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

2. CDI Physician Education Catch Them and Hold Them

3. By: Monica Dancu, RN, BSN Sylvia Hoffman, RN Darlene Shelffo, RN, CCDS, CDI Manager Tampa General Hospital Tampa, FL

4. Tampa General Hospital Academic Medical Center: 929-bed teaching facility affiliated with The University of South Florida College of Medicine (USF) USF affiliation: 1,200 community and university affiliated attending physicians, 285 resident physicians, and 400+ medical students

5. Physician education Educating physicians can be quite a challenge. They may be: – Busy – Bored – Resistant – Confused – Angry – Tired

6. Creativity is a must Doctors are bombarded with information on a daily basis. If you want them to remember, you must make it memorable!

7. Presentation tips State the facts Keep it simple Make it interesting Make it relative Use physician “speak” Provide buy–in

8. Keep your audience interested Quote specific physicians Show documentation examples Include personal progress notes or forms Insert physician pictures Break up boredom with humor Involve your audience; ask questions Provide CMEs

9. Say, “Cheese!”

10. Alert physicians about public profiling HealthGrades.com Disclosure Project Delta Group Leapfrog Medicare Physician Data Etc.

11. Explain how profiles are derived Take into account: – Principal diagnosis – All other diagnoses (CCs and MCCs) – Principal procedure – All other procedures Give a more accurate reflection of mortality risk by reflecting all severity elements.

12. Provide physician-specific data Documentation examples Case studies Severity-adjusted statistics for specialties Mortality rates Missed opportunities for individual practices E/M billing documentation

13. Give rationale for accurate documentation Each note must: – Support what will be coded and billed – Be legible – Show medical necessity Example: Urosepsis = UTI Is this what you mean?

14. Point out missed opportunities Pulmonary Embolism w MCC Pulmonary Embolism w/o MC 3 cases 20 cases 13% of cases 87% of cases COPD w MCC COPD w CC COPD w/o CC/MCC 21 cases 39 cases 42 cases 20.6% of cases 38.2% of cases 41.2% of cases Pneumothorax w MCC Pneumothorax w CC Pneumothorax w/o CC/MCC 3 cases 10 cases 9 cases 13.6% of cases 45.5% of cases 40.9% of cases Resp System Diagnosis w MCC Resp System Diagnosis w/o MCC 8 cases 19 cases 29.6% of cases 70.4% of cases MCC = Major comorbidities CC = Comorbidities

15. Explain case-mix index (CMI) Case-mix index is the sum of all MS-DRG relative weights (RW) divided by the number of discharges. Factors that can positively affect the CMI include: Admitting and treating a more resource intensive patient mix Improvement of documentation in the medical record

16. Give real-life examples Lack of complete documentation can skew mortality and morbidity data, case-mix index scores, and possibly reimbursement Low CMI and high mortality scores influence physician and hospital profiles Poor profiles can mean lower patient volumes and possible higher malpractice rates

17. Describe how wording affects data Patient with respiratory insufficiency – Has a low mortality score Patient with acute respiratory failure – Has a 30% mortality score Patient with pneumonia due to pseudomonas – Has a 40%–70% mortality rate

18. Use physician language Good documentation can serve as a benefit to your practice Proper documentation supports the severity of the presenting problem and the complexity of your decision-making The clinical documentation team is your ally in providing the precise terms needed to capture the best representation of your patients’ needs and services

19. Explain what’s in it for them Show how documentation affects billing. Give real life examples.

20. Give them the tools Brochures Pocket cards Query forms Signs

21. Make It Unforgettable YEEEEEAAAAAAAAAAAHHHHHHH!!!!!!

22. CDI-CSI DOCUMENTATION INVESTIGATION Avoiding a Documentation Felony !

23. Medical documentation is not what it used to be !

24. Cost per patient Cost per patient Morbidity scores Morbidity scores Mortality scores Mortality scores Length of stay Length of stay Utilization Utilization Audits Audits Physician performance and documentation are under scrutiny

25. Severity of illness (SOI) Risk of mortality (ROM) Length of stay (LOS) Case-mix index (CMI) Statistics are being collected Statistics are being collected

26. Documentation impacts data Lack of complete documentation may alter mortality and morbidity (M&M) data and case- mix index scores Lack of complete documentation may alter mortality and morbidity (M&M) data and case- mix index scores Low CMI and high mortality scores influence physician and hospital profiles Low CMI and high mortality scores influence physician and hospital profiles Did the patient die from a UTI ?

27. Medical data sources are growing Physician profiles Physician profiles Hospital report cards Hospital report cards Medicare physician data Medicare physician data HealthGrades, Delta Group, Leapfrog HealthGrades, Delta Group, Leapfrog “Medicine is under the microscope.”

28. HealthGrades.com Example of Web sites

29. Disclosure project

30. But that’s not all, now a new danger threatens

31. Centers for Medicare & Medicaid Services The Centers for Medicare & Medicaid Services adds or changes ICD-9 codes each year. This requires adjustments in how physicians must document in the medical record. The Centers for Medicare & Medicaid Services adds or changes ICD-9 codes each year. This requires adjustments in how physicians must document in the medical record. It can make you crazy !

32. Must obey the law Specificity is vital; a definitive Specificity is vital; a definitive diagnosis must be documented New Golden Rule: If it is not written If it is not written in the correct language, in the correct language, it didn’t happen. it didn’t happen.

33. The CMS word game Specificity is paramount Specificity is paramount Certain diagnoses should be linked Certain diagnoses should be linked Diagnostic medical/coding language only Diagnostic medical/coding language only Remember: Lab, pathology, and radiology reports cannot be used for coding Remember: Lab, pathology, and radiology reports cannot be used for coding

34. Wording must be specific NonspecificSpecific AnemiaBlood loss anemia HypoalbuminemiaMalnutrition U/A abnormalUTI UrosepsisSepsis Altered mental statusEncephalopathy COPDCOPD exacerbation CHFAcute diastolic HF

35. Specific terms are necessary for documenting severity of illness AcuteChronicUnstableExacerbatedPostoperative Secondary to Due to Severe She had acute aspiration pneumonia!

36. Severe sepsis Severe malnutrition Acute diastolic CHF Acute respiratory failure Acute confusional state Acute renal failure Unstable angina Exacerbated COPD Examples Examples She died from severe sepsis!

37. What do you mean? Unless a condition is given a diagnosis and documented by a physician, the diagnosis cannot be captured. (Remember, lab results and pathology reports cannot be used.) This was a major skin disorder, according to the path report!

38. Point out missed opportunities MCC = Major comorbidities CC = Comorbidities Pulmonary Embolism w MCC w/o MC Pulmonary Embolism w/o MC 3 cases 20 cases 13% of cases 87% of cases COPD w MCC COPD w CC w/o CC/MCC COPD w/o CC/MCC 21 cases 39 cases 42 cases 20.6% of cases 38.2% of cases 41.2% of cases Pneumothorax w MCC Pneumothorax w CC w/o CC/MCC Pneumothorax w/o CC/MCC 3 cases 10 cases 9 cases 13.6% of cases 45.5% of cases 40.9% of cases Resp System Diagnosis w MCC w/o MCC Resp System Diagnosis w/o MCC 8 cases 19 cases 29.6% of cases 70.4% of cases

39. Why is this important? Hypotension Shock Low mortality score 50%–70% mortality rate Simple pneumonia Complex pneumonia 2.5% mortality rate 20% mortality rate Respiratory insufficiencyAcute respiratory failure Low mortality score 30% mortality rate UTI (urosepsis) Sepsis 1.5% mortality rate 20% mortality rate

40. Give a diagnosis, not a symptom

41. No use of symbols Symbols and numbers do not translate into a diagnosis. Na 124 = nothing U/A + = nothing Hgb = nothing Albumin 1.5 = nothing Troponins = nothing Symbols = nothing No more use of symbols. No more use of symbols.

42. Example This cannot be coded *comorbidites will not be counted in patient’s diagnosis

43. Legibility Make sure what you write is legible. If your coworkers If your coworkers can’t read it, can’t read it, your patient may your patient may be at risk. be at risk. I can’t make it out. It either says patient released or patient deceased.

44. Legibility? This is a true crime scene ! Illegible ! ! Signature illegible?

45. Recognize POA clues

46. Present on admission (POA) Any condition present at the time the order for inpatient admission occurs Any condition present at the time the order for inpatient admission occurs Any condition that develops during an outpatient encounter Any condition that develops during an outpatient encounter She had a vascular catheter-associated infection present on admission.

47. Hospital-acquired conditions (HAC) Any condition that could reasonably have been prevented through the use of evidence-based guidelines. Any condition that could reasonably have been prevented through the use of evidence-based guidelines. They gave me the wrong blood and I almost died!

48. Most common HACs resulting in decreased reimbursement Urinary catheter-associated urinary tract infection Urinary catheter-associated urinary tract infection Vascular catheter-associated infection Vascular catheter-associated infection Surgical site infection following orthopedic procedures, bariatric procedures, and CABG Surgical site infection following orthopedic procedures, bariatric procedures, and CABG DVT or PE following total knee and hip replacement DVT or PE following total knee and hip replacement 11 total HACs for FY 2010

49. E/M billing Don’t gamble on your documentation.

50. Elements of E/M services (evaluation and management) Seven elements of E/M services (physician billing) 1. History 2. Examination 3. Medical decision-making 4. Counseling 5. Coordination of care 6. Nature of problem 7. Time spent

51. Time element Time spent with patient or family Time spent checking labs or reports Coordinating services or consults *If more than 50% of time is spent with counseling *If more than 50% of time is spent with counseling and/or coordination of care, the code should be selected on the basis of time.

52. Initial hospital careSubsequent inpatient care Level 1$86$35 Level 2$117$64 Level 3$172$91 Documentation supports billing Example

53. Show your work The sicker your patient is … the lengthier your workup would be, affecting your level of service: HistoryExamDecision-makingRisk Time spent … Documentation must support the billing level!

54. Who needs help with documentation ? Don’t let these smiles fool you!

55. Deadly documentation excuses Already written Takes too long Don’t have time Doesn’t help me Too hard to remember

56. What can be done to help? Let the CDI department shed some light on your documentation needs!

57. Tools/weapons Pocket cards Handouts Clarification forms Newsletters CDI specialists

58. Pocket cards

59. Acute Blood Loss Anemia Acute Blood Loss Anemia Acute Blood Loss Anemia 2nd to GI Bleed Acute Blood Loss Anemia 2nd to GI Bleed Acute Confusional State Acute Confusional State Acute MI Acute MI Acute Postop Respiratory Insufficiency Acute Postop Respiratory Insufficiency Acute Renal Failure Acute Renal Failure Acute Respiratory Failure Acute Respiratory Failure AIDS AIDS Alzheimer’s Dementia with Behavior Disturbance Alzheimer’s Dementia with Behavior Disturbance Anorexia Anorexia Aspiration Pneumonia/Bronchitis Aspiration Pneumonia/Bronchitis Dementia w/ Delirium Dementia w/ Delirium Drug Dependence Ongoing/ Continuous Drug Dependence Ongoing/ Continuous Encephalopathy Encephalopathy End-Stage Renal Disease End-Stage Renal Disease Heart Failure: Acute/Chronic, Systolic/Diastolic Heart Failure: Acute/Chronic, Systolic/Diastolic Hypo-/Hypernatremia Hypo-/Hypernatremia Malnutrition Malnutrition Pneumonia 2ndary to … Pneumonia 2ndary to … Pressure Ulcer Stage 3 or 4 Present on Admission Pressure Ulcer Stage 3 or 4 Present on Admission Severe Malnutrition Severe Malnutrition Sepsis, Severe Sepsis, or Septic Shock Sepsis, Severe Sepsis, or Septic Shock Use of these words in your documentation helps support the severity of the presenting problem and the complexity of your decision-making. This has a direct effect on your severity of illness (SOI) and risk of mortality (ROM) scores. Helpful documentation words Helpful documentation words

60. Date _____________________________________________ Pt Name __________________________________________ Acct # ____________________________________________ Dear Dr. and/or Associates: Please document the Etiology of __________________________ in the Progress Notes, Consult Notes, or Discharge Summary when and if able to determine. This form will NOT be maintained as part of the legal permanent medical record. Your patient’s severity of illness (SOI) and risk of mortality (ROM) scores are affected by what you document in the medical record. Take credit for the severity of your patient by using the correct and thorough medical terminology in your documentation. Thank You! _____________________________________________________________ Coding/Clinical Documentation Specialist ______________________________________________________________ Phone # Etiology form

61. Documentation Clarification Request Dr.____________________________ Findings in chart:________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Thank You!  Noted clarification request, no response documentation  Clarification response documented in the medical record  Comments_________________________________________________________________________________ ________________________________________________________________________________ Please document your response in the PROGRESS NOTES section of the patient’s chart. _______________________________________________ _______________________________________________ Coding/Clinical Documentation Specialist Coding/Clinical Documentation Specialist Phone #________________________________________ Phone #________________________________________ This form will NOT be maintained as part of the legal permanent medical record. Your patient’s severity of illness (SOI) and risk of mortality (ROM) scores are affected by what you document in the medical record. Take credit for the severity of your patient by using the correct and thorough medical terminology in your documentation. Date: ________________________________________ Patient Name: ________________________________ Acct#: _______________________________________

62. Clarification response Document your response using the current date and time in one of the following areas: Progress note Progress note Consult note Consult note Discharge summary Discharge summary Addendum note Addendum note Get the evidence!

63. Summary Use appropriate documentation verbiage Use appropriate documentation verbiage Document pathology results Document pathology results Document whether present on admission Document whether present on admission Document legibly Document legibly Give a diagnosis, not a symbol or a symptom Give a diagnosis, not a symbol or a symptom Answer clarification requests for specificity Answer clarification requests for specificity Use your tools Use your tools

64. CSI Tampa Thank You Crime Scene Investigation

65. Questions?