Transcript Slide 1

"Stayin' Alive" in today's healthcare
market: Bettering your observed to
expected mortality rates
Terri Adell, RN, MS, CNRN, CCM
Clinical Documentation Specialist Supervisor
Stony Brook University Medical Center
Catherine Morris, RN, MS, CCM, CMAC
Executive Director of Care Management
Stony Brook University Medical Center
Stony Brook University Medical
Center
591-bed academic medical center
Level 1 trauma center
Regional stroke center, neuroscience institute
Pediatric emergency room
Comprehensive psychiatric emergency room
Burn center
Located in Stony Brook, Long Island, NY
> 30,000 inpatient discharges/year
Objectives
• Define severity of illness and risk of mortality
• Discuss the risks and benefits of the current
public reporting systems
• Describe how to develop a mortality review
program
• Understand the benefits of using a risk-adjusted
system
• Describe some of the intricacies of coding
certain patient types
Current Issues in Healthcare
• High cost of services, push for reform and cost
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containment
Change to severity-based reimbursement
Decreased revenues due to MS-DRGs and RAC
initiatives
Public access to physician/hospital report
cards/outcomes
Change to ICD-10
New Focus: Risk
Adjustment/Quality
• Clinical documentation improvement programs
initially focused on capturing major complications
and comorbidities (MCC) and complicating
conditions (CC) that impacted the DRG and that
resulted in higher utilization of resources and higher
reimbursement
• SBUMC now uses a four-level subclass of APRDRG data, which more accurately defines a
patient’s severity of illness and risk of mortality:
– Level 1: Minor
– Level 2: Moderate
– Level 3: Major
– Level 4: Extreme
Benefits of Using a Risk-Adjusted
System
• Provides a higher level of specificity about the
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patients’ condition and the care/treatment
provided
Improve facilities’ quality data
Improve physicians’ and hospitals’ public report
cards
Enhance revenue, impact LOS
Ensure regulatory compliance
Avoid retrospective audit “money recovery” and
penalties
CMS Severity Levels
• MS-DRGs introduced October 1, 2007, to better
account for severity of illness and resource
consumption of Medicare beneficiaries
• There are 3 levels of severity based on
secondary diagnosis codes:
1. MCC (major complication/comorbidity), highest level
of severity
2. CC (complication/comorbidity)
3. Non-CC does not significantly affect severity of
illness and resource use
Definitions of SOI/ROM
• Severity of illness:
The “extent of physiologic decompensation or
organ system loss of function experienced by
the patient” (HCPro)
• Risk of mortality:
Likelihood patient will die from this illness
The ratio of the SOI to the ROM =
Mortality index
SOI ≠ ROM
• Although severity of illness and risk of mortality
are highly correlated for many conditions, they
often differ because they relate to distinct
patient attributes
Acute choledocholithiasis
(acute gallstone attack)
Severity of illness is major (level 2)
(because of organ system dysfunction)
Risk of mortality is minor (level 1)
• If a more serious diagnosis presents, severity of
illness and risk of mortality may increase – e.g.,
patient develops peritonitis as a complication of
choledocholithiasis:
Extreme (level 4) severity of illness
Major (level 3) risk of mortality
Reasons for Mortality Reviews
• Identify adverse events, errors
• Prevention and process improvement
• Documentation of core measure elements
• Improve O/E severity of illness & risk of mortality
• Revenue capture
• Public reporting
Public Reporting Sites
CMS’ Hospital Compare
www.hospitalcompare.hhs.gov
U.S. News & World Report
www.healthgrades.com
Thomson-Reuters
www.100tophospitals.com
Leapfrog Group
https://www.leapfroghospitalsurvey.org
UHC (University Healthsystem Consortium)
https://www.uhc.com
Premier, Inc.
www.premierinc.com/quality-safety/tools-services/performance-suite/clinicaladvisor.jsp
State governments/DOH _______.gov
In New York state:
Myhealthfinders.com or NYSDOH.gov
Problems With Public Reporting
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No standard data collection methods
Diverse data sources
Provider editing ability
Timeliness
Intent
Relevance, methodological rigor
Different measures of quality, inconsistent
definitions used, different reporting periods
• Institutional variability in the definitions
Improving Standardization
• Because mortality measures are
ErrorProne
Collection
Methodology
obtained through claims rather than
clinical data, we must work to
improve the standardization of
documentation and coding that
drives mortality rates
Potential Problem
Overcoding
• There is always the risk of hospitals
overcoding, either intentionally or
unintentionally, and skewing results
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Disclaimer: The information, techniques, situations, and references in this presentation
are for information purposes only. They are not communicated with reference to any
specific issue, do not constitute legal or clinical advice, and are not in any way a
substitute for such due diligence inquiries and investigations as otherwise may be
required by law or clinical standards. Laws, regulations, clinical standards, and other
professional due diligence requirements vary from state to state. It is your responsibility
to check with your compliance department before using any of the
information/techniques from this presentation.
Our Mortality Review Process
and Documents
Initially
• Estimated yearly mortalities: 600
• Estimated reviewed records: 50 per month
• One documentation specialist assigned to
mortality review per week
• Project length: Three months
Mortality Review Process–
Documentation Improvement
• Mortalities coded by HIM
• Record “GROUPED” for severity and mortality risk by
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coder and second attestation printed and given to
coding supervisor
Each mortality record placed on “MQ” bill hold (if it is a
SMART chart, it will be placed on “MR” bill hold as usual
until the record is reviewed by the coding supervisor and
will then be changed to “MQ”)
Chart sent to tech park for scanning by coder
Report on mortalities run by coding supervisor daily to
be picked up by CDS with attached attestations
Assigned CDS reviews records daily (Mon–Fri)
No query identified, coding supervisor notified to
removeMQ bill hold by CDS
Mortality Review Process–
Documentation Improvement
• Queries identified, physician contacted regarding query by
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CDS
If physician does not agree, coding supervisor notified to
remove MQ bill hold by CDS
If he or she agrees, physician documents on HIM retro query
form
CDS brings retro query form to coding supervisor
Appropriate coding changes are made by coding supervisor
and an attestation is sent as a priority scan to tech park
Chart regrouped for severity and mortality risk
Bill hold removed
CDS maintains database to be sent to coding supervisor by
e-mail by close of business every Thursday for reconciliation
Report run every month on changes to severity and mortality
Patient name
Patient enc #
Age
Admitting dx
Attending
Service
Unit
Readmit within 30 days
Admit date
Date of death
LOS
Day of week of death
Time of death
Rapid response
Date/time of code blue
Cause of death
Palliative care
Hospice
DNR/DNI
MCC already coded
CC already coded
New MCC
New CC
Coder DRG
CDS DRG
ROM
Comments
Identified Opportunities
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Data collection
Neonates
Short-stay deaths
Palliative care/“V” code
Assigning an attending
PATIENT NAME
ENCOUNTER NUMBER
81
subdural hematoma
Alpa Desai
89
chf
William Lawson
92
Intracerebral hemorrhage
Riyaz Kamadoli
70
breast cancer
Ostrow
86
copd
Stavola, Thomas
MCU
CAD
GMX
MOL
CAD
ADMIT DATE
MICU 17s
no
3/21/2010
CCU
no
3/31/2010
16n
no
3/31/2010
19N
yes
4/2/2010
CCU
no
3/17/2010
DATE OF DEATH
3/24/2010
4/12/2010
4/3/2010
4/8/2010
3/27/2010
3 days
2
3
6
10
Wednesday
Monday
Sat
Thursday
Saturday
2127
0220
1PM
0309
2220
no
no
no
no
no
na
na
no
AGE
ADMITTING DX
ATTENDING
SERVICE
UNIT
READMIT WITHIN 30 DAYS
LOS
DAY OF WEEK OF DEATH
TIME OF DEATH
RAPID RESPONSE
DATE/TIME OF CODE BLUE
3/21 & 3/24 (2105)
CAUSE OF DEATH
cardio pulm arrest/sepsis
Septic shock
Intracerebral hemorrhage
metastic breast ca
anoxic brain injury
PALLIATIVE CARE
no
no
yes
yes
yes
HOSPICE
no
no
no
yes
no
DNR/DNI
no
yes
yes
yes
yes
MCC ALREADY CODED
yes
no
no
yes
yes
CC ALREADY CODED
yes
no
no
yes
yes
NEW MCC
acute resp failure
multiple
no
acute resp failure
NEW CC
chronic sys. Chf
see comments
no
no
85
293
64
374
246
280
64
374
246
4
3
Retroquery for acute
resp. Failure based on
freq documentation of
resp distress w sats low
80s. Retroquery signed
by attending
4
CODER DRG
CDS DRG
ROM
COMMENTS
Financial impact
New ROM
3
2
Retro query acute resp Review of chart revealed multiple
failure with agreement. mccs not capture because no
attending cosign. Retroqueried Dr
Lawson in person who wrote on
retroquery: "Non STEMI,
cardiogenic shock w multiorgan
system failure, renal, respiratory,
gastrointestinal, cerebral"
none
$5,102.00
none
4
4
4
Neonates
New York State Law
• If there is documentation that the infant “drew a
breath,” then the child must be encountered as
a live birth and considered an inpatient
mortality..
Definition of Stillbirth
• A stillbirth is when a fetus that was expected to
survive dies during birth or during the last half of
pregnancy*
*In the United States, the term stillbirth or fetal demise does not have a
standard definition.
For statistical purposes, fetal losses are classified according to gestational
age.
A death that occurs prior to 20 weeks' gestation is usually classified as a
spontaneous abortion; those occurring after 20 weeks constitute a fetal
demise or stillbirth.
Many states use a fetal weight of 350 g or more to define a fetal demise.
More Confusion
• However, not all states interpret the weeks
New York
vs.
California
of gestation in the same manner.
• In California, 20 weeks' gestation is worded
"twenty utero gestational weeks" and has
therefore been interpreted to be 23 weeks
from the last menstrual period.
(Implantation in the uterus does not occur
until 1 week after fertilization.)
• In New York state, intrauterine fetal death
(IUFD) includes a death at a gestational
age of 20 completed weeks or greater, or if
fetal weight is 300 g or more.
Neonates
• When are neonatologists/pediatricians involved?
• Under what week gestational age are they
coded solely from the obstetrician's notes?
• Neonatologist language
– Apnea vs. acute respiratory failure
Short-Stay Patient Deaths
• There are many difficulties to address:
– Medical history
– Assessment is focused on the problem
– Etiology
– No/incomplete diagnosis
– “Unresponsive”
– Lack of studies or clinical findings
– Lack of indication for procedures
– Who is the attending of record?
Short-Stay Patient Deaths
• A 57 y/o patient was brought in as a Code H
from an outside hospital s/p cardiac arrest and
intubation. He underwent emergent stenting
upon arrival. He was clearly extremely ill, and
his death in the CCU within 24 hours of arrival
was not unexpected.
• This patient was coded as having a ROM of 1
(the lowest risk in a scale from 1–4).
Short-Stay Patient Deaths
• The sickest patients who arrive as a code H and
expire rapidly and only have a slim chart may
end up with the lowest ROM if the right verbiage
is not stated by an attending physician or NP.
– Cardiac arrest should be queried for cardiogenic
shock
– Intubation as acute respiratory failure
– Renal insufficiency as acute renal failure
– Glasgow coma scale of 5 must be stated as coma
MORTALITY REVIEW QUICK REFERENCE
DX OR INFO PRESENT
DX INCREASING RISK OF MORTALITY
Renal insufficiency, elevated creatinine
SOB, increases respirations, respiratory distress,
increases O2 demand
Acute renal failure
Obtunded, unconscious
Unresponsive to verbal or tactile stimuli, pupils &
dilated
Coma
Positive tropinins, no EKG changes, demand ischemia
NSTEMI
Ascites, pleural effusion secondary
to…malignancy
Ascites, pleural effusion
Cardiac arrest
Cardiac arrest
Acute respiratory failure
Coma
Cardiogenic shock, acute respiratory failure
Pulmonary insufficiency secondary to
shock/trauma
Increases ammonia levels with ams in liver dz
Hepatic encephalopathy
Increasing liver enzymes in pt with cirrhosis, liver mets,
etc.
Liver failure
SAH, SDH, ICH, CVA, head trauma
Cerebral edema, brain edema
Pneumonia
Increased WBC, hypotensive on vasopressors,
bacteremia
Aspiration pna, gm neg pna, fungal
Septic shock
Cath Notes
Palliative Care
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Comorbidities
Lack of specific treatment
Palliative care – V667
Top 9 diagnoses
DNR code – V49.86
V66.7 Code
• Effective October 1, 1996
• Terminally ill patient receiving palliative care
• Palliative care is an alternative to aggressive
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treatment – the focus is toward management of pain
and symptoms
Care provided is dependent on the terminal illness
Always a secondary code – terminal condition is
always the principal diagnosis
Comfort care, end-of-life care, and hospice care are
synonymous terms
MD documentation must include these or similar
terms
Hospice or Palliative Care Code Usage
UHC
CMS Hospital
Compare
U.S. News & World
Report America’s Best
Hospitals
Thomson-Reuters
100 Top Hospitals
HealthGrades
Admitted from
a hospice
No
Yes, if
Medicare
benefit used in
last 12 months
No
No
No
Palliative care
code v66.7
excluded?
No
No
No
Yes
Excluded in 12
dx-based
cohorts
Risk adjusted
Yes
No
Yes
NA/No
NA/No
Necessary
position to be
applied
Any
Top 9
(within top 25
this year)
Top 9
Top 9
Top 9
Assign an
Attending Physician
Mortality Progress Note
• Improve documentation
• Clarify cause of death
• Include other diagnoses
• Ensure attending is identified
Mortality
Note
Case Study
Attestation
Clinical documentation specialist
queried for further clarification of
primary diagnosis based on
documentation of unresponsiveness
and GCS of 5.
Physician documented that the patient
was in a coma secondary to large
intracranial hemorrhage and cerebral
edema. This increased the SOI and the
ROM
to 4.
Case Study
This patient underwent CPR in
the ED with futile outcome.
Because of documentation of
prior cardiac interventions et
al., the SOI/ROM increased to
4/4.
Results
Month
January
February
March
April
May
June
July
August
September
October
November
December
SBUMC %
observed
2.55
2.43
2.30
2.43
1.83
2.62
2.33
1.95
3.14
2.07
2.49
SBUMC %
expected SBUMC index NYS index UHC index
2.76
0.92
1.03
0.91
2.75
0.88
1.00
0.83
2.80
0.82
0.93
0.80
2.75
0.88
0.87
0.79
2.56
0.72
0.91
0.81
2.76
0.95
0.93
0.79
2.65
0.88
0.94
0.80
2.56
0.76
0.92
0.80
3.04
1.04
0.94
0.80
2.68
0.77
0.98
0.82
3.07
0.81
0.96
0.79
Excludes implant of heart assist system; heart, liver, and lung transplants; neonatology; normal newborn; obstetrics; psychiatry; and rehabilitation product
lines.
Mortality Index
1
0.9
0.8
0.88
Index
0.7
0.84
0.75
0.73
0.6
0.69
0.5
0.4
0.3
0.2
0.1
0
2010-01
Discharge month
2010-01
2010-02
2010-03
2010-04
2010-05
2010-02
2010-03
Discharge Month
2010-04
2010-05
% deaths (observed)
% deaths (expected)
Mortality index
2.01
2.29
1.86
2.22
0.88
0.84
1.68
2.29
0.73
1.81
2.41
0.75
1.41
2.03
0.69
Mortality Observed and Expected
3.50
3.00
PERCENT
2.50
2.00
1.50
SBUMC %observed
SBUMC %Expected
1.00
0.50
0.00
2010
O/E Index
1.20
1.00
INDEX
0.80
SBUMC
0.60
NYS
UHC
0.40
0.20
0.00
January
February
March
April
May
June
2010
July
August
September October
November
Severity of illness and
risk of mortality are highly
dependent on the patient's
underlying clinical problems
Terri Adell [email protected]
Catherine Morris [email protected]
Hughes J. 3M Health Information Systems (HIS) APR™-DRG Classification Software—Overview. In Mortality Measurement. February 2009. Agency for
Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/mortality/Hughessumm.htm The History of Medical Coding
John Landers, eHow Contributor. Mortality Rates as a Measure of Quality and Safety, “Caveat Emptor” Robert Klugman, MD,1, Lisa Allen, PhD,2,
Evan M. Benjamin, MD,3, Janice Fitzgerald, MS,4, and Walter Ettinger, Jr., MD, MBA1 American Journal of Medical Quality OnlineFirst,
published on January 21, 2010 as doi:10.1177/1062860609357467
Evaluation of Fetal Death Author: James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical
Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of Medicine
Coauthor(s): Sultana L Sultani, MD, Resident Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center
Contributor Information and Disclosures Updated: Jan 18, 2011
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