Data Abstraction and Validation Updates Changes effective with 1012006 discharges

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Data Abstraction and Validation Updates
Changes effective with 10/1/2006 discharges
Diana Smith, Senior Clinical IS
Specialist December 14, 2006
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Topics for Discussion

• Validation Requirements
• Validation Process
• Validation Errors Q1 2006
• Q4 2006 Changes/Updates
• AMI
• HF

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Validation Requirements

• Validation requires complete medical record for
  acute inpatient stays only.
• All payer sources
• Topic-specific populations
• All data submitted to the QIO Clinical Warehouse
  is subject to validation.
• Hospitals must achieve 80 or better to be
  considered passing validation.
• Validation records are selected approximately one
  week following a data submission deadline.

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Validation Process

• Hospital staff (Quality and HIM)
• Audit copies for completeness.
• Hold copy services accountable for timely copying
  and submission of complete records.
• Attach the green cover sheet to each record.
• Send charts via FedEx retain tracking number.
• Monitor CDAC receipt of records via QualityNet
  Case Selection Report.

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Validation Tips to Remember

• CDAC staff performs complete re-abstraction.
• Do not mark charts going to the CDAC to highlight
  answers.
• Submit all documents used by abstractor, i.e. lab
  reports, electronic MAR, etc.
• GMCF will review appeal CMS monitors QIO
  overturns.

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Validation Errors Q1 2006

• Common Mismatches
• Non-abstraction mismatches
• Wrong chart
• Wrong admission
• Missing pages
• Copy quality
• Observation and swing bed stays

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Validation Errors Q1 2006

• Frequent Data Element Mismatches
• Admission Source
• Comfort Measure Only
• Discharge Instructions
• Discharge Status
• LVSD
• Medication Contraindications
• Smoking History/Counseling
• Transfer from another ED

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Admission Source

• The intent of the admission source is to look at
  where the patient was admitted from.
• For validation purposes it is important that the
  medical record reflect the admission source, as
  the CDAC does not have access to the UB and can
  only validate from the medical record.

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Admission SourceCase Scenario

• Physician Referral, Clinic Referral, and HMO
  Referral
• If the medical record reflects that the patient
  was received as a direct admit from Hospital As
  ED to Hospital B. Admission Source 1
  Physician referral.
• If the medical record reflects that patient was
  admitted as a direct admit from a physicians
  office. Admission Source 1 Physician
  referral.

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Admission Source Case Scenario

• If the medical record reflects that the patient
  was admitted to XYZ Hospital from XYZ Physician
  Clinic. Admission Source 2 Clinic referral
• If the medical record reflects that the patient
  was admitted to XYZ Hospital from clinic.
  Admission Source 1 Physician referral, even if
  the abstractor knew that the clinic was owned by
  the facility.
• HMO referral would only be used if the medical
  record reflected that the patient was admitted to
  their facility upon recommendation of a health
  maintenance organization physician.

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Admission Source Case Scenario

• Transfer from a hospital (Different
  Facility), Skilled Nursing Facility, Another
  Health Care Facility
• If the medical record reflects that the patient
  was admitted to Hospital B as a transfer from
  Hospital A where they were an inpatient.
  Admission Source 4 Transfer from a hospital
• If the medical record reflects that patient was a
  direct admit from the skilled care unit of XYZ
  Nursing Home. Admission source 5 Skilled
  Nursing Facility

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Admission Source Case Scenario

• If the medical record reflects only that the
  patient was a direct admit from XYZ Nursing Home.
  Admission source 6 Transfer from Another
  Health Care Facility
• If the medical record reflects that the patient
  was received as a transfer from XYZ Long Term
  Care Hospital. Admission source 6 Transfer
  from Another Health Care Facility
• If the medical record reflects only that the
  patient was received as a transfer from XYZ
  Hospital. Admission source would be 4, even
  though the abstractor knew it was a LTCH.

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Admission Source Case Scenario

• Emergency Room (7)
• Used if the medical record reflects that the
  patient was evaluated and/or treated and admitted
  to acute inpatient status from your facilitys
  Emergency Department
• Used regardless if the physician was the EDs
  physician, personal physician or a consulting
  physician

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Admission SourceCase Scenario

• If the medical record reflects that the patient
  was a direct admit, i.e., physician order to
  admit as direct admit to acute inpatient
  services, but the patient was held in the ED
  waiting for bed placement, then the admission
  source would be 1 physician referral.
• If the medical record reflects that the patient
  was a direct admit, was held in the ED and while
  in the ED was evaluated and/or treated, then the
  admission source would be 7 Emergency room.

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Admission SourceCase Scenario

• Transfer from a Critical Access Hospital (A),
  Transfer from Hospital Inpatient in the Same
  Facility Resulting in a Separate Claim to the
  Payer (D)
• If the medical record reflects that the patient
  was admitted from XYZ Critical Access Hospital,
  then the admission source would be A.
• If the medical record reflects that the patient
  was received as a transfer from the skilled unit
  of XYZ Hospital to acute status in XYZ Hospital,
  then the admission source would be D.

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Admission SourceCase Scenario

• If the medical record reflected only that the
  patient was admitted from XYZ Hospital, even if
  the abstractor knows that it is a CAH, the
  admission source would be 4.
• If the medical record reflected only that the
  patient was received as a transfer from a skilled
  unit to acute status then the admission source
  would be 4, even if the abstractor knew that it
  was the skilled unit of their facility.

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Comfort Measures Only

• If the status of hospice care is applicable, it
  MUST apply to the acute care stay.
• Comfort measures only are not equivalent to do
  not resuscitate (DNR), living will, no code, no
  heroic measures.

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Discharge Instructions Address Medications

• Definition written discharge instructions or
  other documentation of written material given to
  the patient/caregiver addressing the names of all
  discharge medications.

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Discharge Instructions Address Medications

• Abstraction is a two-step process
• Determine all of the medications being prescribed
  at discharge, based on available documentation
  elsewhere in the record.
• Check the list against written discharge
  instructions given to the patient to ensure that
  these instructions addressed at least the names
  of all discharge medications prescribed. If a
  list of discharge medication is not documented
  elsewhere in the record, and the completeness of
  the medication list in the medication list in the
  written discharge instructions cannot be
  confirmed, select No.

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Discharge Instructions Address Activity and Diet

• Written discharge instructions or other
  documentation of educational material given to
  patient/caregiver addressing the patients
  activity level after discharge

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Discharge Instructions Address Follow-up

• Written discharge instructions or documentation
  of educational material given to
  patient/caregiver addressing follow-up with a
  MD/ARNP/PA after discharge
• Exclusion Follow-up with MD/ARNP/PA described on
  PRN or as needed basis.

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Discharge Instructions Address Symptom Worsening

• Written discharge instructions or other
  documentation of educational material given to
  patient/caregiver addressing what to do if heart
  failure symptoms worsen after discharge
• Call MD if symptoms get worse.
• Call MD if difficulty in breathing increases.

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Discharge Status

• The values for discharge status are taken from
  the National Uniform Billing Committee (NUBC)
  manual, which is used by billing to complete the
  UB-92.
• For validation purposes it is important that the
  medical record reflect the discharge status, as
  the CDAC does not have access to the UB and can
  only validate from the medical record.

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Discharge Status 03

• Discharged/Transferred to a Skilled Nursing
  Facility (SNF)
• Used if the medical record reflects that the
  patient was discharged to a skilled nursing bed
  or facility
• Includes transfers to a rehabilitation unit that
  is located within a skilled nursing facility
• Includes transfers to a Transitional Care Unit
  (TCU)

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Discharge Status 04

• Discharged/Transferred to an Intermediate Care
  Facility (ICF)
• Should be used when the medical record reflects
  that the patient was discharged to a non-skilled,
  custodial or residential level of care
• Includes Extended Care Facility, Intermediate
  Care Facility, and Nursing Homes

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LVSD

• Defined as a left ventricular ejection fraction
  less than 40 or a narrative description
  consistent with moderate or severe systolic
  dysfunction. (Appendix H, Table 1.5)
• When there are two or more documented LVF
  numeric/narrative results, abstract the LVF
  closest to discharge
• OR closest to hospital arrival, if only
  pre-arrival LVF results are documented.

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Medication Contraindications

• Medication contraindication elements should be
  answered independently and irrespective of
  whether the patient was prescribed the medication.

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Medication Contraindications

• Absolute contraindications
• Active bleeding on arrival or within 24 hours
  after arrival (ASA on Arrival/ASA at Discharge)
• Allergy (all categories of meds)
• Heart Failure on arrival or within 24 hours after
  arrival lt90 (Beta Blocker on Arrival)
• Aortic Stenosis (ACEI/ARB)

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Medication Contraindications

• Other reason Explicit
• - Chronic hepatitis No ASA
• - COPD No BB
• - Kt 5.5 No ACEI
• Other reason Implied
• - Intolerant of ASA
• - Hold Lopressor
• - History ACEI induced cough

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Smoking History/ Counseling

• In cases where conflicting information about the
  smoking history is documented, select Yes.
• If there is documentation of current smoking or
  tobacco use, or a history of, and the type of
  product is not specified, assume this refers to
  cigarette smoking.

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Transfer from Another ED

• Notes for Abstraction
• The emergency department of another hospital
  includes both emergency room AND observation
  bed/unit stays at that hospital.
• If a patient is transferred in from the emergency
  department or observation unit of ANY outside
  hospital, option Yes should be selected,
  regardless of whether the two hospitals are close
  in proximity, part of the same hospital system,
  have a shared medical record or provider number,
  etc.

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Invalid Record Selection Q1 2006

• Invalid Record Selection the leading cause for
  validation failure in Georgia
• Submission of one incorrect record can cause
  overall validation failure.
• CDAC will not request the correct record score
  will be zero for the case(s).
• Hospitals cannot appeal.
• Wrong record non-submission

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Specification Manual for National Quality
Measures Version 2.1c

• Acute Myocardial Infarction (AMI)
• Congestive Heart Failure (HF)

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Data DictionaryVersion 4.1 - 10/1/06

• Comfort Measures Only
• Physician/NP/PA documentation that the patient
  was receiving comfort measures only anytime
  during the stay, select Yes.
• Documentation that comfort only measures are
  planned after discharge, not during this
  hospitalization, select No.
• Only accept terms identified in the list of
  inclusions. No other terminology will be accepted.

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Data DictionaryVersion 4.1 - 10/1/06

• Comfort Measures Only
• Inclusion (new terms in bold)
• Comfort care
• Comfort measures
• Comfort measures only (CMO)
• End of life care
• Hospice care
• Palliative care
• Terminal care
• V66.7 encounter for palliative care

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Data DictionaryVersion 4.1 - 10/1/06

• Comfort Measures Only
• Exclusion Added
• Do not resuscitate (DNR)
• Keep comfortable
• No aggressive treatment
• No cardiopulmonary resuscitation (NCR)
• No CPR
• Supportive care

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Data DictionaryVersion 4.1 - 10/1/06

• Heart Failure Discharge Instructions
• Notes for Abstraction
• IF brochures, booklets, teaching sheets and
  electronic teaching media are given to the
  pt/caregiver, documentation must clearly convey
  the (discharge instruction category, e.g.,
  activity) instructions are included in the
  material. Only documentation in the medical
  record itself can be used.

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Data DictionaryVersion 4.1 - 10/1/06

• Heart Failure Discharge
  Instructions
• Notes for Abstraction
• When a teaching sheet, brochure, booklet,
  or other instruction material is present in the
  medical record, and there is no explicit
  documentation pt was given the discharge
  instruction document, the inference only can be
  made if the medical record number appears on the
  material AND hospital staff or the
  patient/caregiver has signed the material.

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Data DictionaryVersion 4.1 - 10/1/06

• Heart Failure Discharge Instructions
• Notes for Abstraction
• Some hospitals use brochures, booklets, and
  teaching sheets to provide written instructions
  to the patient. Others use electronically
  formatted media such as videos, CDs, and DVDs,
  which are also acceptable educational materials.
  In these cases, the following guidelines apply
• Documentation must clearly convey that activity
  instructions are included in the material. Use
  only the documentation provided in the medical
  record itself. If literature is located outside
  of the medical record, it should not be reviewed
  and used in abstraction.

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Data DictionaryVersion 4.1 - 10/1/06

• Illegible
  Handwriting
• All documentation in the medical record must be
  legible and complete, and identified by name and
  discipline by the person who is responsible for
  ordering, providing, or evaluating the service
  provided.
• When abstracting the medical record, if the CDAC
  is unable to verify an answer due to illegible
  handwriting, the documentation in question will
  not be used.

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Data DictionaryVersion 4.1 - 10/1/06

• National Provider Identifier (NPI) - optional
  data element beginning 10/1/2006
• Patient HIC - change length from 9-12 to
  7-12.

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Data DictionaryVersion 4.1 - 10/1/06

• Undated Medication Administration Record
• If, in the course of abstraction, an undated MAR
  is found in the medical record, it cannot be
  used.
• Handwritten MARs must have the administration
  date documented on the form.
• Handwritten MARs that only have the start/stop
  dates of each medication will not be sufficient
  as they would not reflect the actual
  administration date.
• For EHRs only, accept documentation that reflects
  the actual administration of the medication in
  the context of the chart.

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Resources

• Specifications Manual for National Hospital
  Quality Measures http//xrl.us.stcp
• QualityNet Quest http//xrl.us/s4yv
• MedQIC http//xrl.us/to9y
• GMCF Website http//gmcf.org
• QualityNet-Help Desk qnetsupport_at_rfmc.sdps.org
  or [phone]

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The Right Care for Every Person Every Time
This material was prepared by GMCF under contract
with the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not
necessarily reflect CMS policy. Publication No.
8SOW-GA-HOSP-06-137