Teaming for Documentation Integrity

1. PMMC PHYSICIAN ORIENTATION 2008 Teaming for Documentation Integrity

2. What is TDI? • A process designed to • Provide education for complete, compliant documentation to achieve an accurate reflection of resource utilization for the care of patients admitted. • Address documentation and coding connection. • Bridge the gap between clinical documentation and technical coding. • A concurrent review process to clarify documentation in order to achieve clinical accuracy in the medical record during the hospitalization • A process to eliminate the need for retrospective Medical Records queries after discharge because TDI clarifies documentation prior to discharge.

3. Benefits That Can BeGained From TDI • Complete, accurate and timely medical record documentation. • Improved quality of care. • Accurate Hospital and Physician profiles. • Enhanced teamwork between the Hospital and Medical Staff. • Hospital’s Case Mix Index (CMI) is more reflective of the types of patients treated by the facility.

4. Why incorporate TDI into current operations? • Improve data accuracy • Case Mix Index does not accurately reflect intensity of service and resource utilization. • Publicly available data increasingly scrutinized to measure hospital performance. • Coding language and requirements often differ from the clinical thought processes and documentation.

5. Better Quality Information (BQI) • Medicare announced its Better Quality Information (BQI) project to improve care for Medicare beneficiaries. In a February 15 press release, CMS stated the following: The results of the BQI Project will be used for two primary purposes: first, to provide performance information to physicians that will assist them in improving the quality of care they are delivering to Medicare beneficiaries; and second, to give physician performance information to Medicare beneficiaries in order to help them with physician selection. The objective of the Initiative is to provide the public and providers with reliable and consistent measures of quality care. http://www.justcoding.com/premium/content.cfm?content_id=67915

6. Documentation Querys • Diabetes: • Type I or Type II • Controlled or uncontrolled (even temporarily) • Complicating conditions (i.e. diabetic neuropathy) • Please do not use arrows to indicate hyper or hypo. • Patient admitted with signs & symptoms (S&S) as diagnosis: • Please link S&S to an etiology, if known • “Syncope due to hypovolemia” • “Abdominal pain due to diverticulitis”

7. Documentation Querys • Debridement: • “Excisional” or “Non excisional” • Urosepsis = “UTI unspecified” in the Coding World • If clinically applicable please document “sepsis due to urinary tract source” • Post Op Anemia: • “Post op blood loss anemia” • CHF: • Acute, Acute on Chronic or Chronic? • Systolic, Diastolic or both?

8. TDI Awareness • Scheduled lunch/ breakfast meetings • Initiated a TDI information/education board • Share pertinent literature regarding TDI • Implementation of TDI Steering Committee

9. Questions? • Dr. N. Dodhia TDI Physician Advisor • Mary Ellen Totzke R.N Quality Documentation Coordinator (630) 801-5861