Clinical Documentation Improvement Langley Provider Group Colleen Garry RN, BS Mary Beth Genovese RN, BS, CCS, CCDS

JAMA: April 26, 2006 p. 1918 “The era of accountability defined as measured performance with consequences, is rapidly arriving in the US for medical practitioners and health care facilities. Soon, both reputations and incomes of practitioners and health care facilities may well be altered depending on how one scores on a limited set of performance metrics”

Hospital Life Today Affordable Care ACT Changes Decreased reimbursement Bundled payments Pay for Performance/VBP EMR Implementation ICD 10 Pay for Outcomes

Deficit Reduction Act of 2005 SECTION 501 c of PL 109-71 Congress authorizes CMS to adjust for Medicare IPPS hospital payments to encourage the prevention of certain conditions (VBP) Requires CMS to choose at two conditions; High volume high cost or both Condition is a cc or MCC Reasonably preventable thru evidenced based guidelines No addition payment when these conditions develop after admission (when condition is the only one to bring to the higher RW tier)

Who’s Profiling Physicians? Federal State and Regulatory agencies Joint Commission CMS Peer Review Organizations Managed Care organizations/Profiling Agencies Prospective Payment Systems Hospitals (one of the major indices is based on SOI)

Is your profile accurate? How complex is the care being delivered? What overall severity is being reported and collected? What risk of mortality is being reflected? How do secondary diagnoses affect reflection of severity and risk? Do I have any control over my profile?

WIKIPEDIA DEFINITIONS Severity of illness (SOI) is defined as the extent of organ system derangement or physiologic decompensation for a patient. It gives a medical classification into minor, moderate, major, and extreme. The SOI class is meant to provide a basis for evaluating hospital resource use or to establish patient care guidelines. The risk of mortality (ROM) provides a medical classification to estimate the likeli-hood of in-hospital death for a patient. The ROM classes are minor, moderate, major, and extreme. The ROM class is used for the evaluation of patient mortality.

Flow of Documentation MD DOCUMENTATION Converts into ICD 9 Codes NOW FEDERAL GOVT. RANKING REIMBURSEMENT MD DOCUMENTATION Converts into ICD 9 Codes NOW And ICD 10 codes OCTOBER 1, 2014 RACS OVERSIGHT RECOVERY TIER STATUS CREDENTIALING INSURANCE COMPANIES HEALTHGRADES LEAPFROG INTERNET PATIENT BALTIMORE SUN

Governmental AUDITS NAME OF AUDIT Governmental AGENCY RAC POST BILL DCS INC. FOR CMS RAC PRE-BILL RAC A to B RE-BILL CMS NGS PRE-BILL AUDIT 1 DAY STAY NGS CMS PART B PHYSICIAN AUDIT

RAC’s: YOUR BEST DEFENSE: A GOOD OFFENSE (CDI) To Assess: Level of Acuity Severity of Illness Clinical Indicators Utilization of resources

LANGUAGE INCOMPATABILITIES

Clinical Language vs. Diagnostic Statements CODING LANGUAGE ↓ NA Hyponatremia Fluid resuscitation Dehydration, hypovolemia, hypovolemic shock Enzymes + St elevation V leads Acute anterior MI (STEMI vs. NSTEMI) ↓ HGB transfuse 2 units Acute blood loss anemia Urosepsis Urinary tract infection Sepsis from a urinary source

Effective CDI LEADERSHIP SUPPORT DATA TRACKING COMMUNICATION COLLABORATION & ONGOING EDUCATION

ACCOMPLISHED BY: CDI team fully trained in CDI (clinical, coding, compliance) Concurrent “real” time record reviews Ensure proper assignment of: DRG/CC/MCC/POA Status/ HAC’s Tracking tool to report on vital data Scheduled reports to CDI Steering Committee with regularly scheduled meetings Continuous feedback to Mid Level Providers and Physicians

Benefits of CDI: Regulatory Compliance Improved outcome indicators Thorough documentation enhances accurate hospital and physician profiles Enhanced support for the patient’s treatment plan LOS and medical necessity are supported by SOI Fewer Denials Added support for E&M coding levels Risk management tool

What are the drivers for change? Accurate and Comprehensive clinical documentation is essential for: Safe, high quality patient care Accurate performance data Appropriate reimbursement revenue Regulatory compliance e.g., MS DRG . POA, HAC’s, Core Measures, PSI’s, RAC ????

Critical Success Factors To ensure accurate comprehensive clinical documentation: Provide Strong Medical and Administrative Leadership Support Communicate and Collaborate Perform Robust Data Tracking Offer ongoing education Implement an effective CDI program

Improvement Activities Benchmarking Regularly monitor performance Determine processes to be studied Identify relevant performance data /gather data Compare discover critical success factors Adopt/adapt successful strategies

COUNTDOWN TO ICD 10 502 DAYS 71 WEEKS + 5 days MAY 17, 2013 OCTOBER 1, 2014 MAY 17, 2013

CHANGES TO VOLUME ICD-10-CM 68,069 ICD-9-CM 14,025 CODES 3,824 DIAGNOSIS CODES ICD-9-CM 14,025 CODES ICD-10-CM 68,069 PROCEDURE CODES 3,824 ICD-10-PCS 72,589

Thank you QUESTIONS ? mgenovese@langleyprov.com cgarry@langleyprov.com