1. 3M Health Information Systems © 3M 2014 All Rights Reserved. 3M provides these slides to promote a better understanding of 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only. Advocate Health Care Christ Medical Center April 16, 2015 * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guaranty the use of this product. 3M provides these slides to better understand 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only.

2. 2 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Clinical Documentation Improvement Goals and Objectives Clear concise accurate documentation Across the continuum of care: inpatient and outpatient Capture the severity of illness (SOI) and the Risk of Mortality (ROM) Support hospital and physician reimbursement Improve quality report cards and clinical outcomes Prepare for ICD-10

3. 3 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Impact of Accurate Complete Documentation Profiling Risk Management Accountable Care Critical Pathways Case Management Quality Management (CQI, TQM) Core Measures Regulatory Compliance Validating LOS Reimbursement ICD-9-CM ICD-10 Present-on- Admission Indicators RAC Audits 2 Midnight

4. 4 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. General Rules for Documentation  All diagnoses must be documented by a physician in the body of the medical record  To report a diagnosis, it must meet one of the following criteria: ―Clinical evaluation ―Therapeutic treatment ―Diagnostic procedures ―Extended length of hospital stay ―Increased nursing care and/or monitoring  Conditions cannot be coded from lab, x-ray, or other diagnostic reports without documentation by a licensed hands provider

5. 5 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Documentation & Coding Issues Physician Document in CLINICAL terms Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms This gap will be increased with ICD-10 Two separate languages Advocate System Documentation Improvement Program can help bridge the gap

6. 6 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Basic Physician Documentation Requirements  Document the reason(s) for the inpatient admission and the complex medical judgment factors including: 1)Severity of the signs and symptoms 2)Prediction of adverse event 3)Expectation of a two midnight length of stay  All medications, treatments and diagnostic studies, document the corresponding medical diagnoses  Document all conditions including probable, suspected or questionable based on your independent professional judgment and the clinical evidence and treatment provided.  Document if a condition was treated resolved or was considered probable at the time of discharge and include the medical decision making process and supportive clinical information.

7. 7 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Liver failure, renal failure, resp failure Respiratory failure : acute, acute on chronic Hypotension, shock-cardiogenic/septic Dehydration, hypovolemia Ventricular tachycardia Simple UTI Hypokalemia Right lower lobe pneumonia Pancytopenia secondary Chemotherapy Acute/Chronic Blood Loss Anemia Dementia, Coma Protein Calorie Malnutrition Able to CodeUnable to Code Multi-system organ failure Severe respiratory distress Hemodynamically unstable Will rehydrate Rhythm stable today “Urosepsis” ↓ K = 2.0, will give KCL Chest X pneumonia ↓ Platelets↓wbc ↓Hct ↓ HgB 5.2, Transfuse Altered Mental Status Emaciated, Total Protein/Albumin Low Unable/Able to Code Examples

8. 8 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Quality Report Cards  Profiles Hospital  Profiles Physicians  Healthcare Consumerism  Healthgrades.com  Leapfroggroup.org  CMS.gov  Patient Safety Initiatives Copy Right 3M 2014 All Rights Reserved

9. 9 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems 3M™ DRG Assurance Program Assure all conditions are documented in the medical record  To promote the appropriate assignment of  S everity O f I llness (SOI) & R isk O f M ortality (ROM)  Based on CMS’s rules and regulations  Documentation Specialists  “Real Time” Physicians Medical Record Professionals Clinical Doc. Specialists Patient

10. 10 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Concurrent Query Process Query Opportunity Query Posed to Physician Physician Agrees? Yes Write Diagnosis in Progress Note NoNo Response Write “NO” on the Query Form 3M 360 Medical Record

11. 11 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Physician, Physician Assistant and Nurse Practioners Role  Focus remains on patient care  Complete documentation – diagnostic terms  Respond to written/verbal/electronic queries  Do not need to learn coding  Minimal impact on day-to-day routine  C linical D ocumentation I mprovement Specialists server as a Resource to the physician

12. 12 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems When should there be a query regarding clinical documentation? “ whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure” AHIMA Practice Brief “Managing an Effective Query Process” October 2008

13. 13 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Impact of Responding to Query Impact w/ Response to Query  RW = 2.9797  GLOS = 8.98  SOI = 3 Major  ROM = 2 Moderate Impact w/o Response to Query  RW = 2.9797  GLOS = 8.98  SOI = 2 Moderate  ROM = 2 Moderate Query: “ Patient had a magnesium level of 1.6 and received magnesium sulfate. Please provide a corresponding diagnosis for the treatment provided.” ** CDI seeks documentation of “ hypomagnesemia “ Cranial Procedure

14. 14 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Appropriate Reimbursement And Profiles Provider Documentation Principal & Secondary Diagnoses Principal & Secondary Procedures ICD-9-CM Codes ICD-10-CM Codes ICD-10-PS Codes DRG Assignment Severity & Risk of Mortality Classification Profiling/Reimbursement (Providers/Hospitals)

15. 15 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems 3M™APR DRG All Patient Refined DRGs  Developed by 3M Yale and the National Association of Children ’ s Hospitals – based on discharge data from 8.5 mil discharges, 1K hospitals, 10 states., all-payers, 47 Peds Hosps (updated every 2 years)  Most widely used severity-of-illness and risk-of-mortality adjustment U.S. News & World Report hospital rankings AHRQ Patient Inpatient quality Indicators 45 state and federal agencies JCAHO accreditation survey process Thomsen Reuter Utilized for reimbursement Medicaid Florida © 3M 2011. All Rights Reserved.

16. 16 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems APR-DRG 3M™ Severity of Illness Subclasses 1.Minor 2.Moderate 3.Major 4.Extreme Risk of Mortality Subclasses 1.Minor 2.Moderate 3.Major 4.Extreme Mortality at < 4 suggests care, coding or documentation opportunities Subdivide into subclasses

17. 17 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Underlying Principle of 3M™ APR DRGs Severity Of Illness (SOI) and Risk Of Mortality (ROM) are dependent on the patient’s underlying problems. High SOI and ROM are characterized by: (a) multiple (b) serious diseases and (c) the interaction among those diseases.

18. 18 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. When do I document “other” diagnoses? What is the impact? “ additional conditions that affect patient care in terms of requiring at least one of the following”: ― Clinical evaluation ― Therapeutic treatment ― Diagnostic procedures ― Extended length of hospital stay ― Increased nursing care and/or monitoring

19. 19 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems Principal Diagnosis "XYZ" Impact of Secondary Diagnosis

20. 20 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. “Diabetic Neuropathy” Non Specific code in ICD-10 ―Document : Diabetic mononeuropathy Diabetic polyneuropathy Diabetic autonomic neuropathy Diabetic amyotrophy ― Type of diabetes as Type 1 or Type 2 or drug induced ― Control status Document : “inadequately controlled,” “ out-of-control,” or “ poorly controlled” and Type with hyperglycemia. ―Associated complications (atherosclerosis, peripheral angiopathy, PVD, gangrene ―Document a cause and effect link ( PVD due to diabetes, diabetic foot ulcer) ―)

21. 21 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Medicare Risk-Adjusted Mortality Analysis System Hospitals Higher Than Expected (Unfavorable) Lower Than Expected (Favorable) Source:Risk Adjustment – by the 3M TM APR DRG Classification System and MEDPAR 2012; Expected deaths are based on the State of Illinois’s average death rate, risk adjusted by the 3M APR DRG Classification System. Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. 21 © 3M 2014 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M. State Average

22. 22 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Medicare Severity Index Comparisons System Hospitals Higher Than Expected (Favorable) Lower Than Expected (Unfavorable) Source:3M TM APR DRG Classification System and MEDPAR 2012 22 © 3M 2014 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M. State Average

23. 23 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M  APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 139 - OTHER PNEUMONIA Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. Data Source: 3M APR DRG Classification System utilizing MEDPAR 2012 data Improved documentation may have increased the ROM to a higher level

24. 24 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Document the Specific Type of Pneumonia DiagnosisMCCCCNon-CC Aspiration pneumonia X E. Coli pneumonia X Hemophilus Influenzae (H. Influenzae) pneumonia X Hypostatic pneumoniaX Influenza with pneumoniaX Interstitial pneumonia (BOOP)X Klebsiella pneumoniaX Legionnaires’ diseaseX MCC vs. CC Disease Progression Tables for Secondary Diagnoses

25. 25 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Pneumonia: Complex vs. Simple  Complex Pneumonia Higher SOI; consume more resources RW = 1.9934 ―Anaerobic pneumonia ― Aspiration pneumonia ―Gram-negative pneumonia, which includes: E. coli pneumonia Hemophilus parainfluenzae pneumonia Legionnaires’ disease Moraxella catarrhalis Proteus pneumonia Serratia marcescens pneumonia Xanthomonas pneumonia ―Klebsiella pneumonia ―Pseudomonas pneumonia ―Staphylococcus pneumonia MRSA MSSA  Simple Pneumonia Lower weight and SOI; consume less resources RW = 1.4550 ―Chlamydia ―Gram-positive pneumonia ―Hemophilus influenzae pneumonia ―Mixed bacterial pneumonia ―Mycoplasma pneumonia ―Pneumococcal pneumonia ―RSV Pneumonia ―Streptococcus pneumonia ―Vancomycin resistant Enterococcus (VRE) ―Viral pneumonia ―Unspecified pneumonia, CAP, HAP Link cause of pneumonia

26. 26 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. "Probable" "Possible" "Suspected" "Unable to Rule Out"  Inpatient application: ―Code these conditions as though they exist – applies to hospital setting only ―If condition is ruled out, it may not be coded  Outpatient application: ―Must code signs/symptoms, not the suspected condition

27. 27 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Possible/Probable Cause of Chest Pain Cardiac Cath MS-DRGs 286/287 RW = 1.9634 What’s new in ICD-10?

28. 28 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Acuity: ― Acute ― Chronic ― Healed/old  Specify “history of PE ” ― Patient has had the condition for a while or patient no longer has the condition ― i.e.“chronic pulmonary embolism” vs. “healed PE” or “old PE”  Type : ― Saddle ― Septic ― Postprocedural or due to a vascular device  Cause/ other : ― Atrial fibrillation ― DVT (specify site and laterality) ― Hypercoagulable state ― Malignancy ― Orthopedic surgery ― Sepsis ― Trauma  Presence of cor pulmonale (acute/chronic) Documentation for Pulmonary Embolism: More Specificity

29. 29 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Codes for STEMI: Increased Specificity

30. 30 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M  APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 720 - SEPTICEMIA & DISSEMINATED INFECTIONS Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. Data Source: 3M APR DRG Classification System utilizing MEDPAR 2012 data

31. 31 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Sepsis is classified in ICD-10 as: Streptococcal or Other Sepsis (e.g., MRSA, Pseudomonas)  Severe sepsis Must document associated organ dysfunction and the basis for same and Document presence of septic shock (combination codes) Sepsis/ Severe Sepsis

32. 32 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Respiratory Failure Documentation  Document acuity: ―Acute ―Chronic ―Acute on chronic  Document presence of: ―With hypoxia ―With hypercapnia  Specify the etiology or cause of respiratory failure in progress notes and discharge summary DISCHARGE DIAGNOSES: 1. Acute respiratory failure secondary to MRSA pneumonia improved. 2. Severe sepsis due to E. Coli treated and resolved. 3. Anemia of chronic disease stable. 4. Anasarca improving. 5. Protein malnourishment mild improving. 6. End-stage liver disease. Acute, chronic, acute on chronic? With hypoxia, hypercapnia, or both? Etiology?

33. 33 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Syncope Alternatives”: “possible” “probable” Arrhythmia MS-DRGs 308/309/310 RW = 1.2188 Syncope MS-DRG 312 RW =.7215 Stroke or CVA MS-DRGs 64/65/66 RW = 1.8258 Anemia MS-DRGs 811/812 RW = 1.2431 Dehydration MS-DRGs 640/641 RW = 1.0896 Heart Failure MS-DRGs 291/292/293 RW = 1.4609 Hypotension MS-DRGs 314/315/316 RW = 1.7589 Dig Poisoning MS-DRGs 917/918 RW = 1.4449 Alcohol Abuse MS-DRGs 896/897 RW = 1.4155.

34. 34 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Cerebral Infarction ICD-10  Cerebral Infarction ―Document if the cause of infarction is due to: Embolism Thrombosis Occlusion Stenosis ―Specify artery involved: Precerebral arteries: Vertebral artery Basilar artery Carotid artery ―Distinguish between intraoperative or postprocedural cerebral infarction occurring during cardiac surgery or another type of surgery ―Document laterality : Right Left Cerebral arteries: Middle cerebral artery Anterior cerebral artery Posterior cerebral artery Cerebellar artery

35. 35 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Cerebral Infarction Following Surgery  What remains the same ICD-9 ? Etiology = thrombosis or embolism  What’s new ― Site = precerebral, cerebral, or cerebellar arteries If precerebral :  Vertebral, basilar, carotid, or other ― Laterality = right or left, when applicable ― Intraoperative or ― Post procedural ― During cardiac surgery or ― Another type of surgery If cerebral :  Middle, anterior, or posterior

36. 36 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M  APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 194 - HEART FAILURE Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. Data Source: 3M APR DRG Classification System utilizing MEDPAR 2012 data

37. 37 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10: Heart Failure Specify  Acuity acute, chronic, acute on chronic/exacerbation  Type systolic and/or diastolic heart failure  Etiology if known or suspected: Anemia Supraventricular tachycardia Myocarditis Cardiomyopathy: dilated, hypertrophic (obstructive vs. non obstructive), restrictive Structural heart disease Hypertension Renal failure Ischemia Copy Right 3M 2014 All Rights Reserved

38. 38 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Document The Reason for Drug Underdosing  New clinical terminology in ICD-10  Identifies intentionally or unintentionally taking less of a medication than prescribed  Document intentional versus unintentional or accidental ―Intentional For example, due to financial hardship ―Unintentional or accidental For example, due to age related disability –Age-related dementia –Rheumatoid arthritis of hands

39. 39 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. "Postoperative”: Complication or expected outcome Clinical Definition “A condition occurring in the postoperative period”. Coder Definition “A diagnosis related to the surgical procedure” Complication-900 code “Coder cannot make the determination if it is a complication or an expected outcome” (Coding Clinic 4/27/2011).

40. 40 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Examples Complication  Postop ileus (997.4 + 560.1 )  Ileus secondary to surgery (997.4 + 560.1)  Post op atelectasis (997.39 + 518.0)  Post op anemia (998.11 + 285.1) Non-Complication  Ileus  Prolonged ileus  Expected ileus  Incidental atelectasis  Atelectasis  Acute blood loss anemia

41. 41 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Complications of Surgery  ICD-10 for some complications, timeframe of when complication occurred Intraoperative or postoperative Body system of organ related to complication Body system on which the procedure was performed Example: – Colon resection :accidental puncture of artery resulting in postoperative hemorrhage status

42. 42 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Complete and Accurate Documentation and Coding: Example: Patient with CA, syncope falls: Pathologic Fracture Pathologic fracture documentation and coding will need to include:  Exact location of fracture Site Laterality POA  Etiology of fracture Osteoporosis Neoplastic disease (primary each secondary site)  Encounter type Initial encounter for fracture Subsequent encounter for fracture Subsequent encounter for fracture with delayed healing Sequela ICD-9-CM Pathologic Fracture 8 Codes (733.13-733.19) ICD-10-CM Pathologic Fracture 150+ Codes (M80-M84)

43. 43 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Require Documentation of Encounter Specificity:  Initial – patient is receiving active treatment for the condition such as: ―Surgical treatment ―Emergency department encounter, and ―Evaluation and treatment by a new physician  Subsequent – patient has received active treatment of the condition and is currently receiving routine care for the condition during the healing or recovery phase. ―Cast change or removal ―Removal of external or internal fixation device ―Adjustment of medication ―Other aftercare and follow-up visits following treatment of the injury or condition  Sequela – used for complications or conditions – late effects - that arise as a direct result of a condition. ICD-10 Encounters

44. 44 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 0 2 7 B 3 4 Z 0 2 7 B 3 4 Z Med/Surg Heart & Great Vessels Dilatation Coronary Artery Percutaneous Transluminal Device, Drug Eluting None Section Body System Body System Root Operation Root Operation Body Part Body Part Approach Device Qualifier ICD-10-PCS: Illustration only: stent

45. 45 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. End of Life/Palliative Care Documentation  When further treatment is deemed futile and /or  Patient/family has declined further treatment, the patient’s chart may document only the following: ―“Comfort measures” ―“Supportive care” ―“Condition grave”  No aggressive treatment may be rendered…….but…….  Document clinical all conditions and treatments required to accurately reflect patient’s extreme severity of illness and risk of mortality. Examples: ―Coma ―Agonal respirations ―Respiratory failure ―Brain Death ―Heart failure ―Renal failure  Document the underlying terminal diagnosis (cancer, end-stage heart or renal failure)

46. 46 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Pulmonary (Pocket card example) Clinical Terms (Documentation needs clarification) Diagnostic Statement (Accurate code may be assigned) 1.LUL infiltrate 2.+ sputum culture, productive cough Pneumonia (specify type and organism, if known, such as Klebsiella pneumonia – must link responsible pathogen to the pneumonia; document cause such as aspiration pneumonia) Fever, cough, infiltrates on CXR, suspect aspiration, abnormal swallow study, speech therapy consult, aspiration precautions Aspiration pneumonia, aspiration pneumonitis, aspiration bronchitis New onset fever, cough, productive sputum, fever Acute bronchitis (specify organism, if known), pneumonia (document causative organism, if known), pneumonitis SOB, pO 2 55, pCO 2 64, pH 7.32, O 2 sat 88%, BiPAP O 2 Respiratory distress, cyanosis, ↑HR, labored respirations Respiratory failure (specify acuity, if known: acute, chronic or acute on chronic; document if acute respiratory failure is hypoxemic, hypercapnic or both) CXR shows chronic lung changes. Nurses’ notes indicate COPD. Home meds of inhalers and O 2 noted. COPD (document if with acute exacerbation or decompensated, document if oxygen dependent) History of asthma, continues marked wheezing, SOB, O 2 sat 88%, ↓FEV1 Asthma (document severity and type [mild intermittent, mild persistent, moderate persistent, severe persistent], document status [uncomplicated, acute exacerbation, status asthmaticus]) A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

47. 47 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Cardiology (Pocket Card example) Clinical Terms (Documentation needs clarification) Diagnostic Statement (Accurate code may be assigned) Chest pain will treat with IV nitro and evaluate by cathCAD (known or suspected), stable angina, unstable angina, AMI, aortic stenosis, hypertension, CHF Chest pain, noncardiac, treated with NSAID and H2-blockersSpecify diagnosis being treated even if considered probable or suspected such as chest wall pain, GERD, costochondritis Continue home medications such as nitrates, beta-blockers, furosemide, phenoytoin Document specific diagnosis such as CAD, atrial fibrillation, chronic systolic heart failure, angina, HTN, seizure disorder History of previous heart problemsDocument specific diagnoses such as CAD, angina, old MI (document date when MI occurred), s/p CABG ECHO, EKG, CXR, laboratory resultsDocument diagnoses based on diagnostic study results in progress notes and in discharge summary indicating the clinical significance of the diagnosis 1.History of CHF, will continue furosemide, ACE inhibitors 2.CXR reveals cardiomegaly, patient treated with diuretics, progress notes reveal no overt CHF 3.Ejection fraction 24%, JVD, lungs bibasilar rales Heart failure (specify type such as systolic, diastolic, combined systolic and diastolic; specify acuity such as acute, chronic, acute on chronic) ↓BP, hemodynamically unstable, IV fluid bolus started, dopamine ordered Shock, hypotension (specify type such as drug-induced, iatrogenic, idiopathic, intra-dialytic, orthostatic, postoperative) A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

48. 48 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Infectious Disease (Pocket Card example) Clinical Terms (Documentation needs clarification) Diagnostic Statement (Accurate code may be assigned) Chronic liver disease, now with altered mental status Viral hepatitis (document acuity such as acute or chronic; document hepatic coma when present; for hepatitis B patients, document any findings of delta agent) History of IV drug use, HIV+, fever, cough, weight loss AIDS, symptomatic HIV infection Endocarditis, SOB, CHF EF <40% Acute systolic heart failure due to endocarditis (document acuity) Fever, headache, cough, weight loss +LP Meningitis (specify type such as bacterial or viral; document organism, if known; document acuity) Abdominal pain, headache, fever, diarrhea Foodborne poisoning (specify type such as Salmonella) Urosepsis, new cystostomy, + culture Cystitis (specify acuity; document if due to cystostomy tube; document organism if known such as E. coli) Cellulitis, gangrene footDocument location, laterality, and organism; document underlying cause, if known, of gangrene such as diabetes, atherosclerosis A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

49. 49 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Impact of Documentation MS-DRG 330 2.4981 Bowel Procedure with CC PDx: Colon cancer SDx: Dehydration Post-op ileus (codes to 997.4 + 560.1) “Ulcer/Wound” noted by RN PPx: Left hemicolectomy MS-DRG 329 5.1396 Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer, site unspecific PPx: Left hemicolectomy APR DRG:221 SOI Level:2 APR Weight:1.7681 ROM Level:1 Peer Group 0.0% APR DRG:221 SOI Level:3 APR Weight:2.9531 ROM Level:3 Peer Group 2.5% highest MS-DRG payment MS-DRG 329 5.1396 Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer Stage IV on Sacrum PPx: Left hemicolectomy APR DRG:221 SOI Level:4 APR Weight:6.3732 ROM Level:4 Peer Group 24.2%

50. 50 3M Health Information Systems © 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Impact of Documentation MS-DRG 330 2.4981 Bowel Procedure with CC PDx: Colon cancer SDx: Dehydration Post-op ileus (codes to 997.4 + 560.1) “Ulcer/Wound” noted by RN PPx: Left hemicolectomy APR DRG:221 SOI Level:2 APR Weight:1.7681 ROM Level:1 Peer Group 0.0% APR DRG:221 SOI Level:4 APR Weight:6.3732 ROM Level:4 Peer Group 24.2% MS-DRG 329 5.1396 Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer Stage IV on Sacrum PPx: Left hemicolectomy Not just about reimbursement

51. 51 3M Health Information Systems © 3M 2014. All rights reserved. 3M Confidential – Not for distribution 3M Health Information Systems APR DRGs Pay for Reporting Hospital-acquired conditions (HACs) Potentially preventable Readmissions (PPRs) Potentially preventable Complications (PPCs) Pay for Performance “Accountable” Episodes of Care” Value Based Purchasing Prepare for ICD-10 Pay for Outcomes 2008 2014 2016 Value to Advocate Physicians Preparation For Future Changes