1. Saint Peter’s University Hospital
Presentation to
Division of Pediatrics
“Physician Documentation Issues Affecting Hospital Severity Profiling”
Presented By:
Susan A. Klein, RN
Director, Clinical Documentation Management

2. Purpose of Clinical Documentation Quality Improvement Program - CDQIP
The Clinical Documentation Quality Improvement Program or CDQIP is a concurrent medical record documentation analysis process, dedicated to improving physician, nursing, and ancillary documentation to better reflect severity of illness of our patients, and the intensity of services provided at Saint Peter’s University Hospital.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

3. Clinical Documentation Quality Improvement Program - CDQIP
To improve medical record documentation, for our specialized pediatric patient population, The Clinical Documentation Management Department has developed a comprehensive analysis program that incorporates a “Team” approach between the Attending Physician, Residents, Physician Assistants, Nursing, Care Managers, HIM Coding and Tumor Registry Department.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

4. Adverse Effects of Problematic Documentation
Inefficient and/or missing documentation leads to:
Unbilled or denied charges
Lost revenue
Does not explain continued length of stay or excessive charges
Increases insurance audits
Does not reflect true severity of illness and resources consumed
Negatively impact clinical efficiency profiling for both the physician & Hospital
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

5. Clinical Documentation Quality Improvement Program Objectives
To ensure that the Principal Diagnosis / Reason for admission is identified correctly.
Co-morbid conditions and/or complications are identified and reported accurately.
Surgical Complications are accurately identified.
Establishing a possible etiology to explain Signs and Symptoms.
Ensure procedures are identified, especially procedures performed at bedside.
All diagnoses and procedures are clinically significant and their reporting is justified.
Information responsible for Compliant DRG assignment is legible and well documented.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

6. Impact that Clinical Documentation has on Severity Profiling
The principal diagnosis is the diagnosis that occasioned the admission, and the diagnosis that is responsible for hospital reimbursement (DRG). It is not necessarily the diagnosis that requires the majority of care.
For example: A patient with cerebral palsy is admitted for an infected (complicated) wound. Patient aspirates during the admission, develops respiratory failure, and requires mechanical ventilation. The DRG assignment will be Complicated Wound. The hospital will not be reimbursed for the mechanical ventilation, since this was not the reason for admission.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

7. Why the Emphasis on Clinical Documentation Management?
Problem Documentation Areas:
AIDS vs. HIV+
HIV+ does not impact Hospital Profiling
Documentation must specify AIDS.
A patient with a PMH of disease progression, and has a stable CD-4 count is still classified as AIDS not HIV+. It is appropriate to document “compensated” AIDS.
Past medical history to support the diagnosis of AIDS must be documented in the patient’s medical record.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

8. Medical Record Documentation Establishing the Reason for Admission
Medical Record documentation in the Emergency Room Record and H&P is the first step for establishing the reason for admission, and identifying the “Principal Diagnosis.”
Errors in assignment occur when signs and symptoms documented in the H&P, as the cause of admission, do not have a clear etiology established after study. If a presumptive diagnosis is ruled-out – this needs to be documented in the progress notes.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

9. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
Case Study # 1
A six year old patient presented to the Emergency Room with persistent nausea and vomiting with decreased oral intake. Physician documentation for the reason for admission: hypovolemia, gastroenteritis, and pre-renal azotemia.
Urine output was decreased with an elevated BUN/creatinine, therefore the physician was queried if this was actually an acute kidney injury second to hypovolemia. The physician indicated, yes, and documented same in the progress notes.
Severity profiling was revised to Acute Renal Injury.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

10. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
Case Study 1
Dehydration $ 5,235
Acute Renal Injury $ 8,549
Recovered Hospital Reimbursement by revising the Principal Diagnosis to Acute Renal Injury $ 3,314.
Reference:
AHA Coding Clinic Guideline, Third Quarter 2002, p. 21.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

11. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
Case Study 2
An 8 year old patient admitted with fever, increased WBCs, lethargy, chills with positive urine culture, and negative blood cultures. Physician documented reason for admission: urosepsis.
Physician was queried if the term urosepsis can be equated to clinical septicemia, 2nd to urinary tract infection. Physician indicated yes, and documented same in the patient’s medical record.
Case was re-profiled to Clinical Septicemia.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

12. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
Case Study 2
Urosepsis $ 5,819
Clinical Septicemia $ 8,604
Recovered Hospital Reimbursement by revising the Principal Diagnosis to Clinical Septicemia $ 2,785
Note: the term urosepsis profiles to a urinary tract infection.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

13. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
Documentation Tips
Inpatient coding regulations allow possible, suspected, or probable diagnoses.
Symptom diagnoses should be documented as “etiology unknown,” if a definitive diagnosis or suspected diagnosis is undetermined. If the physician intends to continue work-up as an outpatient for a suspected condition, this diagnosis can be documented as a possible cause of the symptom.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

14. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
Documentation Tips
Documentation should be clear and legible enough for the non-clinical person to understand. Audit problems, and denied days occur when documentation is misunderstood.
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

15. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
Documentation Tips
If a diagnosis is ”ruled-out,” then the R/O must be written after the diagnosis. Writing it before will be interpreted as a ruled-in condition which can result in a reporting / billing errors.
It is preferred that R/O be written as, “ruled-out.”
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

16. Ensuring Accurate Clinical Information and Severity Profiling
Remember, time is of the essence. If the Clinical Documentation Management Team places a physician query form with a note to you, your answer, if you agree, MUST be written in the progress notes to support severity profiling. We provide our pager number, so feel free to page us if you want to discuss a case.
Thanks very much for your support & assistance!
Susan A. Klein, RN - Director, Clinical Documentation Mgt.

17. Susan A. Klein, RN - Director, Clinical Documentation Mgt.
The End
Susan A. Klein, RN - Director, Clinical Documentation Mgt.