Clinical Validation: How to Ask a Delicate Question

• FirstHealth of the Carolinas • Serves 15 counties• Licensed for 4 hospitals • Total 582 beds• 294 providers- 95% board certified

• CDI program initiated 2009

• Documented diagnoses not supported by clinical data• Acute Respiratory Failure• Malnutrition• Sepsis• Encephalopathy• Inconsistency between providers • Concern for RAC compliance• Billing Accuracy

4444

What and Why

Who We Are

• Multidisciplinary input• Hospitalists• Infectious Disease• Neurology• Nutrition• Pulmonology• Standardized documentation• Query format

44444

Team Approach

• RAC proof charts• Greater compliance• Expect similar outcomes in other diagnoses when approved by medical staff

Conclusion

Total samples were from charts coded with acute respiratory failure or malnutrition as

primary or secondary diagnoses

Our Findings

Acute Respirator y Failure

Name of Form

Page 1 of 1 CCNO.TB.ITEMNO.RV Sunset Date: 3/2016

Place  Patient  Label    Inside  This  Box  

FirstHealth Moore Regional Hospital: ___Moore Campus ___Richmond Campus ___Hoke Campus _________________________________________________________________________________________________________ Your patient has been seen by a Registered Dietitian. Please review the findings and assessment below. For additional information, please see the complete nutritional assessment in the electronic medical record. Dietitian Signature: __________________________________________ Date/Time: __________________ __________________________________________________________________________________________________________

___ Mild Risk Category (3 of 6 indicators must be present)

___% Usual body weight 96-99% * ____Fluid accumulation: +1 edema ___ PO intake <75% for more than 2 days ____ Mild muscle or subcutaneous fat loss** ___ BMI 17 – 18.9 ____ Pressure ulcer stage 1 present ___ Albumin 2.5 – 3.5

____ Moderate Risk Category

(3 of 6 indicators must be present…OR 2 indicators from the list below AND at least 2 from the Mild Category list) ___ % Usual body weight 90 – 95% * ____ Fluid accumulation: +2 edema ___ PO intake < 50% avg for more than 2 days ____ Moderate muscle or subcutaneous fat loss ** ___ BMI 16 – 16.9 ____ Pressure ulcer stage II present ___ Albumin 2.0 – 2.5

___ Severe Risk Category

(3 of 6 indicators must be present…OR 2 indicators from the list below AND at least 2 from the Moderate category list)

___ % Usual body weight less than 90% * ____ Fluid accumulation: +3 edema ___ PO intake < 25% for more than 2 days (or NPO/clear liquids ____ Severe muscle or subcutaneous fat loss ** 4 days or greater) ____ BMI < 16 ___ Pressure ulcer stage III or > present ___ Albumin < 2.0 _______________________________________________________________________________________________________________ Dr. ___________________________ Based on the nutritional assessment and findings, please document below (AND IN SUBSEQUENT PROGRESS NOTES) which of the following most accurately represents the patient’s nutritional status. ___ Malnutrition (specify as mild, moderate, severe) ______________________________ ___ Nutritional marasmus ___ Cachexia ___ Other (specify) __________________________________________ ___ Unable to determine ___ No nutritional deficiency Physician/PA Signature _______________________________________________ Date/Time __________________________ *Dietitians have parameters from the ADA/ASPEN for % UBW for other time frames **Dietitians utilize parameters from the ADA/ASPEN for muscle loss and subcutaneous fat loss __________________________________________________________________________________________________________ RETAIN WITH MEDICAL RECORD

Malnutrition

Solution

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

Charts  Reviewed   Charts  Met  Criteria   Percentage  Met  Criteria  

Malnutri?on  

2013   2014  

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

Charts  Reviewed   Charts  Met  Criteria   Percentage  Met  Criteria  

Malnutri?on  

2013   2014  

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

Charts  Reviewed   Charts  Met  Criteria   Percentage  Met  Criteria  

Malnutri?on  

2013   2014  

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

Charts  Reviewed   Charts  Met  Criteria   Percentage  Met  Criteria  

Acute  Respiratory  Failure    

2013   2014  

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

Charts  Reviewed   Charts  Met  Criteria   Percentage  Met  Criteria  

Acute  Respiratory  Failure    

2013   2014  

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

Charts  Reviewed   Charts  Met  Criteria   Percentage  Met  Criteria  

Malnutri?on  

2013   2014  

Improvement percentage from 2013-2014= 21%

Improvement percentage from 2013-2014 = 32%

Query

Patient Name:

Medical Record #:

Account #:

Admit Date:

Physician's Documentation Request: Date: Please review the following and provide your response in the progress notes and the discharge summary.

Based on FirstHealth clinical validation guidelines, the current documentation does not meet clinical criteria for____________. Conflicting clinical data: **please see attached guidelines** Please document any additional indicators or factors that clinically support _________________ or provide a revised diagnosis. Use of terms such as suspected, possible, or probable (associated with a specific diagnosis) are acceptable and can be coded in the inpatient setting Thank you,

Please use your independent medical judgment in providing your response.

Worksheet – CDS

Acute Respiratory Failure Documentation Guidelines

Not all patients with acute respiratory failure require intubation and mechanical ventilation. Many can be managed with non-invasive techniques such as BIPAP and other aggressive respiratory modalities. Please use the following guidelines when considering the use of Acute Respiratory Failure:

ABG results: (consider Fi02 pt receiving)

• pH <7.35 or > 7.45

• pC02 >50

• p02 < 60 on room air

Physical signs and symptoms

• Respiratory rate <8 or > 26

• rapid breathing/air hunger/increased work of breathing

• use of intercostal/accessory muscles

• retractions

• unable to speak in complete sentences

• Room air Sa02 < 80% not easily resolved with low dose 02/medications

Impending respiratory failure can not be coded. This language suggests a threat of respiratory failure--------

Respiratory Failure (postoperative)

Respiratory failure should not be documented when patient is left on the ventilator electively/or for airway protection, but should be considered if not able to wean in 48 hours. Always remember to document clinical picture of why patient continues to require mechanical ventilation.

Respiratory failure should be documented if patient was extubated and re-intubated after surgery or failed weaning process and remained on ventilator.

****When patient does not meet above guidelines, please document other clinical indicators/co-morbidities leading to conclusion of acute respiratory failure****

THIS DOCUMENT IS NOT PART OF THE PERMANENT RECORD

Reviewed and Approved by MRH Hospitalist Group-------11/2013

Myra Phillips, RN, CCDS . Angela Brisson RN, BSN, CCDS

49869 Banner.indd 1 4/25/14 12:07 PM