1. Clinical Documentation Improvement Program In-Patient Status
University of New Mexico Hospital
Family Medicine
November 6th
Terry Peyton, RN, CCDS
CDI Educator and Physician Advisor

2. Why Documentation Matters:
Quality Management Profiling
Joint Commission
Core Measures
State Reporting
Supports
DRG & Coding Assignment…
Severity of
Illness and Risk of Mortality
More accurate
Case Mix Index
Links with Compliance Program
Key Driver:
DOCUMENTATION
Helps justify LOS inconsistencies
RAC Audits-CMS recovery audit program
Appropriate Reimbursement
Supports
Medical Necessity/ Denials Reduction

3. What is Your role? The most important thing to remember is
you are here to treat the patient.
Nobody else can coordinate and direct the medical care of the patients like you have been trained to do.
The CDI role is to assure accurate documentation is in the record to support the medical diagnosis, the medical necessity of the care being given, and obtaining the most complete record to meet the Centers for Medicare & Medicaid Services guidelines.

4. How documentation can impacts the Length of Stay
FY2018/2019 data
Patient presents from nursing home with pneumonia.
Pneumonia (simple)
With no comorbid conditions
DRG SOI 1 ROM 1 R.W GLOS 2.6 days
With comorbid condition of chronic systolic heart failure (HFrEF)
DRG SOI 2 ROM 2 R.W GLOS 3.3 days
With major comorbid condition of acute hypoxic respiratory failure
DRG SOI 3 ROM 3 R.W GLOS 4.2 days
Pneumonia due to gram negative bacteria (or complex pneumonia i.e. aspiration)
DRG SOI 1 ROM R.W GLOS 3.2 days
With comorbid condition of chronic systolic heart failure
DRG SOI 2, ROM 2 R.W GLOS 4.3 days
With major comorbid condition of acute respiratory failure
DRG SOI 3 ROM 3 R.W GLOS 5.5 days

5. How documentation paints the picture we see
Symptom
Lab Value
No Dx
Lab Value
Vital Sign
“75y/o chronic lunger w fever, leukocytosis, SOB with hypoxia and altered mental status.”
How about: “75 y/o with COPD exacerbation with acute and chronic hypoxic respiratory failure; now presenting with pneumonia, probably Gram negative in view of age, and likely a gram negative empyema, probable severe sepsis, with acute septic encephalopathy as well.”
Clinical Finding
DRG 204 Respiratory Signs and Symptoms
SOI ROM R. W GLOS days CC
MCC
MCC
Principal Dx
MCC
MCC
DRG Sepsis w/o MV 96+ hours w/MCC
SOI 4 ROM 4 R.W GLOS 4.9
Same patient, same treatment, may “ look “ different with more complete documentation and the acuity of the actual care given will be reflected in the code assigned after discharge

6. Our goal is to have the most complete record at the time of discharge.
Our Process
Daily review of the information available in Cerner. (from ER, H/P, Anesthesiology, progress notes, OP notes, tests, labs, x-rays, CT’s)
With this information and the specific software, we identify gaps in documentation . With complete documentation we will have an accurate reflection of the acuity of care given for each hospital admit.
Our goal is to have the most complete record at the time of discharge.
To be sure each comorbid condition (CC) or major comorbid condition (MCC) is identified and documented
This can get challenging with the shorter lengths of stay

7. How do you know when additional documentation is needed ?

8. Our expectation is that any Clinical Documentation Clarification or Coder Query will be addressed within 48HOURS –
A clarification is delivered to your
Please Document your response in the progress notes and discharge summary
If you need to communicate with the CDS you can respond to the message with any additional information

9. Now what do you do????
Include the information in your daily progress notes along with the ongoing status and you’re done!
Include all medical diagnoses treated or monitored in the discharge summary to support the treatment rendered through the hospital stay
Carry the information forward and verify any notes that are copied and pasted forward are accurate for documenting continuity of care.
the discharge summary should be a synopsis of the patient's condition(s) and treatments(s) received from admission to the time of release

10. IF you Treat it – Diagnose It IF you Monitor it, Diagnose it!

11. Who’s Who in CDI Catherine E. Porto, MPA, RHIA, CHP, FAHIMA
HIM Executive Director
Alethea Martinez, MSN
CDI Director
Erlinda Smith, CCS, CCDS
Educator, coding and documentation
Terry Peyton, BSN, CCDS
Interim CDI Educator
Physician Advisor14 internal CDI’s
Questions?

12. Thank you for working with us to take care of our patients
Health is the thing that makes you feel that NOW is the
best time of the year
Franklin P. Adams