the principal diagnosis (PDx) for which they were admitted to the hospital.
This PDx determines the MDC assignment.
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Surgical Procedures
• • After this determination has been made, patients are further defined based on any surgical procedure performed. A patient can have multiple procedures related to their principal diagnosis during a single hospital stay, yet only one surgical DRG may be assigned. Consequently, patients who require multiple procedures are then placed in the surgical group that is determined by the surgical hierarchy.
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Identify the Medical Principal Diagnosis and MDC Identify Co-morbid condition or complication (CC/MCC)
How a DRG Is Assigned
YES Surgical Procedure Same MDC?
YES Was a Surgical Procedure Performed?
NO NO NO DRG in same MDC is assigned with appropriate CC/MCC Was procedure a PROSTATIC procedure?
Was procedure classified as MINOR?
Note:
If a surgical procedure is one of the Pre-MDC DRGs, this is the DRG that is directly assigned.
Assign DRG 984-986 Assign DRG 987-989 Assign Medical DRG NO Was procedure classified as EXTENSIVE?
Assign DRG 981-983
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All Patient Refined DRGs
DRG Min
Severity of Illness
1
Risk of Mortality
1 Low 2 2 Moderate 3 3 Severe 4 4 • • • • Proprietary DRG system by Ingenix.
It accounts for severity of illness and risk of mortality based on documentation of complications and co morbidities.
Lack of CCs and now Major CCs will suggest higher than expected mortality.
Used by Thompson Solucient .
Acute Care Hospital (IPPS)
RW Blended Rate DRG Reimbursement*
*Regardless of length of stay
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Relative Weight –Examples
• Relative Weight (RW): The relative weight assigned to each DRG is intended to reflect resource consumption and severity of illness.
Diagnosis
Allergic Shock (Anaphylaxis) CHF Pneumonia Pneumonia w/ UTI Pneumonia w/ ESRD
DRG
916 Allergic Reactions w/o mcc 293 Heart Failure & Shock w/o cc/mcc 195 Simple Pneumonia & Pleurisy w/o cc/mcc 194 Simple Pneumonia & Pleurisy w/cc 193 Simple Pneumonia & Pleurisy w/mcc
RW
0.4867
0.6853
0.7096
1.0152
1.4796
Heart/Lung Transplant w/ ARF 001 Heart Transplant w/ mcc 26.3441
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Reimbursement Calculations
Diagnosis DRG RW
Allergic Shock (Anaphylaxis) 916 Allergic Reactions w/o mcc 0.4867
CHF 293 Heart Failure & Shock w/o cc/mcc Pneumonia 195 Simple Pneumonia & Pleurisy w/o cc/mcc Pneumonia w/ UTI Pneumonia w/ ESRD 194 Simple Pneumonia & Pleurisy w/ cc 193 Simple Pneumonia & Pleurisy w/ mcc 0.6853
0.7096
1.0152
1.4796
Heart/Lung Transplant w/ ARF 001 Heart Transplant w/ mcc 26.3441
* $5164.00 is a Blended Rate example used for this demonstration **Regardless of length of stay Expected Reimbursement* (BR $5164.00)
$2513** $3538** $3664** $5242** $7640** $136,040**
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Case Mix Index
Case mix index (CMI) is driven by case mix complexity.
CMI is derived by adding the total relative weights for all Medicare patients discharged within a specified timeframe, then dividing by the total number of Medicare discharges within that same time period. This time frame is typically by month or year.
• • CMI is designed to reflect the level of severity and complexity of a hospital’s patient population. – A higher CMI indicates that the hospital treats patients who require greater hospital resources.
– A low CMI may denote DRG assignments that do not adequately reflect the resources used to treat Medicare patients.
CMI fluctuates month-to-month and is impacted by several variables.
– Census – Service lines – Length of Stay
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CMI – a demonstration Sum of Relative Weights Number of Cases
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CMI
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Case Mix Index (CMI) – Example
The sum of the RWs divided by the # of cases = CMI
Diagnosis
Chest Pain CHF Sepsis
DRG
313 Chest Pain 293 Heart Failure & Shock w/o cc/mcc 872 Septicemia w/o MV 96+ hours w/o mcc Pneumonia w/ UTI 194 Simple Pneumonia & Pleurisy w/ cc AMI w/ CABG w/ Cath w/o mcc 234 Coronary Bypass w/ cardiac cath w/o mcc DJD w/ ORIF w/ acute blood loss anemia Total cases = 6 481 Hip & femur procedures except major joint w/ cc
RW
0.5499
0.6853
1.1545
1.0152
4.8281
1.8896
Sum of RW = 10.12
CMI = 1.69
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CMI – a demonstration 10.12
Sum of Relative Weights 6 Number of cases
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CMI 1.69
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• • • • • •
Coding Clinic Guidelines
The purpose of a Coding Clinic is to promote accuracy and consistency in the use of ICD-9-CM and the definitions specified in the Uniform Hospital Discharge Data Set (UHDDS) and the Uniform Billing (UB-04) system for hospitals. There are many organizations that publish coding advice, but the only publication endorsed by CMS is the Coding Clinic for ICD-9-CM published by the American Hospital Association (AHA).
These guidelines have been developed to assist the user in coding and reporting in situations where the ICD-9-CM manual does not provide direction.
The guidelines are reviewed on an ongoing basis and new guidelines are developed as needed.
New Coding Clinic guidelines are published quarterly. A newer Coding Clinic on a subject will always override an older Coding Clinic on the same subject and a current Coding Guideline will always override a Coding Clinic.
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CMS Position on Clinical Documentation Integrity
“ We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” “… We encourage hospitals to engage in complete and accurate coding.” Source: CMS Federal Register August 2008 Final Rule (CMS-1533-FC page 208) http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf
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•
What is a Clinical Documentation?
Improvement Program?
A documentation program focuses on: – A clinical approach to comprehensive, quality documentation by the multidisciplinary team – Concurrent documentation review – Clear, accurate and complete documentation – Continuing education to support Documentation Improvement
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CDI Team Members
• Physicians • Professional Coders (PC) • Clinical Documentation Specialists (CDS) • Case Managers (CM) • Healthcare Quality • Allied care providers
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A Clinical Documentation Program
• • • • •
The Role of the Clinical Documentation Specialist:
Monitor the clinical documentation so that it accurately demonstrates the intensity of service and level of care provided for the patient.
Review all Medicare admissions after the first 24 hours to ensure comprehensive documentation outlining the reason for admission, the patient’s treatment, and any POA indicators.
Review medical records for accuracy and compliance.
Clarify all documentation for accuracy of severity of illness and resource consumption Provide ongoing education regarding clinical documentation for the multidisciplinary team.
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A Clinical Documentation Program
• •
The Role of the Clinical Documentation Specialist (continued):
Query the physicians for clarification of diagnoses.
Adhere to metrics established by your specific facility: – Daily caseload (new admissions and follow-up queries) – Number of queries per day – Physician query rate (verbal and written) – Physician response rate
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Medical Staff Responsibilities
• • Respond to the CDS queries prior to discharge.
Provide accurate and timely documentation in order to: – Assist in assignment of the proper codes for hospital and physician billing – Assist in the planning, evaluation and delivery of patient care resulting in the best outcome – Provide other physicians in the organization clear opinions regarding the patient’s condition, treatment options and response to the prescribed care – Result in fewer payment denials and facilitate the overturn of denials – Improve results in the areas of strategic planning, quality measures, outcomes and physician profiling – Lower potential litigation with focused and accurate documentation to support the appropriate, best practice care
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A Clinical Documentation Program
• • • •
The Role of the of the Professional Coder
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Clinical Documentation and the RAC
• A good Clinical Documentation Improvement program protects the hospital’s resources – Accurate and complete documentation in the chart ensures accurate coding practices • Principle diagnosis • Secondary diagnoses • Appropriate capture of co-morbidities • Appropriate capture of major complications
Clinical Documentation Program
PHYSICIAN IMPACT
Inpatient Documentation
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Case Study
• • • • Chart notes a elderly female admitted for unsteady gait, watery diarrhea, vomiting, chills and leukocytosis.
Lab: WBC 30K 94% PMNs, Hb 9.1 with MCV 72.9; Albumin 2.0
Pulse Ox 81%, BP noted 83/52 X-ray: Acute Vertebral Compression Fracture, Rt Basilar Infiltrate
Case Study
• • Final Coded Diagnosis: Medical Back Outcome: Death
Case Study #1
• • • • • Risk of Mortality based on documentation 1 of 4.
Undiagnosed: Severe Malnutrition, Aspiration Pneumonia, Septic Shock.
If documented ROM 4 of 4.
Numerically this was an unjustified mortality… The patient’s chart suffered from
Symptom Excess Disorder
.
Symptom Excess Disorder©
• • • • • A hospital chart with many symptoms (and signs) such as: pain, chills, fever, low BP, demand ischemia but no actual diagnosis. The disorder understates the patients severity of illness, risk of death and expected resource utilization. Insurers love this disorder because they tie hospitals to DRG based symptoms rather than charge. Physicians suffer because their profiles are fully loaded with high costs, long LOS, deaths, complications but no real diagnosis to justify their profiles.
Consider the Possibilities for Precise Documentation
If this is written: Is it an INDICATOR of: ACS w elevated troponin Any infection; bacteremia, C diff Albumin 2.8/ underweight Altered mental status CAD, Angina Cardiac Arrest Chest Pain Hypertensive emergency Hypotension Non Q wave MI Septicemia/Sepsis Severe Malnutrition Acute confusion, encephalopathy, or 2 nd Parkinson’s Stable angina, Angina-at-rest, Progressive Angina Cause-probable V Tach, V Fib/AMI Probable –cause GERD arrhythmia/gallstones/angina/cocaine Malignant/Accelerated HTN/Hypertensive encephalopathy Cause-hypovolemia/autonomic 2 nd Parkinson's/diabetic/septic shock
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Consider the Possibilities for Precise Documentation
If this is written: LLL infiltrate/Rx w Zosyn Na 125 Hgb 7 guaiac positive Neutropenic fever Pleural effusion Is it an INDICATOR of: Probable gram negative pneumonia Hyponatremia and cause –SIADH Acute/chronic blood loss anemia Underlying cause- sepsis/bacterial infection of unknown etiology Underlying condition- CHF/empyema/malignancy Ph 7.25, PCO2 34 PO2 80 CAP/NH acquired pneumonia Respiratory Insufficiency Respiratory Acidosis/Hypoxemia/Hypercapnia Metabolic acidosis Organism covering for- Zosyn, poss aspiration/gram negative- Vancomycin, prob MRSA Respiratory Failure if – ph <7.35 pCO2 >50 pO2 <60 and special resources utilized
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Pulmonary Edema & Respiratory Failure
• • Remember that you do not need ABGs to identify Respiratory Failure The absence of mechanical ventilation does not preclude the diagnosis of respiratory failure • Pulse Oximetry – patient’s oxygen saturation on room air should be < 90% or < 95% if the patient is on supplemental oxygen – Documentation of tachypnea, respirations > 26, use of accessory muscles, or cyanosis is necessary if oximetry is used instead of Arterial Blood Gases – In addition, documentation of labored breathing, and/or aggressive respiratory treatments all can be supportive of a respiratory failure.
Prevalence of Malnutrition
• • PEM is the most common form of nutritional deficiency among patients who are hospitalized in the United States . As many as half of all patients admitted to the hospital have malnutrition to some degree. In a recent survey in a large children's hospital, the prevalence of acute and chronic PEM was more than one half.
In hospitalized elderly persons, up to 55% are undernourished. Up to 85% of institutionalized elderly persons are undernourished. Studies have shown that up to 50% have vitamin and mineral intake that is less than the recommended dietary allowance and up to 30% of elderly persons have below-normal levels of vitamins and minerals.
The Laboratory Evaluation of Malnutrition
Protein
Albumin Transferrin Prealbumin Total Lymphocyte Count
Half-life
18 days
Malnutrition
3.0 g/l
Severe Malnutrition <2.8 g/l
9 days 2 days NA <200 g/l <200 mg/l <1,500/ml
<100 g/l <150 mg/l <800/ml Significance
For every 2.5 g/l decrease there is a 24 to 56%increase in mortality As above Should increase by 10 mg/day with adequate repletion 4-fold increase in mortality when even a moderate decrease is seen Assessment of Protein Energy Malnutrition in Older Persons, Part ll: Laboratory Evaluation; ML Omran MD and J.E Morley MB, BCh; Nutrition 16:131-140, 2000
This Definition of Sepsis in the Literature
NEJM: 351: 159 169, July 8, 2004
Acute Renal Failure
Classification/Staging System for AKI
Stage 1 2 3 Creatinine Criteria Increased serum creatinine of >0.3 mg/dl or increase to ≥150% - 200% from baseline Increase serum creatinine to > 200% 300% from baseline Increase serum creatinine to >300% from baseline (or serum creatinine ≥4.0mg/dl with an acute rise of at least 0.5 mg/dl) Urine Output Criteria <0.5ml/kg/hr for > 6hr <0.5ml/kg/hr for >12 hrs <0.3ml/kg/hr x 24 hrs or anuria x 12 hr
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Physician Query Process
• • • Query timeframes for clarification Concurrently (recommended) – Done while the patient is in the hospital – – Direct communication with the physician is optimal Documented in the record at the time of query request Retrospectively (prior to billing) – Should be done as soon as possible but within 7 days of discharge – Query answered, record completed, coded and billed by 14 days Post billing – Within 60 days of discharge – Understand that a change to the DRG will automatically force a full review of the record, especially medical necessity – Up to one year for other purposes, anything past a year infers suspicion
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Physician Query Process (continued) • • • Questions from the CDI staff to the physicians are intended to: – Clarify unclear, incomplete, or inconsistent documentation – Specify a suspected or implied diagnosis – Link diagnoses – Provide detail – Ensure documentation of clinical significance of lab or test findings Queries are based on evidence in the patient’s record Physicians are expected to respond to queries
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Physician Query Process (continued)
• Concurrent Queries should include: – Risk factors – Signs and symptoms – Treatment Property of Wellspring Partners. Reproduction prohibited without express permission.
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• • •
Present on Admission (POA)
In its landmark 1999 report ‘‘To Err is Human: Building a Safer Health System,’’ the Institute of Medicine found that medical errors, particularly hospital-acquired conditions (HACs) caused by medical errors, are a leading cause of morbidity and mortality in the United States.
As one approach to combating HACs, including infections, in 2005 Congress authorized CMS to adjust Medicare IPPS hospital payments to encourage the prevention of these conditions.
In 2007, CMS announced that it will curtail payments to hospitals for specific conditions that a patient acquires while an inpatient and that can be “reasonably prevented” by following established evidence-based guidelines.
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Present On Admission
• • The President’s FY 2009 Budget: (1) Prohibits hospitals from billing the Medicare program for ‘‘never events’’ and prohibits Medicare payment for these events and (2) requires hospitals to report any occurrence of these events or receive a reduced annual payment update. Generally patients with these diagnoses have a longer length of stay, increased utilization of hospital resources, and are often elevated to a higher paying DRG.
• Present on admission is defined as present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. (ICD-9-CM Official Guidelines for Coding and Reporting, Effective October 1, 2008, Page 104 of 119)
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• POA
Present on Admission
A diagnosis is considered to be ‘present on admission’
: – If the physician includes “present on admission” in the documentation – If it is included in the PMH list – If the condition was diagnosed during the admission, but was clearly present on admission, i.e.: • chronic conditions and cancers – If the diagnosis was possible, probable, rule out, suspected, or a differential on admission and was confirmed at discharge – If the condition developed during an outpatient encounter, such as emergency room, physician office, outpatient surgery or observation – If the signs and symptoms of the condition were clearly present on admission, listed later in the record as a diagnosis with a POA clarifier
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• POA
Present on Admission
A diagnosis is considered NOT ‘present on admission’ if
: – The physician documents that it was not present on admission – It occurs or develops after the admission, therefore during the inpatient stay – A final diagnosis cannot be linked to signs and symptoms present at the time of admission or a suspected, possible, probably, rule out or differential diagnosis on admission
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POA Payment Example
MS-DRG Assignment DRG
PDX: Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCC PDX: Intracranial hemorrhage or cerebral infarction (stroke)
with SDX: Dislocation of patella-open due to a fall (code 836.4 (CC)
PDX: Intracranial hemorrhage or cerebral infarction (stroke)
with SDX: Dislocation of patella-open due to a fall (code 836.4 (CC)
MS-DRG 066 MS-DRG 065 MS-DRG 065 67
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Present on Admission Median Payment
$5,347.98
Yes
No
$6,177.43
$5,347.98
• • ICD-9-CM Official Guidelines for Coding and Reporting
Two or more diagnoses that equally meet the definition for principal
diagnosis - In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. (p 96) Two or more comparative or contrasting conditions - In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first. (p 96)
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ICD-9-CM Official Guidelines for Coding and Reporting • There is no required timeframe as to when a provider (per the definition of “provider” used in these guidelines) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider’s best clinical judgment. (p 105) • If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification. (p 105)
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Summary
• An effective Clinical Documentation Improvement program benefits the hospital in the following ways: – Using a physician documentation review process, the CDI team identifies missing, conflicting or incomplete information in the medical record – The CDI program uses a physician query process to obtain clarification of documentation in the medical record to • Identify the Principle Diagnosis • Identify Co-Morbidities • Identify Major Complications • Facilitate timely capture of documentation to support CMS Quality Indicators
Summary
• An effective Clinical Documentation Improvement program benefits the hospital in the following ways: – – Reduction in clinical denials Appropriate assignment of patient status (Observation vs Inpatient) – – Reduction in potential litigation Facilitating discharge planning needs of patients and improved patient throughput – Accurate reflection of severity of illness for • Use of hospital resources • Physician profiles • Public reporting