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

CDI Goals Accurately reflect the Severity of Illness with direct correlation to Risk of Mortality Improve physician and hospital profiles Increase Case Mix Index Appreciate maximum reimbursement for resource utilization

Severity of Illness and Documentation Severity of Illness and Risk of Mortality Reimbursement Medical Necessity & Length of Stay Profiling Hospital Physicians POA RAC Audits Compliance

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 : Clarification for ambiguous/conflicting documentation : Further specificity required for accurate coding : Documentation of diagnosis based on clinical indicators : Assignment of POA

Common MCCs and CCs MCCs Acute Systolic/Diastolic Heart failure Acute Renal Failure(ATN)* Acute Respiratory Failure* Acute Pulmonary Edema DKA and HHNK Encephalopathy* Hepatorenal syndrome Hypovolemic Shock Peritonitis (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, Hypertensive Commonly documented indicators: AMS NH3 / treatment with lactulose Increased/Acute Confusion Seizure, tremors, muscle twitching

Heart Failure Acute or Acute on Chronic or Chronic and 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 GFR Urine Osmolality < 450mosmols/kg, Urine NA > 40 meq/L ,FENa >2%(ATN) Nausea, vomiting, diarrhea Decreased urine output Metabolic acidosis Proteinuria Anemia Documentation must be consistent and specific: Acute Renal Failure/Acute Kidney Injury ( specify if 2nd 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

Documentation must include severity and type 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

Documented Indicators Include: Sepsis Local or Systemic Infection + SIRS = Sepsis Sepsis + Organ Dysfunction = Severe Sepsis Severe Sepsis + Hypotension/pressors = Septic Shock Documented Indicators Include: Organ Failure/Dysfunction Hypoxemia Altered mental status Oliguria Metabolic Acidosis Source of infection (UTI, PNA, wound, bloodstream, peritoneal) WBC >12,000/mm or < 4,000mm or > 10% immature neutrophils Temp >101° F (>38° C) or <97° F (<36° C) Tachycardia >90 Tachypnea >20 Hypotension/shock

UROSEPSIS Please clarify UTI SEPSIS from a UTI

Acute Blood Loss Anemia Clinical indicators for blood loss anemia include: Anemia Significant 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.

Points to Remember Acuity and consistency matters Document all co-morbidities that are monitored/evaluated /treated. Note if Present on Admission Avoid sign/symptom dx followed by differential dx in the D/C summary Link all symptoms to a probable cause. Eg AMS UTI: Sepsis Picc :PNA HIV

Are you taking credit for the patients you see? 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 Newsletters Resident Healthstream Course www.ACDIS.org

We are your DOCUMENTATION TEAM! WE ARE HERE FOR YOU!!! Donisia Lee, RN Ina T. Corley, RN We are your DOCUMENTATION TEAM!