Download 252229

3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
Ethics ENDS with
the clarification
Robert S. Gold, MD
CEO, DCBA, Inc.
Don’t gamble with your charts
How do you look in an
orange jumpsuit?
We never promised it would be easy
Clinical documentation
improvement definition
• The process by which the medical record
documentation produced by licensed
providers of healthcare accurately reflects
the diseases suffered by their patients in
any encounter
– ALL patients
– ALL payers
– ALL conditions
Clinical documentation
improvement definition (cont.)
•
•
•
•
It does NOT imply “Medicare only”
It does NOT imply DRG payers only
It does NOT imply documenting for dollars
It does NOT imply overcoding for dollars
It’s help in documentation to save lives
• When “pneumonia” is there rather than
“infiltrate” or “LRTI,” Core Measures can
intervene
• When “chronic systolic failure” is there, ACE or
ARB can be started for heart failure Core
Measures
• When “wound infection” rather than “soupy
drainage” is there, SCIP can be effective
• When “NSTEMI” is there rather than “ACS with ↑
troponin,” AMI Core Measures can be instituted
It’s documentation to justify
resource utilization
• When “persistent hypotension post CABG
d/t diabetic autonomic neuropathy” is
there, that extra day on the ICU is justified
• When “embolic R MCA infarct occurring
1.5 hours ago” is there, TPA is justified
• When “von Willebrand’s” is there, factor
VIII administration is covered
What drives it all?
Physician documentation!
Improper Payment by Type of Error
FY 1997
1%
3%
15%
44%
37%
Documentation Errors
Lack of Medical Necessity
Incorrect Coding
Noncovered/Unallowable Services
Other
Who gets measured?
• All acute care
hospitals
• All service lines
at the hospitals
• All surgeons at
the hospital
• All internists at
the hospitals
Mortality = death rate
Morbidity = complications and
patient safety
Concentration on Medicare
THE LAW: “Medicare has no obligation to
pay for items and services if a provider
treats Medicare beneficiaries differently
from non-Medicare patients.”
Don’t code complications for dollars
“Try to get surgeons to document postop
ileus, postop urinary retention, postop
atelectasis—that will change the DRG and
bring the hospital more money.”
Everyone’s looking at us
It’s ALL payers
Subj:
BLUE CROSS
Date:
3/3/2010 5:11:28 PM Eastern Standard Time
From
[email protected]
To:
[email protected]
Received from Internet: click here for more information
Hi,
Remember I told you a few weeks ago about Blue Cross
going to pay us a visit? Well, guess what - they did. We got
a 9% increase in payment and Mr. Betz says that’s about a
million dollars we are looking at. Across the river in Memphis
they got a 16% cut in payment. What does that tell you
about their million dollar program?
Accelerated hypertension
• Just because a blood pressure is high
does NOT mean accelerated or malignant
hypertension
• Hypertensive urgency definition
• Hypertensive emergency definition—with
an organ dysfunction!
Accelerated hypertension
Target organs
• Heart
– Acute diastolic heart failure (acute pulmonary
edema)
– Stress MI
• Kidneys
– Acute renal failure
• Brain
– Stroke
– Hypertensive encephalopathy
Definitions of uncontrolled
• HbA1C over 7.0 (goal 6.0 American Diabetes Association, 6.5
American Association of Clinical Endocrinologists) or …
– Persistent refractory hyperglycemia associated with metabolic
–
–
–
–
–
deterioration
Recurring fasting hyperglycemia greater than 300 mg/dl
refractory to outpatient therapy, or a glucose greater than or
equal to 100% above the upper limit of normal
Recurring episodes of severe hypoglycemia (i.e., less than 50
mg/dl, or 2.8 mmol/l), despite intervention
Metabolic instability manifested by frequent swings between
hypoglycemia (less than 50 mg/dl) and fasting hyperglycemia
(greater than 300 mg/dl)
Recurring diabetic ketoacidosis without precipitating infection or
trauma
Repeated absence from school or work due to severe
psychosocial problems, causing poor metabolic control that the
patient cannot manage on an outpatient basis
Acute on chronic
• Decried by nephrologists
• Chronic kidney disease has its causes
• Acute kidney injury (acute renal failure)
has its causes
• They’re NOT exacerbations of the same
condition—name each
• But …
Acute on ESRD?
• Coding guidelines
set us WRONG
• There is NO acute
renal failure on
ESRD
Acute renal failure
• If the physician documents “acute renal
insufficiency,” that ALONE is NOT reason
to ask for documentation of acute renal
failure
• The history, clinical circumstances, and
lab support must be there before you
bother the doc
Official coding guidelines
• If the diagnosis documented at the time of discharge
is qualified as “probable,” “suspected,” “likely,”
“questionable,” “possible,” or “still to be ruled out,”
code the condition as if it existed or was
established.
• The basis for these guidelines are the diagnostic
workup, arrangements for further workup or
observation, and initial therapeutic approach that
correspond most closely with the established
diagnosis.”
Impossible, improbable, or unlikely
“The patient in 322 is from a
nursing home and is 72
years old and has COPD. Is
this gram negative
pneumonia?”
“I don’t know.”
“Is it possible that it’s gram
negative pneumonia?”
“I don’t know.”
“But is it POSSIBLE?”
“Sure, it’s possible.”
7/26/2005 Barbara
told me to write that
this is possible gram
negative pneumonia
Impossible, improbable, or unlikely
(cont.)
• If the usual treatment for all pneumonia is
Rocephin and Zithromax, and this patient
was treated with Rocephin and Zithromax,
it was NOT:
– Gram negative pneumonia
– Aspiration pneumonia
– Mixed bacterial pneumonia
– “Hypostatic pneumonia”
Possible, probable, or likely
• 57 year old WM with painless jaundice. CT
shows 8 cm mass at head of pancreas with
dilated common and hepatic ducts, paraaortic
lymphadenopathy, multiple foci of metastases in
liver, lungs, and brain. Refused PTBD for
symptomatic relief. No chemo can help.
Palliative care through hospice.
• Imp: Probable cancer of head of pancreas
Acute respiratory failure
• Patients being purposely maintained on
the ventilator after surgery because of
weakness, chronic lung disease, massive
trauma are NOT in acute respiratory
failure
• Just because the patient is on oxygen is
NOT a reason to ask the doc for acute
respiratory failure
Preventive maintenance
on respirator
• Abdominal compartment syndrome is a wellknown complication after abdominal trauma and is
increasingly recognized as a potential risk factor
for renal failure and mortality after adult orthotopic
liver transplantation (OLT).
• The techniques of temporary abdominal closure
(TAC) are varied. All techniques face a similar
challenge: the management of the open abdomen.
• These data consistently show that maintaining the
open abdomen protocol in high-risk groups has
been effective in reducing mortality in a clinical
setting.
Preventive maintenance
on respirator (cont.)
• Postop issues in the morbidly obese patient.
• Patients who have obesity-related comorbidities
carry a dramatically greater risk of perioperative
complications. Therefore, any obese patient
undergoing major surgery, or those with a
history of comorbidities, should be nursed in an
appropriate level 2 or level 3 facility.
Infiltrate reasoning
• 518.3 as principal diagnosis with no CC
leads to DRG 198 (Interstitial lung disease
w/o CC/MCC) with RW = 0.8137
• 486 as principal diagnosis with no CC
leads to DRG 195 (Simple pneumonia w/o
CC/MCC) with RW = 0.7095
Pulmonary infiltrate
• A finding on a chest x-ray 793.1 is NOT a
disease
• Pulmonary eosinophilia 513.8 is NOT the
code for pulmonary infiltrate—it is the code
for allergic (eosinophilic) pneumonia
• If a pulmonary infiltrate is worked up and
no finding identified, you must assign the
symptom code—it’s an abnormal x-ray
finding, not Loeffler’s
Rationale for 514
• 514 as principal diagnosis leads to DRG
189 (Respiratory failure and pulmonary
edema) with RW = 1.3455
• 486 as principal diagnosis leads
to DRG 195 (Simple pneumonia without
CC/MCC) with RW = 0.7095
Lung congestion is NOT 514
• Lung congestion on physical exam is a
physical finding and is NOT to be assigned
a code
• Pulmonary edema on a chest x-ray is an
x-ray finding and is NOT to be assigned a
code
Hypostatic pneumonia
• Code was developed for passive lung congestion in
1800 – it was NOT an infection, but hepatization of
the lungs due to prolonged position in a
malnourished patient
– Hypostatic pneumonia: Pulmonary congestion due to the
stagnation of blood
in the dependent portions of the lungs in
old persons or in those who are ill and lie
in the same position for long periods.
• “Hypostatic pneumonia” is a disease of large farm
animals
• Pneumonia treated with antibiotics is 486
Infection with two criteria for SIRS
is NOT sepsis
Encoders may lead
you down the garden
path—DON’T be
fooled
How good do YOU
look in orange?
• Sepsis has a higher
RW than UTI or
pneumonia
• Surgery for sepsis
has a higher RW
than appendicitis
Jonathan Ball,
St. George’s Hospital
“Sepsis syndrome has been, and remains, a major focus of
intensive care research and the subject of a large number of
international multicentre trials. Despite these facts, there is
limited awareness of the condition among the general public and
health care providers.
One of the explanations for this is felt to be the confusing
definitions and terminology surrounding the condition, in
particular the SIRS diagnostic criteria, which have been the
standard diagnostic tool employed, especially in therapeutic
trials. However, SIRS has multiple deficiencies, not least that two
of the criteria are met performing normal daily activities such as
running for a bus (tachycardia and tachypnoea).”
45
More dissatisfaction
“Vincent began by asking the panel to define sepsis.
Artigas proposed the view that sepsis is a syndrome of
systemic inflammation, which occurs in response to
infection. He felt that the SIRS criteria were too vague,
failed to include vital parameters, failed to consider the site
of infection and failed to usefully assess severity of illness.
In response, Bakker felt that the SIRS criteria are a useful
concept in the early identification of patients who may have
or are developing sepsis, a view supported by Schroeder
and Sherry. However, there appeared to be unanimous
agreement that the SIRS criteria were overly sensitive and
insufficiently specific to be used as diagnostic criteria for
sepsis in clinical practice or therapeutic trials.”
46
Arthur Baue, MD from Yale
• “Systemic inflammatory response syndrome was defined by a
consensus conference of the American College of Chest
Physicians and the Society of Critical Care Medicine as a
clinical syndrome that is thought to be the result of an overly
active inflammatory response. Vincent, Bone, Opal, and
others believe that the concept of SIRS does not help, and I
agree.”
• “I have no problem with the use of SIRS as a nonspecific
description of being sick. I do have a problem with going
beyond that such as using SIRS criteria for randomized trials
of therapy. No one has reported on the appearance of
patients with SIRS. Don't they look sick? Can't clinical
observation also tell you that they are sick?”
47
Baue (cont.)
“Anyone with SIRS is sick. Systemic inflammatory
response syndrome has been highly touted as a way to
define and measure sickness. Has it helped? Is it
worthwhile? Let us go beyond the hype of those who have
a vested interest in SIRS because they invented the
concept. The trained clinician observes his patients beyond
just vital signs. I recommend to my students and residents
that during rounds, they should go into the patient's room or
cubicle in the intensive care unit or elsewhere and observe
and talk to the patient before they check the chart and the
vital signs. This allows them to determine the patient's state
as the patient feels it or experiences it.”
48
Urosepsis is NOT sepsis
• Unless it is
– Dorland’s definition changed about 1992
– Sepsis due to … a named infectious process
is the way to adequately address it
– If the patient has NO signs/ symptoms
consistent with sepsis, leave it alone
What is encephalopathy?
• Internally produced toxins in liver disease
(hepatic encephalopathy), renal disease (uremic
encephalopathy), persistent effects of lack of
blood flow to the brain (hypoxic encephalopathy)
• Internal poisoning by products produced by
sepsis (metabolic encephalopathy), effects of
hypertension (hypertensive encephalopathy)
• Persistent effects of long term alcohol use
(Korsakoff’s, Wernicke’s—a toxic
encephalopathy)
Other encephalopathies
•
•
•
•
•
•
Mitochondrial encephalopathy
Hashimoto’s encephalopathy
Lyme encephalopathy
Transmissible spongiform encephalopathy
Lyme encephalopathy
Hypoxic ischemic encephalopathy (HIE)
newborns only
What ISN’T encephalopathy
• Coma after stroke or head trauma
• Drunkenness
• Effects of illicit drugs or poisoning with
overdosage of prescribed drugs
• Adverse effects or desired effects of
sedative medications
Issue with toxic-metabolic
• All encephalopathies are toxic—the
difference is the source of the toxin
– 349.82 toxic (metabolic) encephalopathy
– 348.31 metabolic (septic) encephalopathy
– 348.39 other encephalopathy (except
alcoholic 291.2, hepatic 572.2, hypertensive
437.2)
Which is metabolic?
Metabolic encephalopathy is always due to an underlying
cause. There are many causes of metabolic
encephalopathy, such as brain tumors, brain metastasis,
cerebral infarction or hemorrhage, cerebral ischemia,
uremia, poisoning, systemic infection, etc. Metabolic
encephalopathy is also a common finding in 12–33% of
patients suffering from multiple organ failure. The
development of metabolic encephalopathy may be the first
manifestation of a critical systemic illness and may be
caused by various reasons—one of the most important
being sepsis.
Coding Clinic, Fourth Quarter, 2003
Compression fracture is not
pathologic fracture
• Unless it is—must be able to determine
from documentation that it is a fracture in
the absence of trauma or trauma
inadequate enough to have fractured a
normal bone or documented “fracture due
to” a specific named process (bone cyst,
osteoporosis, malignancy, etc.)
TIA with carotid occlusion is NOT
carotid occlusion without infarct
• TIAs occur because of transient cessation of
blood flow to specific areas of the brain
– Subclavian steal
– Platelet clot from A Fib
– Vertebro basilar attack
• Carotids without ulceration are not presumed
to be source of TIA
• Totally occluded carotid asymptomatic
March 25, 2008
Amy L. Blum MHSA, RHIA, CTR
Medical Classification Specialist
Classifications and Public Health Data Staff
National Center for Health Statistics
Centers for Disease Control and Prevention
Mail Stop P08
Hyattsville MD 20781
Re: ICD-9-CM coding for acute renal failure
Dear Ms Blum,
On behalf of our members, we write to request that the terminology in the current 584 series
be updated to conform to current usage. Acute kidney injury (AKI) is a term that is now in
wide use in the nephrology and critical care literature, replacing acute renal failure (ARF). It
refers to an abrupt reduction in kidney function as evidenced by a pronounced increase in
serum creatinine and/or reduction in urine output, which can but does not always result in
kidney failure. The term AKI has been adopted by the major nephrology and critical care
societies to better reflect an event that leads to a decline in kidney function.
We recommend the following changes:
1. AKI (non-traumatic) should be indexed to 584.9.
2. 584 should be changed to “acute renal failure or acute kidney failure”.
3. Acute kidney disease should be added as an inclusion term under 584.
We believe these changes will enhance data collection in this area, and set the stage for
classification of AKI, as new epidemiologic and outcomes data are reported.
Thank you for the opportunity to comment on this important issue.
Sincerely,
Peter Aronson, MD
President, ASN
Allan Collins, MD
President, NKF
David Warnock, MD
Alan S. Kliger, MD
OOPS!
Oh, no-o-o-o!
RIFLE criteria ARF
Stages of AKI
Stg
Serum creatinine criteria
Urine output criteria
1
Increase in serum creatinine of more than or
equal to 0.3 mg/dl or increase to more than
or equal to 150% to 200% from baseline
Less than 0.5 ml/kg per
hour for more than 6
hours
2
Increase in serum creatinine to more than
200%–300% from baseline
Less than 0.5 ml/kg per
hour for more than 12
hours
3
Increase in serum creatinine to more than
300% from baseline or serum creatinine of
more than or equal to 4.0 mg/dl with an
acute increase of at least 0.5 mg/dl
Less than 0.3 ml/kg per
hour for 24 hours or
anuria for 12 hours
The future of AKI
584.1x
584.2x
584.3x
Acute Kidney Injury (Acute Renal Failure) Stage I (“R”)
Acute Kidney Injury (Acute Renal Failure) Stage II (“I”)
Acute Kidney Injury (Acute Renal Failure) Stage III (“F”)
584.x0
584.x1
584.x2
Unknown long term decrease in renal function
Complete measurable return of renal function
Partial return of renal function – measurable long term
decrease in renal function
Kidney failure – need for renal replacement therapy
584.x3
NSTEMI
• Guidelines for diagnosis and management
of UA, NSTEMI from ACC/AHA since 2001
• Recent definition of myocardial infarction
from AHA 2007
• We only have one code for NSTEMI
• Core measures compliance depends on
codes
Recommendation
• 410.71 NSTEMI
directly due to
coronary occlusion
• 411.1 UA other acute
and subacute forms
of ischemic heart
disease
• 411.71 NSTEMI
directly due to
demand cause in face
of whatever stage of
CAD first visit
• 411.72 subsequent
visit
• 411.81 other demand
MI
You be careful out there!