1. 3M Health Information Systems, Inc. 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. Innovating Health Language of the Innovating Health Language of the Good Samaritan Advocate CPIC Draft April 15 8 am Thomas C Kravis MD © 3M 2015 - 3M Confidential - For Customer's Internal Review Only.explaiFurther use or disclosure requiresexplain apr and inpatint prior approval from 3M.

2. 2 3M Health Information Systems © 3M 2015. 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 Capture the severity of illness (SOI) and the Risk of Mortality (ROM) Support hospital and physician reimbursement Improve quality report cards hospital, physician Prepare for ICD-10

3. 3 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Value of Accurate and Complete Documentation MD and Hospital Quality Reports Care Coordination Team Medical Necessity Value Base Purchasing PSIs Core Measures Compliance Fraud Abuse RAC 2 MIDNIGHT RULE E&M Pro fees Denial related claims ICD-9-CM ICD-10 POA HACs Preventable Readmission Complications

4. 4 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Documentation & Coding Issues at Advocate 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 Documentation Improvement can help bridge the gap

5. 5 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Liver failure, renal failure, resp failure Respiratory failure : acute, acute on chronic Hypotension, shock-cardiogenic/septic Dehydration, hypovolemia Simple UTI Hypokalemia Pneumonia Left Lower Lobe Pancytopenia secondary to Chemotherapy Acute/Chronic Blood Loss Anemia Coma, Encephalopathy Protein Calorie Malnutrition Able to CodeUnable to Code Multi-system organ failure Severe respiratory distress Hemodynamically unstable Will rehydrate “Urosepsis” ↓ K = 2.0, will give KCL Chest X infiltrate ↓ Platelets ↓ Wbc ↓Hct ↓ HgB 5.2, Transfuse Altered Mental Status Emaciated, Total Protein/Albumin Low Clinical Diagnostic

6. 6 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Physician and advanced practioners role  Focus remains on patient care  Real time 3M 360 :Natural Language Processing  Respond to query and document in the EMR  Do not need to learn coding  Minimal impact on day-to-day routine  Clinical Documentation Specialists – a resource to the physician

7. 7 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. When should a physician be queried 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 © 3M 2011. All Rights Reserved.

8. 8 3M Health Information Systems © 3M 2015. 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: “ The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesimia” Cranial Procedure

9. 9 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. All Patient Refined DRG 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  Quality  Coding  Documentation Subdivide into subclasses

10. 10 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Principal Diagnosis "XYZ" Impact of Secondary Diagnosis

11. 11 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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. GS Hopital Risk-Adjusted Mortality Analysis: Quality Measure Advocate

12. 12 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. RISK OF MORTALITY APR DRG 194, HEART FAILURE Quality Documentation or Coding

13. 13 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Acuity Acute, chronic, acute on chronic/exacerbation  Type Systolic and/or diastolic heart failure  Etiology If known or suspected: ―Ischemia ―Anemia ―Hypertension ―Myocarditis ― Kidney failure ―Structural heart disease ―Supraventricular tachycardia ―Cardiomyopathy : Alcoholic congenital, congestive, constrictive, dilated, endomyocardial, idiopathic hypertrophic sub aortic stenosis,nonobstructive hypertrophic, obstructive hypertrophic, restrictive Heart Failure

14. 14 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Insufficient documentation ―Acute renal insufficiency SOI 1; ROM 1 ―Acute kidney injury (AKI) SOI 3; ROM 3 ―Acute kidney failure SOI 3; ROM 3 Preferred specificity if clinically appropriate ―Acute kidney failure due to: Acute tubular necrosis SOI 4; ROM 4 Cortical necrosis SOI 4; ROM 3 Medullary (papillary)necrosis SOI 4; ROM 3 Acute Kidney Failure – Impact of Documentation

15. 15 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Heart Failure  Sample Physician: SOI less than Peers  Target for training Training objective:  Respond to query  Document the drivers of SOI  Treat underlying cause: clinical effectiveness Lower SOI

16. 16 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Probable, Possible, Suspected Diagnosis Uncertain Diagnosis Inpatient application only :  These conditions may be coded 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  Supports appropriate E&M professional component

17. 17 3M Health Information Systems © 3M 2015. 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 ICD-10 GERD Gastritis MS-DRGs 391/392 RW = 1.0958 Chest Pain MS-DRG 313 RW = 0.5404 Anterior CP Pleuritic CP Chest Wall Pain MS-DRG 204 RW = 0.6472 Costochondritis Tietze’s Disease MS-DRGs 205/206 RW = 1.2566 Pulmonary Embolism MS-DRGs 175/176 RW = 1.6121 Cardiac Arrhythmia MS-DRGs 308/309/310 RW = 1.2188 Angina MS-DRG 311 RW = 0.5128 CAD MS-DRGs 302/303 RW = 0.9999 Shingles MS-DRGs 595/596 RW = 1.7691 Psychogenic Chest Pain MS-DRG 882 RW = 0.6676 Pleurisy MS-DRGs 193/194/195 RW = 1.4378 Psychogenic Angina Pericarditis MS-DRGs 314/315/316 RW = 1.7589 Anxiety MS-DRG 880 RW = 0.6191 Biliary Colic MS-DRGs 444/445/446 RW = 1.5055 Cardiac Cath MS-DRGs 286/287 RW = 1.9634

18. 18 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Document acuity: ― Acute ― Chronic ― Healed/old  Specify meaning of “history of PE” ― Chronic PE being treated ― no longer has the condition ― “chronic pulmonary embolism” /“healed PE” or “old PE”  Specify type: ― Saddle ― Septic ― Postprocedural or due to a vascular device  Specify if related to any other condition such as: ― Atrial fibrillation ― DVT (specify site and laterality) ― Hypercoagulable state ― Malignancy/Orthopedic surgery/Sepsis/Trauma ― Not POA and after an operative episode is considered a patient safety indicator (PSI 12) ― A hospital acquired condition (HAC) when following certain orthopedic procedures  Cor pulmonale (acute /chronic) Documentation for Pulmonary Embolism ICD-10

19. 19 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 ICD-10-CM : Type of infarction (STEMI or NSTEMI) Specific site of myocardium involved ( anterior wall, inferior wall) Coronary artery involved (LAD, RCA, LMCA, LCx) New MI within 4 weeks of a previous MI Specify date of onset) Myocardial Infarction

20. 20 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Sepsis  Sepsis is classified by the bacteria causing the infection ―Streptococcal sepsis (group A, group B, Streptococcus pneumoniae, other streptococcal) or ―Other sepsis (e.g., MRSA, pseudomonas)  Severe sepsis is associated with organ dysfunction/failure ―Document the specific associated organ dysfunction (not MOD) and ―Document presence of septic shock

21. 21 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Respiratory Failure  Acute/chroni c/acute on chronic  Etiology :pneumonia,COPD,drug,trauma  If following surgery was it POA ( PSI ) or due to underlying pulmonary condition, failure to wean  Signs :RR> 26, accessory muscles use, altered mental status  Arterial blood gas and pH:  pH of 7.50  pCO 2 of >50  pO 2 of <60 (impacted by hemoglobin level)  Type I Hypoxemic : pO 2 60 mm Hg normal or low pCO 2  Type II Hypercapnic: pH 50  Chroni c : As above and low flow 02 at home; polycythemia ;cor pulmonale; heart failure

22. 22 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. “ Postoperative” Diagnosis: Two Definitions 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).

23. 23 3M Health Information Systems © 3M 2015. 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

24. 24 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Impact of Documentation and Quality 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%

25. 25 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-9 vs. ICD-10 Structural Changes  ICD-9 (Diagnoses) 3-7 characters a a # # a/# Category etiology, site, manifestation extension a/# ICD-10 (Diagnoses) # # # # # # # # # # Category etiology, site, manifestation 3-5 characters t

26. 26 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Documentation Requirements for Procedures  Laterality of site ― Left ― Right ― Bilateral  Specificity of approach Open Percutaneous Percutaneous endoscopic Via natural or artificial opening Via natural or artificial opening- endoscopic Open with percutaneous endoscopic assistance External

27. 27 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Objective of the procedure ― Root operation “dilation” is defined as “expanding an orifice or the lumen of a tubular body part”  Vessel and laterality  Approach ―Open ―Endoscopic ―Percutaneous endoscopic  Type of stent inserted ― Drug-eluting intraluminal device ― Non-drug-eluting stent ― Bare metal stent Example:Angioplasty with Stent Procedures

28. 28 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Cause and effect ― Subarachnoid hemorrhage secondary to fall during skiing accident  Specific ― Salter Harris Type I physeal fracture proximal left femur  Anatomical site and laterality ― Displaced fracture of olecranon process with intraarticular extension of right ulna  Encounter ―Initial vs. subsequent vs. sequela ICD-10 Trauma Documentation Tips

29. 29 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 OB/Gyn Documentation Tips  Use adjectives ―Acute, chronic, acute on chronic, mild, moderate, severe Example: Moderate pre-eclampsia  Indicate cause and effect ―Use “due to” or “secondary to” Acute salpingitis secondary to Neisseria Gonorrhoeae  Clinical aspects of the disease ― Gestational hypertension without proteinuria  Patient’s trimester or number of weeks ― Admitted for proteinuria in 34 th week of pregnancy  Specify anatomical site ― Example: Acute salpingitis and oophoritis

30. 30 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Documentation Tips Mental Health  Adjectives ―Acute, chronic, acute on chronic, mild, moderate, major, severe, persistent Bipolar disorder, acute episode manic, moderate  Cause and effect Dementia due to Alzheimer’s disease