ACDIS Chapter Meeting January 25, 2017 A teaching hospital of Harvard Medical School ACDIS Chapter Meeting January 25, 2017

Agenda Malnutrition: Nutrition Assessment Tools and Severity Levels/Risk Litsa Georgakilas, RD, LDN, CNSC Pressure Ulcers: Staging and Differentiation of Unstageable Pressure Ulcers vs. Deep Tissue Injury Maureen Lira, RN, BSN, CWCN, CHI

Agenda Clinical Documentation Challenges and Best Practices for Malnutrition and Pressure Ulcer Code Capture Nancy Friedlander-Hosken RN, MEd, CCDS Clinical Documentation Specialist Coding Guideline Review, I10 Requirements and Quality Reporting Considerations for Malnutrition and Pressure Ulcer Staging and Progression Luisa DiIeso RHIA, MS, CCS Coding Training Manager

Clinical Documentation Challenges: Malnutrition Service Specific Clinical Correlation and Recognition Source Documentation BMI – Multiple Conflicting Sources and Variations Retrospective Clinical Denials: RAC Examples OIG and Internal Compliance Screens; Data Mining – Severe Malnutrition vs. Kwashiorkor

Best Practices: Malnutrition Nutrition Forms Template Re-Design: Physician Co-Sign Internal Data Mining: Compliance Pre-Bill Validation: Kwashiorkor Internal BMI Policy and Procedure: Source Documentation Hierarchy

Clinical Documentation Challenges: Pressure Ulcers Staging Variations Timely Physician Clinical Documentation of Specific Ulcer and Anatomic Site(s) Pressure Ulcers vs. DTIs POA-Present on Admission Documentation Pressure Ulcer Stage Progression

Best Practices: Pressure Ulcers CDI Clarification and Education Internal Pressure Ulcer Staging Policy and Procedure: Source Documentation Hierarchy

Coding Guidelines and I10 Requirements: Malnutrition Dx. And Severity: Physician Documentation BMI Documentation: Other (Nursing, Anesthesia, Nutrition) Hierarchy Retrospective Appeals: RAC; Other Kwashiorkor Dx- Inpatient: Pre-bill Validation Kwashiorkor Dx- Outpatient: Internal Compliance Data Mining and Validation Coding Clinic Highlights: Severity and BMI

Coding Guideline Review; I10 Requirements; Quality- Pressure Ulcer Staging and Progression Pressure Ulcers Stage/Progression: Diagnosis- Physician Documentation I10: Laterality; Anatomic Site Code Expansion Stage and Progression: “Other” Non-MD Coding Guideline Updates 10/1/16: Progression of Stage with Corresponding POA Assignments Multiple Codes; POA Differences Coding Clinic Advice and Changes: 3Q, 2016

Coding Guideline Review; I10 Requirements; Quality- Pressure Ulcer Staging and Progression Pressure Injury= Pressure Ulcer Deep Tissue Injury- Meaning Pressure Ulcer – See Ulcer pressure, unstageable, by site PSI; Quality Reporting Considerations Importance of POA assignments Internal Source Documentation Hierarchy: Wound Care, Bed Side Nursing