What is Clinical Documentation Integrity? A daily scavenger hunt

More accurate documentation reflective of true acuity and services provided More accurate profiling data for both Hospital and medical staff More appropriate case mix and reimbursement Reduced compliance risk Potential reduction in denials More appropriate patient severity, mortality, outcomes and resource consumption data Increased cooperation between physicians and hospital Benefits of Clinical Documentation

A consulting group reviewed the appropriateness of the DRG assignment for a sample of inpatient Medicare cases at HPRHS based on the clinical documentation in the Medical Record. Based on their findings, there was a potential financial impact of approximately $1.8 million in missed opportunities, contributed to documentation.

Documentation was the key factor, not the quality of care or service. We know that we deliver exceptional health care services to the people of our region! Many times the documentation doesn’t support the true severity of illness of our patients.

HPRHS Data Analysis: Why Does Data Matter? Hospital and physician profiling data is available to the public Research & Compare Physicians

HPRHS Data Analysis: Why Does Data Matter? Hospital Report Cards

POA vs. Hospital-acquired Conditions Present on admission (POA) is defined as present at time the order for inpatient admission occurs - - conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. Hospital-acquired conditions (HACs) are those that developed / occurred during an inpatient hospital stay.

Purpose of POA Intention of this new concept is to reduce increased payments for complications that occurred after admission / during the hospitalization. Hospitals have to submit data on all Medicare claims indicating whether the diagnoses were POA. Coders indicate (Y or N) beside the principal diagnosis and all secondary diagnoses.

The 10 categories of HACs include: Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Stage III and IV Pressure Ulcers Falls and Trauma Manifestations of Poor Glycemic Control Catheter-Associated Urinary Tract Infection (UTI) Vascular Catheter-Associated Infection Surgical Site Infection Following –Orthopedic Procedures Spine Neck,Shoulder,Elbow Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Total Knee and Total Hip Replacement Payment implications began October 1, 2008, for these 10 categories of HACs.

Medicare 101 DRG (Diagnosis Related Groups) Basics How are DRGs used: –Calculating Hospital reimbursement –Evaluate quality of care –Evaluate utilization of resources Each DRG represents the average resources utilized to care for a patient within the grouping Every DRG has a relative weight (RW) assigned to it The RW is used in the calculation of the Hospitals Case Mix Index

Medicare 101 DRG Basics –Major enhancement is revision of the CC list and development of MCC list –With the development of MS-DRGs, CMS reduced the CC capture rate from 77% to 40% –CC’s are categorized: MCC (Major complication/comorbidity) CC (complication/comorbidity) Non CC

MS-DRG’s Heart failure with no MCC/CC DRG 293 = RW = $3,699 CHF LOS 3.7days TX O2 and IV Lasix Heart Failure with CC DRG 292 = RW = $5,155 CHF LOS 5 days TX O2, IV Lasix, echo, med adjustment, Chronic obstructive bronchitis acute exacerbation Heart Failure with MCC DRG 291 = RW = $7,481 CHF LOS 6.5 days intubated ED, admit to ICU, In ICU 7 days, IV Dobutamine, multiple tests, multiple med adjustment, critical care, complicated by acute renal and respiratory failure CMS DRGs vs. MS-DRGs

The Goals of Clinical Documentation Integrity (CDI) Process are as follows: – Drive appropriate coding for accurate reimbursement – Reflect accurate patient acuity levels – Meet standards – Reduce compliance risks – Provide accurate data for quality indicators and other hospital metrics – Reduce coding turnaround time – Decrease post-discharge queries to the physicians by utilizing concurrent physician queries when indicated

Clinical Documentation Analysts Nita Campbell, RN ICU/CCU/OCU Janice Davis, RN 6S/7N/PJC Alletheia Fitzgerald, RN 6N/7N/5N Tamika Jones, RN CPU/MTU Elinore Poindexter, RN 5S/CTU Medical Records x 2938