Tulane Medical Center Clinical Documentation Program - PowerPoint Presentation

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Tulane Medical Center Clinical Documentation Program

Hospitalist Presentation 10/18/10

What is CDI?

BRIDGING THE GAP Between what CMS (Center for Medicare & Medicaid Services) recognizes (technical terminology of the ICD-9 system) and the clinical language physicians use to describe the patient’s condition

CMS Position on Clinical Documentation Integrity

“ We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”… “We encourage hospitals to engage in complete and accurate coding.”Source: CMS Federal Register August 2008 Final Rule p. 208

4

Query Updates (10/1/2010)

All forms utilized by CDI and coding staff will be referred to as a “QUERY”The Query form will NO longer display the title.The Present on Admission form is the only form that allows the physician to indicate the POA status without documentation in the progress notes. New Queries: 1. Specificity – to obtain further specificity of documented dx or procedure

2.

Infectious disease/organism

– query to link organism to identified infection

3

. Pathology findings

– query to determine significance of pathology report

findings. MD must confirm the diagnosis from the pathology report in the body

of the record.

QUERIES

CDI places queries concurrently for: : Clarification of diagnosis in CMS terms :

C

larification for ambiguous/conflicting documentation

:

F

urther specificity required for accurate coding

:

D

ocumentation of diagnosis based on clinical indicators

:

A

ssignment of POA

Common MCCs and CCs

MCCsAcute Systolic/Diastolic Heart failureAcute Renal Failure(ATN)*Acute Respiratory Failure*Acute Pulmonary EdemaDKA and HHNKEncephalopathy*Hepatorenal syndromeHypovolemic ShockPeritonitis (SBP, surgical)*

Pneumonia

Pressure Ulcer- Stage 3 or 4

Quadriplegia

Shock

Sepsis*

(if due to bacteremia note so)

Severe Malnutrition*

V-Fib/V-Flutter

CCs

Acidosis/Alkalosis

Acute Renal Failure (Pre-renal)

Ascites *

Acute Blood Loss Anemia*

Acute COPD exacerbation

Atrial flutter

Bacteremia

(

if sepsis, must note both present)

BMI <19 or >40

(must include indicators of cachexia or obesity)

Cellulitis

Chronic Systolic/Diastolic heart failure

Complications of Transplant

Hyper/Hyponatremia

Jaundice

Pleural Effusion

Protein Calorie Malnutrition

UTI

ENCEPHALOPATHY

Hepatic, Toxic, Metabolic, HypertensiveCommonly documented indicators: AMS NH3 / treatment with lactulose Increased/Acute Confusion Seizure, tremors, muscle twitching

Heart Failure

Documentation must include Acuity and Type:Acute or Acute on Chronic

or

Chronic

and

Systolic

or

Diastolic

or

Combination

Commonly documented indicators for acute episode:

Elevated BNP/Troponin

CXR : pleural effusion, pulmonary congestion/edema

SOB/DOE

Presence of edema

Administration of diuretics

Echo: systolic, diastolic dysfunction, and low EF

Acute Renal Failure

Increased Creatinine (RIFLE or AKIN), BUN, and/or K+ from baseline, decreased GFRUrine Osmolality < 450mosmols/kg, Urine NA > 40 meq/L ,FENa >2%(ATN)Nausea, vomiting, diarrheaDecreased urine outputMetabolic acidosisProteinuriaAnemia

Documentation must be consistent and specific:

Acute Renal

Failure

/Acute Kidney

Injury

(

specify if 2

nd

to ATN or other renal necrosis

)

Acute on Chronic Renal

Failure

Acute Kidney

Injury

on Chronic Kidney Disease (

specify stage of CKD)

**Alert!

The term Acute Renal

Insufficiency

does not impact severity of illness

Malnutrition

Documentation must include severity and type

Commonly documented conditions/indicators:

Cancer, Cirrhosis, CVA, Alzheimer's, Dementia, Malabsorption syndromes

Cachexia, temporal wasting (cc)

Documented weight loss

BMI less than 19 (cc)

Inability to consume adequate caloric intake (Eg. NPO)

Edema/fluid retention

Enlargement/tenderness of liver/abdomen

Laboratory values of low serum protein/albumin/prealbumin

Current nutritional support with TPN/PEG or tube feedings

Nutritional consult

** ALERT

protein calorie malnutrition is a co-morbidity

severe malnutrition is a major co-morbidity

mild or moderate malnutrition

will not

impact severity of illness

Sepsis

WBC >12,000/mm or < 4,000mm or > 10% immature neutrophilsTemp >101° F (>38° C) or <97° F

(<36° C)

Tachycardia >90

Tachypnea >20

Hypotension/shock

Local or Systemic Infection + SIRS =

Sepsis

Sepsis + Organ Dysfunction =

Severe Sepsis

Severe Sepsis + Hypotension/pressors =

Septic Shock

Organ Failure/Dysfunction

Hypoxemia

Altered

mental

status

Oliguria

Metabolic

Acidosis

Source of infection (UTI, PNA, wound, bloodstream, peritoneal)

Documented Indicators Include:

UROSEPSIS

UTI

SEPSIS

from a

UTI

Please clarify

Acute Blood Loss Anemia

Clinical indicators for blood loss anemia include:AnemiaSignificant drop in H&H

Hypotension

GI bleed

Transfusion(s)

Acute bleed from sites other than GI

Tachycardia

History & Physical→ Progress Notes→ Discharge Summary

 Any pertinent hx that is being monitored, evaluated, or treated should be brought in to the current in-patient record via the assessment/plan in the H&P or the progress notes. E.g. CHF with previous echo EF%, late effects of CVA, Decubitus, ETOH or drug current abuse, CKD staged, malignancies c mets, protein calorie malnutrition, BMI with cachexia or obesity. All diagnosis should be listed in problem list. Listing a DX next to a lab or CXR interpretation or it may be missed during the reconciliation process. Consistency and acuity within the record essential.   E.g. 3 documentations in progress notes within 24 hours:

AKI, acute on chronic kidney disease, acute kidney

Insufficiency (Implies 3 different dx for coding purposes)

Interpretations from any diagnostic imaging must be brought into the Progress notes.

All differential diagnosis (either/or) and all R/O should be continuously addressed. If both present, use the word (and)

Link any infections to a probable source and causative organism if suspected or known

Legibility! Avoid writing on sides, angles, in corners

Chief Complaint:

Hospital Course by problem:

list all problems, (diagnosis) interventions, supporting studies and labs 

Procedures:

Discharge Diagnosis:

List the Principal Diagnosis

as the reason for admission after further study precipitated by the patients chief complaints or findings upon admission. (There may be more than 1)

E.g. CHF and COPD

List all diagnosis at the highest acuity

from all levels of care (ED, ICU, Med/Surg). They should match what has been previously documented unless ruled out.  E.g. Hypovolemic shock, sepsis, Acute Respiratory failure , ATN

previously documented in the ED or ICU; (differs from Hypotension,

Bacteremia, Respiratory Insufficiency, renal insufficiency, noted in D/C

summary

Link all symptoms

to a likely, probable, possible diagnosis based on clinical findings

E.g. Altered Mental Status most likely due to Dilantin toxicity.

other Possibilities may include, UTI, dehydration and hypovolemia

List all confirmed diagnosis from diagnostic studies

pathology, radiology, echo, etc.

E.g. Admit dx: Renal Mass, path reports notes final dx: renal cell carcinoma

Important Notes

DO NOT

follow a Symptom dx with terms “either/or/vs.” as it will result in a symptom diagnosis in the final coding.

E.g. Chest pain, SOB, Weakness, Altered Mental Status, Syncope, fever,

due to ________ vs/or ___________

Any Diagnosis with the term

R/O

or

possible

should either be confirmed or ruled out. A rule out diagnosis may be coded

inappropriately

as an actual diagnosis.

Acuity

and consistency mattersDocument all co-morbidities that are monitored/evaluated /treated. Note if Present on AdmissionAvoid sign/symptom dx followed by differential dx in the D/C summaryLink all symptoms to a probable cause. Eg AMS UTI: Sepsis Picc :PNA HIV

Points to Remember

Do you know what your individual physician profile is?

Severity of illness equates to your Case Mix Index (CMI) and is correlated with a risk of mortality

Are you taking credit for the patients you see?

CDI Resources

Tulane Intranet – Clinical Documentation Link Program Description CDI Inquiry Forms Monthly NewslettersResident Healthstream Course www.ACDIS.org

WE ARE HERE FOR YOU!!!

Donisia Lee, RNIna T. Corley, RN

We are your DOCUMENTATION TEAM!