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Level II Training Clinical Documentation Improvement. DoIM – Hospitalists 7/09/14 Presented by: Catherine P orto, MPA, RHIA, CHP Exec. Director HIM, UNMH ICD-10 Executive Project Lead & Erlinda Smith, CCS CDI Provider Education & Kayode Balogun CDI Program Development - Precyse.

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level ii training clinical documentation improvement

Level II TrainingClinical Documentation Improvement

DoIM – Hospitalists

7/09/14

Presented by:

Catherine Porto, MPA, RHIA, CHP

Exec. Director HIM, UNMH

ICD-10 Executive Project Lead

&

Erlinda Smith, CCS

CDI Provider Education

& KayodeBalogun

CDI Program Development - Precyse

unmmg coding staff current state
UNMMG Coding Staff – Current State

UNMMG Professional Fee Coding:

  • Assign ICD-9-CM diagnosis code (for that visit)
  • Assign CPT procedure Codes (for that visit)
    • Evaluation & Management (E/M)codes for provider services
    • Procedure codes –for provider fees
unmmg provider coding
UNMMG Provider Coding
  • 4 Day Hospital Stay (Evaluation &Management)
    • Day 1 = Initial Hospital Care (CPT 99223)
      • Charge = $514.00
      • wRVUs = 3.86
    • Day 2 = Subsequent Hospital Care/Follow up (CPT 99233)
      • Charge = $265.00
      • wRVUs = 2.00
    • Day 3 = Subsequent Hospital Care/Follow up (CPT 99233)
      • Charge = $265.00
      • wRVUs = 2.00
    • Day 4 = Hospital Discharge (CPT 99239)
      • Charge = $269.00
      • wRVUs = 1.90
  • Total Provider Charges = $1,313
  • Total Provider wRVUs = 9.86
unmh coding staff
UNMH Coding Staff
  • Hospital (Facility) Coders are responsible for Facility Coding for the hospitals and clinics:
  • Assignment of one DRG Code derived from:
      • One Principle Diagnosis (ICD-9-CM)
      • All Secondary Diagnoses (ICD-9 & capturing all present on admission (POA) diagnoses)
      • One Principle Procedure (ICD-9-PC)
      • All Secondary Procedures (ICD-9-PC)
      • Any & all Co-morbidities & Complications(CC & MCCs)
      • Assignment of the DRG
assignment of the ms drg
Assignment of the MS-DRG
    • DRG(Diagnosis Related Grouping)
      • One DRG is assigned for each Inpatient stay
      • Using all diagnoses and procedures codes
      • Includes codes for all complications & comorbidities (CCs and MCCs)
  • DRGs are assigned a relative weight (RW)
    • RW is the calculation of resource consumption
    • Used to determine payment
ms drg financial impact
MS-DRG Financial Impact
  • Relative weight (RW): Number assigned to each account based on the DRG assigned. The higher the RW, the sicker the patient.
    • 1: Average
    • <1: Below average
    • >1: Above average
  • Case Mix Index (CMI): The average of all relative weights for apatient population (Month, Year, etc.) for any given period of time.
secondary data uses the role of the apr drgs
Secondary Data UsesThe role of the APR-DRGs
  • APR-DRG (All-Payer Refined DRG-3M Software)
      • Calculates Severity of Illness (SOI)
      • Calculates Risk of Mortality (ROM)
        • Based on diagnoses, procedures and
        • Complications & Co-morbidities (CC and MCCs)
  • SOI & ROM scales (APR-DRG & UHC scale)
    • 1. Minor
    • 2. Moderate
    • 3. Major
    • 4. Extreme
poa and hac
POA and HAC

There is a BIG difference in whether a condition was:

  • POA: Present on Admission – documentation in the H&P or progress notes after a definitive diagnosis is made—whether each condition was present on admission (provider’s best clinical judgment)
    • Does this patient have a pressure ulcer (where)?

OR

  • HAC: Hospital Acquired Condition
    • For some selected conditions (diagnoses) that were not present on admission, but were acquired during hospitalization, the case may be paid as though the secondary diagnosis is not present
      • Fracture occurring during the IP stay
      • Diabetic Ketoacidosis (MCC) not present on admission
      • Foreign object retained after surgery
      • Vascular Catheter-Associated Infection
      • Surgical Site Infection
documenting questionable diagnoses
Documenting Questionable Diagnoses

Provider should document all possible, probable, or suspected conditions – this communicates what the provider is thinking.

  • Example:
    • Professional fee Dx: Cannot code R/O-- rolls back to coding a symptom
    • IP - Possible Sepsis, r/o sepsis: Sepsis coded as though it exists
    • Sepsis ruled out: Sepsis would not be coded—IP remember to confirm prior to discharge or in the discharge summary
    • Pneumonia vs. CHF: Both can be coded (IP); pro fee-- codes to a symptom (i.e. chest pain, shortness of breath etc.)
mission meaningful clinical process telling the patient s story
Mission: Meaningful Clinical Process “Telling the Patient’s Story”

Clinical Information is used by clinicians for “telling the story” for this episode of care.

Primary uses of clinical documentation:

  • The Documentation storycritical for patient care
  • The Medical Record is a communication tool among care providers
  • The Documentation should tell/demonstrate the clinical pathway to diagnoses

Many times the story is lost in our current “cut and paste” or more forward world or documentation.

secondary uses of clinical information as documented in the emr
Secondary Uses of Clinical Information “As Documented in the EMR”

Secondary Clinical Information/Data Uses:

  • Disease & Operative Indexing for research (ICD & CPT codes)
  • Validates the patient care provided
  • Serves as a legal document of the care provided
  • Drives Revenue/Reimbursement (Coding)
  • Permits accurate comparisons to other providers/institutions/national benchmarks
  • Identifies the quality and efficiency of the care we give. Computer extractions of:
    • Quality Indicators (PQRS)
    • Meaningful Use Data (MU)
    • Compliance/Regulatory Standards (TJC, CMS, DOH)
    • Metrics used for Value Based Purchasing
why does cdi matter medicine is under the microscope
Why does CDI Matter?Medicine is Under The Microscope
  • Cost per patient
  • Resource utilization
  • Length of stay
  • Complication Rates
  • Morbidity Scores
  • Mortality Scores
  • Outcome Analysis
  • Payer Audits
physician profiling
Physician Profiling
  • Hospital Report cards
  • Healthgrades, Delta Group, Leapfrog
  • Medicare Physician Data (since 2007)
  • Federal and state regulatory agencies (e.g. OIG)
  • The Joint Commission (TJC)
  • Centers for Medicare and Medicaid Services (CMS)
  • Quality Improvement Organizations (QIO)
icd 10 advancing healthcare
ICD-10: Advancing Healthcare…

The Federal Government through CMS is driving the healthcare industry to upgrade diagnosis and procedure coding standards (ICD-10) by October 1, 2015.

ICD-10 Changes

Implications

  • Pervasive Impacts
  • Diagnosis codes and procedure codes flow through mission critical operational systems and analytical tools
  • Alignment of technology remediation with business and technology strategies
  • Business process reengineering, training and change management is essential
  • Comprehensive Benefits
  • Quality Measurement
  • Public Health Disease Surveillance
  • Clinical Research
  • Organizational Monitoring and Performance
  • Reimbursement
  • ICD-10
  • (International Classification of Diseases version 10)
  • The ICD is the international standard diagnostic classification for general epidemiological, health management purposes and clinical use.
  • ICD-10 CM & PCS is an upgrade of the U.S. developed Clinical modification (ICD-9-CM) of Diagnosis and Procedure Codes, first adopted in 1979.

Significant Increase in Clinical Granularity

ICD-9 CM (Diagnosis)

ICD-10 CM (Diagnosis)

3-5 characters

alphanumeric

3-7 alphanumeric

characters

>14,000 unique codes

> 68,000 unique codes

ICD-9 CM (Procedure)

ICD-9 CM (Procedure)

ICD-10 CM (Procedure)

3-4 characters

numeric

7 alphanumeric

characters

> 4,000 unique codes

5 digits

> 72,000 unique codes

> 4,000 unique codes

the basics of the icd 10 cm change
The ICD-10-CM diagnosis code set is a full replacement of the ICD-9 code set that will provide additional granularity for diagnosis and procedure codes. This additional granularity is the primary driver of value.The Basics of the ICD-10-CM Change

An Example of Structural Change

ICD-9

ICD-10-CM

.

.

Etiology, anatomic site, manifestation

Category

Category

Etiology, anatomic site, manifestation

Extension

X

X

X

X

X

X

X

X

X

X

X

X

.

An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes

Type 1 diabetes mellitus with diabetic neuropathy, unspecified

E

1

0

4

0

One ICD-9 code is represented by multiple ICD-10 codes

.

Type 1 diabetes mellitus with diabetic mononeuropathy

E

1

0

4

1

.

Type 1 diabetes mellitus with diabetic amyotrophy

E

1

0

4

4

.

Diabetes mellitus with neurological manifestations type I not stated as uncontrolled

2

5

0

6

1

.

Type 1 diabetes mellitus with other diabetic neurological complication

E

1

0

4

9

The industry expects that mapping ICD-9 and ICD-10 codes will be a complex task

the basics of the icd 10 pcs change
The Basics of the ICD-10-PCS Change

An Example of Structural Change

ICD-9

ICD-10-PCS

.

Section

Body System

Root Operation

Approach

Device

Qualifier

Body Part

X

X

X

X

X

X

X

X

X

X

X

An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes

One ICD-9 code is represented by multiple ICD-10 codes

.

Total hip replacement

8

1

5

1

The ICD-10-PCS is an American procedure coding system that represents a significant step toward building a health information infrastructure that functions optimally in the electronic age.

icd 10 coding snapshot diabetes scenario
ICD-10 Coding Snapshot: Diabetes Scenario
  • A 68 y/o male has type I diabetes with diabetic chronic kidney disease stage 3, is being seen for regulation of insulin dosage. The patient has an abscessed right molar, which was determined, in part, to be responsible for elevation of the patient’s blood sugar.
  • ICD-10 codes:
    • E10.22 Diabetes type 1 with CKD
    • N18.3 CKD Stage 3
    • K04.7 Abscess Tooth
    • Z79.4 Long term drug therapy, insulin
icd 10 physician education
ICD-10 Physician Education
  • Don’t need to turn doctors into coders
  • We Need good documentation habits
  • We Need specialty specific documentation education
  • We need to Begin the process of education now for ICD-9 and incorporate ICD-10 issues into the education as we prepare for Oct. 1, 2014 (Now 2015)
sepsis
Sepsis
  • SIRS Criteria
  • Assess for 2 or more
  • (Fever) Temp > 38⁰C or < 36⁰C
  • (Tachycardia) HR > 90
  • (Tachypnea) Resp rate > 20 or pa CO₂ < 32
  • (Leucocytosis/Leukopenia) WBC > 12K, < 4K, or > 10% bands
sirs suspected infection
SIRS: Suspected Infection

If infection is known:

  • Document organism and site
  • Document whether infection is present on admission
  • May document possible, probable, likely or suspected sepsis
  • Complete Sepsis M-Page
  • Determine Sepsis Severity
sepsis severity
Sepsis Severity

Sepsis

  • Lactate levels documented
  • No organ dysfunction
  • No hypotension

Severe Sepsis

  • Lactate levels
  • Organ failure
    • Organ dysfunction must be linked to the Sepsis *

(Occult) Septic Shock

(Written as Septic Shock)

  • Lactate levels
  • No hypotension

Septic Shock

Written as Septic Shock

  • Hypotension
  • Refractory to IV fluids

*see organ reference pages

smite bundle
SMITE Bundle

Basic SMITE Bundle

  • Lactate q 4h x2
  • Blood Culture

3. Antibiotics within 1 h

4. Fluids

5. Re-evaluate as needed

Advanced SMITE Bundle

Basic Bundle Plus:

  • Fluids bolus
  • CVP
  • Vasopressors
severe sepsis organ dysfunction
Severe Sepsis : Organ Dysfunction

Documentation of

  • (Encephalopathy) Altered mental status
  • (Acute kidney injury)Creat levels/abnormal labs
  • (Acute liver failure) Abnormal LFTs/Total Bili
  • (Coagulopathy) INR level documented
  • (Acute respiratory failure) Hypoxemia and/or hypercapnia

*Please refer to organ reference for detailed documentation suggestions

case study 1
Case Study #1

MS DRG –178 Respiratory Infections & Inflammations w CC

PDX:Cystic Fibrosis with pulmonary manifestations

SDX: protein-calorie malnutrition. GERD, several other dx

SOI level: 3

ROM level: 2

DRG Wt. 1.4403

DRG Reimb: $13,091.09

Additional documentation in chart CDI Queries for: nutrition note documentation, malnutrition related to CF. Pt with BMI 15.9 on high calorie diet and clinimixi at 80 cc an hr for nutritional support. Malnutrition documented on PN. CDI query for the severity of the malnutrition. If provider agreed with query and documents severe protein calorie malnutrition.

MD DRG-177 Respiratory Infections & Inflamationsw MCC

SOI level: 3

ROM level: 3

DRG WT. 2.0549

DRG Reimb: $18,677.24

case study 2
Case Study # 2

MS DRG –872 Septicemia or Severe Sepsis w/o MCC

PDX:Septicemia due to E coli

SDX: protein calorie malnutrition, DM without complications type II, acute pancreatitis

SOI level: 3

ROM level: 2

DRG Wt. 1.0687

DRG Reimb $8,120.74

Additional documentation in chart: Sepsis with AMS

CDI Queries for: Specific type of Encephalopathy . If provider agrees and documents metabolic encephalopathy

MS DRG-871 Septicemia or Severe Sepsis W MCC

SOI level: 3

ROM level: 3

DRG WT.1.8527

DRG Reimb: $14,078.15

department training schedule
Department Training Schedule
  • Level I Training – Completed by April 30, 2014
  • Level II Training – Completed by June 1, 2014
  • Level III Training – Expectation: You are here
    • Dept Champion (s) Complete 1:1 training by June 1, 2014
    • All Dept. Specialty Training to be completed in June/July 2014 for ICD-10: Date to be determined by UNM HSC (RFP Vender selection underway 6/1/14
    • Metrics & Measures part of Monthly Department Meetings by June 2014
    • Top Dx/Tip Sheets & All Staff Trained by Dept/Div Champions by June 30, 2014
upcoming in fall 2014
Upcoming in Fall 2014:
  • Dept./Div. Specialty-Specific CDI Training
    • Vendor Proposals for Level III Training chosen by RFP Committee. Next steps:
        • Top vendors on-site to demonstrate their sub-specialty training method & tools – week of July 21
        • Encourage All Dept/Division Champions and anyone else interested to attend
        • Dept/Division – Specialty Specific ICD-10 Documentation Sessions to be scheduled in the Fall of 2014 (following UNM HSC approval of vendor and purchase)
contacts
Contacts

UNMH Coding & Clinical Documentation

ErlindaSmith, CCS

UNMH Coding Educator (Inpatient)

EVSmith@salud.unm.edu

KayodeBalogun, MD, CCS

CDI Program Manager, UNMH

kbalogun@salud.unm.edu

Catherine Porto, RHIA, MPA, CHP

Exec. Director HIM

cporto@salud.unm.edu

CDI Information to be posted on the following web site:

https://hospitals.health.unm.edu/intranet/HIM

Provider Documentation and ICD-10 Tab