Clinical Documentation Improvement Specialist How many of you have ever had the pleasure of reviewing a medical record?? Then you know that there are a few challenges… For instance, is it legible or do you have to turn it upside down and close one eye to read it? If you can read it, does it make sense? Flow? Tell a story? Is there a diagnosis documented for every medication? Every diagnostic test? Is the documentation consistent? Is it specific enough to clearly illustrate the patient’s acuity? If you answered “no” to any of these questions, then you will be able to relate. After many years of coding (and querying), I thought there must be a more efficient way to get the details required to accurately assign codes. At the time, I had read about CDIPs in Advance and AHIMAs Journal, but the hospital where I worked did not have a program. I saw an ad in the Journal for a CDI Specialist, applied, interviewed, was offered the position, accepted, sold my house, and moved to Gainesville FL - 900 miles from my home, to start the CDIP at Shands at the UF. Has anyone here played the game of Clue? As CDIS we are looking for what is NOT documented – we sometimes feel like detectives… A day in the life of a Clinical Documentation Improvement Specialist

What Killed Mr. Boddy was the victim in the game of Clue. In this version of Clue, we’re asking what – not who killed Mr. Boddy.

Was it urosepsis? A urinary tract infection? or Sepsis resulting from the decomposition of extravasated urine? Was it a simple UTI or something more sinister?

Was it pneumonia? Pneumonia, unspecified? or Pneumonia related to aspiration?

Was it an appendicitis? Appendicitis, unspecified? or Appendicitis with rupture & peritonitis?

These are just a few questions a Clinical Documentation Improvement Specialist may ask

Why do we ask and why does it matter? Let’s investigate…..

Coders must rely on physician documentation They cannot assume or interpret what is in the medical record Code Assignment Physician Documentation Physicians are surprised to learn that coders are not allowed to assign codes based on diagnostic reports – especially pathology reports. Sometimes there is a “broken link” between the clinical and “codeable” documentation

Any time documentation in the medical record is: ambiguous conflicting incomplete or missing lacks specificity unclear whether a condition was present on admission So anytime the documentation is ambiguous such as “urosepsis” which means two entirely different things to a physician and a coder. Conflicting - two clinicians document conflicting diagnoses. You’ll frequently find this in academic medical centers due to the many Residents, consultants, etc. that document in the record. If the condition lacks specificity such as in this case - pneumonia. Did you know there are over 40 different ICD-9 codes for pneumonia?? An example of incomplete documentation would be “appendicitis”. In this case, the physician failed to document that the appendix had ruptured resulting in peritonitis. Clarification is necessary to ensure accurate assignment of codes, severity of illness & risk of mortality scores, length of stay targets, and appropriate reimbursement for utilization of resources

A Clinical Documentation One solution….. A Clinical Documentation Improvement Program aka – Master Detective Agency

Clinical Documentation Improvement Program (CDIP) What is a CDIP? – An initiative which focuses on improving the documentation concurrently or at the point of service to the patient.

A 2007 HCPro survey found that 50% of US hospitals have a CDIP CDIP Models: HIM CM Quality Finance The CDIP at Shands reports to the Coding Supervisor in the HIM Dept. We consist of 4 CDIS – 2 CCS & 2 RNs

Effect on Quality of Care Why have a CDIP? – Effect on Quality of Care Identifying a condition by your thoughts permits others who follow to know what you’re thinking - What is the patient’s clinical picture during your assessment What work-up has been done so far What were the results What treatment has been started What is the plan of care Our slogan is “Think in Ink”

Effect on Legal Risk Reduction Why have a CDIP? – Effect on Legal Risk Reduction The better the documentation reflects the complexity and the risks, the easier it is to explain morbidity and mortality – and the likelihood of frivolous liability claims is reduced. If it’s not documented – it didn’t happen including excellent patient care!

Effect on Public Quality Measures Why have a CDIP? – Effect on Public Quality Measures Results in better physician and hospital outcomes on consumer-oriented health care websites such as: Health Grades US News & World Report Consumer Reports

According to a 2009 PricewaterhouseCoopers consumer survey, 48% of consumers said they use health websites to find information to make decisions about their healthcare. Interesting statistic… This tells us that health care consumers are using the internet to compare care and outcomes. Complete and accurate documentation illustrates the true acuity of the patient and adjusts the mortality risk so that health care consumers can make better decisions about where to go for care. It allows them to compare “apples-to-apples”.

Here is an example of Health Grades web site

US News and World Report compares 5000 hospitals in 16 adult and 10 pediatric specialties. The rankings are dependent upon variables such as Reputation with physicians, Relative death rate, and Patient safety. This slide shows Shands at UF to rank #24 in Heart and Heart Surgery

Many of us depend on Consumer Reports to help us decide which car, TV, camera, etc. to buy. Consumer Reports now has a website which assists us in deciding where to receive our healthcare based on patient ratings. The survey asks about everything from pain control and communication with doctors and nurses to cleanliness and quietness of the rooms.

Impact on Mortality Risk Adjustment Why have a CDIP? – Impact on Mortality Risk Adjustment Provides a more accurate illustration of patient acuity and the care provided. Impacts Severity of Illness (SOI) and Risk of Mortality (ROM) statistics. Severity adjusted expected mortality rate depends on ICD-9 codes being assigned that demonstrate SOI & ROM

Two of the most common metrics used for mortality risk adjustment: Severity of Illness How sick is the patient? Risk of Mortality What is the likelihood of death? The four levels of SOI & ROM are: 1 = minor 2 = moderate 3 = major 4 = extreme At Shands we use the 3M Encoder along with the APR-DRG Grouper to determine MS-DRG and SOI/ROM scores for each record we review.

More appropriate payment for the hospital and physicians. Why have a CDIP? – Contributes to appropriate and timely reimbursement for utilization of resources More appropriate payment for the hospital and physicians. Accurate severity-adjusted Case Mix Index (CMI) Reduces number of retrospective queries which negatively impacts the revenue cycle. CMI definition – the sum of all DRG relative weights divided by the number of Medicare cases

How are questions communicated? Either verbally on the patient care floors, or written via a Physician Documentation Query Form. To maintain a paper trail for verbal queries, the CDIS will document a brief synopsis of the discussion on a concurrent query form.

Where will the query forms be found? - When appropriate, a query form is placed in the progress notes. Where should physician document response? -Query response may be documented in the progress, consultation, or procedure notes, and/or the discharge summary. Responses then become a permanent part of the medical record. Who may respond to query? - Any physician (or physician extender) who provides “face to face” care. Our concurrent query response rate is 86%

What happens if the concurrent query is not addressed while the patient is in-house? A retrospective or post-discharge electronic query is sent to the Attending Physician

Disadvantages of a Post-Discharge Query Since the Post-Discharge query is sent a week or more after the patient is discharged: The details of the patient’s condition are not as clear The record is scanned so the physician must access the electronic record For physicians who rotate, they may be out of town or even out of the country Negatively impacts the DNFB (Discharged Not Final Billed) In the week since the patient was discharged, the physician has probably cared for 50 to 100 patients. Most everyone loves electronic records, however there are some who are brilliant doctors but are clueless about computers. Believe it or not, physicians do take an occasional vacation. In response to the request to complete a post-discharge query, I have been told “I won’t bother you when you’re on vacation and I don’t expect you to bother me!” Every hospital tries to keep their DNFB as low as possible. At Shands our goal is to code the discharged accounts within 4 days. The coding on post discharge queries is not finalized until the physician responds – which may take days or weeks.

Query Guidelines for Concurrent & Post-Discharge Queries The query should not: Sound presumptive, directing, prodding, probing, or as though the physician is being led to make an assumption Give only choices that increase the reimbursement Indicate the financial impact of the response to the query Be designed so that all that is required is a physician signature Our CDIP strives to follow the same AHIMA Guidelines coders are obligated to follow.

Physician Documentation Education One-on-one Small groups – on the nursing units Large groups – Departmental Grand Rounds New Housestaff Orientation Pocket cards In addition to reviewing records concurrently, we provide ongoing education

What Killed So let’s return to our investigation

Mr. Boddy, a 64-year-old male was found on his living room floor Mr. Boddy, a 64-year-old male was found on his living room floor. On arrival to the ED - Altered mental status RLQ abdominal pain Elevated temperature Hypotensive Tachypnea & tachycardia Positive UA & BC – e coli Chest x-ray revealed bilateral lower lobe infiltrates Our clues -

Mr. Boddy was taken to the OR and underwent an appendectomy Mr. Boddy was taken to the OR and underwent an appendectomy. Thick, purulent pelvic fluid was encountered. He was kept in the SICU for eight days where he received IV antibiotics and Vasopressin. Unfortunately, he did not survive. His course of treatment -

Physician documented cause of death as: Urosepsis Pneumonia Appendicitis s/p appendectomy

Urosepsis… To a coder, this = UTI GMLOS=3.5 days SOI=1 ROM=1 Reimbursement=$5,883 To a physician, this = sepsis from a urinary source GMLOS=4.6 days SOI=1 ROM=1 Reimbursement=$8,514 The impact is on LOS and $

Pneumonia… Pneumonia, unspecified = Pneumonia due to aspiration = GMLOS=3.3 days SOI=1 ROM=1 Reimbursement=$5,415 Pneumonia due to aspiration = GMLOS=4.3 days SOI=1 ROM=2 Reimbursement=$7,700 The impact is on LOS, ROM and $

Appendicitis (with appendectomy) Appendicitis, unspecified = GMLOS=1.7 days SOI=1 ROM=1 Reimbursement=$7,144 Appendicitis with rupture & peritonitis = GMLOS=3.4 days SOI=2 ROM=1 Reimbursement=$9,310 The impact is on LOS, SOI and $

GMLOS = 5.1 days SOI = 2 (moderate) ROM = 1 (minor) Without the investigative services (concurrent query) of the CDIS (aka – Master Detective) it would appear that Mr. Boddy died from a simple urinary tract infection, pneumonia, and an appendicitis. GMLOS = 5.1 days SOI = 2 (moderate) ROM = 1 (minor) Reimbursement = $ 16,875

This shows the MS DRG (746 classifications of diagnoses in which patients demonstrate similar resource consumption and LOS patterns) with associated GMLOS and expected reimbursement, and the soi/rom scores The most important factor here is the ROM – Mr. Boddy died and his ROM is only 1 (minor).

GMLOS = 12.5 days SOI = 4 (extreme) ROM = 4 (extreme) After receiving clarification from the physician in response to a concurrent query, it was determined that Mr. Boddy died from septic shock related to a urinary tract infection and aspiration pneumonia. In addition, he had a ruptured appendix with peritonitis. GMLOS = 12.5 days SOI = 4 (extreme) ROM = 4 (extreme) Reimbursement = $41,938

Notice the new MS DRG, GMLOS - 7 additional days, expected reimbursement - $25,000, SOI went from 2 (moderate) to 4 (extreme) and the ROM went from 1 (minor) to 4 (extreme)

Impact of CDI Investigation and intervention Greater specificity of existing conditions Appropriate severity of illness score The patient was extremely ill Appropriate risk of mortality score The patient died – his ROM should be extreme Increased length of stay allowance Appropriate reimbursement for utilization of resources

Questions aka – Master Detective Donna Fisher, CCS, CCDS Lead Clinical Documentation Improvement Specialist Shands at the University of Florida fishdl@shands.ufl.edu 352-265-0680 extension 48769 aka – Master Detective