3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. CDI Physician EducationCatch Them and Hold Them

3. By: Monica Dancu, RN, BSN Sylvia Hoffman, RN Darlene Shelffo, RN, CCDS, CDI Manager Tampa General Hospital Tampa, FL

4. Tampa General Hospital • Academic Medical Center: 929-bed teaching facility affiliated with The University of South Florida College of Medicine (USF) • USF affiliation: 1,200 community and university affiliated attending physicians, 285 resident physicians, and 400+ medical students

5. Physician education • Educating physicians can be quite a challenge. They may be: • Busy • Bored • Resistant • Confused • Angry • Tired

6. Creativity is a must Doctors are bombarded with information on a daily basis. If you want them to remember, you must make it memorable!

7. Presentation tips • State the facts • Keep it simple • Make it interesting • Make it relative • Use physician “speak” • Provide buy–in

8. Keep your audience interested • Quote specific physicians • Show documentation examples • Include personal progress notes or forms • Insert physician pictures • Break up boredom with humor • Involve your audience; ask questions • Provide CMEs

9. Say, “Cheese!”

10. Alert physiciansabout public profiling • HealthGrades.com • Disclosure Project • Delta Group • Leapfrog • Medicare Physician Data • Etc.

11. Explain how profiles are derived • Take into account: • Principal diagnosis • All other diagnoses (CCs and MCCs) • Principal procedure • All other procedures Give a more accurate reflection of mortality risk by reflecting all severity elements.

12. Provide physician-specific data • Documentation examples • Case studies • Severity-adjusted statistics for specialties • Mortality rates • Missed opportunities for individual practices • E/M billing documentation

13. Give rationale for accurate documentation • Each note must: • Support what will be coded and billed • Be legible • Show medical necessity Example: Urosepsis = UTI Is this what you mean?

14. Point out missed opportunities CC = Comorbidities MCC = Major comorbidities

15. Explain case-mix index (CMI) Case-mix index is the sum of all MS-DRG relative weights (RW) divided by the number of discharges. Factors that can positively affect the CMI include: • Admitting and treating a more resource intensive patient mix • Improvement of documentation in the medical record

16. Give real-life examples • Lack of complete documentation can skew mortality and morbidity data, case-mix index scores, and possibly reimbursement • Low CMI and high mortality scores influence physician and hospital profiles • Poor profiles can mean lower patient volumes and possible higher malpractice rates

17. Describe how wording affects data • Patient with respiratory insufficiency • Has a low mortality score • Patient with acute respiratory failure • Has a 30% mortality score • Patient with pneumonia due to pseudomonas • Has a 40%–70% mortality rate

18. Use physician language • Good documentation can serve as a benefit to your practice • Proper documentation supports the severity of the presenting problem and the complexity of your decision-making • The clinical documentation team is your ally in providing the precise terms needed to capture the best representation of your patients’ needs and services

19. Explain what’s in it for them • Show how documentation affects billing. • Give real life examples.

20. Give them the tools • Brochures • Pocket cards • Query forms • Signs

21. Make It Unforgettable YEEEEEAAAAAAAAAAAHHHHHHH!!!!!!

22. CDI-CSI DOCUMENTATION INVESTIGATION Avoiding a Documentation Felony !

23. Medical documentation is not what it used to be !

24. Cost per patient Morbidity scores Mortality scores Length of stay Utilization Audits Physician performance and documentation are under scrutiny

25. Severity of illness (SOI) Risk of mortality (ROM) Length of stay (LOS) Case-mix index (CMI) Statistics are being collected

26. Documentation impacts data Lack of complete documentation may alter mortality and morbidity (M&M) data and case-mix index scores Low CMI and high mortality scores influence physician and hospital profiles Did the patient die from a UTI ?

27. Medical data sources are growing Physician profiles Hospital report cards Medicare physician data HealthGrades, Delta Group, Leapfrog “Medicine is under the microscope.”

28. HealthGrades.com Example of Web sites

29. Disclosure project

30. But that’s not all, now a new danger threatens

31. Centers for Medicare &Medicaid Services The Centers for Medicare & Medicaid Servicesadds or changes ICD-9 codes each year. This requires adjustments in how physicians must document inthe medical record. It can make you crazy !

32. Must obey the law Specificity is vital; a definitive diagnosis must be documented New Golden Rule: If it is not written in the correct language, it didn’t happen.

33. The CMS word game Specificity is paramount Certain diagnoses should be linked Diagnostic medical/coding language only Remember: Lab, pathology,and radiology reports cannotbe used for coding

34. Wording must be specific NonspecificSpecific Anemia Blood loss anemia Hypoalbuminemia Malnutrition U/A abnormal UTI Urosepsis Sepsis Altered mental status Encephalopathy COPD COPD exacerbation CHF Acute diastolic HF

35. Specific terms are necessary for documenting severity of illness Acute Chronic Unstable Exacerbated Postoperative Secondary to Due to Severe She had acute aspiration pneumonia!

36. Severe sepsis Severe malnutrition Acute diastolicCHF Acute respiratory failure Acuteconfusional state Acute renal failure Unstable angina Exacerbated COPD Examples She died from severe sepsis!

37. What do you mean? Unless a condition is given a diagnosis and documented by a physician, the diagnosis cannot be captured. (Remember, lab results and pathology reports cannot be used.) This was a majorskin disorder, according to thepath report!

38. Point out missed opportunities CC = Comorbidities MCC = Major comorbidities

39. Why is this important? Hypotension Shock Low mortality score 50%–70% mortality rate Simple pneumonia Complex pneumonia 2.5% mortality rate 20% mortality rate Respiratory insufficiency Acute respiratory failure Low mortality score 30% mortality rate UTI (urosepsis) Sepsis 1.5% mortality rate 20% mortality rate

40. Give a diagnosis,not a symptom

41. No use of symbols Symbols and numbers do not translate into a diagnosis. Na 124 = nothing U/A + = nothing Hgb= nothing Albumin 1.5 = nothing Troponins= nothing Symbols = nothing No more use of symbols.

42. Example This cannot be coded *comorbidites will not be counted in patient’s diagnosis

43. Legibility Make sure what you write is legible. If your coworkers can’t read it, your patient may be at risk. I can’t make it out. It either says patient released or patient deceased.

44. Legibility? Illegible ! ! Signature illegible? This is a true crime scene !

45. Recognize POA clues

46. Present on admission (POA) Any condition present at the time the order for inpatient admission occurs Any condition that develops during an outpatient encounter She had a vascular catheter-associated infection present on admission.

47. Hospital-acquired conditions (HAC) Any condition that could reasonably havebeen prevented through the use ofevidence-based guidelines. They gave me the wrong blood and I almost died!

48. Most common HACs resulting in decreased reimbursement Urinary catheter-associated urinary tract infection Vascular catheter-associated infection Surgical site infection following orthopedic procedures, bariatric procedures, and CABG DVT or PE following total knee and hip replacement 11 total HACs for FY 2010

49. E/M billing Don’t gamble on your documentation.

50. Elements of E/M services(evaluation and management) Seven elements of E/M services (physician billing) • History • Examination • Medical decision-making • Counseling • Coordination of care • Nature of problem • Time spent