Level II Training Clinical Documentation Improvement

1
Level II TrainingClinical 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

2
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

3
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

4
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

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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
• lt1 Below average
• gt1 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.

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Secondary Data UsesThe 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. Minor
• 2. Moderate
• 3. Major
• 4. 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 MS DRG 193 with MCC MS DRG 193 with MCC MS DRG 177 with MCC
           
PDX Pneumonia, organism Unspecified PDx Pneumonia, Organism Unspecified PDx Pneumonia Organism Unspecified PDx Pneumonia Organism Unspecified PDx Pneumonia Organism Unspecified PDx Pneumonia, Staphyloccus Aureus
           
SDx COPD SDx COPD with Exacerbation 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 (BMIlt19)
    Decubitus Ulcer Pressure Ulcer Stage IV   Pressure Ulcer, Stage IV, lower back (site needed for ICD-10)
          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
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POA and HAC

• There is a BIG difference in whether a condition
  was
• POA Present on Admission documentation in the
  HP or progress notes after a definitive
  diagnosis is madewhether each condition was
  present on admission (providers 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

10
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 codedIP
  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 Patients 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.

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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

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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)

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Healthgrades.com
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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
Implications

• 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

• ICD-10
• (International Classification 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-9-CM) of
  Diagnosis and Procedure Codes, first adopted in
  1979.

Significant Increase in Clinical Granularity
ICD-9 CM (Diagnosis)
ICD-10 CM (Diagnosis)
3-5 characters alphanumeric
gt14,000 unique codes
ICD-9 CM (Procedure)
ICD-9 CM (Procedure)
ICD-10 CM (Procedure)
3-4 characters numeric
gt 4,000 unique codes
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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
ICD-10-CM
.
.
Etiology, anatomic site, manifestation
Category
Category
Etiology, anatomic site, manifestation
Extension
.
An Example of One ICD-9 code being Represented by
Multiple ICD-10 Codes
Type 1 diabetes mellitus with diabetic
neuropathy, unspecified
E
1
0
4
0
One ICD-9 code is represented by multiple ICD-10
codes
.
Type 1 diabetes mellitus with diabetic
mononeuropathy
E
1
0
4
1
.
Type 1 diabetes mellitus with diabetic amyotrophy
E
1
0
4
4
.
Type 1 diabetes mellitus with other diabetic
neurological complication
E
1
0
4
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The industry expects that mapping ICD-9 and
ICD-10 codes will be a complex task
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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
ICD-10-PCS
.
Section
Body System
Root Operation
Approach
Device
Qualifier
Body Part
An Example of One ICD-9 code being Represented by
Multiple ICD-10 Codes
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
0SRB0J5 Replacement of Left Hip Joint with Synthetic Substitute, Metal on Polyethylene, Open Approach
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
One ICD-9 code is represented by multiple ICD-10
codes
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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
  patients blood sugar.
• ICD-10 codes
• E10.22 Diabetes type 1 with CKD
• N18.3 CKD Stage 3
• K04.7 Abscess Tooth
• Z79.4 Long term drug therapy, insulin

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ICD-10 Physician Education

• Dont 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)

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UNMH SRMC- CMI(Case Mix Indicator)
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UNMH- Facility-Wide SOI(Severity of Illness
Indicator
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UNMH- Facility-Wide ROM(Risk of Mortality
Indicator)
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SRMC - SOI
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SRMC - ROM
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DoIM UNMH - CMI
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DoIM UNMH - SOI
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DoIM UNMH - ROM
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DoIM Hospitalists UNMH - SOI
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DoIM Hospitalists UNMH - ROM
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April Discharges OrthoMajor Joint Replacement
Lower Extremity
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Sepsis

• SIRS Criteria
• Assess for 2 or more
• (Fever) Temp gt 38C or lt 36C
• (Tachycardia) HR gt 90
• (Tachypnea) Resp rate gt 20 or pa CO2 lt 32
• (Leucocytosis/Leukopenia) WBC gt 12K, lt 4K, or gt
  10 bands

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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

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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

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SMITE Bundle

• Basic SMITE Bundle
• Lactate q 4h x2
• Blood Culture
• 3. Antibiotics within 1 h
• 4. Fluids
• 5. Re-evaluate as needed

• Advanced SMITE Bundle
• Basic Bundle Plus
• Fluids bolus
• CVP
• Vasopressors

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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

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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

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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

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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 11 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

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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)

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Contacts

• UNMH Coding Clinical Documentation
• Erlinda Smith, CCS
• UNMH Coding Educator (Inpatient)
• EVSmith_at_salud.unm.edu
• Kayode Balogun, MD, CCS
• CDI Program Manager, UNMH
• kbalogun_at_salud.unm.edu
• Catherine Porto, RHIA, MPA, CHP
• Exec. Director HIM
• cporto_at_salud.unm.edu

• CDI Information to be posted on the following web
  site
• https//hospitals.health.unm.edu/intranet/HIM
• Provider Documentation and ICD-10 Tab