Transcript Auditing & Monitoring

Auditing & Monitoring
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
Vidant Medical Center
Auditing & Monitor
• What is the overall desired goal?
• Are there sources of guidance or
references?
• What is auditing?
• What is monitoring?
• How does auditing fit in?
• What are some of the tools & resources?
Auditing & Monitor
The General Goal:
Auditing & Monitor
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What is being achieved by our CDI program
How well is it being done
What are the improvement opportunities
Where are the areas that need special focus
Focus topics for education
• What are your program’s goals?
AHIMA 2010 CDI Tool kit
• What Are CDI Goals?
– Identify and clarify missing, conflicting, or nonspecific physician
documentation related to diagnoses and procedures
– Support accurate diagnostic and procedural coding, DRG assignment,
severity of illness, and expected risk of mortality, leading to appropriate
reimbursement
– Promote health record completion during the patient‘s course of care
– Improve communication between physicians and other members of the
healthcare team
– Provide education
– Improve documentation to reflect quality and outcome scores
– Improve coders‘ clinical knowledge
• Tracking the CDI program results is key to demonstrating that the
goals of the program are being achieved
Auditing & Monitor
• Tools & Resources
– Internal data gathering, processing & analysis
– Consultant engagements
– CMS annual data
– UHC & other organizations to benchmark
– ACDIS surveys
– AHIMA standards
Auditing & Monitor
• Monitoring: Outcomes & measures
– Data & Metrics
– Measures
– Compare to benchmarks
• Should drill down to individual staff
• Useful flags to identify trends, excellence,
areas of concern
• Identify areas of focus or special studies
ACDIS 2010 Physician Query Benchmarking Report
Items Monitored
• 71% Origin of query
• 78% Name of query author
• 88% Name of physician
• 58% Method (written,verbal)
• 46% Paraphrase verbal query
& response
• 64% Focus of query (DRG,
SOI/ROM, etc.)
• 84% Physician agreement
• 60 – 70% DRGs (initial,
potential, working, final)
• 58% CDS / Coding agreement
• 59% # reviews per day
• 44% # re-reviews per day
• 63% CC/MCC capture rate
• 70% Query rate by CDS
• 58% Query rate by physician
• 73% Financial impact of
queries
• 43% SOI / other impact
• 75% rate for positive & negative
responses
Auditing & Monitor
• Basic Benchmarks:
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18% Query Rate (10 – 30%)
87% Physician Response (>70%)
88% Physician Agreement ( 70 – 95%)
12 New charts per day (6 – 20)
• 92% target < = 48 hours
– 12 Re-reviews per day (6 – 20)
• 58% daily, 24% every other day
– Staffing basis 152 discharges per CDS per month
– 50% CDI Programs have a Physician Advisor
• Variable time, about 50% good or better effectiveness
– 3-5% CDI programs 10 years or older
Auditing & Monitor
• Auditing: Doing the right thing at the right
time in the right way
– Active examination
– Application & comparison standards
• Benchmarking data
• P&P
• Available guidance
Auditing & Monitor
• Key Guidance (AHIMA):
– Managing an Effective Query Process
– Guidance for CDI Programs
– CDI Tool Kit
• Background of current state (2010)
– ACDIS Physician Query Benchmarking Report
– ACDIS CDI Program Benchmarking Survey
– ACDIS White paper: CDI Staffing Survey
– ACDIS On-line polls
Auditing & Monitor
Critical importance:
• Establishing written policies & procedures to establish
expectations and standards
• Ensure consistent CDI practices
• Define among other elements:
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Compliant query practices
Indications of when to query
Process
Who / how / when
Resolution
Background of individuals who do query
Auditing & Monitor
8/16/10 Does your CDI program have written policies and procedures in place?
35%
30%
25%
20%
32%
15%
26%
10%
14%
5%
12%
10%
6%
0%
Yes, we have created Yes, we have created a
multiple, detailed P&P
few P&P
Yes, we use P&P
developed by a
consulting firm
No, but we are
currently developing
P&P
No, but we plan to No, we do not have P&P
develop P&P when we
have time
ACDIS 2010 Physician Query Benchmarking Report
2010 ACDIS Query Benchmark Survey
80%
70%
67%
60%
51%
50%
39%
40%
26%
30%
20%
10%
8%
10%
0%
Yes
No
Don't know
Does your facility have a standard policy for written/electronic
queries?
Yes
No
Don't know
Does your facility have a standard policy for verbal queries?
AHIMA Query Brief: P&P
• The healthcare entity’s documentation or compliance policies can
address situations such as:
– unnecessary queries,
– leading queries,
– repetitive overuse of queries without measureable improvement in
documentation,
– and methods for provider education
• Permanence and retention of the completed query form should be
addressed in the healthcare entity’s policy
• policy should specify whether the completed query will be a
permanent part of the patient’s health record
• query policy should address the question of who to query (could
include the attending physician, consulting physician, or the surgeon)
• address the issue of yes/no queries in their policies
AHIMA 2010 CDI Program Guidance: P&P
• The CDI department must be governed by written policies and
procedures. These policies and procedures should be developed with
the assistance of other departments affected by clinical
documentation, including compliance, case management, and HIM.
CDI policies can include (but are not limited to) education,
experience, and credentials for hiring CDI professionals; initial
orientation and training; ongoing education and training; compliant
query practices; and a CDI quality assurance process
• Organizations require comprehensive, facility-specific policies and
procedures that govern the CDI clarification process. These should
include, but are not limited to, when and how to format an appropriate
question to a provider (verbal and written queries), query retention,
and conducting audit and monitoring activities to determine the
appropriateness and effectiveness of the CDI program.
AHIMA 2010 CDI Program Guidance: P&P
• Organizations should also outline the following procedures for written
queries:
– A protocol to identify where queries are placed in the medical record
– A process for notifying the medical staff of the presence of a query in the
medical record
– A protocol to address open (concurrent) queries, including:
• How frequently open queries will be addressed
• How long queries are allowed to remain unanswered or open
• How queries opened under concurrent review are addressed when the patient
is discharged
• without a response
– A protocol for query maintenance
– A QA process of written queries, including:
• Who will monitor the written queries
• How many queries will be reviewed for compliance and how often
• The feedback and corrective action needed, including who will take corrective
action and when
• Reporting documents for CDI QA processes
AHIMA 2010 CDI Program Guidance: P&P
• Organizations should outline the following procedures for
verbal queries:
– When verbal queries are appropriate
– An initial and ongoing training process that includes mentoring
and testing trainees and a process for ongoing compliance
monitoring
– A process for documenting the verbal queries
• A QA process of verbal queries, including:
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Who will monitor the verbal queries
How many queries will be reviewed for compliance and how often
The feedback and corrective action needed
Reporting documents for CDI QA processes
AHIMA 2008 Managing an Effective Query Process
• Since the query process has become a tool to improve
provider documentation, it is critical that the design of
these processes be maintained with legal, regulatory, and
ethical issues in mind. Healthcare entities can create and
maintain a compliant query process by:
– Creating comprehensive policies and procedures for query
processes
– Generating queries only when documentation is conflicting,
incomplete, or ambiguous
– Conducting auditing and monitoring activities to determine the
effectiveness of the query process
– Providing education and training for the staff involved in
conducting provider queries
AHIMA 2008 Managing an Effective Query Process
• Healthcare entities should consider establishing an auditing and
monitoring program as a means to improve their query processes
• Queries can be reviewed retrospectively to ensure that they are
completed according to documented policies
– That the query was necessary
– That the language used in the query was not leading or otherwise
inappropriate
– That the query did not introduce new information from the health record
• the healthcare entity may need to identify follow-up actions
– codes be corrected
– tracked and trended
– appropriate education and training
AHIMA 2008 Managing an Effective Query Process
• reviewing both performance measures and
compliance monitors, the errors related to
documentation will become apparent
• Healthcare entities should have a process in
place to support and educate the staff involved in
conducting provider queries. Ongoing education
and training is a key component of the auditing
and monitoring process
Auditing & Monitor
39 1/23/09 Does your facility maintain two separate query policies for CDI and coding?
45%
40%
35%
30%
25%
43%
20%
28%
15%
29%
10%
5%
0%
Yes, our nurses/CDI staff are
allowed more flexible queries
No, we have one policy for all staff
who query
We don't have a query policy
Auditing & Monitor
What is your process/policy for ensuring that physician queries are compliant (i.e., non-leading)?
60%
50%
40%
30%
52%
20%
21%
10%
16%
6%
6%
0%
Rvw all queries at regular Rvw random sample when
intervals (monly/ qtrly/
we have time
yrly)
Outside auditor
Other
Don't audit our queries for
compliance
Auditing & Monitor
77 2/9/10 Do you audit your CDI specialists queries (e.g., for compliance, effectiveness, completeness,
etc.)?
60%
50%
40%
30%
51%
36%
20%
13%
10%
0%
Yes
No
Not currently, but we plan to do this
Auditing & Monitor
9/16/10 Are you following the latest AHIMA physician query guidance
(Guidance for Clinical Documentation Improvement Programs)?
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
48%
17%
13%
8%
14%
Yes, everyone who Yes, we follow most Our HIM/coding No, we have our Don't know/have not
queries/clarifies of the recommended department follows own internal set of read latest AHIMA
documentation with
guidance
it, but our CDI query guidelines that query guidance
physicians follows it
specialists have their
we follow
own query policy
ACDIS 2010 Physician Query Benchmarking Report
2010 ACDIS Query Benchmarking Survey
60%
54%
50%
40%
30%
21%
20%
12%
7%
10%
4%
1%
0%
Yes, fully
Yes, partially
Yes, partially -- we have
separate policies (HIMS
fully, CDI do not)
Don't know / haven't
read
No, we follow our
internal set of guidance
Other
Do your query forms follow the American Health Information Management Association (AHIMA) physician query guidance?
ACDIS 2010 Physician Query Benchmarking Report
ACDIS 2010 Query Benchmarking Survey
30%
28%
28%
25%
20%
15%
15%
12%
10%
8%
4%
5%
5%
1%
0%
Monthly
Quarterly
Biannually
Yearly
Once every 2 or
3 years
As needed
How often do you review/audit your query forms for compliance?
We do not
review them
Other
ACDIS 2010 Physician Query Benchmarking Report
ACDIS 2010 Query Benchmarking Report
50%
45%
45%
40%
35%
31%
30%
25%
23%
25%
22%
20%
15%
11%
10%
7%
7%
Physician
Advisor
Other
5%
0%
Self Auditing
CDI Peers
CDI Manager
Consultant
Compliance
HIMS / Coding
If you do audit your query forms for compliance, Who does the reviews (check all that apply)?
ACDIS 2010 Physician Query Benchmarking Report
2010 ACDIS Query Benchmark Report
60%
52%
48%
50%
40%
40%
36%
35%
38%
26%
30%
30%
20%
7%
10%
0%
Unnecessary
Queries
Leading
Queries
Wording /
Clarity
Missed Query
NonOpportunity compliance
with
standards
Not clinically Inaccurate
supported / information
appropriate
on form
We don't
monitor
queries for
quality
Do you audit/monitor the following indicators for query quality (check all that apply)?
Other
AHIMA 2008 Managing an Effective Query Process
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conducted on a regular basis.
include a representative sample of total queries
as well as a sampling by individuals initiating the query
Effective elements of an auditing and monitoring program include
– percentage of negative and positive provider responses
• high negative response rate
• may indicate overuse of the query by the coding staff; a high positive
response rate may indicate a
• pattern of incomplete documentation that needs further investigation
– format of query forms – may lead to specific education
– individual providers to indicate improvement in health record
documentation…result in a decreased number of queries for an individual
provider
– high-risk or problem diagnoses. The results may determine whether
additional
– education resulted in a decreased number of queries for a particular
diagnosis
Reasons to Query:
AHIMA Query Brief
• Queries may be made in situations such as the following:
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Clinical indicators of a diagnosis but no documentation of the condition
Clinical evidence for a higher degree of specificity or severity
A cause-and-effect relationship between two conditions or organism
An underlying cause when admitted with symptoms
Only the treatment is documented (without a diagnosis documented)
Present on admission (POA) indicator status
• A query should be initiated when there is conflicting, incomplete, or
ambiguous documentation in the health record or additional
information is needed for correct assignment of the POA indicator.
• whenever there is conflicting, ambiguous, or incomplete information in
the health record regarding any significant reportable condition or
procedure
Reasons to Query:
AHIMA Query Brief
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consider a policy in which queries may be appropriate when documentation in the
patient’s record fails to meet one of the following five criteria:
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Legibility. This might include an illegible handwritten entry in the provider’s progress notes,
and the reader cannot determine the provider’s assessment on the date of discharge.
Completeness. This might include a report indicating abnormal test results without notation of
the clinical significance of these results (e.g., an x-ray shows a compression fracture of lumbar
vertebrae in a patient with osteoporosis and no evidence of injury).
Clarity. This might include patient diagnosis noted without statement of a cause or suspected
cause (e.g., the patient is admitted with abdominal pain, fever, and chest pain and no
underlying cause or suspected cause is documented).
Consistency. This might include a disagreement between two or more treating providers with
respect to a diagnosis (e.g., the patient presents with shortness of breath. The pulmonologist
documents pneumonia as the cause, and the attending documents congestive heart failure as
the cause).
Precision. This might include an instance where clinical reports and clinical condition suggest
a more specific diagnosis than is documented (e.g., congestive heart failure is documented
when an echocardiogram and the patient’s documented clinical condition on admission
suggest acute or chronic diastolic congestive heart failure).
AHIMA 2008 Managing an Effective Query Process
• Queries should not be used to question a
provider’s clinical judgment … a healthcare
entity’s policies can provide guidance on a
process for addressing the issue without
querying the attending physician
AHIMA 2008 Managing an Effective Query Process
• A query generally includes the following information:
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Patient name
Admission date and/or date of service
Health record number
Account number
Date query initiated
Name and contact information of the individual initiating the query
Statement of the issue in the form of a question along with clinical
indicators specified from the chart
• The preferred formats for capturing the query include facility-approved
query form, facsimile transmission, electronic communication on
secure e-mail, or secure IT messaging system
• Verbal queries have become more common as a component of the
concurrent query process … entities should develop specific policies
to clearly address this practice and avoid potential compliance risks
AHIMA 2008 Managing an Effective Query Process
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Queries be written with precise language, identifying clinical indications from the health
record and asking the provider to make a clinical interpretation of these facts based on
his or her professional judgment of the case. The query format should not sound
presumptive, directing, prodding, probing, or as though the provider is being led to
make an assumption.
The introduction of new information not previously documented in the medical record is
inappropriate in a provider query
In general, query forms should not be designed to ask questions about a diagnosis or
procedure that can be responded to in a yes/no fashion. The exception is present on
admission (POA) queries when the diagnosis has already been documented.
Multiple choice formats that employ checkboxes may be used as long as all clinically
reasonable choices are listed, regardless of the impact on reimbursement or quality
reporting. The choices should also include an “other” option, with a line that allows the
provider to add free text. Providers should also be given the choice of “unable to
determine.” This format is designed to make multiple choice questions as open ended
as possible.
A single query form can be used to address multiple questions. If it is, a distinct
question should be asked for each issue
the query should never indicate that a particular response would favorably or
unfavorably affect reimbursement or quality reporting
AHIMA 2010 CDI Program Guidance: Queries
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the term “query” will be used to identify any physician communication tool
A query is a routine communication and education tool used to advocate
complete and compliant documentation. Although AHIMA refers to this
communication to providers as a “query,” CDI programs may use different
names, such as clinical clarification, documentation alerts, and
documentation clarification. Regardless of what the communication is called,
the query should adhere to the guidance outlined in the 2008 practice brief
“Managing an Effective Query Process” and this current practice Guidance
for Clinical Documentation Improvement Programs brief.
Typical situations addressed by a query include presenting clinical indicators
of an undocumented condition, requesting further specificity or the degree of
severity of a documented condition, clarifying a potential cause and effect
relationship, and addressing present on admission issues.
AHIMA 2010 CDI Program Guidance: Queries
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the standard query [template] should be individualized to each patient and
contain clinical evidence specific to the case
Template queries should not be titled with a diagnosis that has not already
been documented in the health record, as this may prejudice the provider’s
response
CDI professionals must craft their queries skillfully. The query should assist
the physician in understanding the documentation problem without leading
the provider to a particular conclusion.
The advantage of a verbal query is the ability to interact with the provider to
facilitate understanding of the issues that need to be addressed. However,
caution must be used to ensure that the provider is allowed to make his or
her own conclusions
One of the main challenges of a verbal query is accurate documentation of
the interaction. What, where, and how it should be documented are all issues
to be addressed by policies and procedures
AHIMA 2010 CDI Program Guidance: Queries
• All written queries should include the following
standard elements:
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Patient name
Admission date and time
Account number
Medical record number
Date the query is initiated
Contact information of the CDI professional
Individualized diagnosis-specific templates to the
particular patient, which provide clinical evidence
relevant to the particular patient
AHIMA 2010 CDI Tool kit:
CDI Quality Assurance Audit Tool
CDI Quality Assurance Audit Tool
• helps monitor the work of the CDI professional
• checks and balances in place to ensure the highest level
of integrity as CDI programs are likely to be scrutinized
during external audits … aid in achieving a successful and
compliant program
• no recommendations as to how often these reviews
should be completed and what volume of cases should be
reviewed … each organization specify the frequency and
volume of audits within its departmental policy
AHIMA 2010 CDI Tool kit:
CDI Quality Assurance Audit Tool
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support the appropriateness of the query
evidence of a missing or incomplete diagnosis to illustrate the query is not an attempt
to introduce new information
issued query did not rely on a yes/agree or no/disagree response
ensure the revised documentation is present in the health record
physician response is twofold: did the physician respond, and if so, what was the
physician‘s response.
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Lack of response represents a different problem than a lack of agreement.
A low agreement rate by the physicians may be an indicator of inappropriate queries or poorly
constructed queries.
Conversely, an agreement rate of 100 percent may also be indicative of a problem, as
physicians may not perceive the ability to disagree with queries
focus on the ability of the CDI professional to correctly identify the need for additional
documentation and additional reviews
identify differences between the final working DRG as determined by the CDI
professional and the billed DRG
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CDI professional is not a coder may expect DRG disagreements due to coding rules,
inadequately capturing procedures
complicating conditions that arise after the CDI review
other causes of disagreements may be learning opportunities for the CDI professional
AHIMA 2010 CDI Tool kit:
CDI Quality Assurance Audit Tool
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Clinical Documentation Improvement
Quality Assurance Audit Tool
Name of CDI staff:
___________________________
Review date: __________________
MR# of reviewed chart: _________________
Admission Date: ________
D/C Date: _______
Date of Initial CDI review: _______________
Date of subsequent review(s) ____________
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Did the query contain relevant medical evidence?
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Could the query be perceived as leading?
Did the physician respond to the query?
Did the physician agree with the recommendation?
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Was the additional documentation added to the health
record?
Were all opportunities for Present on Admission (POA)
clarified?
Was there clinical evidence of a diagnosis, which did not
result in a query?
Was there clinical evidence of a procedure, which did not
result in a query?
Were subsequent reviews performed?
If more than one review occurred, were the subsequent
reviews at appropriate intervals?
Was the working DRG revised during the review process?
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Was the final working DRG the same as the billed DRG?
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If not, what was the difference between the two DRGs i.e.,
CC found, CC not verified, etc.?
What were the medical evidence and the possible diagnosis
and/or procedure?
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Which of the following was the rational for
issuing the query? The documentation was
(circle all that apply):
– Illegible
– Incomplete
– Unclear
– Inconsistent
– Imprecise
– Conflicting documentation
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Auditing & Monitor
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Based on medical record information & physician documentation at the time of the
Final DRG assignment…
CDS Review Process
• Initial and Poss PDX assignment supported with tx, monitoring, and/or evaluation etc.
• Initial and Poss Secondary Diagnoses (CC/MCC) supported with tx,
• DRG assignment was reflective of the highest documented severity i.e most optimal
and within the appropriate MDC?
• Identified query opportunity initiated?
Query
• Was the query necessary, based on the need for Present On Admission status, clinical
indicators for a higher degree of specificity, conflicting, incomplete, or ambiguous
(diagnoses that may have multiple impressions) documentation?
• Was the query language appropriate, based on clinical S&S, treatment, or other
information from the medical record?*
• Was the query addressed to the appropriate provider (based on the query policy)
•
Did the query allow the provider options: The query allowed the physician to render his
own clinical judgment?
Auditing & Monitor
• How to apply – varies by size, staff,
organization…
• Audit even for standard query forms without
customization