Download 280175

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.