1. Tulane Medical Center Clinical Documentation Program
Hospitalist Presentation
10/18/10

2. What is CDI? BRIDGING THE GAP
Between what CMS (Center for Medicare & Medicaid Services) recognizes (technical terminology of the ICD-9 system) and the clinical language physicians use to describe the patient’s condition

3. CMS Position on Clinical Documentation Integrity
“ We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”… “We encourage hospitals to engage in complete and accurate coding.” Source: CMS Federal Register August 2008 Final Rule p. 208

4. CDI Goals Accurately reflect the Severity of Illness
with direct correlation to
Risk of Mortality
Improve physician and hospital profiles
Increase Case Mix Index
Appreciate maximum reimbursement for resource utilization

5. Severity of Illness and
Documentation
Severity of Illness and
Risk of Mortality
Reimbursement
Medical Necessity
&
Length of Stay
Profiling
Hospital
Physicians
POA
RAC Audits
Compliance

6. Query Updates (10/1/2010)
All forms utilized by CDI and coding staff will be referred to as a “QUERY”
The Query form will NO longer display the title.
The Present on Admission form is the only form that allows the physician to indicate the POA status without documentation in the progress notes.
New Queries:
1. Specificity – to obtain further specificity of documented dx or procedure
2. Infectious disease/organism – query to link organism to identified infection
3. Pathology findings – query to determine significance of pathology report
findings. MD must confirm the diagnosis from the pathology report in the body
of the record.

7. QUERIES CDI places queries concurrently for:
: Clarification of diagnosis in CMS terms
: Clarification for ambiguous/conflicting documentation
: Further specificity required for accurate coding
: Documentation of diagnosis based on clinical indicators
: Assignment of POA

8. Common MCCs and CCs MCCs Acute Systolic/Diastolic Heart failure
Acute Renal Failure(ATN)*
Acute Respiratory Failure*
Acute Pulmonary Edema
DKA and HHNK
Encephalopathy*
Hepatorenal syndrome
Hypovolemic Shock
Peritonitis (SBP, surgical)*
Pneumonia
Pressure Ulcer- Stage 3 or 4
Quadriplegia
Shock
Sepsis* (if due to bacteremia note so)
Severe Malnutrition*
V-Fib/V-Flutter
CCs
Acidosis/Alkalosis
Acute Renal Failure (Pre-renal)
Ascites *
Acute Blood Loss Anemia*
Acute COPD exacerbation
Atrial flutter
Bacteremia (if sepsis, must note both present)
BMI <19 or >40 (must include indicators of cachexia or obesity)
Cellulitis
Chronic Systolic/Diastolic heart failure
Complications of Transplant
Hyper/Hyponatremia
Jaundice
Pleural Effusion
Protein Calorie Malnutrition
UTI

9. ENCEPHALOPATHY Hepatic, Toxic, Metabolic, Hypertensive
Commonly documented indicators:
AMS
NH3 / treatment with lactulose
Increased/Acute Confusion
Seizure, tremors, muscle twitching

10. Heart Failure Acute or Acute on Chronic or Chronic and
Documentation must include Acuity and Type:
Acute or Acute on Chronic or Chronic
and
Systolic or Diastolic or Combination
Commonly documented indicators for acute episode:
Elevated BNP/Troponin
CXR : pleural effusion, pulmonary congestion/edema
SOB/DOE
Presence of edema
Administration of diuretics
Echo: systolic, diastolic dysfunction, and low EF

11. Acute Renal Failure
Increased Creatinine (RIFLE or AKIN), BUN, and/or K+ from baseline, decreased GFR
Urine Osmolality < 450mosmols/kg, Urine NA > 40 meq/L ,FENa >2%(ATN)
Nausea, vomiting, diarrhea
Decreased urine output
Metabolic acidosis
Proteinuria
Anemia
Documentation must be consistent and specific:
Acute Renal Failure/Acute Kidney Injury ( specify if 2nd to ATN or other renal necrosis)
Acute on Chronic Renal Failure
Acute Kidney Injury on Chronic Kidney Disease (specify stage of CKD)
**Alert! The term Acute Renal Insufficiency does not impact severity of illness

12. Documentation must include severity and type
Malnutrition
Documentation must include severity and type
Commonly documented conditions/indicators:
Cancer, Cirrhosis, CVA, Alzheimer's, Dementia, Malabsorption syndromes
Cachexia, temporal wasting (cc)
Documented weight loss
BMI less than 19 (cc)
Inability to consume adequate caloric intake (Eg. NPO)
Edema/fluid retention
Enlargement/tenderness of liver/abdomen
Laboratory values of low serum protein/albumin/prealbumin
Current nutritional support with TPN/PEG or tube feedings
Nutritional consult
** ALERT protein calorie malnutrition is a co-morbidity
severe malnutrition is a major co-morbidity
mild or moderate malnutrition will not impact severity of illness

13. Documented Indicators Include:
Sepsis
Local or Systemic Infection + SIRS = Sepsis
Sepsis + Organ Dysfunction = Severe Sepsis
Severe Sepsis + Hypotension/pressors = Septic Shock
Documented Indicators Include:
Organ Failure/Dysfunction
Hypoxemia
Altered mental status
Oliguria
Metabolic Acidosis
Source of infection (UTI, PNA, wound, bloodstream, peritoneal)
WBC >12,000/mm or < 4,000mm or > 10% immature neutrophils
Temp >101° F (>38° C) or <97° F (<36° C)
Tachycardia >90
Tachypnea >20
Hypotension/shock

14. UROSEPSIS
Please clarify
UTI
SEPSIS from a UTI

15. Acute Blood Loss Anemia
Clinical indicators for blood loss anemia include:
Anemia
Significant drop in H&H
Hypotension
GI bleed
Transfusion(s)
Acute bleed from sites other than GI
Tachycardia

16. History & Physical→ Progress Notes→ Discharge Summary
Any pertinent hx that is being monitored, evaluated, or treated should be brought in to the current in-patient record via the assessment/plan in the H&P or the progress notes.
E.g. CHF with previous echo EF%, late effects of CVA, Decubitus, ETOH or drug current abuse, CKD staged, malignancies c mets, protein calorie malnutrition, BMI with cachexia or obesity.
All diagnosis should be listed in problem list. Listing a DX next to a lab or CXR interpretation or it may be missed during the reconciliation process.
Consistency and acuity within the record essential.
E.g. 3 documentations in progress notes within 24 hours:
AKI, acute on chronic kidney disease, acute kidney
Insufficiency (Implies 3 different dx for coding purposes)
Interpretations from any diagnostic imaging must be brought into the Progress notes.
All differential diagnosis (either/or) and all R/O should be continuously addressed. If both present, use the word (and)
Link any infections to a probable source and causative organism if suspected or known
Legibility! Avoid writing on sides, angles, in corners
Chief Complaint:
Hospital Course by problem: list all problems, (diagnosis) interventions, supporting studies and labs 
Procedures: 
Discharge Diagnosis:
List the Principal Diagnosis as the reason for admission after further study precipitated by the patients chief complaints or findings upon admission. (There may be more than 1)
E.g. CHF and COPD
List all diagnosis at the highest acuity from all levels of care (ED, ICU, Med/Surg). They should match what has been previously documented unless ruled out.
E.g. Hypovolemic shock, sepsis, Acute Respiratory failure , ATN
previously documented in the ED or ICU; (differs from Hypotension,
Bacteremia, Respiratory Insufficiency, renal insufficiency, noted in D/C
summary
Link all symptoms to a likely, probable, possible diagnosis based on clinical findings
E.g. Altered Mental Status most likely due to Dilantin toxicity.
other Possibilities may include, UTI, dehydration and hypovolemia
List all confirmed diagnosis from diagnostic studies pathology, radiology, echo, etc.
E.g. Admit dx: Renal Mass, path reports notes final dx: renal cell carcinoma
Important Notes
DO NOT follow a Symptom dx with terms “either/or/vs.” as it will result in a symptom diagnosis in the final coding.
E.g. Chest pain, SOB, Weakness, Altered Mental Status, Syncope, fever,
due to ________ vs/or ___________
Any Diagnosis with the term R/O or possible should either be confirmed or ruled out. A rule out diagnosis may be coded inappropriately as an actual diagnosis.

17. Points to Remember Acuity and consistency matters
Document all co-morbidities that are monitored/evaluated /treated. Note if Present on Admission
Avoid sign/symptom dx followed by differential dx in the D/C summary
Link all symptoms to a probable cause.
Eg AMS UTI: Sepsis Picc :PNA HIV

18. Are you taking credit for the patients you see?
Do you know what your individual physician profile is?
Severity of illness equates to your Case Mix Index (CMI) and is correlated with a risk of mortality
Are you taking credit for the patients you see?

19. CDI Resources Tulane Intranet – Clinical Documentation Link
Program Description
CDI Inquiry Forms
Monthly Newsletters
Resident Healthstream Course

20. We are your DOCUMENTATION TEAM!
WE ARE HERE FOR YOU!!!
Donisia Lee, RN
Ina T. Corley, RN
We are your DOCUMENTATION TEAM!