Documentation and Coding: Understanding CMGs, RIWs and LOS

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Documentation and CodingUnderstanding CMGs,
RIWs and LOS

• What does It All Mean, and Why Should I Care?

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Two Reasons to Document Accurately and Completely

• To ensure high quality patient care
• To ensure that there are sufficient resources to
  treat the patients that we need to care for

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Documentation Why Do It Accurately?

• Accurate Clinical Documentation

Fewer medication errors
Appropriate Medical care
Continuity of care
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A Guide to Better Physician Documentation

• Physician Documentation Expert Panel
• Chair Dr Ralph Kern (17 MDs Reps form CIHI,
  OMA, CPSO, OHA, Health results Team for Primary
  Care, Canadian and Ontario HIMA)
• Patient Care and Outcomes
• 20 of patients experience adverse events during
  first several weeks post discharge
• most common adverse drug reactions
• 1/3 preventable
• 1/3 reduced severity if corrective measures
  taken early

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A Guide to Better Physician Documentation

• Risk of re-hospitalization decreased when
  patients were assessed for follow-up by
  physicians who received a discharge summary
• Van Walraven et al J Gen Intern Med 17 (3)
  186-192, 2002
• Visits in ED of teaching hospital were 1.2 hr
  longer on average for patients with an
  information gap in their health records
• Forster e al. J Gen Intern Med 20 (4) 317-323,
  2005
• Discharge summary only effective if complete,
  accurate and made available in a timely manner
  family physician and patient disadvantaged if
  discharge summary incomplete and/or arrives late

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Documentation Why Do It Accurately?

• Accurate Clinical Documentation

Fewer medication errors
Appropriate Medical care
Accurate data abstracted and submitted to CIHI
System errors detected
Continuity of care
Improved management
Appropriate funding
Equitable resource allocation
Improved regional planning
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The Context Hospital Accountability Agreements

• Hospital Accountability Agreement (HAA) is the
  legal document that describes the obligations of
  the hospital and the Ministry with respect to
• Funding
• Deliverables (volumes, LOS)

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Under the HAA, the Hospital is expected to

• Maximize service levels and outcomes
• Meet agreed upon performance targets
• Manage within resources provided

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HAPS

• Hospital Annual Planning Submission (HAPS)
  describes the services to be provided, and how
  they will be measured and evaluated
• HAPS assumes a balanced operating budget
• focus on expense management rather than service
  reductions

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Selected HAPS Indicators

• Patient Access and Outcomes
• Relative Acute LOS
• Relative Risk of Readmission
• Conservable Days
• Financial Health
• Operational Efficiency

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Efficiency Measure - CPWC

• Cost per Weighted Case (CPWC)
• actual cost of care
• number of weighted cases
• Used to determine the approximate average cost of
  hospital programs and services
• MOHLTC wants CPWC to be as low as possible
• Achieved by reducing costs and/or increasing
  weighted cases

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The Relationship Between Documentation and Funding

• Hospital funding is based on the expected cost to
  deliver a certain volume of weighted cases
• Physician documentation directly determines the
  weight of the case and therefore the CPWC

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Efficiency Measure

• Resource Intensity Weight (RIW)
• a relative value based on case complexity and
  case costing
• For HHS an RIW of 1.00 means costs of
  approximately 5,500
• Patient with an RIW of 2.3 would be expected to
  cost 2.3 x 5,500 12,650
• This is not what the hospital receives in
  funding but a measure used by MOHLTC to assess
  hospital efficiency

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Definitions

• CMG Case Mix Groups
• A grouping of cases with a similar diagnosis
  (e.g. pneumonia, heart failure), further broken
  down by age and complexity to define resource
  utilization.
• Four levels of complexity for each diagnosis
• The more complex the case, the greater is the
  resource utilization, which is expressed as RIW
  (Resource Intensity Weight)

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Definitions

• Complexity methodology identifies cases for which
  a prolonged LOS and/or more costly treatment
  might reasonably be expected
• 1. No complexity
• 2. Complexity related to chronic conditions
• 3. Complexity related to serious/important
  conditions
• 4. Complexity related to potentially
  life-threatening conditions
• Documentation of co-morbid conditions can add to
  complexity level and increase the RIW for
  individual cases

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How CMGs are Assigned
MCC Major Clinical Category
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Major Clinical Category 5A
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Coding

• Coding determines the Resource Intensity
  Weighting (RIW), complexity, and expected length
  of stay (ELOS) assigned to each patient
  discharged
• Values are derived from what the physician writes
  as the Most Responsible Diagnosis, Secondary
  Diagnosis and co-morbidities that add to length
  of stay (LOS)
• The MoHLTC uses these file codes to determine
  hospital efficiency

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Chart Coding

• Done by a team of trained abstractors in health
  records
• All charts have to be submitted to CIHI within 60
  days of discharge (virtually never go back to
  redo a chart).
• Can only code what the physician has indicated,
  on front sheet, physician notes or MD orders
  cant code from nursing notes, radiology or path
  reports etc.
• BIG risk of under reporting

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Definitions

• LOS length of stay in days
• ELOS the Expected Length of Stay for a
  typical case in each diagnostic complexity
  level. Derived from provincial data set.
• Conservable Days the difference between the
  Actual LOS and the Expected LOS when the actual
  is greater than the expected

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Definitions

• Atypical Case cases are not used in the
  calculation of RIW or ELOS
• Deaths
• Transfers to or from other acute-care
  institutions
• Sign outs
• Outliers (cases with LOS beyond trim points)

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LOS Opportunity HAPs CMGs
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Hospital Accountability (HAPS) Clinical
Indicators (Conservable Days) for ALL CMGs
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Impact of Incomplete Documentation/ Coding

• Incomplete documentation/coding results in low
  complexity rating which translates into a lesser
  RIW, and therefore an increased CPWC
• Hospital is faced with cutting costs because we
  look inefficient
• Low RIW implies shorter ELOS and may increase
  conservable days
• Conservable days result in Bed Opportunities
  which in Adminspeak results in loss of beds.

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Case Example

• A 68 yr. female presents with NSTEMI. She has
  Type II diabetes, hyperlipidemia, centripetal
  obesity, a creatinine of 180 mmol/L, and a 40
  pack/yr history of smoking.
• On day 2 of admission she develops atrial
  fibrillation with a rapid rate and a degree of
  CHF, is treated appropriately, improves and on
  day 4 undergoes cardiac cath with PCI of 2
  vessels and discharged on day 6.

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Case Example
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Examples of Documentation
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Examples of Documentation
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Examples of Documentation
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New Codes for 2007-08Intervention Flags

• Pleurocentesis
• Dialysis
• Radiotherapy
• Mechanical Ventilation
• Cell Saver
• Parenteral Nutrition

• Feeding Tubes
• Vascular Access Device
• Tracheotomy
• Chemotherapy
• Paracentesis
• Heart Resuscitation
• Cardioversion

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Contribution by Physicians

• Document all primary and secondary clinical
  diagnoses in notes or front sheet
• Document all procedures
• State when ALC status begins, otherwise
  considered as acute LOS

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Contribution by Physicians

• Sign off charts promptly, dictate a discharge
  summary
• Accurate coding will help hospital get the
  appropriate level of funding to deliver care to
  the patients we serve and reduce the risk of
  closing beds inappropriately

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Legal Requirements and Hospital By-Laws

• The Ontario Public Hospitals Act
• Sets requirements on what health information must
  be recorded by health facility
• Within 24 hrs an admitting note, authenticated by
  the physician is placed on the health record
• Within 72 hs after a patient has been admitted,
  the MRP must take a medical history of the
  patient, give the patient a physical examination
  and record, date and authenticate the history and
  report findings of that examination and the
  provisional diagnosis
• Hospital By-Laws and Chart Completion Policies
• Given the authority to enact by-laws to govern
  internal affairs develop their own policies on
  chart completion

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Expert Panels Chart Completion Policy

• 3 Step Process recommended
• Hospital Health Records alerts MD when chart is
  ready for completion
• If not complete within 2 weeks of initial
  notification, the department sends a written
  warning that is copied to the Chief of Staff
• If chart is not complete 2 weeks after issuing
  the warning, then the hospitals Board of
  Directors can suspend the physician

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Questions/Discussion