Coding and Documentation Improvement

1. Coding and Documentation Improvement Theresa Cuoco, MD, FACP Ashley Duckett, MD Medical University of South Carolina 2012

2. Objectives • Understand purpose of Utilization Review • Improve History and Physical and Progress Note documentation • Learn “buzzwords” that can improve hospital reimbursement and limit “chart enquiries”

3. Purpose of Utilization Review • Hospital reimbursement is dependent upon physician documentation • Billing at the incorrect level of care is Medicare fraud • UR helps ensure patients are receiving the correct level of hospital services based on medical necessity

4. Inpatient versus Observation Status • Orders must always include an “admission status” • Interqual Criteria are used by UR staff to decide “inpatient” v “observation”. Criteria include severity of illness, comorbidities and intensity of services needed. You are not expected to memorize these. • Rules of thumb • Any patient with hemodynamic instability at point of admission generally meets criteria for inpatient status • If no definitive diagnosis (just constellation of signs/symptoms), admit under observation.

5. Observation • Defined by Medicare as an OUTPATIENT service • Typically limited to 48 hours (but occasionally can be longer) • Room and board charges are billed at an hourly rate • Hourly rate does not start until order to admit to observation is entered in CPOE • If you aren’t sure, ask the AOD, your attending or call Utilization Review. If this is not possible, admit as observation. • It is easier to convert to inpatient then to change to observation.

6. Key Messages • UR staff and hospital coders can only use what's written in the chart so be clear and thorough in documentation  • Use "observation" status for hemodynamically stable patients without a clear diagnosis. • All H and Ps must include a family history and at least 10 systems documented in ROS •  Use buzzwords like "sepsis", "encephalopathy", and "respiratory failure" to make sure patient acuity is accurately represented and to cut down on chart inquiries

7. Observation • Emergency room: • Patient’s condition must be resistant to at least 4 hours of ER treatment • Pain, dehydration, nausea/vomiting • If you expect at least 6 more hours of observation, it’s reasonable to “observe” in the hospital • Clinic admissions: • Most direct admits from clinic (or home) should be observation status Patients can “convert” to inpatient if their acuity increases (UR will let you know!)

8. Inpatient Vs. Observation • UR staff completes admission review every 24 hours on observation patient to monitor for changes in acuity • There must be daily documentation to support the need for observation services • Do not change the admission status order without the direction of the UR staff

9. History • Chief Complaint must be included • History: Comprehensive requires: 3 of 3 elements - HPI, ROS, PFSH • HPI: 4+ descriptors or status of 3+ chronic problems • Location, duration, quality, severity, timing, modifying, signs/symptoms • ROS: 10+ systems are REQUIRED • Unacceptable ROS statements: “10 systems reviewed,” “Extensive” (without elaboration) • Acceptable ROS statements: “All others negative,” “All others reviewed and are negative,” and “All others unremarkable,” with at LEAST ONE ROS documented • Can’t double dip – if using for HPI can’t use for ROS

10. History • Past Medical, Family, and Social History: All must be present • Unacceptable: Noncontributory, unremarkable, or negative • Acceptable: Family history reviewed and not pertinent (IF you reviewed it) • Smoking cessation: Document counseling if smoked within the last 365 days • Especially if admitted for PNA, ACS, or CHF

11. Physical Exam • 1997 Multi-system Exam: Need 9 systems with 2 bullets each

12. Physical Exam Tips • Anything < 9 systems with 2 bullets each down codes to level 1 • Neck-supple: Counts as musculoskeletal • Extremities: No clubbing, cyanosis, or edema: MSK/CV/Skin • Unacceptable: Rest of exam negative • If patient refuses exam can’t bill higher level • Make sure to document decubitus ulcers present on admission and whether patient has chronic indwelling catheter at time of admission

13. H&P Tidbits… • No family history: down codes to straightforward or level 1 H&P • Less than 10 ROS: down codes to straightforward or level 1 H&P • A straight line drawn down ROS boxes does not count! • Be honest! When using all others negative with ROS make sure you actually ask the questions – it takes less than 5 minutes • MAKE SURE YOUR NOTE IS TIMED BEFORE THE ATTENDING’S NOTE

14. Bouncebacks • Acceptable to use if patient admitted within last 30 days. • Always photocopy old H&P and place in new chart • Document “PFSH, meds, allergies: REVIEWED AND UNCHANGED” – must include new ROS • Need to document that this is NEW PROBLEM or NEW EXACERBATION and not ongoing treatment from last admission or both admissions will be “bundled” • Reminds us to document “stable or resolved” at time of discharge • Document if someone was noncompliant with their treatment plan • AMA should be utilized if patient is truly not ready for discharge

15. Subsequent Care VisitsThe Silly Stuff • Date and time your note… Including the YEAR! • NEVER EVER use “No acute events” under subjective. Coders see this and may down code to the lowest level. • INSTEAD give pertinent HPI and ROS (“Cough mildly improved, still SOB. No CP”) • Always think every day… Why does this patient need to remain hospitalized and document that reason in your note.

16. Documentation Improvement

17. Documentation Improvement • Supports medical necessity • Severity of Illness • Quality Reporting • Correct ICD-9 Coding

18. Documentation Basics • Document diseases not signs and symptoms whenever possible • i.e. “suspected,” “probable,” or “likely” gram positive bacterial pneumonia • Indicate acuity even when obvious • i.e. congenital, chronic, acute on chronic • Avoid “multiorgan failure” and list each organ • Document SIRS when present • >2 of following: WBC >12K, <4K, or >10%bands; Temp >101 or <96; P >90, RR>20

19. Sepsis • “Systemic” diagnosis more important than local • i.e. “Sepsis secondary to urinary source;” NOT UROSEPSIS • Whenever patient meets criteria for SIRS with evidence of infection, SEPSIS is present! • Try to document from time of admission otherwise it looks like it occurred during hospitalization

20. Pneumonia • CAP = Gram positive bacterial pneumonia (confirmed or suspected irrelevant – you are treating for it) • HCAP/HAP/VAP = Gram negative or MRSA bacterial pneumonia – again, you can document this is suspected, because this is what you are treating for.

21. Respiratory Failure • Document “chronic respiratory failure” with anyone on chronic O2 at home • If patient comes in with COPD exacerbation document “Acute exacerbation of chronic respiratory failure.” • If newly requiring O2 in hospital document “acute hypoxic respiratory failure”.

22. Encephalopathy • Avoid “AMS” or “altered mental status” or “acute confusion” for patients that are altered or delirious • Use “encephalopathy” • Metabolic encephalopathy (electrolytes) • Toxic metabolic (Drugs)

23. Alcohol and Narcotics • Acute alcohol withdrawal patients • Document suspected thiamine deficiency if patient is getting vitamin supplementation during hospitalization • Patients on chronic narcotics • Document “narcotic dependence” – this is not synonymous with “narcotic abuse”

24. Kidney Disease • If patient has “”The abrupt (within 48hours) absolute increase in serum creatinine of ≥0.3mg/dl from baseline, a percentage increase in serum creatinine of ≥50%, or oliguria of less than 0.5ml/kg/hour for more than 6 hours” then document ACUTE RENAL FAILURE (instead of renal insufficiency) • Document “CKD” and Stage • Stage 1 GFR > 90 • Stage 2 GFR 60-89 • Stage 3 GFR 30-59 • Stage 4 GFR 15-29 • Stage 5 GFR <15

25. Congestive Heart Failure • Acute/Chronic or Acute on Chronic • Systolic or Diastolic or Combined • Core Measures: • 1. Document LV Systolic Function or schedule an echo • 2. ACE I/ARB given unless contraindication • 3. CHF Discharge Instruction Sheet must be given • 4. Smoking cessation

26. Skin Ulcers • Document at time of admission! You must do a full exam and document that they are present. Wound care nurses are very helpful. • Give SIZE and STAGE: • 1 Intact skin with non-blanchable redness • 2 Partial thickness loss of dermis or intact or open blister • 3 Full thickness tissue loss • 4 Full thickness tissue loss with exposed bone, tendon or muscle • Unstageable – full thickness tissue loss with base covered by slough or eschar

27. Diabetes • Uncontrolled: A1C>7 • Goal: blood sugars <200 within 24 hours • Document diabetic complications • Retinopathy • Autonomic neuropathy • CKD/nephropathy • Neurogenic bladder • Gangrene • Coma • Ulcer

28. Anemia and Nutrition • Anemia: be specific as to the etiology whenever possible (ie acute blood loss anemia) • Morbid obesity – document this when BMI> 40 • Malnutrition:

29. Palliative Care • Document “palliative care” if still actively treating medical conditions • Document “comfort care” if not still actively treating medical problems • This will ensure that patients at end-of-life are not assessed for compliance with quality measures

30. These are considered “Hospital-Acquired Conditions” if not “Present on Admission” DVT/PE Manifestations of poor glycemic control Vascular cath infection/clot Fall/trauma/fracture/dislocation Cath-assoc UTI Pressure ulcers Surgical site infections Therefore you must document these on H & P:

31. Diagnoses that are “ruled out” • Often we treat for suspected diagnoses that are later ruled out • Ex – Treating for “bacteremia” in a pt with GPC on gram stain, later found to be coag-neg staph. • Ex – Antibiotics are given for pneumonia in the ER, but it is determined that patient does not have pneumonia and they are stopped. • If you don’t document that the diagnosis was “ruled out” than the coders will code and bill for that diagnosis

32. Final Words… • If you didn’t document it, you didn’t do it. • Date (month/day/year) and time your notes. • Choose your words wisely. Level of care and thus reimbursement is based on what you write.