Clinical Collaborations for Improvement in CHF and Sepsis Coding Kathy Fennick, RHIA, CCS

Objectives Gain an understanding of the need to collaborate with clinical partners regarding coding for Congestive Heart Failure (CHF) and Sepsis Discuss the impact of CHF readmissions Discuss the impact of mortality due to sepsis Understand the coding guidelines Discuss implementing a collaborative process

Congestive Heart Failure CHF - most common discharge diagnosis for patients age > 65. Incidence of heart failure for patients age >80 is 9%. CHF cases continue to increase and currently resulted in an annual expenditure of $10 billion for diagnosis and treatment. Average hospital LOS for treatment of this disease is 9 days, and the overall five-year mortality rate is 50%.

Congestive Heart Failure 30% to 40% of CHF patients are readmitted within 6 months of hospitalization. Studies show 40% of the CHF readmissions could be prevented. Unnecessary readmissions contribute significantly to the cost of this disease both clinical and administratively. New strategies can been introduced to help reduce the need for hospitalization/readmission.

Develop the Process CHF Patient Identification Protocol Create a reporting protocol for CHF patients Develop the list of codes that represent CHF (i.e. hypertensive cardiovascular disease Add patient demographic information to the CHF log Add FYI flag in EPIC or other EMR FYI flag triggers the CHF resource nurse visit CHF resource nurse provides discharge education including diet instructions Coding performed once the patient is discharged Coding notifies the CHF resource nurse all cases with CHF as the principal diagnosis that were coded each day prior to finalizing coding

Develop the Process CHF Patient Identification Protocol - continued CHF resource nurse reconciles the case to the CHF log Discrepancies are discussed and escalated to the physician liaison as needed CHF clinical team analyzes cases that are not identified upon admission CHF team meets on a weekly basis Coding guidelines are discussed on a ad hoc basis Physician queries are placed for ambiguous documentation Coding reconciliation is presented to the team on a monthly basis Measure the results using pre-defined metrics

Sepsis Mortality Sepsis - most common cause of mortality in U.S. hospitals. Nationally – 20% - 50% of the mortality for sepsis cases entering the hospital through the emergency department.

Develop the Team Core Team Members and Roles Facilitator/Data Management Clinical Champions Leadership Support Quality Coding/Clinical Documentation Support

Coding SIRS/SEPSIS Some patients—particularly those who are critically ill—may meet necessary criteria for SIRS and truly have sepsis or another severe diagnosis. Others, however, may meet two of four criteria (e.g., heart rate > 90 and respiratory rate > 20)—which technically constitutes a SIRS diagnosis—but not have SIRS.

Coding SIRS/SEPSIS As with all documentation challenges, coders should emphasize to physicians the importance of capturing patient severity. This includes the following elements related to sepsis and SIRS: The inflammatory condition, whether infectious or noninfectious The causal organism Whether a noninfectious process is contributing to a patient's illness and the specific process When in doubt, coders should query.

Coding SIRS/SEPSIS Know how to apply sequencing guidelines. Applying sequencing guidelines is really clear if a patient comes in with some type of localized infection and then develops sepsis while they're in the hospital. However, sequencing isn't as clear when patients appear to be admitted for organ failure, localized infection, or something else.

Develop the Process Sepsis Mortality Validation Coding identifies mortality cases with PDX of sepsis Coder places a mortality review coding status on case in EPIC and case is routed to Mortality work queue Coding Quality Specialist performs coding validation Clinical Documentation Specialist performs documentation review Quality Specialist performs clinical protocol review Physician query is used when needed Review results entered in EPIC Provide feedback to coders as needed Review results are sent to the physician oversight committee Coding guidelines are discussed on a ad hoc basis Physician queries are placed for ambiguous documentation and Present On Admission (POA) clarification

Questions? Kathy Fennick, RHIA, CCS kfennick@gmail.com 724-674-9168