Is Clinical Documentation Improvement the Answer?

MAPAM /MAHIMA Joint MeetingThursday, November 19, 2009Thomas D. Sills, M.D.Lori Beaudry, CCS-PClinical Financial Resource

What are the Issues?• Inpatient

– MS-DRGs– AP-DRGs

• SOI• ROM

– Quality rankings• Health Grades• US News &WR• CMS data• Blue Cross

Outpatient• Emergency Department

–Levels, procedure capture, medical necessity

• Ancillary services: lab, radiology, etc.–Medical necessity

• Anesthesia/Pain Clinic–Accurate coding

Professional Services

• Emergency Department• Hospitalists• Clinics• Anesthesia/Pain

Audits

• RAC• MIC• BC• Other payors

A physician who heals for nothing is worth nothing. - The Talmud

All Billing Depends on Documentation

Documentation

Coding

Billing

Quality Measurement

Documentation

Coding Quality metrics

Billing

Inpatient CDI

Hospitals with Clinical Documentation Improvement Program Report Increased Reimbursement...

Mon Aug 11, 2008 8:30am EDT

-(Business Wire)--J.A. Thomas and Associates, the leader in healthcare clinical documentation improvement, published today a set of benchmarking reports that show 188 hospitals using its Compliant Documentation

Management Program (CDMP(R)) have realized an overall 5 % improvement in CMI than projected by the Centers for Medicare and Medicaid Services/MEDPAR for hospitals adjusting to the new MS-DRG coding system. To download the full report, visit www.jathomas.com.

Inpatient Example 1

• 77 y/o pt admitted from N.H. with documented urosepsis, azotemia, and chronic sacral decubitus. Treated with IV antibiotics; seen by plastic surgeon, who leaves illegible note. Discharged after 8 days.

• Principal dx: UTI, 599.0• Secondary dx: azotemia, 790.6; sacral

decubitus 707.03 • MS-DRG 690 Kidney and Urinary

Infections without MCC• Relative weight 0.7708• Payment $ 4600• ROM 2

• Principal dx: UTI, 599.0• Secondary dx: azotemia, 790.6; sacral

decubitus 707.03; stage III decub

• MS-DRG 689 Kidney and Urinary Infections with MCC

• Relative weight 1.2122• Payment $ 7300• ROM 3

• Principal dx: Septicemia, 038.9,• Secondary dx: sepsis, 995.91; azotemia,

790.6; sacral decubitus 707.03; stage III decub

MS-DRG 871 Septicemia w/o MV 96h+ w/ MCC

• Relative weight 1.8437• Payment $11,000• ROM 3

• Principal dx: Septicemia, 038.9,• Secondary dx: sepsis, 995.91; AKI, 584.9

sacral decubitus 707.03; stage III decub

• Px: Excisional Debridement, 86.22

• MS-DRG 853 Septicemia with MCC with procedure

• Relative weight 5.4946• Payment $33,000• ROM 4

Hospitalist - Example 2

• 77 y/o pt admitted to the ICU with urosepsis. On hospital day 2, progress note documents, “Looks better. VS stable but rales 1/3 up. Will decrease IVF and give IV lasix. +BC for E Coli. Cr down to 1.8. Continue Rocephin. Check CXR.”

• Documentation as is supports assignment of Level 1 subsequent care, 99231– RVU = 1.03– Payment = $37

• Good documentation would support assignment of Critical Care, 99291– RVU = 5.88– Payment = $212

Radiology - Example 3

• 65 y/o sees his primary care physician with a persistent headache, one day after falling and striking his head. The only findings were tenderness of scalp. Because pt was on Plavix, a head CT was obtained.

• Contusion of head, 920, was documented on record and requisition. Blue Cross denied payment due to lack of Medical Necessity.

• Head injury, 959.01, was documented on record and requisition. Blue Cross paid the claim.

In the midst of your illness you promise a goat, but when you have recovered, a chicken will seem sufficient. - African Proverb

Causes of poor inpatient documentation

• Lack of education• Lack motivation• Lack of structure for documentation• Lack of uniformity of medical semantics• Mismatch between language of clinical

medicine and coding

Approaches to CDI

• Multiple targets• Multiple methodologies• No one silver bullet• Detail driven• Look at each category

Inpatient CDI

Improve documentation to fully capture complexity by coding. –Severity of Illness (SOI)

• Affects Case Mix–Risk of Mortality (ROM)

• Quality measures

Organizational Issues

Potential conflict between:– Quality and Coding– CDS and Coding

Increased Staffing:– CDI– Coding staff

Inpatient - Example 3

• 65 y/o admitted for elective hemicolectomy. On post op day #1 post op patient has episode of atrial fibrillation which resolves with treatment. Pt had prior episode of a fib. 4 years before.

Principal dx: Colon Cancer, 153.6Secondary dx: a. fib, 427.31 Procedure: rt hemicolectomy, 45.73MS-DRG 331 Major bowel

surgery w/o cc/mccRelative weight 1.8415Payment $11,417ROM 1

• Principal dx: Colon Cancer, 153.6• Secondary dx: a. fib, 427.31; cardiac

comp 997.1 • Procedure: rt hemicolectomy, 45.73• MS-DRG 330 Major bowel

surgery w/o cc/mcc• Relative weight 2.8935• Payment $17,940• ROM 1

Inpatient - Example 4• 69 y/o pt with widely metastatic breast CA is for

management of pain due to new bony mets. CT of head showed 4 cm brain lesion in temporal lobe with vasogenic edema and effacement of sulci and compression of lateral ventricle. Neuro is consulted because of question of focal seizures. The pt is seen in consult and is started on anti seizure medication. During her stay the pt also received a Greenfield filter for recurrent DVT and contraindication to anti coagulation.

• Principal dx: bone mets 198.5• Secondary dx: seizure, 345.50; brain

met, 198.3; DVT, 453.40• Procedure: Vena Cava filter, 38.7• MS-DRGs 516 Other Musc/Skel proc

with cc• Relative weight 1.8083• Payment $11,400• ROM 3

• Principal dx: bone mets 198.5• Secondary dx: seizure, 345.50; brain

met, 198.3; DVT, 453.40; brain edema 348.5; compression brain, 348.4

• Procedure: Vena Cava filter , 38.7• MS-DRG 515 Musc/Skel proc/ mcc• Relative weight 3.0669• Payment $18 ,800• ROM 3

Inpatient - Example 5

• 65 y/o male was admitted for surgical resection of his pancreatic cancer. The patient had obstructive jaundice and CAT scan showed dilated biliary and pancreatic ducts. The patient had surgical resection with mild post op ileus and was discharged home after 7 days.

• Principal dx: Pancreatic Cancer, 157.1• Secondary dx: post op ileus, 997.4;

hypertension, 401.9; gout 274.9

• Px: Radical Pancreatectomy, 57.2• MS-DRG 406 Pancreas procedures w cc• Relative Wt. 2.6729• Payment $16,000• ROM 2

The pt was admitted for surgical resection of his pancreatic cancer. The patient presented with obstructive jaundice and CAT scan showed dilated biliary and pancreatic ducts. Did the pt have: 1. obstruction of the biliary duct? 2. obstruction of the pancreatic duct? 3. other_____________?

• Principal dx: Pancreatic Cancer, 157.1• Secondary dx: post op ileus, 997.4;

hypertension, 401.9; gout 274.9; obstruction of bile duct, 576.2

• Px: Radical Pancreatectomy, 57.2• MS-DRG 405 Pancreas procedures w MCC• Relative Wt. 5.5911• Payment $33,500• ROM 3

A physician is an angel when employed but a devil when one must pay him. - Latin Proverb

How to approach Inpt CDI

• Conventional approach: – Hire RNs; train them in coding issues; educate

physicians; concurrent chart review on floor; prompt physicians for documentation; communicate with coders

Advantages: Dedicated staff to CDIIncrease CMI

• Disadvantages:–High cost–Staffing–Lack of coding expertise–New level of bureaucracy

• Reporting relationship with HIM• Compliance Issues

Inpatient CDI

• Thorough Coding: Back end validation with robust physician query system

• Front end review and back end queries• Adding focused reviews of documentation

with ongoing feed back to medical staff

Inpatient CDI

• Separate but equally important issue of documentation for medical necessity

Impact of Documentation on E.D. Facility Coding and Billing

• Assignment of levels

• Procedure coding

• Diagnostic coding (Medical Necessity)

Assignment of E.D. levels

• "While awaiting the development of a national set of facility-specific codes and guidelines, we have advised hospitals …”

1. Levels should reasonably relate to intensity of services.2. Levels should be consistently applied.

Assignment of E.D. levels

• Point systems– Includes electronic records; documentation

and coding can be problematic

• ACEP guidelines (2004/2007)– Documentation is not an issue

E.D. Procedure Coding

• Documentation can be problematic–Infusions and Injections

• Drug, dose, route of administration, time started, time stopped

–Splinting• Explicit documentation of application

E.D. Facility Documentation Improvement

• Direct organizational issue

• Pressure VP Nursing

Nurse Manager of E.D.

E.D. Staff Nurses• Ongoing monitoring

E.D. Diagnostic Coding

• Problematic diagnoses:– ‘Normal exam’– ‘Medical Clearance’– Odd diagnoses

E.D. Diagnostic Coding

Professional Coding and Billing

• Evaluation and Management (E/M)–E.D. Physicians–Hospitalists–Clinic Physicians

Physician documentation example

• 64 y/o male c/o chest pain for 2 days. Hx of CAD with prior CABG 2004 and repeat CABG in 2007. Pt had done well until two months ago pt underwent cardiac catheterization after episode of chest pain— Drug eluting stent was placed in circumflex artery. Pt last saw own doctor last week.

• Two elements of HPI: location and duration

Physician documentation example

• 64 y/o male c/o mild, dull, constant chest pain for 2 days, better after eating and associated with dyspnea. NTG helped slightly.

• Seven elements of HPI: location, quality, timing, duration, context, associated signs/symptoms, modifying factors.

EMERGENCY DEPARTMENT E/M E/M CODE

HISTORY EXAM DECISION MAKING

99281 LEVEL 1

c.c. 1-3 HPI

AFFECTED AREA STRAIGHTFORWARD

99282 LEVEL 2

c.c. 1-3 HPI 1 ROS

AFFECTED AREA+ 1 OTHER

LOW COMPLEXITY

99283 LEVEL 3

c.c. 1-3 HPI 1 ROS

1-3 AREAS OR SYSTEMS

MODERATE COMPLEXITY

99284 LEVEL 4

c.c. 4+ HPI 2-9 ROS 1 PFS Hx

5-7 SYSTEMS MODERATE COMPLEXITY

99285 LEVEL 5

c.c. 4+ HPI 10+ ROS 2-3 PFS Hx

8+ SYSTEMS HIGH COMPLEXITY

HPI ROS Past Medical,

Fam. Soc. HxBody Areas Organ Systems

1. location2. quality3. severity4. duration5. context6. timing7. modifying factors8. signs/symp.

1.constitutional2.eyes3.ENT4.cardiovascular5.respiratory6. GI7. GU8.musculoskeletal9.derm10.neuro11.psych12.heme/lymph/ immuno

1. past med hx2. family hx3. social hx

1. head&face2. neck3. chest4. abdomen5.genitals6.back&spine7. each extremity

1.constitutional2.eyes3.ENT4.cardiovasc.5.respiratory6.GI7.GU8.musculo- skeletal9.skin10.neuro11.psych12.heme/lymph/ immuno

2 OUT OF 3 TYPE OF DECISION MAKING

NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS

COMPLEXITY OF DATA OF TO BE REVIEWED

RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY

STRAIGHTFORWARD

MINIMAL (1) MINIMAL (1) OR NONE

MINIMAL (1 Minor problem) e.g. insect bite, cold

LOW COMPLEXITY

LIMITED (2) Limited (2) Low (Acute uncomplicated illness or injury)

MODERATE COMPLEXITY

MULTIPLE (3) (new problem or 3+ stable problems)

MODERATE (3)

MODERATE (prescriptions, acute illness w/syst symp, mild exac. chronic illnesses, undiagnosed new problem)

HIGH COMPLEXITY

EXTENSIVE (4)

EXTENSIVE (4)

HIGH ( severe exac. of chronic illness: threat to life or function: parenteral controlled substances

E/M

TABLE OF RISK

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered

Management Options Selected

Minimal one self-limited or minor problem, e.g., cold, insect bite, tinea corporis

laboratory tests requiring: venipuncture chest x-rays EKG/EEG urinalysis ultrasound echocardiography KOH prep

rest gargles elastic bandages superficial dressings

Low two or more self-limited or minor problems one stable chronic illness, e.g., well controlled hypertension, non-insulin-dependent diabetes, cataract, BPH acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

physiologic tests not under stress, e.g., pulmonary function tests non-cardiovascular imaging studies with contrast, e.g., barium enema superficial needle biopsies clinical laboratory tests requiring arterial puncture skin biopsies

over-the-counter drugs minor surgery with no identified risk factors physical therapy occupational therapy IV fluids without additives

Moderate one or more chronic illnesses with mild exacerbation, progression, or side effects of treatment two or more stable chronic illnesses undiagnosed new problem with uncertain prognosis, e.g., lump in breast acute illness with systematic symptoms, e.g., pyelonephritis, pneumonitis, colitis acute complicated injury, e.g., head injury with brief loss of consciousness

physiologic test under stress, e.g., cardiac stress test, fetal contraction stress test diagnostic endoscopies with no identified risk factors deep needle or incisional biopsy cardiovascular imaging studies with contrast and no identified risk factors e.g., arteriogram, cardiac catheterization obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdocentesis

minor surgery with identified risk factors elective major surgery (open, percutaneous, endoscopic) with no identified risk factors prescription drug management therapeutic nuclear medicine IV fluids with additives closed treatment of fracture or dislocation without manipulation

Hospitalist Documentation Example

• Called to see 75 y/o woman admitted by PMD earlier today to ICU for pneumonia and COPD exacerbation. Patient has hx of severe COPD and was quite dyspneic on admission. Improved initially with Solumedrol, nebs but increasing dyspnea and confusion over last 20’. Pulse ox now 88.

• Meds-- • Physical exam: fully documented

• Labs, ABGs, repeat CXR done• Pt placed on BiPAP, given pressors, diuretics,

watched closely for 90 minutes.

• Consult or initial hospital visit– 99252 to 99255, 99221-99223

• Critical Care 99291, 99292

Documentation of Procedures

• Sutures• Incision and Drainage• Splinting• Smoking cessation• Central lines

Documentation for Pain Clinic

• Facet joint injections of spine• Trigger point injections• Procedures under Fluoroscopic guidance

Approach to CDI Identify all areas where improved

documentation will have significant impact - inpatient coding - inpatient medical necessity - E.D. coding - Professional coding - Other services

Obtain Administrative Support

Educate Physicians

Effective Feedback

Never stop monitoring

The doctor demands his fees whether he has killed the illness or the patient. - Polish Proverb