Alan E. Williamson, MD, FACS Vice President of Medical Affairs/CMO Eisenhower Medical Center Rancho Mirage, California Expected event or surgical complication? A surgeon’s perspective

The care and feeding of surgeons

“Why won’t the surgeon just document what we want?!” “I don’t have time for this!” “But that’s what I meant!” – “We’re not speaking the same language!” – “Duh!” “What’s in it for me?” “They’re after me!”

“I don’t have time for this!”

“Everybody wants a piece of me” Core measures National Patient Safety Goals Third-party insurer metrics Internal quality improvement projects “Defensive” medicine Documentation demands for:

“But that’s what I meant!”

“Urosepsis” Per Stedman’s Medical Dictionary – – “Sepsis resulting from the decomposition of extravasated urine” Per Dorland’s Illustrated Medical Dictionary – – “Septic poisoning from the absorption and decomposition of urinary substances in the tissues” Per Wikipedia – – “When pyelonephritis or other urinary tract infections lead to sepsis, it is termed urosepsis”

“Urosepsis” – per CMS coding guidelines “The term urosepsis refers to pyuria or bacteria in the urine” (not the blood) and is coded to 599.0, Urinary tract infection, site not specified

Financial impact Dx – “Urosepsis” – Urinary tract infection without CC – DRG 321 RW $2881 Dx – Sepsis secondary to urinary tract infection – Septicemia w/o MV 96+ hrs; Age > 17 – DRG 576 RW $7955

“Anemia” Per Stedman’s Medical Dictionary: – “A condition in which there is a reduction in number of circulating red blood cells or in hemoglobin, or in the volume of packed red blood cells per 100 ml of blood. It exists when hemoglobin content is less than gm/100ml for males or gm/100ml for females.”

“Anemia” – per CMS coding guidelines Hgb, Hgb=8, Hct=24, etc., are not anemia unless a physician specifically states that it is

Take-home lesson #1 Physician documentation is: – To communicate with other physicians and caregivers as to the patient’s progress and your impressions and plans – To provide historical background to assist in future episodes of care, by yourself or others – So you can get paid! Physician documentation is not: – A tool to explain the patient’s condition in “layman” terms to nonclinicians

“We’re not speaking the same language!”

CMS coding rules Part B – physician professional services – ICD-9 (diagnosis) codes must be specific – Physicians may not code probable, likely, suspect, etc. Part A – hospital coding rules – Physicians should document presumptive diagnoses driving resource utilization such as “probable, likely, suspect, presumptive,” etc. – Coders may assign DRG based on presumptive diagnoses

“Complication” Per coding guidelines: – “Conditions not present on admission are considered to be complications.” – Include both “expected” and “unexpected” events Per the surgeon: – Unexpected event – Usually the result of poor cognitive or technical performance, more often than not by me! – Embarrassing – Might get me in trouble

Clinical scenario 85-year-old man presents to the ER with acute abdominal and back pain and hypotension. Ruptured AAA found on CT. On opening abdomen approx. 1000ml blood found. Total estimated blood loss for procedure = 1300ml. Post-op Hgb = 8.5. Patient doing well. Complication??

Clinical scenario 85-year-old man presents to the ER with acute abdominal and back pain and hypotension. Ruptured AAA found on CT. On opening abdomen approx. 1000ml blood found. Total estimated blood loss for procedure = 1300ml. Post-op Hgb = 8.5. Patient doing well. Complication?? No!! It was a great save! I should be congratulated!

Clinical scenario 16-year-old male with perforated appendicitis. Despite prompt surgical intervention, copious intra-operative irrigation, and broad-spectrum antibiotics, he develops an intra-abdominal abscess requiring CT-guided drainage. Complication??

Clinical scenario 16-year-old male with perforated appendicitis. Despite prompt surgical intervention, copious intra-operative irrigation, and broad-spectrum antibiotics, he develops an intra-abdominal abscess requiring CT-guided drainage. Complication?? Maybe. But what more could I do?? It’s the patient’s fault for not coming in sooner!

Duh!

Clinical scenario 72-year-old woman with shaking chills, temperature 103.8°F, pulse 112, BP 90/48, requiring multiple IV pressors in the ICU

Clinical scenario 72-year-old woman with shaking chills, temperature 103.8°F, pulse 112, BP 90/48, requiring multiple IV pressors in the ICU Query from CDCI reviewer: “Doctor, could the patient’s high pulse rate and decreased blood pressure represent possible sepsis?”

Clinical scenario 72-year-old woman with shaking chills, temperature 103.8°F, pulse 112, BP 90/48, requiring multiple IV pressors in the ICU Query from CDCI reviewer: “Doctor, could the patient’s high pulse rate and decreased blood pressure represent possible sepsis?” Physician’s response: DUH!

Clinical scenario OP report – – Procedure: Aortobifemoral bypass – Complications: Left iliac vein laceration – EBL: 2200 ml POD 1 Hgb: 8.1

Clinical scenario OP report – – Procedure: Aortobifemoral bypass – Complications: Left iliac vein laceration – EBL: 2200 ml POD 1 Hgb: 8.1 Query from CDCI reviewer: – “Doctor, could the patient’s low hemoglobin be anemia due to acute blood loss?”

Clinical scenario OP report – – Procedure: Aortobifemoral bypass – Complications: Left iliac vein laceration – EBL: 2200 ml POD 1 Hgb: 8.1 Query from CDCI reviewer: – “Doctor, could the patient’s low hemoglobin be anemia due to acute blood loss?” Physician’s response: Do you think?! (I just said that!)

What’s in it for me?

More paperwork! More headaches! More time! More money?

Employment of physicians by hospitals

What’s in it for me? Physicians potentially benefit by documenting comorbid conditions (higher acuity) – We often treat – but fail to document – a diagnosis – Examples: Hypovolemia, post-hemorrhagic anemia, acute urinary retention Public reporting of outcomes Pay for performance

They’re after me!

Pay for performance The P4P slope

Pay for performance The P4P slope Non-pay for poor performance

Pay for performance The P4P slope Non-pay for poor performance Economic credentialing

Summary “I don’t have time for this!” – Do whatever you can to make appropriate documentation easier “But that’s what I meant!” – Avoid the “C” word whenever possible “What’s in it for me?” – Use competitive nature to your advantage “They’re after me!” – Understand our paranoia; we could be right

Questions?