level ii training clinical documentation improvement
DESCRIPTION
Level II Training Clinical Documentation Improvement. DoIM – Hospitalists 7/09/14 Presented by: Catherine P orto, MPA, RHIA, CHP Exec. Director HIM, UNMH ICD-10 Executive Project Lead & Erlinda Smith, CCS CDI Provider Education & Kayode Balogun CDI Program Development - Precyse. - PowerPoint PPT PresentationTRANSCRIPT
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Level II TrainingClinical Documentation Improvement
DoIM – Hospitalists 7/09/14
Presented by:Catherine Porto, MPA, RHIA, CHP
Exec. Director HIM, UNMHICD-10 Executive Project Lead
&Erlinda Smith, CCS
CDI Provider Education& Kayode Balogun
CDI Program Development - Precyse
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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
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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
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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 codesIncludes codes for all complications &
comorbidities (CCs and MCCs)• DRGs are assigned a relative weight (RW)
RW is the calculation of resource consumptionUsed 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– <1: Below average– >1: 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
Impact of Complete DocumentationMS 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 COPDSDx: 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 (BMI<19)
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 H&P or progress notes
after a definitive diagnosis is made—whether each condition was present on admission (provider’s 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
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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 coded—IP 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.)
Mission: Meaningful Clinical Process “Telling the Patient’s 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.
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
Cost per patientResource utilizationLength of stayComplication RatesMorbidity ScoresMortality ScoresOutcome AnalysisPayer Audits
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Why does CDI Matter?Medicine is Under The Microscope
Hospital Report cardsHealthgrades, 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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Physician Profiling
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Healthgrades.com
ICD-10: Advancing Healthcare…
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.
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 Changes Implications
Significant Increase in Clinical Granularity
5 digits
> 4,000 unique codes
3-7 alphanumeric characters
> 68,000 unique codes
7 alphanumeric characters
> 72,000 unique codes
ICD-9 CM (Procedure)
ICD-10 CM (Diagnosis)
ICD-10 CM (Procedure)
3-5 characters alphanumeric
ICD-9 CM (Diagnosis)
>14,000 unique codes
ICD-9 CM (Procedure)
3-4 characters numeric
> 4,000 unique codes
The Federal Government through CMS is driving the healthcare industry to upgrade diagnosis and procedure coding standards (ICD-10) by October 1, 2015.
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.
X X X X X.ICD-9 ICD-10-CM
X X X X X X XCategory CategoryEtiology, anatomic
site, manifestationEtiology, anatomic site, manifestation
.Extension
An Example of Structural Change
Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E 1 0 4 0.
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 9.
Diabetes mellitus with neurological manifestations type I not stated as
uncontrolled
2 5 0 6. 1
An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes
One ICD-9 code is
represented by multiple ICD-
10 codes
The industry expects that mapping ICD-9 and ICD-10 codes will be a complex task
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.
X X X X.ICD-9 ICD-10-PCS
X X X X X X XSection
An Example of Structural Change
Total hip replacement
8 1 5 1.
An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes
One ICD-9 code is
represented by multiple ICD-
10 codes
Body System
Root Operation
Body Part Approach Device Qualifier
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
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 patient’s 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
Don’t need to turn doctors into codersWe Need good documentation habitsWe Need specialty specific documentation
educationWe 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)
ICD-10 Physician Education
UNMH & SRMC- CMI(Case Mix Indicator)
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-141.3000
1.3500
1.4000
1.4500
1.5000
1.5500
1.6000
1.6500
1.7000
1.7500
SRMCUNMH Overall
UNMH- Facility-Wide SOI(Severity of Illness Indicator
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140
100
200
300
400
500
600
700
800
900
1234
UNMH- Facility-Wide ROM(Risk of Mortality Indicator)
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140
200
400
600
800
1000
1200
1400
1600
1
2
3
4
SRMC - SOI
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140
20
40
60
80
100
120
1234
SRMC - ROM
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-140
20
40
60
80
100
120
140
160
1
2
3
4
DoIM UNMH - CMI
Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-141.2000
1.4000
1.6000
1.8000
2.0000
2.2000
2.4000
2.6000
2.8000
3.0000
3.2000
3.4000
DoIM CardiologyMedicine - HospitalistsMICUUNMH Overall
DoIM UNMH - SOI
Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140
20
40
60
80
100
120
140
160
180
1234
DoIM UNMH - ROM
Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140
20
40
60
80
100
120
140
160
1234
DoIM – Hospitalists UNMH - SOI
Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140
20
40
60
80
100
120
140
160
180
1234
DoIM – Hospitalists UNMH - ROM
Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-140
20
40
60
80
100
120
140
160
1234
April Discharges – OrthoMajor Joint Replacement – Lower Extremity
1
2
3
4
0 5 10 15 20 25 30 35 40 45 50
ROMSOI
Sepsis
• SIRS Criteria• Assess for 2 or more• (Fever) Temp > 38⁰C or < 36⁰C• (Tachycardia) HR > 90• (Tachypnea) Resp rate > 20 or pa CO₂ < 32• (Leucocytosis/Leukopenia) WBC > 12K, < 4K, or
> 10% bands
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
Sepsis Severity
Sepsis• Lactate levels
documented• No organ dysfunction• No hypotensionSevere 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 ShockWritten as Septic Shock• Hypotension• Refractory to IV fluids
*see organ reference pages
SMITE Bundle
Basic SMITE Bundle1. Lactate q 4h x22. Blood Culture3. Antibiotics within 1 h 4. Fluids5. Re-evaluate as needed
Advanced SMITE BundleBasic Bundle Plus:5. Fluids bolus6. CVP7. Vasopressors
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
Case Study #1MS DRG –178 Respiratory Infections & Inflammations w CCPDX: Cystic Fibrosis with pulmonary manifestationsSDX: protein-calorie malnutrition. GERD, several other dxSOI level: 3ROM level: 2DRG Wt. 1.4403DRG 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 MCCSOI level: 3ROM level: 3DRG WT. 2.0549DRG Reimb: $18,677.24
Case Study # 2MS DRG –872 Septicemia or Severe Sepsis w/o MCCPDX: Septicemia due to E coliSDX: protein calorie malnutrition, DM without complications type II, acute pancreatitisSOI level: 3ROM level: 2DRG Wt. 1.0687DRG Reimb $8,120.74
Additional documentation in chart: Sepsis with AMSCDI Queries for: Specific type of Encephalopathy . If provider agrees and documents metabolic encephalopathyMS DRG-871 Septicemia or Severe Sepsis W MCCSOI level: 3ROM level: 3DRG WT. 1.8527DRG Reimb: $14,078.15
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 1:1 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
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, CCSUNMH Coding Educator (Inpatient)[email protected]
Kayode Balogun, MD, CCSCDI Program Manager, [email protected]
Catherine Porto, RHIA, MPA, CHPExec. Director [email protected]
CDI Information to be posted on the following web site:
https://hospitals.health.unm.edu/intranet/HIM Provider Documentation and ICD-10 Tab