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Improving CDI: Taking Your Program from Good to GREAT Fran Jurcak, RN, MSN, CCDS Director, Clinical Documentation Improvement Huron Consulting Group Chicago, IL Evaluating your CDI Program • Scope of practice – Appropriateness of staffing – Administrative oversight – Tracking tools • Physician engagement • Opportunities – Discharged records – Clinical examples • Future Plans Assess Program Scope Program Assessment • Program purposes – Payers being reviewed – Additional diagnoses • CC/MCC capture – Present on Admission – Signs and symptom diagnoses – Completeness of record • Principal diagnosis • Medical necessity • Core Measures Chart Review Priority ACDIS: 2010 CDI Program Benchmarking Survey Best Practice • Dedicated Role • Accuracy of clinical documentation – Principal Diagnosis – Severity of Illness – Risk of Mortality • Review of every record • Physician education • Planning for ICD-10 Impacting Documentation Organizational Structure ACDIS: 2010 CDI Program Benchmarking Survey Balancing Program Goals Finance Quality • Improve • Complete and reimbursement • Reduce risk of denials • RAC calls this DRG Validation accurate documentation of quality measures • RAC calls this Clinical Validation Quality Finance Creating the Balance • Accurate documentation that supports the conditions being monitored and treated throughout the course of the patient stay will result in appropriate severity of illness and compliant reimbursement. Quality Finance Staffing • Number of Reviews – 10-15 Initial reviews/day – 15-20 Follow up reviews/day • Weekend Coverage – Admit and discharge Documentation opportunity does not just occur Monday through Friday, 9-5! Record Review • Goal – 100% of identified payers – Subtract discharge numbers from clinical areas not covered by CDI Specialists • Typical Benchmark – >80% • Retrospective review possibilities – Post discharge – Records of deceased Productivity Review Rate Low Review Rate with Low Query Rate Low Review Rate with High Query Rate High Review Rate with Low Query Rate High Review Rate with High Query Rate Review CDS process Identify areas for education to improve Review CDS process to reflect number of cases to be reviewed Consider additional FTE's Review records for query opportunity Provide necessary education regarding potential queries Review process to ensure enough time per record Excellent program Consider review of additional DRG payers Property of F. Jurcak, 2010 Query Impact ACDIS 2010 Physician Query Benchmarking Survey, Process • Type of Query – Principal Diagnosis – Present on Admission – Procedure – CC/MCC • Query Indicators – Inclusion of rationale for the query – Should include: • Risk factors, signs/symptoms, treatment Process • Method of Query Communication – Concurrent vs retrospective – Paper vs electronic • Templates – Provide consistency – Enhances physician participation Template Example ACDIS Resource Library: Provided by Susan A. Klein, BSN, RN, C-CDI, Saint Peter's University Hospital in Monroe Township, NJ Template Example ACDIS Resource Library: Courtesy of Sandy Beatty, Clinical Documentation Specialist for Columbus Regional Hospital Process • Query Issues – Location in record • Ease of physician recognition – Permanency • Permanent part of record…or not – State QIO and RAC – Leading vs nonleading • Clinical indicators Query Quality • Regular review of query forms – Content – Structure • Quarterly audit of CDI Specialist queries – Peer to peer review • Quarterly updates/education for CDI staff Query Metrics Query Rate Low Process: Evaluate review rate and compare with query rate Property of F. Jurcak, 2010 CDS Issue: Audit records to identify missed opportunity Educate CDS on appropriate topics High CDS Issue: Evaluate query appropriateness Process: Ensure appropriate physician response rate occurs Continue physician education plan Process • Follow up – Frequency • 12-20 Follow up reviews/day – Rationale • Previous query answer • New query • Other measures • Physician Education Program Success • Tracking Data – Method of tracking • Data to Track – Review Rate – Query Rate – Physician Response Rate – Physician Acceptance Rate – CMI changes • Tracking Quality – Query forms – CDI Specialist queries Physician Engagement Process • Physician Response – Identifies • Physician acceptance of CDI program • Quality of process – Goal 100% • Medical Staff by-laws • Physician Report cards Process Physician Response Rate Low Process Issues: CDS needs to have face to face with physicians Physician Education needed CDI Physician Advisor to assist Property of F. Jurcak, 2010 High CDS Issues: Review records to identify CDS education opportunity Evaluate review rate for CDS productivity issues Process Issues: Physicians on board CDS following through to ensure documentation CDS Issues: Ensure credibility of CDS queries CDS following through to ensure answers Physician Support Physician Response Rate Employed Physicians Expected Response Rate 100% Written into contract Part of Performance Measurement Contracted Physicians Expected Response Rate 100% Written into contract Part of Performance Measurement Private Physicians Expected Response Rate 100% (per Medical Staff by-laws) Report cards of performance Physician Communication • How – Face to face – Service Line meetings • Permanent agenda item • 10-15 minute update • Metrics over time – Medical Staff meetings • Permanent agenda item Physician Education • Documentation Concerns – Content • Clarity • Consistency • Appropriateness – Documents • History and Physical • Progress Notes • Discharge Summary Physician Report Cards • Include – Number of Discharges – Length of Stay – CMI – Response Rate • Track metrics monthly • Physician Advisor Involvement – One on one with physicians Support • Physician Advisor – Nearly 50% of CDI programs have an active physician advisor • Role includes: – Follow up with physicians regarding queries – Peer to peer education – Clinical resource to CDI team – Write appeal letters Documentation Improvement Opportunities Process • Retrospective Follow through – Unanswered Queries • Prior to coding/billing – CDI Specialist after discharge • After coding/billing – Continued as coding query ACDIS 2010 Physician Query Benchmarking Survey, Discharged Records Concurrent Queries Retrospective Queries Second Looks • If not completed: • CDS has one business day to contact physician • After one day repose as Retrospective Query • Posed by professional coder • Do not complete until MD response received • Medical Staff By Laws to address time frame for response (14 days) • CDS Retrospective review of records: • Missed due to short stay • Deceased patient • Signs/Symptoms DRG • DRG without CC/MCC APR-DRG • All Patient Refined Diagnoses – Capturing all conditions being monitored and/or treated • Severity of Illness – Extent of physiologic dysfunction • Risk of Mortality – Likelihood of dying Example • 86 yo female with history of COPD, CHF and DM is admitted with shortness of breath and pneumonia. Respiratory rate is 34, pulse oxygenation is 78% on RA. Patient is started on IV antibiotic, O2 via venti-mask and transferred to telemetry. ICD-9 Description 486 Pneumonia, organism unspecified 428.0 CHF, unspecified 250.00 DM 196 COPD, unspecified MS-DRG = 195 APR-DRG = 139 SOI = 2 - moderate ROM = 2 - moderate Specificity • With greater specificity of the stated diagnoses ICD-9 Description 486 Pneumonia, organism unspecified 428.32 Diastolic heart failure, chronic 250.02 Diabetes Mellitus without complication, Type II or unspecified, uncontrolled 491.21 Obstructive chronic bronchitis with (acute) exacerbation MS-DRG 194 APR-DRG 139 SOI = 3 - major ROM = 2 - moderate Documentation Improvement • With documentation of Acute Respiratory Failure ICD-9 Description 486 Pneumonia, organism unspecified 428.32 Diastolic heart failure, chronic 250.02 Diabetes Mellitus without complication, Type II or unspecified, uncontrolled 491.21 Obstructive chronic bronchitis with (acute) exacerbation 518.81 Acute Respiratory Failure MS-DRG 193 APR-DRG 139 SOI = 3 – major ROM = 3 - major • After 24 hours of treatment with IV antibiotics, the patient’s creatinine increases and the physician also documents acute renal failure ICD-9 Description 486 Pneumonia, organism unspecified 428.32 Diastolic heart failure, chronic 250.02 Diabetes Mellitus without complication, Type II or unspecified, uncontrolled 491.21 Obstructive chronic bronchitis with (acute) exacerbation 518.81 Acute Respiratory Failure 584.9 Acute kidney failure, unspecified MS-DRG 193 APR-DRG 139 SOI = 4 – extreme ROM = 4 - extreme Capturing the Total Picture • APR-DRG’s attempt to capture: – Type of patient being treated – Costs incurred in the treatment – Expected services – Anticipated outcomes • Goal of CDI Program: – Ensure that all conditions being monitored and treated are documented clearly and consistently. Capturing the Diagnoses • 67 yo male with history severe COPD and pulmonary HTN presents with shortness of breath, noted neck vein distention and mildly elevated BNP. • Patient is treated with oxygen, nebulizer treatments, IV steroids and IV lasix • Physician documents exacerbation of COPD, pulmonary HTN and CHF Cor Pulmonale • Defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system • Pulmonary Hypertension is the common link between lung dysfunction and the heart in cor pulmonale • Although cor pulmonale commonly has a chronic and slowly progressive course, acute onset or worsening cor pulmonale with lifethreatening complications can occur Pathophysiology • Pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia – This can result in pulmonary hypertension and if the hypertension is severe enough, it causes cor pulmonale • Anatomic compromise of the pulmonary vascular bed secondary to parenchymal or alveolar lung disorders • Chronic obstructive pulmonary disorder is the most common cause of cor pulmonale Prevalence • Cor pulmonale is estimated to account for 6-7% of all types of adult heart disease in the United States • Chronic COPD due to chronic bronchitis or emphysema is the causative factor in more than 50% of cases • Accounts for 10-30% of decompensated heart failure–related admissions in the United States Han MK, McLaughlin VV, Criner GJ, Martinez FJ. Pulmonary diseases and the heart. Circulation. Dec 18 2007;116(25):2992-3005 Signs and Symptoms • General – fatigue, tachypnea, exertional dyspnea, and cough • Physical findings – Wheezes, crackles, right ventricular hypertrophy, labored breathing, increase in chest diameter, cyanosis, hemoptysis, distended neck veins Diagnostics Test Results with Acute Cor Pulmonale EKG Right axis deviation Right Heart Catheterization Elevated pulmonary artery pressure Brain Natriuretic Peptide (BNP) Elevated Arterial Blood Gases (ABG) Abnormal oxygenation, acid/base imbalance Chest X-Ray Right descending pulmonary artery > 16mm 2-D Echocardiogram Right ventricular hypertrophy Elevated pulmonary artery pressure Treatment • • • • • • Care of underlying respiratory condition Oxygen Diuretics Vasodilators Bronchodilators Steroids Accurate Documentation • Clinical picture of the patient • Resources being consumed As principal diagnosis Acute Cor Pulmonale groups to DRG 314-316 Other Circulatory System Diagnoses What was monitored and treated? Future Plans CDI Program Impact • RAC – Medical necessity – Denial assistance • ICD-10 impact – Clinical indicators gain importance • All payer review • Value Based Purchasing – Core Measure documentation – Present on Admission • Emergency Department Record Review Documentation Department Clinical Documentation Core Measures Case Management Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.