Transcript Slide 1

What is Clinical Documentation
Integrity?
A daily scavenger hunt
Benefits of Clinical
Documentation
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More accurate documentation reflective of true
acuity and services provided
More accurate profiling data for both Hospital and
medical staff
More appropriate case mix and reimbursement
Reduced compliance risk
Potential reduction in denials
More appropriate patient severity, mortality,
outcomes and resource consumption data
Increased cooperation between physicians and
hospital
• A consulting group reviewed the
appropriateness of the DRG assignment for a
sample of inpatient Medicare cases at HPRHS
based on the clinical documentation in the
Medical Record.
• Based on their findings, there was a potential
financial impact of approximately $1.8 million in
missed opportunities, contributed to
documentation.
• Documentation was the key factor, not the
quality of care or service.
• We know that we deliver exceptional
health care services to the people of our
region!
• Many times the documentation doesn’t
support the true severity of illness of our
patients.
HPRHS Data Analysis: Why Does Data Matter?
Hospital and physician profiling data is available
to the public
Research
& Compare
Physicians
HPRHS Data Analysis: Why Does Data Matter?
Hospital Report Cards
www.abouthealthtransparency.org
POA vs. Hospital-acquired
Conditions
Present on admission (POA) is defined as present
at 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.
Hospital-acquired conditions (HACs) are those
that developed / occurred during an inpatient
hospital stay.
Purpose of POA
• Intention of this new concept is to reduce
increased payments for complications that
occurred after admission / during the
hospitalization.
• Hospitals have to submit data on all Medicare
claims indicating whether the diagnoses were
POA.
• Coders indicate (Y or N) beside the principal
diagnosis and all secondary diagnoses.
The 10 categories of HACs include:
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Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Stage III and IV Pressure Ulcers
Falls and Trauma
Manifestations of Poor Glycemic Control
Catheter-Associated Urinary Tract Infection
Vascular Catheter-Associated Infection
Surgical Site Infection Following
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Orthopedic Procedures
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(UTI)
Spine Neck,Shoulder,Elbow
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
Total Knee and Total Hip Replacement
Payment implications began October 1, 2008, for these 10
categories of HACs.
Medicare 101
DRG (Diagnosis Related Groups)
Basics
• How are DRGs used:
– Calculating Hospital reimbursement
– Evaluate quality of care
– Evaluate utilization of resources
• Each DRG represents the average resources utilized
to care for a patient within the grouping
• Every DRG has a relative weight (RW) assigned to it
• The RW is used in the calculation of the Hospitals
Case Mix Index
www.hcup-us.ahrq.gov
Medicare 101
DRG Basics
– Major enhancement is revision of the CC list and development
of MCC list
– With the development of MS-DRGs, CMS reduced the CC
capture rate from 77% to 40%
– CC’s are categorized:
• MCC (Major complication/comorbidity)
• CC (complication/comorbidity)
• Non CC
www.hcup-us.ahrq.gov
CMS DRGs vs. MS-DRGs
MS-DRG’s
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Heart failure with no MCC/CC DRG 293 = RW 0.7220 = $3,699 CHF
LOS 3.7days TX O2 and IV Lasix
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Heart Failure with CC DRG 292 = RW 1.0069 = $5,155 CHF LOS 5 days
TX O2, IV Lasix, echo, med adjustment, Chronic obstructive bronchitis acute
exacerbation
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Heart Failure with MCC DRG 291 = RW 1.4601 = $7,481 CHF LOS 6.5
days intubated ED, admit to ICU, In ICU 7 days, IV Dobutamine, multiple
tests, multiple med adjustment, critical care, complicated by acute renal
and respiratory failure
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The Goals of Clinical Documentation
Integrity (CDI) Process are as follows:
Drive appropriate coding for accurate
reimbursement
– Reflect accurate patient acuity levels
– Meet standards
– Reduce compliance risks
– Provide accurate data for quality indicators and
other hospital metrics
– Reduce coding turnaround time
– Decrease post-discharge queries to the physicians
by utilizing concurrent physician queries when
indicated
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Clinical Documentation Analysts
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Nita Campbell, RN
Janice Davis, RN
Alletheia Fitzgerald, RN
Tamika Jones, RN
Elinore Poindexter, RN
• Medical Records x 2938
ICU/CCU/OCU
6S/7N/PJC
6N/7N/5N
CPU/MTU
5S/CTU