Clinical Coding, Activity Based Funding & Clinical Documentation - PowerPoint Presentation

1. Clinical Coding, Activity Based Funding & Clinical DocumentationMary Kouvas – Clinical Documentation Integrity Coordinator/Health Information Manager28th January 2021

2. Learning ObjectivesUnderstand why accurate medical documentation is part of a good medical practice.Understand the relationship between medical documentation and data collection.Understand the relationship between medical documentation and funding for patient care.Evaluations:i-phone – just point camera*Android – use QR reader app / point phone**you may have to switch off TNH wifiOr use this link:https://forms.gle/UzZHUTpoTqog5hLs6

3. Key PointsImportance of a complete healthcare recordWhat is clinical coding and why is it performedCDI program & Clinician QueriesHACsPrincipal DiagnosisAdditional DiagnosesProblems & underlying conditionsInterpreting abnormal resultsImportant conditions to documentCOVID-19 coding

4. Coding & Casemix unitOur team consists of Health Information Managers (Bachelor in HIM) and Clinical Coders (Certificate IV), 25 staffMelissa Sajeva – Operations Manager Coding and CasemixReport to the CFOFind us in Health Information Services (HIS) or we WFHPerform Clinical Coding and Data Quality activities including Clinical Documentation Improvement (CDI) and funding optimisationWe are non-clinicalWe are very friendly and helpfulWe sometimes contact you about documentation queries, please be kind

5. Complete Healthcare RecordThe healthcare record acts as a communication tool and all care must be documented in the healthcare record. Disseminates information between members of the inter-professional healthcare team,Provides a comprehensive, accurate, complete and non-biased account of treatment and care planning, and Documentation is contemporaneous.Clinical coders only have access to CPF, so if individual notes are taken and stored elsewhere, we will not have access to this information and we could potentially be missing important information to abstract from and code.If it isn’t documented, it didn’t happen

6. What is Clinical Coding?Clinical coding translates medical statements. It describes the patient’s episode of care.ICD-10-AM is used to assign codes for diagnoses and the Australian Classification of Health Interventions (ACHI) is used for interventions. Some mirror MBS codes with an added extension.I25.11 = Atherosclerotic heart disease, of native coronary artery38306-00 [671] Percutaneous insertion of 1 transluminal stent into single coronary arteryIt is performed by Clinical Coders and Health Information Managers (non-clinical).Must abide by the Australian Coding Standards (ACS), National Coding Advice produced by the Independent Hospital Pricing Authority (IHPA) and Victorian Coding Advice.On average, our clinical coders can complete around 250 episodes a day, an average of 4.5/hr which includes acute and subacute care. Long LOS and ICU slow us down, but the Chemo and Infusion cases are quick to code.

7. Why is Clinical Coding performed?Coded data is easier to store, retrieve, analyse and manipulate. (DSU reports)The data is submitted to the Department of Health and Human Services.DHHS analyses our data. Look at our activity, complexity of patients, hospital acquired complications, etc and uses the data for planning, research and benchmarking (Health roundtable)Most of our inpatient funding relies on coded data (about 70%). (Activity Based Funding)Without complete and accurate clinical documentation, we may not be reporting patient activity accurately and may not receive the correct reimbursement. The Casemix model of funding has been used in Victoria since 1993! There is talk about moving to the National ABF model next financial year. NWAU instead of WIES.https://youtu.be/VZ1Wvb0dvGI

8. Coding tells the storyPatient presents with acute appendicitis with localised peritonitis. A lap appendicectomy was performed under GA.Was also managed for dehydration. This condition has a DCL or diagnostic complexity level score of 1. During the hospital stay, patient developed Bacterial pneumonia. “HA” denotes hospital acquired complication.This episode is grouped to DRG G07A Appendicectomy, Major Complexity because the ECCS is 6.5.The hospital receives 2.0105 WIES which is approximately $10,655. 1 WIES = $5,029 last year. Yet to know the value for 20/21

9. Activity Based Funding

10. Clinical Documentation Integrity (CDI) programReview of targeted medical records on the ward.Offers documentation advice on the ward.Complete pink form when documentation needs to be clarified.Clarification needs to be written in progress notes and/or discharge summary.Sign/tick when actioned

11. Clinician Queries Once coding has been completed each month, the coding auditor will collate a list of episodes that require clarification of documentation. This is called a clinician query and is an electronic form found in the Admission tab in CPF. Example on following slide.A clinician query is generated to optimise WIES.There a 4 types of queries:Principal Diagnosis (Pdx) clarificationPdx sequencing when multiple optionsAdditional diagnosis clarificationProcedure clarificationHACs

12. Clinician Query Example

13. HACs – Hospital Acquired Complications A condition that is not pre-existing or present on admission.A condition that arose during the inpatient stay.A complication for which clinical risk mitigation strategies may reduce the risk of that complication occurring.Next financial year there will be funding implications, so important to get it right.Example:Patient from HLCNH was admitted with HAP and delirium. Past hx NIDDM and HT. During the admission patient developed AF so placed on meds. HAP is POA so prefixed with a P.Delirium is POA and prefixed with a P.AF has never been diagnosed and developed in hospital so is prefixed with a C = HACIf AF is further specified as paroxysmal, persistent or chronic it will not be recorded as a HAC.

14. HOSPITAL-ACQUIRED COMPLICATIONSDocument clearly whether the following condition(s) were Present on Admission (POA) or arose during the inpatient stay.CARDIACHEALTHCARE-ASSOCIATED INFECTIONS GENERALAMI – STEMI, NSTEMIArrhythmias – AF, SVT, VF, VT, SSS, Ectopic beatsCardiac ArrestHeart Failure – CCF, LVFPulmonary OedemaUnstable AnginaCentral line & IVC InfectionsInfections due to prosthetic devices and surgical siteGastrointestinal infectionsMulti-resistant organism(s)Pneumonia – Bacterial, Viral, AspirationSepsis or BacteraemiaUTIDeliriumFalls resulting in fracture or intracranial injuryMalnutritionNeonatal birth traumaPersistent Urinary IncontinencePressure InjuriesRenal FailureRespiratory Failure and ARDSSURGICAL COMPLICATIONS REQUIRING UNPLANNED RETURN TO THEATREGI BLEEDING & VENOUS THROMBOEMBOLISMMEDICATION COMPLICATIONSAnastomotic leaksSurgical wound dehiscencePost-procedural haemorrhageVascular graft failureAcute haemorrhagic gastritisBleeding ulcersHaematemesis, Melaena, GI haemorrhageDVT and Pulmonary EmbolismBleeding due to anticoagulantsHypoglycaemiaMedication-related respiratory complicationsRespiratory depression

15. Principal Diagnosis After study means evaluation of findings from tests, history of illness, specialist consultations, surgical procedures and so on. It is not a procedure.Example:The Principal Diagnosis should not be SOB FI when after study, the patient was managed for an exacerbation of asthma and CCF. The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care.Pdx: R06.0 SOBDRG E67B Respiratory signs & symptomsCost weight 0.4541PDx: J45.9 Asthma I50.0 CCFDRG E69A Asthma with major complexityCost weight 0.9577Pdx: SOB on b/g asthma and CCF

16. Principal Diagnosis Sometimes there is more than one condition that meets the Pdx definition.For example:Patient presents with fever, tachycardia, hypotension and SOB. After investigation, patient diagnosed as having Bacterial Pneumonia, Sepsis and IECOPD. Patient has a past hx of AF and required adjustment of medications during the episode of care.Principal Diagnosis: Bacterial Pneumonia Sepsis IECOPDAdditional Diagnosis: rAFAs all three diagnoses meet the definition for Principal Diagnosis, the coder will code all three conditions and assign the first listed diagnosis as the Principal Diagnosis.

17. Principal Diagnosis – Grouping Options With bacterial pneumonia as Pdx, the cost weight is 1.3267With IECOPD as Pdx, the cost weight is 1.3096With Sepsis as Pdx, the cost weight is 2.0525Therefore, the clinical coder would send a clinician query.

18. Principal Diagnosis – Clinician Query Dear Doctor,This patient was admitted and managed for multiple conditions equally meeting the Principal Diagnosis definition, please clarify which is the most appropriate to assign as principal diagnosis:(a) Sepsis(b) Bacterial Pneumonia(c) IECOPD(d) Other, please specifyThese clinician queries are located in CPF before the discharge summary in the Admissions tab. These queries are necessary to ensure optimised reimbursement for our hospital.Queries will only be created for WIES optimisation as we do not have the resources to ask for quality reasons.The CDI program was introduced in February 2018 to ensure good quality documentation and optimised reimbursement in real-time, where the CDI team review inpatient notes, in real-time.

19. Pneumonia – provide further specificity Bacterial pneumonia or viral pneumonia usually carry a higher DCL value.Important to be in the habit of documenting bacterial pneumonia when treating patient with antibiotics and when the pneumonia is not due to another cause, like aspiration or viral.We do have specific codes when bacteria or viruses like influenza is found to be linked to the pneumonia.

20. Linking symptoms to a diagnosisPrincipal DiagnosisIs the diagnosis established after study to be chiefly responsible for the admissionThe below patient presented with shoulder and neck painPrincipal Diagnosis should be ‘OA of right shoulder and neck’Link symptoms to a diagnosis where possible even if “likely”. By providing specificity, our data is detailed and our WIES is optimised.

21. Additional Diagnoses Clinical coders can only abstract conditions from the episode of care when they significantly affect the patient management in terms of requiring any of the following criteria (must be clearly documented and linked to condition): Commencement, alteration or adjustment of therapeutic treatment (increased Frusemide for CCF) Diagnostic procedures (CT spine for ongoing LBP) Increased clinical care (anaemia noted on bloods, repeat FBEs to monitor, be clear this is non-routine)Many of the above activities are performed by clinicians in the form of clinical consultation. For the purposes of classification, a clinical consultation refers to documentation provided by the:Treating clinician/team who is primarily responsible for managing a patient’s condition during the episode of careSpecialist who provides advice/opinion, to the referring clinician/team, regarding a patient’s managementNurses, midwives and allied health professionals who are engaged in a patient’s management within their scope of practice.Telephone or electronic consultation with clear documentation of the information exchange is also regarded as a clinical consultation.

22. Additional Diagnoses – progress notes examples# Bacterial pneumoniaPlan: cont IV antis# Hb 86 – anaemiaPlan: repeat FBEs to monitorPlan: Packed cells if no improvement# ↓ BP – hypotensive throughout morningPlan: W/H antihypertensive meds# Low moodPlan: Refer to CL Psych# Increased postop pain of knee following TKRPlan: refer to APS# CXR showed atelectasis of significancePlan: deep breathing and refer to PhysioPlan: follow-up CXR tomorrowDon’t just note findings on reports, explain if there are significant findings that require management or follow-up, or document if findings explain the symptoms being investigated.

23. Additional Diagnoses – progress notes examplesSome specialties have their own templates.In this example, there is no management plan for the Anxiety attack which is important for coding, otherwise it is deemed insignificant. Anxiety has a DCL value

24. How to make a finding significantHere we have an excellent example of how we have linked the hypoxia to a condition, indicating that the finding on CXR is likely to explain the symptom. Atelectasis has a complexity score and contributes to optimising the DRG and funding.There is also a clear plan.

25. Documenting a suspected condition, noting it was ruled out, so we code the symptom.Suspected condition ruled out - example

26. Additional Diagnoses – ED to wardAdmission assessment usually written before official admission to ward:Coders can only assign codes for conditions that are managed during the inpatient episode of care, not what happened in ED.When you review the patient for the first time on the ward, important to document the current issues that require management on the ward.Document the issues that resolved in ED.Some conditions cross over.For example:# DehydrationPlan: IVTIVT could start in ED and finish on the wardFor example:# Sepsis of unknown source, Plan BC, IV antis, IVFOn ward refer to Sepsis secondary to Acute Pyelonephritis

27. Additional Diagnoses - linkageOn presentation to hospital, clinicians note down:Presenting complaintPast medical historyCurrent medicationsPlan of ManagementSometimes in the Plan, there will be things noted that are not linked to a condition. It is not clear why something is on the Management Plan. Coders cannot make assumptions. It may be clear to you and even to the most experienced coder, but if there is no linkage, it cannot be coded.Past history of Dementia, OP, NIDDM, AF on warfarinImp: UrosepsisPlan: Repeat BC, IV antis Diabetes chart INR levels 1:1 nursing care, requires SIMON Past history of Dementia, OP, NIDDM, AF Imp: UrosepsisPlan: Repeat BC, IV antis 1:1 nursing care for dementia

28. Additional Diagnoses – specify each site/type…OA, gout, disc bulges etc – list each site as each site can have a DCL value and therefore optimise WIES easilyPressure injuries – stage and siteInjuries – fractures, dislocations, abrasions, contusionsInfective exacerbations – where is the infection? URTI, LRTI, chest, pneumonia?Shoulder pain post lap surgery – document due to laparoscopyAcute on chronic conditions – each code can have a DCL

29. Problems and underlying conditions - Rules According to the Victorian ICD Coding Committee (VICC) advice number 3207:“VICC does not consider the phrase ‘on a background of’ to be synonymous with the underlying cause of the problem. A number of conditions may co-exist in a patient, but without a documented causal link it cannot be assumed that one is the underlying cause of another.”VICC advice 3210:“VICC does not consider the phrases ‘on a background of’, ‘in context of’, ‘in a setting of’ or any other similar wording to indicate a link for coding underlying causes.”Sometimes conditions don’t have to meet the criteria for Additional Diagnosis if they are linked as an underlying condition.

30. Problems and underlying conditions To make clear links between the problem and underlying cause, you must use the following terminology:The following terms must be used:secondary to2° to due toaetiologycaused by Avoid the following terms:on b/g ofon a background of in the setting ofin context ofrelated toassociated withThis will ensure correct allocation of DRG and a better description of the patient’s episode of care

31. Problems and underlying conditions - Example Heart failure with no causal link.Cost weight is 1.1391

32. Problems and underlying conditions - Example Heart failure due to HTN and dilated CM.DRG is optimised easily.Cost weight is 1.9714Increase of 0.8323Est $4,244

33. Problems and underlying conditions - example “On b/g of” versus “secondary to”Not always about reimbursement, sometimes it is necessary to ensure the episode is grouped to a more appropriate DRG

34. Documenting the underlying cause - example

35. What is the No. 1 Clinician Query asked by our coding auditors (surgical/LUSCS)?Patient admitted for a surgical procedure. Patient underwent division of adhesions and has had previous surgery in that area. Can you please clarify if adhesions are due to? Previous procedureInflammatory processOther, please specify(d) Unable to determineWhy?

36. Adhesions due to previous surgery - exampleDRG – minor complexityCost weight 1.3764

37. Adhesions due to previous surgery - exampleDRG – major complexityCost weight 2.4159Increase of 1.0395Est $5,301As long as DOA is documented we can code it, we do not have a definition for significant time it takes to divide adhesions.

38. What does good clinical documentation look like?“Hypertensive 180/80” is better than BP 180/80 or ↑BP

39. Symptoms & vague termsCognitive impairment is a codeable term but if patient has been diagnosed with Dementia, then this term should be used.CO2 retention is not a codeable term. Does this mean chronic type 2 respiratory failure?

40. Symptoms & vague termsOnly macrocystosis can be coded from these notes as it is listed as an issue and plan is noted (blood film).# GCS# CO2 retention# Decreased consciousness GCS 10# T2RF

41. Symptoms & vague terms↓GCS is also not a codeable term. Better stated as decreased consciousness with GCS 10 or coma or unconsciousness or due to Dementia or infection etc.Coma has a DCL value and is especially important to document for patients admitted with poisonings and require intubation and or admission to ICU.

42. Symptoms & vague termseGFR results – AoCKI or AKI etcAbn or deranged LFTs – is there a cause? Hepatic congestion, ischaemic hepatitis, toxic liver disease due to statin etc. Better stated as LFT dysfunction.

43. Frequently Asked QuestionsQuestion: Can I just write the issue and management plan on the discharge summary?Answer: No, it must also be documented in the progress notes as clinical coders need to verify all the conditions noted on the discharge summary.Question: Do I have to repeat documenting a condition in the progress notes or is once sufficient? For example, can I document anaemia once as an issue and then in the following progress note refer to it as Hb105 →98→95 with a management plan?Answer: As long as you document the issue once in the progress notes and there is evidence that the management plan has been carried out, then yes it is sufficient. Don’t forget to add it on the discharge summary too.

44. Medication changes

45. Medication changes2858685 12/5

46. Acute severe asthma: especially for patients admitted to ICU DCL = 4, more than just asthma (DCL=2) must be written as acute severe, not acute asthma and not severe asthmaDeconditioning: if patients have prolonged hospital stay and require AH or transfer to rehab better term than below PMLOF or fatigue and weakness or functional declineDehydration: often forgotten, dry MM does not mean dehydration for hydration does not mean dehydrationDelirium: was it present on admission or acquired during hospital?Postop complications: document PE due to surgery document anaemia due to blood loss bleeding due to injury to blood vessel during surgerySepsis: patients with systemic response to a localised infection adds to the complexity consider documenting it as Pdx, for eg Sepsis secondary to LL CellulitisImportant conditions to document

47. Good Documentation posters

48. NSLHD Medisearch appGrouped into specialtiesDocumentation tipsConditions affecting the DRGDocumentation ResourcesAlso accessed via Medical Education Workforce, resources. Coming soon – animated short videos on good documentation to be viewed upon commencement of new rotation.WRITEitRIGHT appHelps with specificity

49. COVID-19 – documentationThere is no single code for COVID-19 positiveImportant to specify the condition COVID-19 is linked to, or exacerbating

50. COVID-19 – documentationLink positive COVID-19 result with a condition or symptom(s).Examples:IE COPD due to COVID-19Acute on chronic T2RF secondary to COVID-19Chest infection due to COVID-19 positiveFever and rigors secondary to COVID-19 – no respiratory infection foundClearly state if COVID-19 is negativeDocument if asymptomatic COVID-19 positive (this means NO presenting symptoms)

51. Supplementary Codes for Chronic Conditions The following list of conditions are abstracted from the medical record and coded only when the condition does not meet the Australian Coding Standard 0001 Principal Diagnosis and Australian Coding Standard 0002 Additional Diagnosis:Obesity U78.1Cystic fibrosis U78.2Dementia U79.1Schizophrenia U79.2Depression U79.3Intellectual disability U79.4Parkinson’s Disease U80.1MS U80.2Epilepsy U80.3Cerebral palsy U80.4Quadriplegia, paraplegia, hemiplegia U80.5IHD U82.1Chronic heart failure U82.2Hypertension U82.3Emphysema U83.1COPD U83.2Asthma U83.3Bronchiectasis U83.4Chronic respiratory failure U83.5Crohn’s disease U84.1Ulcerative colitis U84.2Chronic liver failure U84.3Rheumatoid arthritis U86.1Arthritis and OA U86.2SLE U86.3Osteoporosis U86.4CKD stage 3-5 U87.1Spina bifida U88.1Down’s Syndrome U88.2These codes do not carry a DCL and therefore never affect the DRG. Hence, it is important to link any medication changes or treatment/management plans to the abovementioned conditions so that the clinical coders can assign the appropriate code. Clinical coders cannot make assumptions.

52. Contact detailsMary KouvasClinical Documentation Improvement Coordinatormary.kouvas@nh.org.au or 8405 2038Melissa SajevaOperations Manager Coding and Casemixmelissa.sajeva@nh.org.au or 8405 2466Saja SammourClinical Documentation Improvement Specialistsaja.sammour@nh.org.au or 8405 8457

53. Thank you!Please complete the evaluation:i-phone* – just point cameraAndroid* – point camera / use QR reader app*you may need to switch off TNH WifiOr use this link:https://forms.gle/UzZHUTpoTqog5hLs6

54. Learning standardsThis presentation addresses the following components of the Australian Curriculum Framework for Junior Doctors:Professionalism – professional standards; professional responsibilityCommunication – managing written information/electronic information and health recordsThis presentation is aligned with the following NSQHS Standards:Standard 6: Communicating for Safety – Documentation of information