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Clinical Documentation Update for Physicians


Clinical Documentation Update for Physicians November 9 and 16, 2011 Dr. Karen Jerome Kyle Jossi, RN Which hospitals were recently recognized by the Joint Commission ... – PowerPoint PPT presentation

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Title: Clinical Documentation Update for Physicians

Clinical Documentation Update for Physicians
  • November 9 and 16, 2011
  • Dr. Karen Jerome
  • Kyle Jossi, RN

Which hospitals were recently recognized by the
Joint Commission as Top Performers on Key Quality
  • A. Every hospital in the United States
  • B. Every hospital in the DC metro area
  • C. Every hospital in the state of Maryland
  • D. Holy Cross Hospital and no other hospitals in
    Maryland or the DC Metro area or the
    Trinity Health system

Top Performer Award from The Joint Commission
  • In Sept. 2011, Holy Cross Hospital was the sole
    hospital in Greater Washington and all of
    Maryland to receive a "Top Performer on Key
    Quality Measures" award from The Joint Commission
    for 2010.
  • Holy Cross Hospital was one of only 405 U.S.
    hospitals selected out of a total 3,099
    participating. We were recognized for all four
    categories of adult medicine that were rated
    heart attack, heart failure, pneumonia, and
    surgical care.
  • This recognition indicates that we have made real
    improvements in our many, many outside
    measurements of quality. But more importantly, it
    demonstrates our ongoing success in improving the
    care we provide to our patients.
  • This is the first year of this new Joint
    Commission recognition program.

  • Clinical documentation significance
  • Chart coding
  • Case mix
  • ICD-10
  • Select documentation issues
  • Sepsis
  • Clinical Doc. Improvement Program
  • Queries

The Importance of Your Documentation
  • Clinical information for patient care
  • Quality/Core measure adherence
  • Potentially Preventable Complication (PPC)
  • Tumor Registry data
  • Physician and hospital profiling
  • Including mortality data
  • Compliance for reimbursement/denial prevention
  • Commercial payors
  • RAC audits
  • Protection in the event of litigation

Coding Definitions
  • Principal diagnosis the condition established,
    after study, to be chiefly responsible for
    occasioning the patients hospital admission
  • Secondary diagnosis anything that
  • is diagnostically tested
  • is clinically evaluated
  • is treated
  • causes increased nursing care and/or monitoring
  • prolongs the patients length of stay
  • ICD-9 is the current coding terminology.

Coders can code from which sources?
  • A. lab reports
  • B. physician progress notes, HP, operative
    reports, discharge summary
  • C. pathology reports
  • D. echocardiogram reports
  • E. RN notes

Case Weight/Case Mix Index (CMI)
  • Calculated by the coding software
  • Case weight is assigned based on the principal
    diagnosis and the severity of illness, determined
    by the secondary diagnoses.
  • The case weights for all coded cases are combined
    to create the hospitals CMI, on which its
    reimbursement is based.

Case Weight Example - Pneumonia
  • Community Acquired Pneumonia
  • -with no secondary diagnosis
  • SOI 1 ROM 1
    Case weight .40
  • -with 1 secondary dx e.g. urinary
  • SOI 2 ROM 1
    Case weight .54
  • -add acute renal failure (POA) a 2nd
    secondary diagnosis
  • SOI 3 ROM 3
    Case weight .84
  • -add severe malnutrition, a 3rd secondary
  • SOI 4 ROM 4
    Case weight 1.46
  • If the pneumonia is documented more specifically,
    such as aspiration, staphylococcus, TB, or H.
    influenza, the DRG changes. In that DRG, with
  • SOI 1 ROM 2
    Case weight .60
  • SOI 4 ROM 4
    Case weight 1.96

The Future of Coding ICD-10
  • Will be implemented on 10/1/2013
  • Applies to hospital and office coding
  • Will require significantly more specificity
  • Laterality
  • Type of encounter (initial, subsequent)
  • ICD-9 14,300 diagnosis codes 4,000 procedure
  • ICD-10 68,000 diagnosis codes 87,000
    procedure codes

Physician Support for ICD-10
  • Holy Cross Hospital will help you to improve your
    workflow efficiency.
  • The following are being considered
  • At-the-elbow support for building customized
    clinical documentation templates
  • Front-end voice recognition software
  • Computer-assisted codingenables natural language
    processing of charts

Select Documentation Issues
Which of the following diagnoses cannot be coded
as an active problem?
  • A. Rule out myocardial infarction
  • B. Possible sepsis
  • C. History of CHF
  • D. Probable UTI
  • E. Likely pneumonia

History Of
  • HP often cites the patient as having a history
    of various conditions. These may actually be
    currently active problems and, if so, must be
    stated as such or the coder cannot capture them
    as secondary diagnoses.

Differential Diagnoses
  • In the inpatient setting, coding guidelines allow
    coders to pick up diagnoses that are listed as
    rule out, possible, probable, or likely. Unless
    you subsequently specify that such diagnoses have
    been ruled out, they may well be coded.

Laboratory/Diagnostic Results
  • A diagnosis must be provided for every lab value
    that is monitored and/or treated.
  • Lab values and radiology reports that have been
    merely copied and pasted cannot be coded the
    results must be commented on/interpreted.

Clinical Connections
  • Link the diagnosis to the underlying condition,
    as coders can infer nothing.
  • Example A patient with diabetes is admitted
    with vomiting and a history of diabetic
  • If only vomiting is documented then vomiting is
    the coded DRG, with a case weight of .32.
  • If diabetic gastroparesis is documented and thus
    coded, the case weight will be .48.

Signs and Symptoms
  • Clarify their cause, once discovered.
  • Dont let the admitting symptom or lab finding be
    your default final diagnosis, as this will result
    in coding of a DRG with a lower case weight.
  • Examples
  • Document acute respiratory failure (diagnosis)
    instead of respiratory distress (symptom).
  • Document sepsis (diagnosis) instead of bacteremia
    (lab finding).

Signs and Symptoms (cont)
  • Symptom diagnoses often result in medical
    necessity denials from insurers.
  • Example
  • Nausea, vomiting, chest pain, headache are often
    deemed appropriate for observation status,
    whereas diabetic gastroparesis with resultant
    bowel obstruction, unstable angina, or concussion
    with subdural hematoma likely qualify as
    inpatient stays, even if brief.

What is the most common reason for insurance
companies to issue denials to Holy Cross Hospital?
  • A. Inappropriate level of care (tele vs.
  • B. Consult or procedure delays
  • C. Admission (i.e. observation status
  • D. Social issues delaying discharge

HCH Denial Data 10/2010-10/2011
Most Common HCH Admission Denials
  • Abdominal pain
  • Anemia
  • Asthma
  • Atrial fibrillation
  • Cellulitis
  • Chest pain and hypertension
  • DVT
  • Syncope
  • UTI

Present on Admission (POA) Flags Coders Choose
Y, N, or W
  • Y if condition present at the time that
    inpatient admission is ordered
  • Conditions that develop during an outpatient
    encounter (i.e. in the ER, observation status, or
    during outpatient surgery), prior to inpatient
    admission, are POA.
  • N if not present on admission
  • W if physician clinically unable to determine
    whether or not condition was POA

You obtain a first U/A on day 2 of a patients
hospital stay, diagnose and begin treatment for a
UTI. You are queried about the POA status of the
You are uncertain about whether or not the UTI
was actually present on admission, so you
  • A. Answer yes, POA
  • B. Answer not POA
  • C. Ignore the query
  • D. Document that you are clinically unable to
    determine whether or not the UTI was POA

Diagnoses Frequently Requiring Clarification of
POA Status
  • Decubitus or pressure ulcer
  • Examine each patients skin at the time of HP
    performance and document ulcers.
  • UTI
  • Sepsis
  • Pneumonia
  • Acute renal failure

Potentially Preventable Complications (PPCs)
  • Marylands version of never events
  • Financial penalties are possible if POA flagging
    is not accurate and PPCs are (incorrectly)
  • Holy Cross was ranked in the top quartile in the
    state for PPC performance in FY11.

Documentation Specificity
  • Indicates increased resource utilization and so
    justifies higher reimbursement.
  • The more specific the diagnosis, the higher the
    assigned case weight and risk of mortality.
  • Specificity can provide exclusions for some PPCs.
  • e.g. Left sided heart failurePOA Y excludes
    PPC assignment for acute respiratory failurePOA
    N. Heart failure, NOS does not.

Documentation of which of the following is sure
to make a CDS cry?
  • A. SIRS
  • B. Sepsis
  • C. Severe Sepsis
  • D. Septic Shock
  • E. Urosepsis

  • The thread of the sepsis diagnosis should be
    reflected throughout the patients stay, as the
    diagnosis may not be captured by the coder if
    just mentioned in the HP or early progress
  • If treated and resolved then document sepsis
  • Include sepsis diagnosis in the discharge
  • Indicate whether or not sepsis was POA and also
    its severity. (SIRS ? Septic Shock)
  • Urosepsis is not a codable diagnosis it codes as
  • Negative blood cultures do not preclude a
    diagnosis of sepsis.

Clinical Documentation Improvement Program
  • A combination of concurrent (CDS) and
    retrospective (coder) chart review, with
    documentation clarification querying as necessary
  • Common query triggers
  • POA status for
  • pneumonia, UTI, decubitis/pressure ulcers, MI,
  • CHF specificity
  • acute, chronic, or acute on chronic, diastolic or

Query Essentials
  • Where will you find queries?
  • In your Message Center
  • Need help to access/answer a query?
  • Call CDS (x8641) or Physician Coach (x2348)
  • Where should you document your response?
  • As an addendum to your HP, progress note, or
    discharge summary

The appropriate time frame to answer a query is?
  • A. Sometime before Christmas
  • B. It doesnt matter because no one will notice
    if you answer it.
  • C. As soon as you receive it, or when you next
    see the patient, or within 48 hours
  • D. Before the end of the month

Queries (cont)
  • When should you answer a query?
  • ASAP
  • If you disagree, click refuse and explain.
  • Help us understand why you disagree with a
    particular query so we can ask better queries.
  • There will be follow up if query is unanswered.
  • Both CDS and coder queries will be followed up by
    the CDS team.

Top Three Reasons For Prompt Query Response
  • 3 Charts are being coded 2-5 days after
    discharge. If query response is not timely the
    late documentation will require subsequent chart
    recoding or might even be overlooked.
  • 2 You will avoid phone calls from a CDS, and
    your Message Center will be emptier.
  • 1 It will ensure that the patients story has
    been told and that the medical record accurately
    reflects the severity of illness and complexity
    of care provided to your patients.

  • Accurate documentation is critical to
  • tell the patients story
  • details the patients diagnoses and describes how
    they were determined and treated
  • enable proper reimbursement of care
  • correct DRG and SOI assignments result in case
    weight that reflects resources used
  • ensure hospital and physicians correctly rated
  • public reporting

Public Reporting
  • Core Measures
  • Ever expandingsoon including CVA, VTE
  • PPCs
  • Publically accessible websites rating physicians
  • Physician Compare coming in 2012
  • Outcomes based data for inpatient care
  • Independent source of
    physician information and hospital quality

In Conclusion
  • Thank you for the excellent care you provide to
    patients at Holy Cross Hospital and for the
    attention you pay to the documentation of that