1. 3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

2. Bring CDI to your Emergency Department STAT! Laurie Cianfrini, RN Corporate Manager Clinical Documentation Specialists

3. Before We Begin … Although every precaution has been taken in the preparation of these materials, the publisher and speaker assume no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein. Advice given is general, and attendees and readers for the materials should consult professional counsel for specific legal, ethical, or clinical questions.

4. Kaleida Health of Buffalo, NY

5. Emergency Department Highlights Women & Children's Hospital – Level I Trauma Center – Kids Express (Fast Track) Buffalo General Hospital – Cycle III Accredited Chest Pain Center – Dedicated Fast Track

6. Emergency Department Highlights (cont.) Millard Fillmore Suburban Hospital – Accredited Chest Pain Center – Dedicated Fast Track Millard Fillmore Gates Hospital – NYS DOH Designated Stroke Center – Observation Unit Degraff Memorial Hospital – Ranked among “America’s Best Nursing Homes” by US World & News Report

7. Background & History In the summer of 2003, an assessment of documentation, coding, and billing practices found existing opportunities: – To improve communications between the various disciplines – To encourage improved documentation and coding

8. Background & History (cont.) Kaleida Health, in concurrence with the ED initiative, assessed coding and documentation practices relative to inpatient services.

9. Disciplines Nursing HIM Patient access Finance Physician providers Quality

10. Objective To focus primarily on quality, completeness, & accuracy of clinical documentation to support: – The Joint Commission & EMTALA requirements/documentation standard – NYS requirements – Kaleida Health HQA initiatives – Coding & billing compliance

11. ED CDS Timeline

12. Scope A sustained process surrounding complete documentation, charge capture, coding, and billing: Facilitates review of concurrent clinical documentation to support the level of care, resulting in appropriate reimbursement. Performs continuous documentation and charge reviews using internal P&P and Medicare/Medicaid guidelines. Educates staff on clinical documentation, coding, and reimbursement issues. Maintains compliance with internal P&P. Maintains E&M tools used in the EDs to meet the CMS directives.

13. Opportunity Do you know what your facility’s E/M levels look like? … Suburban Hospital nurses were only 20% accurate.

14. Opportunity (cont.) HOW? –R–Revision of ED nursing assessment

15. Revision of ED Nursing Assessment

16. Opportunity HOW? –R–Revision of ED nursing assessment –C–Create point system

17. Create Point System

18. Opportunity HOW? –R–Revision of ED nursing assessment –C–Create point system –R–Revise charge capture tool

19. Revise Charge Capture Tool

20. Opportunity HOW? – Revision of ED nursing assessment – Create point system – Revise charge capture tool

21. Betty Armenia, RN, BSN, CEN Lead Clinical Documentation Specialist The Audit Process

22. Nursing Documentation Audit Cross-reference MD order sheet to nursing documentation Triage, procedures, physician documentation, queried physicians Compliance Charge ticket

23. ED CDI Education Policies, procedures, guidelines Regulatory requirements Coding updates Coding/clinical world comparisons Computer courses

24. What to Measure? Inventory what documentation is currently being measured from the ED chart – “If you’re in the chart anyway …” Understand coding rules for determining E/M level What are separately billable procedures and supplies?

25. What to Measure? (cont.) Make initial audits general Let the results guide specific audit areas Revise, revise, revise based upon results Consider special audits vs. adding to regular audit

26. How Are Data Collected? Paper – Concurrent review in ED – Space and computer availability – Staff comfort with computer Electronic – Formulas for data analysis – Able to manipulate for limited views – Easily stored for future use

27. Early Audit Tool Example

28. ED RN Staff Education Don’t assume the staff already knows documentation; educate everyone – Consider including ancillary staff (reg, secretaries) Recognize staff resistance – All I care about is taking care of my patient – COMPLIANCE drives revenue – Good documentation vs. good clinical care

29. Hot Spot Identification

30. Quarterly Audit Tool: RN-Specific

31. ED RN Staff Education Acknowledge difference between coding and clinical world – “It is what it is.” Provide education on new forms before they are in use Staff feedback – Process issues – Education preferences New RN education: form good habits early

32. ED RN Staff Education (cont.) Document staff deficiencies – Education opportunity Written or verbal – Live time audits – ED management supports – Follow P&P for late entries CDI presence: visual reminder for staff

33. ED RN Staff Education (cont.)

34. Lessons Learned Be careful not to dilute process with non-CDI responsibilities Be proactive in using results to drive documentation changes Collaboration between inpatient and outpatient CDI staff