Download HOSPITAL/INSTITUTE/CENTER - New York University Hospital

Clinical Documentation Excellence Program
February, 2015
Clinical Documentation Team
BRIDGING THE GAP
Between:
The clinical language providers use to describe
the patient’s condition
And
The technical terminology of the ICD-9 system
February 2015
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Provider Scrutiny and Physician Profiling
• Complete documentation, reflective of the true severity of your patients,
helps justify outcomes
• CMS has rules regarding what wording is acceptable for a condition to
be coded
• Documentation that doesn’t meet the set rules / standards leads to:
- Lower severity of illness and risk of mortality assignments
- Increased denials
- Lower case mix index
• Physician Profiling
- Profiles are used for both commercial and public data sources
- Future reimbursement methods will likely incorporate profiles in the formula (e.g..
pay for performance)
- Hospital Report Cards
- Health grades and Leapfrog
- Medicare Physician Data (since 2007)
- Federal and state regulatory agencies (e.g.. OIG)
- Quality Improvement Organizations
February 2015
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Why do we Query?
• Clinical Indicators for diagnosis but no documentation of a condition
• Clinical evidence for higher degree of specificity or severity
• A cause and effect relationship between two conditions or organisms
• An underlying cause when admitted with symptoms
• Only the documentation of treatment is documented, (without
documentation of a diagnosis)
• Possible present upon admission (POA) indicator status
• Suspected diagnosis not clearly ruled in or ruled out “close the loop
In court, an attorney can’t “lead” a witness into a statement. In
hospitals, coders and clinical documentation specialists can’t lead
healthcare providers with queries
February 2015
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Documentation must be written licensed provider
(MD, DO, NP,PA)
• Diagnostic documentation must be written by treating provider (We
cannot code diagnosis from nurses, nutritionists, therapists, etc.)
 It is acceptable to co-sign the nutritionist evaluation
 Nursing documentation of pressure ulcer stage can be coded, but
physicians MUST include the site of ulcer and if present on admission
(POA) in their progress notes
 Any abnormal test or lab value must be interpreted and documented in the
medical record
 Pathology results require an associated diagnosis
 Primary team should confirm diagnoses established by a consultant
February 2015
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Document clear reason for admission
•Principal diagnosis:
The condition established after study to be chiefly
responsible for occasioning the admission
•Secondary diagnosis / Comorbid conditions:
Additional conditions that affect patient care in terms of
requiring one of the following:
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures
- Extended length of hospital stay
- Increased nursing care and/or monitoring
February 2015
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Diagnostic Documentation – Can be coded
•All conditions even when clinically obvious must be clearly
documented
•Documentation must be written in Diagnostic Terms for
compliance, coding and profiling purposes
•In the absence of a definitive diagnosis document as:
- Possible
- Probable
- Suspected
- Likely
•If you don’t know what is causing the patient’s symptom or
condition, this is important to document as well
February 2015
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Specify Causality
Please specify (if known)
•secondary to
•due to
•most likely due to
•probably due to
•sepsis due to UTI or any other condition
•hyperglycemia / uncontrolled DM is due to steroids or other
medications
•cause of pancytopenia most likely due to medications /chemo or
other cause
•cause of AKI most likely due to tubular necrosis or other cause
•chest pain secondary to CAD or Acute MI, or other cause
•link diabetes to ulcers, osteomyelitis, neuropathy, PVD,
gastroparesis
February 2015
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Acute vs. Chronic Conditions
Diagnoses should be documented as:
• Acute
• Acute on chronic
• Chronic
Example:
Acute renal failure
Acute on chronic renal failure
Chronic renal failure with stage
Acute or chronic osteomyelitis
Acute or chronic delirium
Acute or chronic DVT-include site
February 2015
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MCCs & CCs
MCC – Major comorbidity and/or complication
CC – Comorbidity and/or complication
The addition of a single CC or MCC can:
Impact the severity of illness and risk of mortality scores
•Scores based on four levels
1 Minor
2 Moderate
3 Major
4 Extreme
February 2015
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Major Complications & Comorbidities
• Acute and chronic respiratory failure
• Acute respiratory failure / ARDS
• Pneumonia
• Pulmonary embolism
• Acute renal failure specified etiology:
ATN / acute glomerulonephritis
• End stage renal disease
• Hepatorenal syndrome
• Acute systolic & diastolic heart failure
• Acute pulmonary edema
• Cardiac arrest / asystole
• Acute myocardial infarction / necrosis
• Shock: cardiogenic or septic
• Sepsis / Severe sepsis
• Stage 3 and 4 pressure ulcers
• Mediastinitis
• Acute/subacute endocarditis
• Peritonitis
• Ventricular fibrillation
• Acute cor pulmonale
• Toxic and metabolic encephalopathy
• Severe Protein-calorie malnutrition
• Pancytopenia due to chemo
• Acute CVA embolic, hemorrhagic,
ischemic
• Quadriplegia
• Cerebral infarction
• Thoracic aneurysm ruptured
• Diabetic ketoacidosis
February 2015
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Complications & Comorbidities
• Pleural effusion
• Pneumothorax
• Atelectasis
• Acute blood loss anemia/ drop
in Hgb/Hct
• Hyponatremia/Hypernatremia/Siadh
• Acute respiratory insufficiency
• Acidosis/alkalosis
• COPD exacerbation
• Mild →Moderate Degree Malnutrition
(BMI<19)
• Morbid Obesity (BMI>40)
• Pericarditis
• Delirium – etiology e.g.; drug induced
• DVT
• Acute renal failure unspecified / Acute
Kidney Injury
• UTI
• SIRS
• Cellulitis
• Endocarditis unspecified
• Pancytopenia unspecified
• Hydrocephalus
• Atrial flutter
• Chronic systolic/diastolic heart failure
• PSVT
• Complete AV Block / Mobitz type 2
• Primary pulmonary hypertension
• Post op ileus
• Active malignancy
February 2015
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What you say now…
What we might ask for…
Heart failure
Type and status
Urosepsis / Dirty urine
Sepsis due to UTI or UTI
Recent MI
MI within the past 4 weeks
Elevated troponins 2/2 Demand
Demand Ischemia
RLL infiltrate
Pneumonia due to (specified organism)
Renal insufficiency
Is it Acute kidney injury
Severe hypotension
Shock (with type)
Syncope
Underlying cause
Fever, leukocytosis, tachypnea,
Altered mental status
Sepsis
Anemia
Type and etiology
Transfuse for drop in h/h
Blood loss anemia (acute/acute on
chronic/chronic)
February 2015
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What you say now…
What we might ask for…
Altered mental status
Underlying cause:
dementia/delirium/encephalopathy?
Cachexia
Malnutrition (mild, moderate,
or severe)
Na decreased replete
Hyponatremia or Hypernatremia
Severe respiratory insufficiency
Acute respiratory failure
Respiratory distress
Acute respiratory failure
End stage COPD on home O2
Chronic respiratory failure
Diabetes
Type I or II, controlled or uncontrolled
I&D
Drainage? Debridement? Excisional?
Incision reddened, warm, inflamed
Cellulitis
February 2015
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87 year old male admitted with weakness, fatigue and altered mental
status and agitation, no history of dementia. Work up revealed
community acquired pneumonia
Without additional documentation
related to altered mental status
With documentation of metabolic
encephalopathy
MS DRG 195 Simple Pneumonia & MS DRG 193 Simple Pneumonia &
pleurisy without CC/MCC
pleurisy with MCC
DRG Weight: 0.7078
Severity of illness: 1
Risk of Mortality: 1
Estimated Length of Stay: 2.9
Estimated Reimbursement:
$ 6,525.00
DRG Weight: 1.4893
Severity of illness: 2
Risk of Mortality: 2
Estimated Length of Stay: 5.0
Estimated Reimbursement:
$ 13,730.00
February 2015
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60 year old with history of HTN, HLD, CAD, admitted with increased SOB:
CXR showed RLL infiltrate & moderate pulmonary edema; started on
antibiotics for pneumonia, sputum culture showed staph
With documentation of pneumonia
Queried for pneumonia organism
(Staph) linked to the diagnosis
MS DRG 195 Simple pneumonia &
pleurisy without MCC
MS DRG 179 Respiratory infections &
inflammations without MCC
Weight: 0.6997
Severity of illness:1
Risk of Mortality: 1
Estimated length of stay: 2.9
Estimated reimbursement:
$6,382.00
Weight: 0.9741
Severity of illness:1
Risk of Mortality: 1
Estimated length of stay: 3.7
Estimated reimbursement:
$8,886.00
February 2015
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45 year-old female admitted for increased fatigue, weakness
and abnormal labs
Documentation of AML and
pancytopenia
Documentation of AML and
pancytopenia due to
chemotherapy
MS DRG 835 Acute Leukemia
without Major O.R. Procedure with
CC
MS DRG 834 Acute Leukemia
without Major O.R. Procedure with
MCC
Weight: 2.2133
Severity of illness: 2
Risk of mortality: 2
Estimated length of stay: 5.1
Estimated reimbursement:
$20,404.00
Weight: 5.1622
Severity of illness: 2
Risk of mortality: 2
Estimated length of stay: 9.9
Estimated reimbursement:
$47,590.00
December 2013
82 year old male admitted for a-fib and SOB, history of HTN
and heart failure
Documentation of atrial fibrillation
and congestive heart failure (not
further specified)
Documentation of atrial fibrillation
and heart failures specified as
acute on chronic diastolic heart
failure
MS DRG 309 Cardiac Arrhythmia MS DRG 308 Cardiac Arrhythmia
and Conduction Disorders with CC and Conduction Disorders with
MCC
DRG Weight: 0.8098
Severity of illness: 2
Risk of Mortality: 2
Estimated Length of Stay: 2.8
Estimated Reimbursement:
$7,465.00
DRG Weight: 1.2285
Severity of illness: 2
Risk of Mortality: 2
Estimated Length of Stay: 3.9
Estimated Reimbursement:
$11,414.00
February 2015
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89 year old male admitted s/p fall and femoral neck fracture, Alzheimer's
dementia, BMI of 15.5, recent decreased PO intake, given Ensure
Without diagnosis documented
related to nutrition
With diagnosis of severe protein
calorie malnutrition documented
MS DRG 470 Major joint
replacement or reattachment of
lower extremity without MCC
MS DRG 469 Major joint
replacement or reattachment of
lower extremity with MCC
DRG Weight: 2.0953
Estimated LOS: 3.8
Severity of illness: 2
Risk of Mortality: 2
Estimated reimbursement:
$19,316.00
DRG Weight: 3.4196
Estimated LOS: 7.9
Severity of illness: 2
Risk of Mortality: 2
Estimated reimbursement:
$31,525.00
February 2015
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65 year old female history of HTN, CKD presenting with SOB, chest pain,
elevated troponins, on NTG and Heparin drips, cardiac catherization performed.
Baseline creatinine: 1.5 increased to 3.5 GFR 20’s. Documentation of AKI 2/2
contrast
Documentation of NSTEMI and
AKI
Queried: AKI due to contrast and
ATN documented
MS DRG Acute MI discharged
alive with CC
MS DRG Acute MI discharged
alive with MCC
Weight: 1.0568
Severity of illness:2
Risk of Mortality: 2
Estimated length of stay: 3.1
Estimated reimbursement:
$8020.24
Weight: 1.7431
Severity of illness: 3
Risk of Mortality: 3
Estimated length of stay: 4.7
Estimated reimbursement:
$13,228.67
February 2015
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39 year old male with history of hepatitis A, presented with right hip pain,
arthralgias, myalgias, and altered mental status, fever, leukocytosis,
diagnosed with sepsis.
Documentation of sepsis present on
admission due to muscle abscess
Queried for cause of mental status
changes, documentation of metabolic
encephalopathy added to progress
note
MS DRG 872 Septicemia or severe
sepsis without mechanical vent
without MCC
MS DRG 871 Septicemia or severe
sepsis without mechanical vent with
MCC
Weight: 1.0687
Severity of illness:1
Risk of Mortality: 1
Estimated length of stay: 4.1
Estimated reimbursement:
$9,749.00
Weight: 1.8527
Severity of illness: 2
Risk of Mortality: 2
Estimated length of stay: 5.1
Estimated reimbursement:
$16,901.00
February 2015
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Hospital acquired conditions HACs
and Present on Admission (POA)
•All diagnoses that are present on admission (chronic and
acute) must be clearly documented in the patient record
•The hospital is no longer reimbursed for preventable
hospital-acquired conditions (HACs) that were not POA:
- Pressure ulcers Stage III and IV
- Injuries from falls and trauma
- Surgical site infection (after orthopedic or bariatric surgery)
- Object left in surgery
- Air embolism
- Blood incompatibility
- Catheter associated infections
- Manifestation of poor glycemic control
- Mediastinitis after CABG
- DVT or PE after orthopedic procedures
February 2015
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55 year old male, past medical history of migraines and GERD, presents with
complaints of a dull headache, followed by weakness in right arm and leg.
Admitted for stroke versus demyelinating disease work-up. Found to have R
vertebral artery occlusion and R cervicomedullary stroke. Documentation
included RUE/RLE 3/5 strength. LUE/LLE 5/5, sensory intact and Decreased
movement of RUE/RLE 3/5 strength. Queried for specific documentation of right
sided weakness.
Without specific documentation related to
right sided weakness
With documentation of right hemiparesis
DRG 066 Intracranial hemorrhage or
cerebral infarct without CC/MCC
DRG 065 Intracranial hemorrhage or
cerebral infarct with CC
Weight: 0.8135
Estimated LOS: 2.6
Severity of illness: 1
Risk of Mortality: 1
Estimated reimbursement:
$ 7,499.00
Weight: 1.1345
Estimated LOS: 3.7
Severity of illness: 2
Risk of Mortality: 2
Estimated reimbursement:
$ 10,459.00
Stroke Team October 2013
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HACs and PSIs - queries
Problem
Review
Action
• Case triggered validation check for PSI #7- Central Venous CatheterRelated Blood Stream Infection. Coding was confirmed by the Coding
Manager.
• Patient spiked fever, PICC line related sepsis was one of several differential
diagnoses. Although sepsis was documented more than once in progress
notes, the CQE reviewer determined the case did not meet clinical criteria for
sepsis.
• Case referred to CDI for follow-up.
• CDS queried the attending physician, who added an addendum to the
discharge summary stating that line sepsis had been suspected, but ruled
out.
• The code for 999.31, Infection due to central venous catheter, was deleted
Resolution
from the coding summary. This case no longer flags as PSI.
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Acute Respiratory Failure
•Any patient with the onset of new:
- hypercapnea (PCO2>45)
- hypoxemia resulting in oxygen saturation less than
90% requiring high flow oxygen (>4L NC or 35% FiO2)
to keep oxygen saturation above 90%)
•Any patient with significant worsening of chronic
hypercapnea (increase of 10 or more in pCO2)
February 2015
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Bacteremia and SIRS
• Bacteremia: the presence of bacteria in the blood but does not
infer the bacteria is pathological or has resulted in systemic illness
needing treatment
• SIRS (Systemic Inflammatory Response Syndrome): Inflammatory
state affecting the whole body with any two of the following findings:
- Temp <96.8 or >100.4
- HR >90 BPM
- RR >20 / min or PaO2 < 32mmHg
- WBC <4000 or >12000 or >10% bands
Can be infectious or non infectious
Noninfectious causes of SIRS:
- Trauma
- Burns
- Pancreatitis
- Ischemia
- Hemorrhage
February 2015
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SEPSIS
• Sepsis: SIRS with an identified or suspected source of infection
• Severe Sepsis: Sepsis associated with organ dysfunction,
hypoperfusion or hypotension. Manifestation may include:
- Lactic acidosis
- Oliguria
- Acute alteration in mental status.
• Septic Shock:
- Acute circulatory failure unexplained by other causes: SBP<90 or
MAP<60.
- Reduction in SBP 40mmHg from baseline despite adequate
volume
resuscitation.
- Patients who require inotropic or vasopressor support despite
adequate fluid replacement
If you document “meets sepsis criteria” remember to confirm the
diagnosis if ruled in, if not close the loop
February 2015
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Heart Failure
All heart failure diagnoses if known must be specified as:
•Acute Systolic and /or Diastolic heart failure
•Chronic Systolic and/or Diastolic heart failure
•Acute on Chronic Systolic and/or Diastolic heart failure
Commonly documented indicators for acute episode:
• Elevated BNP/Troponin
• CXR : pleural effusion, pulmonary congestion/edema
• SOB/DOE
• Presence of edema
• Administration of diuretics
• Echo: systolic, diastolic dysfunction, and low EF
February 2015
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Chronic Kidney Disease
Stage I: normal GFR (reported as eGFR > 60 cc/min) with either
structural renal disease
(e.g. polycystic kidney disease, one kidney)
or proteinuria
III
Moderate decrease in GFR 30-59
IV Severe decrease in GFR 15-29
V
Kidney failure <15 (or dialysis)
February 2015
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Acute Kidney Injury/
Acute Renal Failure
Criteria for diagnosis:
• If Baseline creatinine < 2.0 mg/dl → rise in creatinine of 0.3 mg/dl or
more
• If Baseline creatinine 2.0 mg/dl-4.9 mg/dl → rise in creatinine 1.0 mg/dl
or more
• If Baseline creatinine > 4.9 mg/dl → rise in creatinine of 1.5 mg/dl or
more
• Urine output of < 600 cc/24h
• Any form of renal replacement therapy (Hemodialysis or continuous
renal replacement therapy)
February 2015
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Malnutrition
Document physical findings and link to specific diagnosis
New criteria was developed by NYU Nutrition Department (handout)
Consider:
• Decreased intake
• % weight loss
• Time frame over which weight was lost
• Muscle mass
• Grip strength
• Temporal wasting
Note: serum proteins (albumin and pre-albumin) are not included in the
diagnostic criteria for malnutrition as recent evidence shows that these
acute phase proteins do not change in response to nutrient intake
February 2015
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Functional Quadriplegia
• Complete inability to move due to a severe disability or frailty caused by
another medical condition without physician injury or damage to the
brain or spinal cord
Patients usually do not have the mental ability to move themselves and
require “total care”
Common causes/ Advanced neurological degeneration from:
•Dementia / Alzheimer’s disease
•Hypoxic injury
•ALS
•Huntington’s disease
•MS
February 2015
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Documentation requirements for DVT
• Acute or Chronic
• Specify vein: if unspecified vein of leg, specify distal or proximal leg
• Specify laterality: e.g. Right, Left, bilateral
• Specify if patient is on anticoagulants for chronic DVT or prevention
• If no longer present, and patient is on anticoagulation to prevent
recurrence- document “no longer
present” rather than “ history of”
• Specify if present upon admission ( POA) or not
February 2015
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.DX PHRASES
•.dxAcuteKidneyFailure
•.dxHeartFailure
•.dxAcuteRespiratoryFailure •.dxHypertension
•.dxArrhythmia
•.dxMyocardialInfarction
•.dxbmiwt
•.dxPelvicInflammatoryDisease
•.dxBurn
•.dxPhlebitis
•.dxChronicKidneyDisease •.dxRheumatoidArthiritis
•.dxCOPD
•.dxStroke
•.dxDementia
•.dxTransportInjury
•.dxDiabetes
•.dxVaricoseVeins
•.dxEntericUlcer
•.dxVaricoseVeins
•.dxHeadache
•.dxWithdrawal
•.dxHeartDisease
February 2015
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.dxheartfailure
February 2015
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.dxstroke
Hospitalist April 2014
THANK YOU!
Questions?
This presentation was created by the NYU Langone Medical Center
HIM Department.
It should not be copied or distributed without permission.
February 2015
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