Transcript 4th ANNUAL ASSOCIATION FOR CLINICAL DOCUMENTATION

Expected event or surgical
complication?
A surgeon’s perspective
Alan E. Williamson, MD, FACS
Vice President of Medical Affairs/CMO
Eisenhower Medical Center
Rancho Mirage, California
The care and feeding of surgeons
“Why won’t the surgeon just
document what we want?!”
• “I don’t have time for this!”
• “But that’s what I meant!”
– “We’re not speaking the same language!”
– “Duh!”
• “What’s in it for me?”
• “They’re after me!”
“I don’t have time for this!”
“Everybody wants a piece of me”
Documentation demands for:
• Core measures
• National Patient Safety
Goals
• Third-party insurer
metrics
• Internal quality
improvement projects
• “Defensive” medicine
“But that’s what I meant!”
“Urosepsis”
• Per Stedman’s Medical Dictionary –
– “Sepsis resulting from the decomposition of
extravasated urine”
• Per Dorland’s Illustrated Medical Dictionary –
– “Septic poisoning from the absorption and
decomposition of urinary substances in the tissues”
• Per Wikipedia –
– “When pyelonephritis or other urinary tract infections
lead to sepsis, it is termed urosepsis”
“Urosepsis” – per CMS coding
guidelines
• “The term urosepsis refers to pyuria or
bacteria in the urine” (not the blood) and is
coded to 599.0, Urinary tract infection, site not
specified
Financial impact
• Dx – “Urosepsis”
– Urinary tract infection without CC
– DRG 321
RW 0.5793
$2881
• Dx – Sepsis secondary to urinary tract infection
– Septicemia w/o MV 96+ hrs; Age > 17
– DRG 576
RW 1.5996
$7955
“Anemia”
• Per Stedman’s Medical Dictionary:
– “A condition in which there is a reduction in number of
circulating red blood cells or in hemoglobin, or in the
volume of packed red blood cells per 100 ml of blood.
It exists when hemoglobin content is less than 13-14
gm/100ml for males or 11-12 gm/100ml for females.”
“Anemia” – per CMS coding
guidelines
• Hgb, Hgb=8, Hct=24, etc., are not anemia
unless a physician specifically states that it is
Take-home lesson #1
• Physician documentation is:
– To communicate with other physicians and caregivers
as to the patient’s progress and your impressions and
plans
– To provide historical background to assist in future
episodes of care, by yourself or others
– So you can get paid!
• Physician documentation is not:
– A tool to explain the patient’s condition in “layman”
terms to nonclinicians
“We’re not speaking the
same language!”
CMS coding rules
• Part B – physician professional services
– ICD-9 (diagnosis) codes must be specific
– Physicians may not code probable, likely, suspect,
etc.
• Part A – hospital coding rules
– Physicians should document presumptive diagnoses
driving resource utilization such as “probable, likely,
suspect, presumptive,” etc.
– Coders may assign DRG based on presumptive
diagnoses
“Complication”
• Per coding guidelines:
– “Conditions not present on admission are considered
to be complications.”
– Include both “expected” and “unexpected” events
• Per the surgeon:
– Unexpected event
– Usually the result of poor cognitive or technical
performance, more often than not by me!
– Embarrassing
– Might get me in trouble
Clinical scenario
• 85-year-old man presents to the ER with acute
abdominal and back pain and hypotension.
Ruptured AAA found on CT. On opening
abdomen approx. 1000ml blood found. Total
estimated blood loss for procedure = 1300ml.
Post-op Hgb = 8.5. Patient doing well.
Complication??
Clinical scenario
• 85-year-old man presents to the ER with acute
abdominal and back pain and hypotension.
Ruptured AAA found on CT. On opening
abdomen approx. 1000ml blood found. Total
estimated blood loss for procedure = 1300ml.
Post-op Hgb = 8.5. Patient doing well.
Complication??
No!! It was a great save! I should be congratulated!
Clinical scenario
• 16-year-old male with perforated appendicitis.
Despite prompt surgical intervention, copious
intra-operative irrigation, and broad-spectrum
antibiotics, he develops an intra-abdominal
abscess requiring CT-guided drainage.
Complication??
Clinical scenario
• 16-year-old male with perforated appendicitis.
Despite prompt surgical intervention, copious
intra-operative irrigation, and broad-spectrum
antibiotics, he develops an intra-abdominal
abscess requiring CT-guided drainage.
Complication??
Maybe. But what more could I do?? It’s the
patient’s fault for not coming in sooner!
Duh!
Clinical scenario
• 72-year-old woman with shaking
chills, temperature 103.8°F, pulse
112, BP 90/48, requiring multiple
IV pressors in the ICU
Clinical scenario
• 72-year-old woman with shaking
chills, temperature 103.8°F, pulse
112, BP 90/48, requiring multiple
IV pressors in the ICU
• Query from CDCI reviewer:
“Doctor, could the patient’s high
pulse rate and decreased blood
pressure represent possible
sepsis?”
Clinical scenario
• 72-year-old woman with shaking
chills, temperature 103.8°F, pulse
112, BP 90/48, requiring multiple
IV pressors in the ICU
• Query from CDCI reviewer:
“Doctor, could the patient’s high
pulse rate and decreased blood
pressure represent possible
sepsis?”
Physician’s response: DUH!
Clinical scenario
• OP report –
– Procedure: Aortobifemoral
bypass
– Complications: Left iliac vein
laceration
– EBL: 2200 ml
• POD 1 Hgb: 8.1
Clinical scenario
• OP report –
– Procedure: Aortobifemoral
bypass
– Complications: Left iliac vein
laceration
– EBL: 2200 ml
• POD 1 Hgb: 8.1
• Query from CDCI reviewer:
– “Doctor, could the patient’s
low hemoglobin be anemia
due to acute blood loss?”
Clinical scenario
• OP report –
– Procedure: Aortobifemoral
bypass
– Complications: Left iliac vein
laceration
– EBL: 2200 ml
• POD 1 Hgb: 8.1
• Query from CDCI reviewer:
– “Doctor, could the patient’s
low hemoglobin be anemia
due to acute blood loss?”
Physician’s response: Do you think?! (I just said that!)
What’s in it for me?
What’s in it for me?
• More paperwork!
• More headaches!
• More time!
• More money?
Employment of physicians by
hospitals
What’s in it for me?
• Physicians potentially benefit by documenting
comorbid conditions (higher acuity)
– We often treat – but fail to document – a diagnosis
– Examples: Hypovolemia, post-hemorrhagic anemia,
acute urinary retention
• Public reporting of outcomes
• Pay for performance
They’re after me!
The P4P slope
Pay for performance
The P4P slope
Pay for performance
Non-pay for poor performance
The P4P slope
Pay for performance
Non-pay for poor performance
Economic credentialing
Summary
• “I don’t have time for this!”
– Do whatever you can to make appropriate
documentation easier
• “But that’s what I meant!”
– Avoid the “C” word whenever possible
• “What’s in it for me?”
– Use competitive nature to your advantage
• “They’re after me!”
– Understand our paranoia; we could be right
Questions?