Improving CDI: Taking Your Program from Good to GREAT Fran Jurcak, RN, MSN, CCDS Director, Clinical Documentation Improvement Huron Consulting Group Chicago, IL

Evaluating your CDI Program Scope of practice Appropriateness of staffing Administrative oversight Tracking tools Physician engagement Opportunities Discharged records Clinical examples Future Plans

Assess Program Scope

Program Assessment Program purposes Payers being reviewed Additional diagnoses CC/MCC capture Present on Admission Signs and symptom diagnoses Completeness of record Principal diagnosis Medical necessity Core Measures

Chart Review Priority ACDIS: 2010 CDI Program Benchmarking Survey

Best Practice Dedicated Role Accuracy of clinical documentation Principal Diagnosis Severity of Illness Risk of Mortality Review of every record Physician education Planning for ICD-10 Good to Great!

Impacting Documentation

Organizational Structure ACDIS: 2010 CDI Program Benchmarking Survey

Balancing Program Goals Finance Quality Improve reimbursement Reduce risk of denials RAC calls this DRG Validation Complete and accurate documentation of quality measures RAC calls this Clinical Validation Quality Finance

Creating the Balance Accurate documentation that supports the conditions being monitored and treated throughout the course of the patient stay will result in appropriate severity of illness and compliant reimbursement. Quality Finance

Documentation opportunity does not just occur Staffing Number of Reviews 10-15 Initial reviews/day 15-20 Follow up reviews/day Weekend Coverage Admit and discharge Documentation opportunity does not just occur Monday through Friday, 9-5! Good to Great!

Record Review Goal 100% of identified payers Subtract discharge numbers from clinical areas not covered by CDI Specialists Typical Benchmark >80% Retrospective review possibilities Post discharge Records of deceased Good to Great!

Productivity Review Rate Low Review Rate with Low Query Rate Review CDS process Identify areas for education to improve Low Review Rate with High Query Rate Review CDS process to reflect number of cases to be reviewed Consider additional FTE's High Review Rate with Low Query Rate Review records for query opportunity Provide necessary education regarding potential queries Review process to ensure enough time per record High Review Rate with High Query Rate Excellent program Consider review of additional DRG payers Property of F. Jurcak, 2010

Query Impact ACDIS 2010 Physician Query Benchmarking Survey,

Process Type of Query Principal Diagnosis Present on Admission Procedure CC/MCC Query Indicators Inclusion of rationale for the query Should include: Risk factors, signs/symptoms, treatment

Process Method of Query Communication Concurrent vs retrospective Paper vs electronic Templates Provide consistency Enhances physician participation

Template Example ACDIS Resource Library: Provided by Susan A. Klein, BSN, RN, C-CDI, Saint Peter's University Hospital in Monroe Township, NJ

Template Example ACDIS Resource Library: Courtesy of Sandy Beatty, Clinical Documentation Specialist for Columbus Regional Hospital

Process Query Issues Location in record Permanency Ease of physician recognition Permanency Permanent part of record…or not State QIO and RAC Leading vs nonleading Clinical indicators

Query Quality Regular review of query forms Content Structure Quarterly audit of CDI Specialist queries Peer to peer review Quarterly updates/education for CDI staff Good to Great!

Query Metrics Query Rate Low High CDS Issue: Process: Evaluate review rate and compare with query rate CDS Issue: Audit records to identify missed opportunity Educate CDS on appropriate topics High Evaluate query appropriateness Ensure appropriate physician response rate occurs Continue physician education plan Property of F. Jurcak, 2010

Process Follow up Frequency Rationale 12-20 Follow up reviews/day Previous query answer New query Other measures Physician Education

Program Success Tracking Data Method of tracking Data to Track Review Rate Query Rate Physician Response Rate Physician Acceptance Rate CMI changes Tracking Quality Query forms CDI Specialist queries

Physician Engagement

Process Physician Response Identifies Goal 100% Physician acceptance of CDI program Quality of process Goal 100% Medical Staff by-laws Physician Report cards Good to Great! Good to Great!

Process Physician Response Rate Low High Process Issues: CDS Issues: CDS needs to have face to face with physicians Physician Education needed CDI Physician Advisor to assist CDS Issues: Review records to identify CDS education opportunity Evaluate review rate for CDS productivity issues High Physicians on board CDS following through to ensure documentation Ensure credibility of CDS queries CDS following through to ensure answers Property of F. Jurcak, 2010

Physician Support Physician Response Rate Employed Physicians Expected Response Rate 100% Written into contract Part of Performance Measurement Contracted Physicians Private Physicians Expected Response Rate 100% (per Medical Staff by-laws) Report cards of performance

Physician Communication How Face to face Service Line meetings Permanent agenda item 10-15 minute update Metrics over time Medical Staff meetings Good to Great!

Physician Education Documentation Concerns Content Documents Clarity Consistency Appropriateness Documents History and Physical Progress Notes Discharge Summary

Physician Report Cards Include Number of Discharges Length of Stay CMI Response Rate Track metrics monthly Physician Advisor Involvement One on one with physicians Good to Great!

Support Physician Advisor Nearly 50% of CDI programs have an active physician advisor Role includes: Follow up with physicians regarding queries Peer to peer education Clinical resource to CDI team Write appeal letters Good to Great!

Documentation Improvement Opportunities

Process Retrospective Follow through Unanswered Queries Prior to coding/billing CDI Specialist after discharge After coding/billing Continued as coding query ACDIS 2010 Physician Query Benchmarking Survey,

Retrospective Queries Discharged Records Concurrent Queries If not completed: CDS has one business day to contact physician After one day repose as Retrospective Query Retrospective Queries Posed by professional coder Do not complete until MD response received Medical Staff By Laws to address time frame for response (14 days) Second Looks CDS Retrospective review of records: Missed due to short stay Deceased patient Signs/Symptoms DRG DRG without CC/MCC Good to Great!

APR-DRG All Patient Refined Diagnoses Capturing all conditions being monitored and/or treated Severity of Illness Extent of physiologic dysfunction Risk of Mortality Likelihood of dying

Example 86 yo female with history of COPD, CHF and DM is admitted with shortness of breath and pneumonia. Respiratory rate is 34, pulse oxygenation is 78% on RA. Patient is started on IV antibiotic, O2 via venti-mask and transferred to telemetry. ICD-9 Description 486 Pneumonia, organism unspecified 428.0 CHF, unspecified 250.00 DM 196 COPD, unspecified MS-DRG = 195 APR-DRG = 139 SOI = 2 - moderate ROM = 2 - moderate

Specificity With greater specificity of the stated diagnoses ICD-9 Description 486 Pneumonia, organism unspecified 428.32 Diastolic heart failure, chronic 250.02 Diabetes Mellitus without complication, Type II or unspecified, uncontrolled 491.21 Obstructive chronic bronchitis with (acute) exacerbation MS-DRG 194 APR-DRG 139 SOI = 3 - major ROM = 2 - moderate

Documentation Improvement With documentation of Acute Respiratory Failure ICD-9 Description 486 Pneumonia, organism unspecified 428.32 Diastolic heart failure, chronic 250.02 Diabetes Mellitus without complication, Type II or unspecified, uncontrolled 491.21 Obstructive chronic bronchitis with (acute) exacerbation 518.81 Acute Respiratory Failure MS-DRG 193 APR-DRG 139 SOI = 3 – major ROM = 3 - major

After 24 hours of treatment with IV antibiotics, the patient’s creatinine increases and the physician also documents acute renal failure ICD-9 Description 486 Pneumonia, organism unspecified 428.32 Diastolic heart failure, chronic 250.02 Diabetes Mellitus without complication, Type II or unspecified, uncontrolled 491.21 Obstructive chronic bronchitis with (acute) exacerbation 518.81 Acute Respiratory Failure 584.9 Acute kidney failure, unspecified MS-DRG 193 APR-DRG 139 SOI = 4 – extreme ROM = 4 - extreme

Capturing the Total Picture APR-DRG’s attempt to capture: Type of patient being treated Costs incurred in the treatment Expected services Anticipated outcomes Goal of CDI Program: Ensure that all conditions being monitored and treated are documented clearly and consistently.

Capturing the Diagnoses 67 yo male with history severe COPD and pulmonary HTN presents with shortness of breath, noted neck vein distention and mildly elevated BNP. Patient is treated with oxygen, nebulizer treatments, IV steroids and IV lasix Physician documents exacerbation of COPD, pulmonary HTN and CHF

Cor Pulmonale Defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system Pulmonary Hypertension is the common link between lung dysfunction and the heart in cor pulmonale Although cor pulmonale commonly has a chronic and slowly progressive course, acute onset or worsening cor pulmonale with life- threatening complications can occur

Pathophysiology Pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia – This can result in pulmonary hypertension and if the hypertension is severe enough, it causes cor pulmonale Anatomic compromise of the pulmonary vascular bed secondary to parenchymal or alveolar lung disorders Chronic obstructive pulmonary disorder is the most common cause of cor pulmonale

Prevalence Cor pulmonale is estimated to account for 6-7% of all types of adult heart disease in the United States Chronic COPD due to chronic bronchitis or emphysema is the causative factor in more than 50% of cases Accounts for 10-30% of decompensated heart failure–related admissions in the United States Han MK, McLaughlin VV, Criner GJ, Martinez FJ. Pulmonary diseases and the heart. Circulation. Dec 18 2007;116(25):2992-3005

Signs and Symptoms General fatigue, tachypnea, exertional dyspnea, and cough Physical findings Wheezes, crackles, right ventricular hypertrophy, labored breathing, increase in chest diameter, cyanosis, hemoptysis, distended neck veins

Diagnostics Test Results with Acute Cor Pulmonale EKG Right axis deviation Right Heart Catheterization Elevated pulmonary artery pressure Brain Natriuretic Peptide (BNP) Elevated Arterial Blood Gases (ABG) Abnormal oxygenation, acid/base imbalance Chest X-Ray Right descending pulmonary artery > 16mm 2-D Echocardiogram Right ventricular hypertrophy

Treatment Care of underlying respiratory condition Oxygen Diuretics Vasodilators Bronchodilators Steroids

Accurate Documentation Clinical picture of the patient Resources being consumed As principal diagnosis Acute Cor Pulmonale groups to DRG 314-316 Other Circulatory System Diagnoses What was monitored and treated?

Future Plans

CDI Program Impact RAC Medical necessity Denial assistance ICD-10 impact Clinical indicators gain importance All payer review Value Based Purchasing Core Measure documentation Present on Admission Emergency Department Record Review

Documentation Department Clinical Documentation Case Management Core Measures

Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.