UCI Clinical Documentation Improvement Program

Hospitalist Grand Rounds

10/15/2018

What is CDI?

• Collaborative effort between physicians, coders, compliance and CDS to improve clinical documentation so that it accurately and completely reflects the severity of illness/complexity of care/risk of mortality

• Concurrent process to review documentation and facilitate the translation of clinical language to coded language according to ICD-10 guidelines

• CDI documentation clarification will be sent when a documentation improvement opportunity is found NEVER MEANT TO QUESTION THE PHYSICIAN’S CLINICAL JUDGMENT

• Acuity

• Type/Stage/Severity

• Etiology

• Associated Conditions

• Manifestations

• Cause/Effect Relationship

• Laterality/Location

• Status changes

Specificity Matters!!!!!

Accurate DRG Assignment

82 year old M admitted for heart failure exacerbation and acute respiratory insufficiency with history of HTN, DM, CKD, end stage lung disease

DRG 293 Codes: I130, E1122, N189, I509, J984, R0689 SOI/ROM 2/2 LOS 2.6

82 year old M admitted for acute on chronic diastolic heart failure and acute hypercapneic respiratory failure with history of HTN, controlled DM2 CKD 4, chronic hypercapneic respiratory failure on home O2

DRG 291 Codes: I130, I5033, J9622, N184, E1122, Z9981 SOI/ROM 3/3 LOS 4.6

Severity of Illness

74 yo F with low grade fever and productive cough x 2 days. Family reports bed-confined since recent stroke. Recent 10 pound weight loss. BMI 19. ↓Na. History of stroke with left sided weakness, dysphagia, HTN. CXR with RLL infiltrate. Admitting dx: PNA. Nutrition consult for weight loss

DRG 194 Codes: J189, Z681, I69354, R634, I10, R1310 SOI/ROM 2/1 LOS 3.6

74 year old F with low grade fever and productive cough x2 days. Family reports bed-confined since recent stroke. Recent 10 pound weight loss. BMI 19. Hx of stroke with left sided weakness, dysphagia, HTN. CXR with RLL infiltrate. Admitting dx: PNA likely due to aspiration. Hyponatremia. Nutrition consult for probable malnutrition.

DRG 178 Codes: J690, Z681, I69354, E871, E46, I10, R1310 SOI/ROM 3/2 LOS 4.7

CLINICAL VALIDATION

Past: If not documented, not done! Current: If it is documented, is it relevant? Documentation of the clinical findings/rationale/treatment to support a diagnosis is imperative to prevent denials All active diagnoses MUST include documentation to support evaluation and treatment. Diagnoses only listed in the problem list are NOT coded

Clinical Validation

CLINICAL DOCUMENTATION DOCUMENTATION TIP FOR ACCURATE CODING

Sepsis Document findings/treatment to clinically validate Sepsis diagnosis

Specify the suspected source of infection or “unknown source”

Link to device when appropriate

For sepsis that occurs in the post-operative period, document the

underlying cause of the sepsis

Document the suspected causative organism

Identify the acute organ dysfunction associated with “severe sepsis”

Avoid using Sepsis, SIRS, and bacteremia interchangeably.

Bacteremia is a lab finding.

Acute Encephalopathy Specify type: Septic, Toxic, Hepatic, Hypoglycemic, Metabolic, etc

Avoid using interchangeably with delirium and/or AMS.

Document findings/treatment to clinically validate diagnosis

Malnutrition Document findings/treatment to clinically validate diagnosis

Specify severity: mild, moderate, severe

Respiratory Failure Specify acuity (acute, chronic, acute on chronic)

Specify type (hypercapneic, hypoxic, hypercarbia)

Document findings/treatment to clinically validate diagnosis

Avoid using interchangeably with respiratory distress/respiratory

insufficiency

Documentation Tips

• Pulmonary Edema: Document acuity.

• PE/DVT: Specify the acuity

• HIV - specify whether there is prior or current AIDS/AIDS defining illness

• Clinical significance of labs/diagnostics

• Pressure ulcers: presence, location and POA status

Dangers of Copy and Paste

Goal of progress note is to provide concise up-to-date reflection of patient’s condition and clinician’s thought process.

Copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information which can undermine the utility of the notes and lead to clinical error.

Could create fraud and abuse concerns

Comparison to Peer Group

CMI

MCC/CC Capture Rate

BY THE NUMBERS

• 43% (511) of all CDI clarifications to hospitalists

• 8% of those clarifications for DRG impact

• 92% response rate

• 1 unanswered clarification for malnutrition potential impact

• CMI: -1.4138

• Financial: - $16499.05

• SOI/ROM: 3/3 instead of 4/4

SHINING STARS with 100% response rates

Bindu Swaroop MD

Heather Hofmann MD

Maylyn Martinez MD

Sonali Iyer MD

Solomon Liao MD

Amish Dangodara MD

James Fry MD

Lanny Hsieh MD

Coders

• Coding is an exact discipline where the clinical documentation must exactly match the coding terminology for a code to be assigned

• There are strict guidelines and directions

• Coders cannot code what is not documented

• Documentation should not be left open to interpretation by coding

• Completeness of documentation is a MUST to accurately reflect the SOI/ROM

Coding Guidelines and Rules

Principal Diagnosis: the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care (defined by the UHDDS). The condition (or at least some sign/symptom referable to the condition) MUST BE PRESENT ON ADMISSION

Coding Guidelines and Rules

Secondary Diagnosis: additional conditions (either present on admission or occurring during admission) that affect patient care in terms of requiring

- Clinical evaluation, or

- Therapeutic treatment, or

- Diagnostic procedures, or

- Increased nursing care/monitoring, or

- Extended length of stay

Coding Guidelines and Rules

Dropped diagnoses Must document if the condition is ruled in, ruled out, resolved, remains possible or confirmed at time of discharge

Conflicting information When there is conflicting information, clarification from the attending is needed, as he/she is ultimately responsible for the final diagnosis, i.e. Bacteremia, SIRS, Sepsis

POA Link the definitive diagnosis back to the signs and symptoms on admission for all diagnoses subsequently confirmed after admission that were uncertain or constitute an underlying cause of a symptom that is present at the time of admission.

Coding Guidelines and Rules

ACTIVE DIAGNOSES ONLY LISTED IN THE PROBLEM LIST ARE NOT CODED. Must be documented in the assessment/plan and include evaluation and treatment

CODERS ARE NOT ALLOWED TO ASSIGN CODES DIRECTLY FROM IMPRESSIONS INCLUDED ON LABS/DIAGNOSTIC REPORTS/PATHOLOGY REPORTS. Link test results to a diagnosis

Discharge Summary

Final diagnostic statement for the entire hospitalization

Should address all diagnoses/medical issues that occurred during the entire hospitalization

Be consistent with what has been previously documented

Significant findings such as admission and discharge diagnoses (as well as those conditions resolved during hospitalization)

List all probable, possible, concern for, suspected, suggestive of, likely diagnoses

Hypertensive Heart Disease

Coding guideline presumes a link between hypertension and heart involvement and between hypertension and kidney involvement.

I11.0 Hypertensive heart disease with heart failure

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

Need documentation that the hypertension is NOT associated with the renal and/or heart failure to not link the conditions. Recommendation to specify the etiology of the heart failure and/or renal condition.

Hypertensive Heart Disease

64 yo F with h/o ESRD on HD, HTN, DM2, chronic combined systolic and diastolic HF. Missed HD due to access issues. Fistulogram showed patient AVF. Discharged after HD

DRG 291 Codes: I132, N186, I5042, E1122, Z992 SOI/ROM 2/2 LOS 4.6

64 yo F with h/o ESRD on HD, HTN, DM2, AV stenosis, chronic combined systolic and diastolic HF due to valvular disease not HTN. Missed HD due to access issues. Fistulogram showed patient AVF. Discharged after HD

DRG 682 Codes: I120, N186, I5042, E1122, Z992, I350 SOI/ROM 2/2 LOS 4.5

VIZIENT VARIABLES

VIZIENT VARIABLES

CONCLUSION

Focus on a quality, accurate and complete record

Be specific

Document your decision making process

Collaboration with coding and CDI teams

QUESTIONS?