Transcript UNMH Clinical Documentation Improvement Program Surgery

Level II Training
Clinical Documentation Improvement
DoIM – Hospitalists
7/09/14
Presented by:
Catherine Porto, MPA, RHIA, CHP
Exec. Director HIM, UNMH
ICD-10 Executive Project Lead
&
Erlinda Smith, CCS
CDI Provider Education
& Kayode Balogun
CDI Program Development - Precyse
1
UNMMG Coding Staff – Current State
UNMMG Professional Fee Coding:
• Assign ICD-9-CM diagnosis code (for that visit)
• Assign CPT procedure Codes (for that visit)
– Evaluation & Management (E/M)codes for
provider services
– Procedure codes –for provider fees
2
UNMMG Provider Coding
• 4 Day Hospital Stay (Evaluation &Management)
– Day 1 = Initial Hospital Care (CPT 99223)
• Charge = $514.00
• wRVUs = 3.86
– Day 2 = Subsequent Hospital Care/Follow up (CPT 99233)
• Charge = $265.00
• wRVUs = 2.00
– Day 3 = Subsequent Hospital Care/Follow up (CPT 99233)
• Charge = $265.00
• wRVUs = 2.00
– Day 4 = Hospital Discharge (CPT 99239)
• Charge = $269.00
• wRVUs = 1.90
• Total Provider Charges = $1,313
• Total Provider wRVUs = 9.86
3
UNMH Coding Staff
• Hospital (Facility) Coders are responsible for
Facility Coding for the hospitals and clinics:
• Assignment of one DRG Code derived from:
• One Principle Diagnosis (ICD-9-CM)
• All Secondary Diagnoses (ICD-9 & capturing all present
on admission (POA) diagnoses)
• One Principle Procedure (ICD-9-PC)
• All Secondary Procedures (ICD-9-PC)
• Any & all Co-morbidities & Complications (CC & MCCs)
• Assignment of the DRG
4
Assignment of the MS-DRG
 DRG (Diagnosis Related Grouping)
 One DRG is assigned for each Inpatient stay
Using all diagnoses and procedures codes
Includes codes for all complications &
comorbidities (CCs and MCCs)
• DRGs are assigned a relative weight (RW)
RW is the calculation of resource consumption
Used to determine payment
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MS-DRG Financial Impact
• Relative weight (RW): Number assigned to each
account based on the DRG assigned. The higher the
RW, the sicker the patient.
– 1: Average
– <1: Below average
– >1: Above average
• Case Mix Index (CMI): The average of all relative
weights for a patient population (Month, Year, etc.) for
any given period of time.
6
Secondary Data Uses
The role of the APR-DRGs
• APR-DRG (All-Payer Refined DRG-3M Software)
• Calculates Severity of Illness (SOI)
• Calculates Risk of Mortality (ROM)
– Based on diagnoses, procedures and
– Complications & Co-morbidities (CC and MCCs)
• SOI & ROM scales (APR-DRG & UHC scale)
–
–
–
–
1.
2.
3.
4.
Minor
Moderate
Major
Extreme
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Impact of Complete Documentation
MS DRG 195
w/o MCC/CC
MS DRG 194
with CC
MS DRG 194
with CC
PDX: Pneumonia, organism PDx: Pneumonia,
Unspecified
Organism Unspecified
SDx: COPD with
Exacerbation
SDx COPD
MS DRG 193
with MCC
MS DRG 193
with MCC
MS DRG 177
with MCC
PDx: Pneumonia,
Staphyloccus Aureus
PDx: Pneumonia
Organism Unspecified
PDx: Pneumonia
Organism Unspecified
PDx: Pneumonia
Organism Unspecified
SDx: COPD with
Exacerbation
SDx: COPD with
Exacerbation
SDx: COPD with
Exacerbation
SDx: COPD with
Exacerbation
Malnutrition, protein
calorie
Malnutrition, protein
calorie
Malnutrition, severe
protein calorie
Malnutrition, severe
protein-calorie (BMI<19)
Decubitus Ulcer
Pressure Ulcer, Stage IV,
lower back (site needed for
ICD-10)
Pressure Ulcer Stage IV
Acute Respiratory Failure
with hypercapnia and/or
hypoxemia
SOI Level:
1
SOI Level:
2
SOI Level:
2
SOI Level:
3
SOI Level:
3
SOI Level:
4
ROM level:
1
ROM level:
1
ROM level:
2
ROM level:
2
ROM level:
3
ROM level:
3
DRG Wt: 0.6997
DRG Wt: 0.9771
DRG Wt: 0.9771
DRG Wt: 1.4550
DRG Wt: 1.4550
DRG Wt: 1.9934
POA and HAC
There is a BIG difference in whether a condition was:
• POA: Present on Admission – documentation in the H&P or progress
notes after a definitive diagnosis is made—whether each condition
was present on admission (provider’s best clinical judgment)
– Does this patient have a pressure ulcer (where)?
OR
• HAC: Hospital Acquired Condition
– For some selected conditions (diagnoses) that were not present on admission,
but were acquired during hospitalization, the case may be paid as though the
secondary diagnosis is not present
•
•
•
•
•
Fracture occurring during the IP stay
Diabetic Ketoacidosis (MCC) not present on admission
Foreign object retained after surgery
Vascular Catheter-Associated Infection
Surgical Site Infection
9
Documenting Questionable Diagnoses
Provider should document all possible, probable, or
suspected conditions – this communicates what the
provider is thinking.
• Example:
– Professional fee Dx: Cannot code R/O-- rolls back to coding a
symptom
– IP - Possible Sepsis, r/o sepsis: Sepsis coded as though it exists
– Sepsis ruled out: Sepsis would not be coded—IP remember to
confirm prior to discharge or in the discharge summary
– Pneumonia vs. CHF: Both can be coded (IP); pro fee-- codes to a
symptom (i.e. chest pain, shortness of breath etc.)
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Mission: Meaningful Clinical Process
“Telling the Patient’s Story”
Clinical Information is used by clinicians for “telling
the story” for this episode of care.
Primary uses of clinical documentation:
– The Documentation story critical for patient care
– The Medical Record is a communication tool among
care providers
– The Documentation should tell/demonstrate the
clinical pathway to diagnoses
Many times the story is lost in our current “cut and
paste” or more forward world or documentation.
11
Secondary Uses of Clinical Information
“As Documented in the EMR”
Secondary Clinical Information/Data Uses:
–
–
–
–
–
Disease & Operative Indexing for research (ICD & CPT codes)
Validates the patient care provided
Serves as a legal document of the care provided
Drives Revenue/Reimbursement (Coding)
Permits accurate comparisons to other
providers/institutions/national benchmarks
– Identifies the quality and efficiency of the care we give.
Computer extractions of:
•
•
•
•
Quality Indicators (PQRS)
Meaningful Use Data (MU)
Compliance/Regulatory Standards (TJC, CMS, DOH)
Metrics used for Value Based Purchasing
Why does CDI Matter?
Medicine is Under The Microscope
Cost per patient
Resource utilization
Length of stay
Complication Rates
Morbidity Scores
Mortality Scores
Outcome Analysis
Payer Audits
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Physician Profiling
Hospital Report cards
Healthgrades, Delta Group, Leapfrog
Medicare Physician Data (since 2007)
Federal and state regulatory agencies (e.g.
OIG)
The Joint Commission (TJC)
Centers for Medicare and Medicaid Services
(CMS)
Quality Improvement Organizations (QIO)
14
Healthgrades.com
15
ICD-10: Advancing Healthcare…
The Federal Government through CMS is driving the healthcare industry to upgrade diagnosis and procedure coding standards
(ICD-10) by October 1, 2015.
ICD-10 Changes
ICD-10
(International Classification
Implications
Significant Increase in Clinical Granularity
of Diseases version 10)
• The ICD is the
international standard
diagnostic classification
for general
epidemiological, health
management purposes
and clinical use.
• ICD-10 CM & PCS is an
upgrade of the U.S.
developed Clinical
modification (ICD-9CM) of Diagnosis and
Procedure Codes, first
adopted in 1979.
ICD-9 CM (Diagnosis)
3-5 characters
alphanumeric
>14,000 unique codes
ICD-9 CM (Procedure)
ICD-9 CM (Procedure)
3-45 characters
digits
numeric
> 4,000 unique codes
> 4,000 unique codes
ICD-10 CM (Diagnosis)
3-7 alphanumeric
characters
> 68,000 unique codes
ICD-10 CM (Procedure)
7 alphanumeric
characters
> 72,000 unique codes
Pervasive Impacts
• Diagnosis codes and procedure
codes flow through mission critical
operational systems and analytical
tools
• Alignment of technology
remediation with business and
technology strategies
• Business process reengineering,
training and change management
is essential
Comprehensive Benefits
• Quality Measurement
• Public Health Disease Surveillance
• Clinical Research
• Organizational Monitoring and
Performance
• Reimbursement
The Basics of the ICD-10-CM Change
The ICD-10-CM diagnosis code set is a full replacement of the ICD-9 code set that will provide additional granularity for diagnosis and procedure
codes. This additional granularity is the primary driver of value.
An Example of Structural Change
ICD-9
X
X
X
ICD-10-CM
.
Category
X
X
X
Etiology, anatomic
site, manifestation
X
Category
An Example of One ICD-9 code being
Represented by Multiple ICD-10 Codes
X
.
X
X
X
X
Etiology, anatomic
site, manifestation
E
1
Extension
0
.
4
.
4
0
Type 1 diabetes mellitus with diabetic neuropathy,
unspecified
2
5
0
.
6
1
Diabetes mellitus with neurological
manifestations type I not stated as
uncontrolled
One ICD-9
code is
represented by
multiple ICD10 codes
E
1
0
1
Type 1 diabetes mellitus with diabetic mononeuropathy
E
1
0
.
.
4
4
Type 1 diabetes mellitus with diabetic amyotrophy
E
1
0
4
9
Type 1 diabetes mellitus with other diabetic neurological
complication
The industry expects that mapping ICD-9 and ICD-10 codes will be a complex
task
The Basics of the ICD-10-PCS Change
The ICD-10-PCS is an American procedure coding system that represents a significant step toward building a health information infrastructure
that functions optimally in the electronic age.
An Example of Structural Change
ICD-9
X
X
.
ICD-10-PCS
X
X
An Example of One ICD-9 code being
Represented by Multiple ICD-10 Codes
X
X
X
X
X
X
X
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
0SRB07Z Replacement of Left Hip Joint with Autologous Tissue Substitute, Open Approach
0SRB0KZ Replacement of Left Hip Joint with Nonautologous Tissue Substitute, Open Approach
0SRB0J7 Replacement of Left Hip Joint with Synthetic Substitute, Ceramic on Ceramic, Open Approach
0SRB0J8 Replacement of Left Hip Joint with Synthetic Substitute, Ceramic on Polyethylene, Open Approach
0SRB0J6 Replacement of Left Hip Joint with Synthetic Substitute, Metal on Metal, Open Approach
8
1
.
0SRB0J5 Replacement of Left Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach
5
Total hip replacement
1
One ICD-9
code is
represented by
multiple ICD10 codes
0SRB0JZ Replacement of Left Hip Joint with Synthetic Substitute, Open Approach
0SR907Z Replacement of Right Hip Joint with Autologous Tissue Substitute, Open Approach
0SR90KZ Replacement of Right Hip Joint with Nonautologous Tissue Substitute, Open Approach
0SR90J7 Replacement of Right Hip Joint with Synthetic Substitute, Ceramic on Ceramic, Open Approach
0SR90J8 Replacement of Right Hip Joint with Synthetic Substitute, Ceramic on Polyethylene, Open Approach
0SR90J6 Replacement of Right Hip Joint with Synthetic Substitute, Metal on Metal, Open Approach
0SR90J5 Replacement of Right Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach
0SR90JZ Replacement of Right Hip Joint with Synthetic Substitute, Open Approach
ICD-10 Coding Snapshot:
Diabetes Scenario
• A 68 y/o male has type I diabetes with diabetic chronic
kidney disease stage 3, is being seen for regulation of
insulin dosage. The patient has an abscessed right
molar, which was determined, in part, to be
responsible for elevation of the patient’s blood sugar.
• ICD-10 codes:
–
–
–
–
E10.22
N18.3
K04.7
Z79.4
Diabetes type 1 with CKD
CKD Stage 3
Abscess Tooth
Long term drug therapy, insulin
ICD-10 Physician Education
Don’t need to turn doctors into coders
We Need good documentation habits
We Need specialty specific documentation
education
We need to Begin the process of education
now for ICD-9 and incorporate ICD-10 issues
into the education as we prepare for Oct. 1,
2014 (Now 2015)
UNMH & SRMC- CMI
(Case Mix Indicator)
1.7500
1.7000
1.6500
1.6000
1.5500
SRMC
UNMH Overall
1.5000
1.4500
1.4000
1.3500
1.3000
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
UNMH- Facility-Wide SOI
(Severity of Illness Indicator
900
800
700
600
1
500
2
3
400
4
300
200
100
0
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
UNMH- Facility-Wide ROM
(Risk of Mortality Indicator)
1600
1400
1200
1000
1
2
800
3
4
600
400
200
0
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
SRMC - SOI
120
100
80
1
2
60
3
4
40
20
0
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
SRMC - ROM
160
140
120
100
1
2
80
3
4
60
40
20
0
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
DoIM UNMH - CMI
3.4000
3.2000
3.0000
2.8000
2.6000
DoIM
2.4000
Cardiology
Medicine - Hospitalists
2.2000
MICU
UNMH Overall
2.0000
1.8000
1.6000
1.4000
1.2000
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
DoIM UNMH - SOI
180
160
140
120
1
100
2
3
80
4
60
40
20
0
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
DoIM UNMH - ROM
160
140
120
100
1
2
80
3
4
60
40
20
0
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
DoIM – Hospitalists UNMH - SOI
180
160
140
120
1
100
2
3
80
4
60
40
20
0
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
DoIM – Hospitalists UNMH - ROM
160
140
120
100
1
2
80
3
4
60
40
20
0
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
April Discharges – Ortho
Major Joint Replacement – Lower Extremity
4
3
ROM
SOI
2
1
0
5
10
15
20
25
30
35
40
45
50
Sepsis
•
•
•
•
•
•
SIRS Criteria
Assess for 2 or more
(Fever) Temp > 38⁰C or < 36⁰C
(Tachycardia) HR > 90
(Tachypnea) Resp rate > 20 or pa CO₂ < 32
(Leucocytosis/Leukopenia) WBC > 12K, < 4K, or
> 10% bands
SIRS: Suspected Infection
If infection is known:
• Document organism and site
• Document whether infection is present on
admission
• May document possible, probable, likely or
suspected sepsis
• Complete Sepsis M-Page
• Determine Sepsis Severity
Sepsis Severity
Sepsis
• Lactate levels
documented
• No organ dysfunction
• No hypotension
Severe Sepsis
• Lactate levels
• Organ failure
– Organ dysfunction must be
linked to the Sepsis *
(Occult) Septic Shock
(Written as Septic Shock)
• Lactate levels
• No hypotension
Septic Shock
Written as Septic Shock
• Hypotension
• Refractory to IV fluids
*see organ reference pages
SMITE Bundle
Basic SMITE Bundle
1. Lactate q 4h x2
2. Blood Culture
3. Antibiotics within 1 h
4. Fluids
5. Re-evaluate as needed
Advanced SMITE Bundle
Basic Bundle Plus:
5. Fluids bolus
6. CVP
7. Vasopressors
Severe Sepsis : Organ Dysfunction
Documentation of
• (Encephalopathy) Altered mental status
• (Acute kidney injury) Creat levels/abnormal labs
• (Acute liver failure) Abnormal LFTs/Total Bili
• (Coagulopathy) INR level documented
• (Acute respiratory failure) Hypoxemia and/or
hypercapnia
*Please refer to organ reference for detailed
documentation suggestions
Case Study #1
MS DRG –178 Respiratory Infections & Inflammations w CC
PDX: Cystic Fibrosis with pulmonary manifestations
SDX: protein-calorie malnutrition. GERD, several other dx
SOI level: 3
ROM level: 2
DRG Wt. 1.4403
DRG Reimb: $13,091.09
Additional documentation in chart CDI Queries for: nutrition note
documentation, malnutrition related to CF. Pt with BMI 15.9 on high calorie diet
and clinimixi at 80 cc an hr for nutritional support. Malnutrition documented on
PN. CDI query for the severity of the malnutrition. If provider agreed with query
and documents severe protein calorie malnutrition.
MD DRG-177 Respiratory Infections & Inflamations w MCC
SOI level: 3
ROM level: 3
DRG WT. 2.0549
DRG Reimb: $18,677.24
Case Study # 2
MS DRG –872 Septicemia or Severe Sepsis w/o MCC
PDX: Septicemia due to E coli
SDX: protein calorie malnutrition, DM without complications type II, acute
pancreatitis
SOI level: 3
ROM level: 2
DRG Wt. 1.0687
DRG Reimb $8,120.74
Additional documentation in chart: Sepsis with AMS
CDI Queries for: Specific type of Encephalopathy . If provider agrees and documents
metabolic encephalopathy
MS DRG-871 Septicemia or Severe Sepsis W MCC
SOI level: 3
ROM level: 3
DRG WT. 1.8527
DRG Reimb: $14,078.15
Department Training Schedule
• Level I Training – Completed by April 30, 2014
• Level II Training – Completed by June 1, 2014
• Level III Training – Expectation: You are here
– Dept Champion (s) Complete 1:1 training by June 1, 2014
– All Dept. Specialty Training to be completed in June/July
2014 for ICD-10: Date to be determined by UNM HSC (RFP
Vender selection underway 6/1/14
– Metrics & Measures part of Monthly Department
Meetings by June 2014
– Top Dx/Tip Sheets & All Staff Trained by Dept/Div
Champions by June 30, 2014
Upcoming in Fall 2014:
• Dept./Div. Specialty-Specific CDI Training
– Vendor Proposals for Level III Training chosen by
RFP Committee. Next steps:
– Top vendors on-site to demonstrate their sub-specialty
training method & tools – week of July 21
– Encourage All Dept/Division Champions and anyone else
interested to attend
– Dept/Division – Specialty Specific ICD-10 Documentation
Sessions to be scheduled in the Fall of 2014 (following UNM
HSC approval of vendor and purchase)
Contacts
UNMH Coding & Clinical
Documentation
CDI Information to be posted on the
following web site:
Erlinda Smith, CCS
UNMH Coding Educator (Inpatient)
[email protected]
https://hospitals.health.unm.edu/int
ranet/HIM
Kayode Balogun, MD, CCS
CDI Program Manager, UNMH
[email protected]
Provider Documentation and ICD-10
Tab
Catherine Porto, RHIA, MPA, CHP
Exec. Director HIM
[email protected]
41