Clinical Documentation Improvement Prevention Program ... · Na 130 ‐> fluid restriction Dirty UA...

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Clinical Documentation Improvement Prevention Program: Best Practices

Carol Tuminaro, RN, BS, MBA, HRM

Senior Manager, Quality, Safety, and Performance Improvement


•Understand the reasons behind a Clinical Documentation Improvement (CDI) Program

• Pinpoint fundamental knowledge needed by CDI staff

• Identify objectives and activities associated with developing a program

• Identify how, when, and who writes the queries

Objectives


• Designed to improve inpatient record documentation by establishing a coordinated, systemic process utilizing a concurrent review team to strengthen communication between caregivers, physicians, and coding professionals

• Ensures that the clinical documentation in the patient record accurately reflects the patient’s principal diagnosis (reason for admission)

• Secondary diagnoses (co morbid conditions) are documented

• Captures procedures performed

• Provides an accurate picture of the patient’s acuity, severity of illness, and expected chance of mortality for this particular hospitalization

What Is a Clinical Documentation Improvement (CDI) Program ?


•New laws and regulations, ongoing federal reforms, and payer initiatives are increasingly aligning quality outcomes with financial incentives and reimbursement

•Medicare and third‐party insurers consider the patient’s severity of illness and post‐admission complications when calculating payment

•Accurate capture of patient acuity and risk of mortality impacts your hospital’s case mix index (CMI), which influences quality outcomes and hospital performance reports that are made available to consumers

Why Implement a Clinical Documentation Improvement Program?


• Proper documentation ensures:

Appropriate severity of illness (SOI)

Risk of mortality (ROM)

Substantiates medical necessity for:

o Necessity of clinical diagnostics

o Level of care provided

o Appropriateness of admission or continued stay

o Observation status or outpatient

• Truly reflects how complex your patient is, how ill they are and how likely they are to die (could impact case mix index)

• Finally…..It is the right thing to do!

Why Care?


• The clinical documentation specialist (CDS)

RN’s who review the medical record concurrently

o Are diagnoses documented with specific terminology so coders can code the most appropriate codes for SOI and ROM

• The coders Review the medical records post‐discharge

o Assign ICD diagnoses and procedure codes to ensure accurate SOI and ROM

o They then assign an appropriate MS‐DRG

• The physicians Responsible for accurate documentation from admission to discharge

o Will respond to “queries” in a timely and appropriate manner

• The physician champion!

The CDI Team


•With every diagnosis, consider:

Etiology

Severity

Type

Present or evolving on admission (POA)**

Clinical manifestations

Treatment

Pathology findings

Proactive Documentation


•A CDI program promotes documentation that is:

Clear

Concise

Complete

Accurate

Compliant

• CDI requires analysis and interpretation of the medical record to:

Identify and rectify situations where documentation is insufficient to accurately support the patient’s severity of illness and care, including specificity of principal diagnosis, associated comorbidities or complications, treatments and procedures

Nursing 101 ‐‐‐‐ CDI 101


•Documentation must:

Support the severity of the patient’s illness

Clearly identify the risk of mortality

Indicate QUALITY measures

Support the need for the care being provided, treatment and ordered procedures

Specify the principal diagnosis

Specify the associated comorbidities

Specify the complications

Analysis and Interpretation


• The CDI staff are responsible to: Analyze the data, thorough review of medical record

Formulate physician queries

Track responses to queries

Communicate with physicians, administration, HIM staff, and others

Clinical Documentation Improvement 101


•Additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extend the length of stay, or increase nursing care and/or monitoring – “ resource utilization”

• These conditions also affect the expected mortality % assigned to each discharge

• They are referred to as “major co morbid conditions”(MCC) or “co morbid conditions” (CC)

Secondary Conditions Are:


• Post surgical anemia

Documentation is “Code” Friendly

•Acute surgical blood loss

•Hypotensive, requires vasopressors, tachycardia, multiple fluid boluses

• Shock and type

• Intubated for airway protection

• Patient unresponsive, desat to 88% re‐intubated

•Acute respiratory failure/ Acute respiratory distress


Documentation Is “Code” Friendly

Unable to Code

Na 130 ‐> fluid restriction

Dirty UA ‐> antibiotics

Post surgical anemia, will monitor/blood loss ‐> PRBC

Elevated creatinine ‐> IVFs

LUL opacity ‐> Zosyn

Flash pulmonary edema

Acceptable to Code

Hyponatremia

UTI

Acute blood loss anemia d/t trauma/ruptured aneurysm

AKI or ARF

LUL bacterial pneumonia

Acute pulmonary edema


Documentation Is “Code” Friendly

Unable to Code

Abdominal fluid

Dyspnea, SOB requiring BiPap / high flow O2 / NC intubation

Hypotension, vasopressors, EBL, temperature, tachycardia, tachypnea

Acceptable to Code

Abscess/intraperitoneal abscess/peritonitis

Acute respiratory distress or acute respiratory failure

Consider shock and type


Principal Diagnosis and Procedure: Subarachnoid Hemorrhage with Repair of Aneurysm


Impact of MCCs and CCs on a Neurosurgery DRG

Intracranial Vascular ProceduresDRG 528 Weight 7.0543

MS-DRG 20 Intracranial Vascular Procedures With A PDX of Hemorrhagic(with a major co morbid condition)

Coma

-Weight7.7073

MS-DRG 21 Intracranial Vascular Procedures With A PDX of Hemorrhagic(with a co morbid condition)

Cachexia

-Weight6.7021

MS-DRG 22 Intracranial Vascular Procedures With A PDX of Hemorrhagic(without a major co morbid condition or co morbid condition)

-Weight5.6085

V24 DRG


Queries


An established method of communication designed to clarify ambiguous, incomplete, or conflicting documentation in the medical record:

AKA… Clinical clarification

Documentation clarification

What Is a “Query”


• To achieve a health care record that better reflects a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment

Why Query ?


• Concurrent

• Retrospective

• Post initial billing query

When to “Query”


• The nurse clinical documentation specialist

Will review the patient’s medical record throughout the patient stay and can query at any time

• The coder When coding the medical record at discharge

Who Can Query?


When is it appropriate to query providers?

» Office of the Inspector General (OIG):

› Coders should communicate with the physician when documentation in the patient record is incomplete or unclear.

» AHA Coding Clinic (Q2 1998):

› The physician should be queried when documentation is “suggestive” of a condition, but not clearly documented by the attending physician.

» AHIMA’s Standards of Ethical Coding:

› Coders “should consult physicians for clarification and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.”

Query Justification


AHIMA states that queries may be made in the following situations:

For clinical indicators without documentation of the diagnosis

When clinical evidence suggests a higher degree of specificity or severity could be documented

For a cause‐and‐effect relationship between two conditions or organisms

For an unstated underlying cause when admitted with symptoms

For a diagnosis when only the treatment is documented

To establish a diagnosis present on admission (POA) status

Existing Compliance Guidance


•Queries may be:

Verbal

o If verbal, the query and response must be documented in writing on a standardized form or in the medical record

Written

o Varity of formats: yes/no, multiple choice or open ended

Electronic

• Regardless of format, the query should be on a standardized form

Hospital policy will dictate if it is part of the medical record or a separate file

“Query” Formatting


•Queries must:

Include clinical indicators

o Clinical indicators supporting the query may include elements from the entire medical record

Provide reasonable options

Include the option that:

o No additional documentation or clarification can be provided

Not be posed to elicit only one response for a condition, diagnosis, procedure, and/or POA indicator

Never intend to lead the physician to a particular outcome

“Query” Formatting


•Queries are usually in a “yes/no” format when:

Substantiating or further specifying a diagnosis already present in the health record

Establishing a cause and effect relationship between documented conditions and

Resolving conflicting documentation from multiple practitioners

• If there is a need for multiple queries, each query needs to be on a separate query form unless they are related

Yes/No “Query”


• Clinical scenario: In the impression of the pathology report, “ovarian cancer” is documented however, the provider documented only “ovarian mass” in the final discharge statement

• Query: Do you agree with the pathology report specifying the “ovarian mass” as an “ovarian cancer”? Please document your response in the health record or below.

Yes _____

No ______

Other ____

Clinically Undetermined ____

Name: __________ Date: ______

Rational: This yes/no query involves confirming a diagnosis that is already present as an interpretation of a pathology specimen in the health record

Example of a Yes/No Query Format


• This query format should include:

Clinically significant and reasonable options that are supported by clinical indicators in the health record

o Important to note: only one reasonable option may exist

Additional options such as:

o Clinically undetermined

o Other

o Not clinically significant

o Integral to

These options will allow the provider to add free text and insure the query is not “leading” the practitioner

This query may also include undocumented “new” diagnoses when clinical indicators are present but the condition/diagnosis has not been documented

Multiple Choice or Open Ended “Query”


• Clinical scenario: a patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure. A recent echo showed left ventricular ejection fraction (EF) of 25%. The patient’s home meds include metoprolol XL, lisinopril, and lasix.

Leading: Please document if you agree the patient has chronic diastolic heart failure.

Nonleading: It is noted in the impression of the H&P that the patient has chronic congestive heart failure and a recent echo noted under the cardiac review of systems an EF of 25%. Can the chronic heart failure be further specified as:

Chronic systolic heart failure ____

Chronic diastolic heart failure ____

Chronic systolic and diastolic heart failure ____

Some other type of heart failure _____

Undetermined ______

Example of a Multiple Choice Query Format


A patient is admitted with pneumonia. The admitting H&P examination reveals WBC 14,000, respiratory rate 24, temperature 102, heart rate 120, hypotension and altered mental status. The patient is given an IV antibiotic and IV fluid resuscitation.

Leading: The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas cultured from the blood. Are you treating for sepsis?

Nonleading: Based on your clinical judgment, can you provide a diagnosis that represents the below listed clinical indicators?

In this patient admitted with pneumonia, the admitting history and physical examination reveals the following:

WBC 14,000

Respiratory rate 24

Temperature 102 F

Heart rate 120

Hypotension

Altered mental status

IV antibiotic administration

IV fluid administration

Please document the condition and the causative organism (if known) in the medical record

Example of an Open Ended Query Format


•Verbal queries must:

Contain the same clinical indicators and follow the same format as written queries

Must be documented at the time of the discussion or immediately following

Written documentation must include the clinical indicators that support the query and the actual question posed to the practitioner

Verbal “Query”


• The documentation of verbal queries should follow a standard format to include all necessary information

“Spoke with Dr. Smith regarding the documentation of (condition(s)/clinical procedure(s)), based upon the following clinical indicators found in the health record (list what was found and where it was found)”

Example of a Verbal Query Format


• All query’s must contain the following: The patient name

The admission date

The medical record number

• Addressed to a specific physician Attending, hospitalist, and/or consulting physician

• Documents the issue Use physician “quotes” to better frame the issue

• Facts outlining the issue• Asks the question

Concise wording

Request clarification

• Conclusion

Format of a Query


•Develop a template/format for all queries (ensures consistency of information)

•Develop protocols around the query process:o Process to alert the practitioner of a query

o Manner of query, written, verbal

o Style of query, open ended (preferred), a yes/no format or multiple choice

o Time frame for response

o **Retention of query responses: in the medical record or separate file

Standardize the Query Process


•Determine who the query should be sent to (address specific individual):

o PCP/ attending physician

o Hospitalist

o Resident

o Surgeon

o Consulting physician

Assign the Query


Begin the query with factual observations, not questions• Questions are often seen as time consuming or invasive

Start with the primary diagnosis (PDx)• Opens with an agreement • Prevents unintended responses

Examples:

“Pt. admitted with Diverticulitis Now receiving respiratory treatments…” or “Albuterol was ordered on…”

“Pt. admitted w/ Diverticulitis Hematocrit now…” or “patient transfused with 2 units of packed cells…”

Start with the Principal Diagnosis


Solid, non‐leading queries require use of:

• Clinical Indicators that are:

Derived from the specific medical record and the unique episode of care

Supportive of the need for a more complete or accurate diagnosis or procedure

Case mix, base case mix, complication and comorbidity (CC) and/or major complication and comorbidity (MCC) percentage, DRG pair percentages and/or volumes are NOT ACCEPTABLE INDICATORS

• Add facts and quotes that:

Provide the evidence on which the query is based

Do not inappropriately lead the physician

Do not make physicians defensive

Relevant facts often imply the problem ‐making the question an afterthought

Quotes avoid sounding like you are interpreting

Clinical Indicators, Facts, and Quotes


When writing a query:

• Do: Use words like possible, probable, suspected or likely

Base queries on patient‐specific clinical indicators

• Don’t: “Lead” the physician

Ask the physician to “assume” something not supported by clinical elements in the medical record

Indicate the financial impact or reimbursement of the response to the query on the query form

Make repeated attempts to clarify a response with the intent of receiving a specific outcome

Utilize a yes/no query form for new diagnoses that may have clinical indicators but are not documented in the medical record

Do’s and Don’ts


•Most physicians feel, queries imply blame…

Something is wrong or incomplete

“I didn’t do it!” or “I am only trying to treat my patient”

Avoid implying the physician has done something wrong

Focus on the facts

Divert Perception of Blame


Getting to the question:

• Provide a “way out”

Forcing a change is leading and makes physicians defensive

o Don’t box the physician in (e.g., when a provider is ‘primed’ with a question asking for ‘Diagnosis A or Diagnosis B)

o Use terms like “if possible”

Leave a Way Out


Asking the Question

• Politely request that physicians help clarify the issue with the medical record

• Educate the physicians to ensure they understand the reason for the query

• Keep in mind:

Physicians are not always responsive to questions (interruptions)

Most physicians want to help

o Frame the question ‐ let the physician know his/her help is being requested to clarify an issue in the chart

Request Help of the Physician


Asking the Question:

• “Yes or No” question formats are permitted under certain circumstances”

• Focus on the fact (test, laboratory results), rather than the diagnosis you suspect

“…please clarify the diagnosis being treated with “gentamicin”

• Ascertaining the POA status of a documented condition

• Substantiating or further specifying a diagnosis that is already present in the health record

• Establishing a cause and effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings

• Resolving conflicting documentation from multiple practitioners

Keep the Query Open‐ended


Take Ownership of the Query

Closing the query:

• Be polite and own your query.

Thank you.Sally Smith, RNClinical Documentation Improvement Specialistx542”

•Actively follow‐up all queries


Before finalizing the physician query…

Step back and double‐check:

Does the query make sense

Is the query specific without leading

Exactly what question is communicated

Is the query brief

Will the physician’s eyes go to the right words

Underline or highlight key information (but not diagnostic options)

Does the query match the physician’s personality or style of communication

Is the diagnosis worth querying

Considerations before Querying


Keep it short, avoid redundancies

Which reads better?

A) “On admission, hemoglobin was 13 and hematocrit was 38, but on day 2, the hemoglobin had dropped to 10 and the hematocrit dropped to 30. Currently, the hemoglobin is 8 and the hematocrit is 27.”

OR

B) “Hct dropped from 38 to 27 over 24 hrs.”

Considerations before Querying (continued)


• Keep it consistent Consistency and Reliability are essential to a successful query process.

o Relies on conscious efforts to maintain consistent approaches and methods

For example, there needs to be a degree of consistency when querying:

o Similar illnesses

o Different payors

o Difficult physicians

o Among different coders (or different CDSs)

Similarity in deciding when to query

o Ex., for which lab abnormalities

Last but not Least….


• Start with the principal diagnosis• Include clinical indicators, facts, and quotes• Provide options•Make sure query is non‐leading

•Document issue

•Ask a question• Request help clarifying issue• Keep it open‐ended• Consistency is key•Own the query

Summary




Intended for internal guidance only, and not as recommendations for specific situations. Readers should consult a qualified attorney for specific legal guidance.

Clinical Documentation Improvement Prevention Program ... · Na 130 ‐> fluid restriction Dirty UA...

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