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WHY WORDS MATTER
PARTNERING WITH PHYSICIANS FOR BEST-IN-CLASS
CLINICAL DOCUMENTATION
Presentation to Palmetto Health
September 27th, 2012
©2012
ADVISORY
BOARD
COMPANY
• ADVISORY.COM
©2012 THE
THE ADVISORY
BOARD
COMPANY
• ADVISORY.COM
DISCLOSURES
I am a consultant for
The Advisory Board Company–
Joe Corcoran, D.O., F.A.C.O.G
2
©2012
ADVISORY
BOARD
COMPANY
• ADVISORY.COM
©2012 THE
THE ADVISORY
BOARD
COMPANY
• ADVISORY.COM
Road Map for Discussion
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
1
The Importance of Documentation Quality
2
Health Care Transformation – Raising the Stakes on Documentation
3
Appendix:
Deconstructing Provider Documentation Clinical Examples
3
All (Reform) Roads Lead to Closer Physician Collaboration
All (Reform) Roads Lead to Closer Physician Collaboration
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
The Physician Stands Alone
A Tale of Two Providers
Financial
Legal
Facility and
Physician
payment
administered
separately
Physicians in
independent
practice
purchase own
liability insurance
Physicians must
manage their
own finances
Physicians bear
high costs of
premiums, high
risk to reputation
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
Ethical
Hippocratic oath,
the foundation of
medical ethics
Physicians
advocate for
individual
patients, not
overall business
performance
5
Societal
Political
Charity care
obligatory for
hospitals,
“recommended”
for physicians
Facilities and
physicians
represented by
entirely separate
professional
associations
Physicians rarely
reimbursed for
charity patients
Physicians fight
for own rights
and protection
Revisiting the Importance of Clinical Documentation
Clinical documentation has long been recognized as a key opportunity for improving reimbursement capture
and safeguarding operating margins. With increasing public reporting and integration of performance
metrics into provider reimbursement, the quality risks of poor documentation have become further magnified.
Physician and Health System Collaboration is Critical to Success
Risks of Poor Documentation Performance
 Inaccurate provider profiling
 Inflated complication rates
 Poor public reporting results
 Inaccurate risk of mortality reporting
 Acuity of patient condition not reflective of
severity of illness
 Increased risk of unnecessary readmissions
 Reduced reimbursement & pay for
performance
 Increased denial rates
 Greater recovery audit contractor (RAC) risk
Key Outcomes of Improved Documentation
Enhanced Care Coordination through Improved Communication and Patient Transitions
Improved Quality Outcomes and Physician Performance
Improved Ability to Accurately Capture Care Provided and Realize Appropriate Reimbursements
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
6
Source: Laschober M, “Hospital Compare Highlights Potential Challenges in Public
Reporting Hospitals,” Issue Brief, Mathematica Policy Research, Inc., March 2006;
Clinical Advisory Board interviews and analysis.
The Price of Omission
Omissions in Documentation have an Outsized Impact on Reimbursement
Top Five Clinical Documentation Issues
Source: Centers for Medicare and Medicaid, “FY 2012 IPPS Final Rule”, available at:
https://www.cms.gov/AcuteInpatientPPS/FR2012/list.asp, accessed February 7 th, 2012; Financial Leadership
Council interviews and analysis; Clinical Advisory Board interviews and analysis.
Condition
Common Documentation Issues
Congestive
Heart Failure
• Clarification needed (e.g., acute vs. chronic,
systolic vs. diastolic)
Sepsis
• Often unclear whether sepsis, severe sepsis,
SIRS1, bacteremia, UTI, Urosepsis, etc
Renal Failure
• Clarification needed (e.g., acute vs. chronic)
• Lack of specificity (renal insufficiency” vs.
“failure,” specify stage of kidney disease)
Pneumonia
• Failure to document cause (e.g., causative
organism, aspiration)
• Need to specify simple vs. complex
Respiratory
Failure
• Clarification needed (e.g., acute vs. chronic)
• Lack of specificity (respiratory “distress” vs.
“insufficiency” vs. “failure”)
Financial Impact
DRG 684:
(Renal Failure without Major
Complications and Co-morbidities)
$3,609.01
vs.
DRG 682:
(Renal Failure with Major
Complications and Co-morbidities)
$9,240.73
Net Revenue Impact:
$5,631.72
1 Systemic inflammatory response syndrome.
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
7
Accurate Quality Performance Hinges on Complete, Clear Documentation
Unclear Documentation Skews Performance Data
Complication Rates
Reasons for Inflated
Complication Rates
• Lack of clear and
concise documentation
resulting in assignment
of complication codes for
expected outcomes from
surgery
• Improvements in
documentation and
coding resulted in
lowered complication
rates across all areas
Case in Brief: Bayberry Hospital1
• 400-bed hospital located in the Northeast
• Realized organization’s complication rates were
significantly skewed by coders reporting complication
due to unclear documentation
1) Pseudonym.
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
Source: Clinical Advisory Board interviews and analysis.
8
Road Map for Discussion
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
1
The Importance of Documentation Quality
2
Health Care Transformation –
Raising the Stakes on Documentation
3
Appendix:
Deconstructing Provider Documentation – Clinical Examples
9
Key Drivers of Physician Under-Documentation
Minimal Physician Education
Med School & Ongoing training minimal
Stretched Thin – Lack of Time
INCOMPLETE
AMBIGUOUS
CONFLICTING
DOCUMENTATION
DOCUMENTATION
DOCUMENTATION
(Majority of Errors)
(Common)
(Least Common)
Examples
Examples
Examples
Diagnostic tests
suggest need for higher
specificity or a
secondary diagnosis
Confusion due to grammar
and/or handwriting – can
affect ID of primary and
secondary diagnoses
Conflicting info from
different physicians, e.g.
consultant vs. attending
HF is documented but
echocardiogram results
confirm systolic heart
failure. Not a MCC
without specification.
- or - Urine test indicates
low sodium. Physician
writes “low sodium” but
not hyponatremia; CC
cannot be coded.
“Syncope secondary to
ischemic colitis and SBO vs.
intestinal abscess”. Is
ischemic colitis the principal
diagnosis with syncope
secondary – or – is syncope
the primary diagnosis & the
result of ischemic colitis and
SBO?
Patient being treated for
an undocumented
condition
Changing Coding Requirements
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
Foley catheter ordered
w/o reason. Nurses
document that patient
urinates 2 days later.
Evidence supports that
patient had post-operative
urinary retention but
physician must document
condition for coding.
10
Principal diagnosis-the
reason for admission, after
study-not clearly identified
- or- Not clear whether a
condition was ruled out
Patient presents with
syncope; MD orders at CT
Scan and MRI to rule out
Stroke, and an echo to rule
out arrhythmia or heart
failure. Physician must
document when/if CVA,
arrhythmia or HF have been
confirmed or ruled out.
Patient admitted by PCP
because of vertigo &
confusion. PCP documents
TIA as a preliminary
diagnosis & requests a
neurology consult.
Neurologist documents
cerebrovascular accident
as the diagnosis. PCP
does not further document
so info is conflicting; coder
either needs clarification
before coding or must
default to PCP diagnosis.
Conflicting info from
progress note to
progress note (same
physician)
Self explanatory error.
Physician must clarify and
add an addendum to
discharge summary/final
progress note for coding.
Source: March 2009 NPD pull up
Looking Ahead: ICD-10 Quick Facts
On August 24th, 2012 CMS
releases a final rule that would
delay ICD-10 compliance until
October 1st, 2014.
CMS cites several reasons:
• Ongoing transition to Version
5010—a necessary precursor
to ICD-10 adoption
• Hospitals, health systems,
and physicians' current efforts
to comply with Meaningful
Use Stage 2 requirements
• The industry's lack of
preparation, as 26% of
providers and 28% of payers
do not expect to be compliant
with ICD-10 by October 1,
2014, according to a recent
CMS readiness survey
Regardless of the transition
timeline and proposed date, a
critical element of ICD-10
preparation is helping
physicians to capture key
clinical concepts and specificity
that will be required in the far
more complex environment.
This will lead to success in
both an ICD-9 and ICD-10
environment.
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
Facts:
ICD-10 Facts
•
•
•
•
ICD-10 CM (clinical modification) diagnosis codes have been
adopted for institutional, outpatient and professional services
ICD-10 PCS (procedure coding system) procedure codes are
used for inpatient
Claims will not be accepted in ICD-9 format after the compliance
date
Compliance date applies to the date of service for outpatient and
professional claims, and date of discharge for institutional claims
New Code Set Breakdown:
The ICD-10 Code Set
~69,000
ICD-10-CM Codes
~72,000
ICD-10-PCS Codes
11
11
50%
Percentage of all ICD-10 codes
are related to the
musculoskeletal system
36%
Percentage of all ICD-10-CM
codes are related to laterality
(distinguishing “right” vs. “left”)
25%
Percentage of all ICD-10 codes
are related to fractures
All (Reform) Roads Lead to Closer Physician Collaboration
Impact Spans the Hospital and Physician Practice
Addressing Documentation and Query Impacts
Potential physician
workflow disruption derive
from new documentation
requirements and
increased query volumes
that may exist to facilitate
code assignment.
Hospital:
Coding Challenges
Documentation
• Additional clinical details must be noted
Queries
• Additional requests from coders attempting to enter
procedures and diagnoses into information systems
• Additional requests from documentation improvement staff
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
Quality Measures Impacted by ICD-10
Acute Myocardial Infarction Example
• Codes related to the cardiovascular system account for the number one primary code set for
inpatient admissions based on charged amount
• Acute myocardial infarction is a significant event related to patient care morbidity and mortality
• Key measures of quality depend on the definition of an acute myocardial infarction at the timing of
the encounter
Definition of Acute Myocardial
Infarction (MI) has Changed
• ICD-9: Eight weeks from initial
onset
• ICD-10: Four weeks from initial
onset
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
Subsequent vs.
Initial Episode of Care
• ICD-9: Fifth character defines
initial vs. subsequent episode of
care
• ICD-10: No ability to distinguish
initial vs. subsequent episode of
care
Subsequent (MI)
• ICD-9: No ability to relate a
subsequent MI to an initial MI
• ICD-10: Separate category to
define a subsequent MI
occurring within 4 weeks of an
initial MI
13
13
Source: Health Data Consulting
Re-capping the Advantages of Better Clinical Documentation
Better Information
Better Indication of
Better Business
Severity & Risk
• Greater detail or
reported condition
• Greater granularity
allows for categorization
of conditions and
procedures
• Greater severity and risk
definition
• Code design allows for
greater flexibility for
modification in the future
• Greater ability to
integrate clinical
information
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
• Improved measurement of
quality, efficiency and
outcome measures
• Greater detail
incorporates attributes
related to severity, risks,
co-morbidities and
classifications that help
distinguish major
differences in conditions
• Enhanced network
management with the
ability to look at network
adequacy for regional
patterns of diseases
14
• COMPLIANCE
• More appropriate
contracting
• More appropriate
payment
• Better fraud, waste and
abuse detection
• An opportunity to
differentiate from less
prepared competitors
Engagement Team
Robert M. Linnander
Partner
[email protected]
202-266-6189
Joe Corcoran, DO, FACOG
Senior Director
[email protected]
202-266-6482
Ben Beadle-Ryby
Project Consultant
[email protected]
202-266-5323
Please do not hesitate to contact your team with any questions or comments.
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
15
Road Map for Discussion
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
1
The Importance of Documentation Quality
2
Health Care Transformation – Raising the Stakes on
Documentation
3
Appendix:
Deconstructing Provider Documentation –
Clinical Examples
16
Clinical Example #1
A patient is admitted through the
emergency department (ED) after
presenting with undiagnosed
abdominal pain. While not optimal,
this single symptom has a
corresponding ICD-9 code (789.00),
which would result in DRG 392, with a
reimbursement at a representative
hospital of $5,008. Further testing,
however, reveals that the abdominal
pain is the result of acute cholecystitis
(ICD-9 575.10); this would result in
DRG 446 (disorders of the biliary tract
without complication), which is
reimbursed $5,175. The CDI specialist
notes an increased creatinine and a
decreased glomerular filtration rate
and queries the physician regarding
the patient’s renal status. If the doctor
provides proper documentation, it
could be possible to assign a
complication for Stage IV chronic
kidney disease (ICD-9 585.4), which
would result in DRG 445 (disorders of
the biliary tract with CC), reimbursed
a total of $7,464. The patient
undergoes a laparoscopic
cholecystectomy (ICD-9 51.23),
changing the DRG to 418
(laparoscopic cholecystectomy with
CC), with a resulting reimbursement
of $11,868. Next, the patient develops
shortness of breath, and the
consulting cardiologist documents
acute-on-chronic systolic heart failure
(ICD-9 428.23), changing the DRG to
417 (laparoscopic cholecystectomy
with MCC) with a resulting
reimbursement of $17,478.
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
Patient is Admitted with Abdominal Pain Through the ED
Summary of Hospital Stay and Financial Impact
Hospital Course
Developing Signs and Symptoms
ICD-9
Code
DRG
History of Present
Illness
A patient is admitted through the
ED after presenting with
undiagnosed abdominal pain
789.0
392
$5,008
Imaging
Further testing reveals that the
abdominal pain is the result of
acute cholecystitis
575.10
446 (disorders
of the biliary
tract without
complication)
$5,175
Laboratory
• The CDIS notes an increased
creatinine and a decreased
GFR and queries the physician
regarding the patient’s renal
status
• If the physician provides proper
documentation, it could be
possible to assign a
complication for Stage IV
chronic renal disease
585.4
445 (disorders
of the biliary
tract with CC)
$7,464
Surgery
Patient undergoes a laparoscopic
cholecystectomy
51.23
418
(laparoscopic
cholecystectom
y with CC)
$11,868
Complications
• Patient develops shortness of
breath
• Cardiologist documents acute
on chronic congestive heart
failure
• Systolic17dysfunction present
428.23
417
(laparoscopic
cholecystectom
y with MCC)
$17,478
Net Revenue Impact
Potential
Reimbursement
$12,470
Clinical Example #2
Providers in health systems
across the country have
struggled to provide complete
and timely sepsis
documentation. As providers
complete their clinical decision
making process, documentation
specialists and EMR templates
should prompt providers to
provide the most specific
clinical information in the
patient record.
Assessing the Completeness of Sepsis Documentation
Clinical Decision Making
Documentation Requirement
Is there a non-infectious process (e.g.
burns, serious injury/trauma) being treated
this stay?
State the non-infectious process
Is there a local infectious process (e.g.,
UTI, pneumonia, decubitus ulcer) being
treated this stay?
State the infectious process
What is the cause of the local infectious
process (e.g. causative organism klebsielia, e.coli)?
State the causative organism
Does the patient have SIRS/septicemia/
sepsis/severe sepsis?
State the sepsis level
Is there an underlying condition that is the
cause of the sepsis?
State the underlying condition (e.g,
organism, local infectious/non-infectious
process)
Is there organ failure?
List each organ that is in failure
What is the cause of the organ failure (e.g.,
State the cause of the organ failure, by
sepsis, noninfectious process, infectious
organ
process)?
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
18
Clinical Example #3
On October 1, 2014, the United
States will join most developed
nations by adopting the
International Classification of
Diseases – 10th Edition (ICD10). ICD-10 CM codes are
used by all providers to
document the diagnoses of a
patient. ICD-10 PCS codes are
used by hospitals to document
inpatient procedures. In
summary, the industry is
moving from approximately
18,000 codes to 150,000
codes.
Preparing for October 1, 2014… The Transition from ICD-9 to ICD-10
ICD-9
• Code structure is 3-5 numeric
characters
• Code data (despite known limitations) is
the basis for patient care improvement,
quality reviews, medical research and
reimbursement
ICD-10
Each character in an ICD-10
code represents a unique
clinical concept associated with
the patient. Therefore,
documentation in the record
must be complete to support
accurate code assignment. If
documentation is incomplete,
physicians may be queried to
provide additional information in
the patient record.
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
• Code structure is 3-7 alphanumeric
characters
• Specific diagnosis and treatment
information better supports quality and
patient safety measurement, the
evaluation of medical processes and
outcomes, and reimbursement for
services rendered
• Precise codes to differentiate body
parts, surgical approaches, and devices
used
19
ICD-9-CM
Pressure Ulcer Codes
• 9 location codes (707.00 – 707.09)
• Show broad location, but not depth
(stage)
ICD-10-CM
Pressure Ulcer Codes
• 125 codes
• Show more specific location as well
as depth, including
 L89.131 – Pressure ulcer of
right lower back, stage I
 L89.132 – Pressure ulcer of
right lower back, stage II
 L89.133 – Pressure ulcer of
right lower back, stage III
 L89.134 – Pressure ulcer of
right lower back, stage IV
 and many more…..
Clinical Example #4
No Longer Able to Use the “Old Favorite” Diagnosis Codes
in the Clinic or Physician Practice Setting
ICD-9
ICD-10
250.02
Diabetes mellitus
without mention
of complication,
type II or
unspecified type,
uncontrolled
E11.65
Type 2 diabetes
mellitus with
hyperglycemia
250.43
Diabetes with
renal
manifestations,
type I [juvenile
type],
uncontrolled
E10.21
Type I diabetes
mellitus with
diabetic
nephropathy
AND
E10.65
Type I diabetes
mellitus with
hyperglycemia
”
The “old favorite” diagnosis
codes used by physicians in
their clinics/practices will cease
to exist after October 1, 2014.
Health systems must partner
together to ensure the EMR is
able to guide physicians
through the documentation and
coding process. Further, paper
cheat sheets and “super bills”
will need to be revised to
account for the coding change.
Well… Not Exactly…
“Not much will change. I use
250.0_ for diabetes in my office
now. In the future, I will still use
250.0_ I will just need to add more
information in the record to
support it”
VPMA
300+ bed facility
Required ICD-10 Concepts: Controlled vs. Uncontrolled, Type, Clinical Details of
Disease Manifestation, Pregnancy, etc.
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
20
Clinical Example #5: Key Clinical Documentation Issues for Cardiologists
Analysis conducted using the Advisory Board’s ICD-10 Compass technology identified the following 9 documentation issues as most
relevant to cardiologists. Relevancy was determined by assessing diagnosis volume, identifying conditions that will require new or
more specific documentation in an ICD-10 coding environment, and identifying issues where the absence of unique ICD-10
documentation was clinically relevant.
ICD-9 Code: Condition:
Documentation Issue:
410.00-410.99
Myocardial Infarction
Identify whether ST elevation was involved and specific coronary artery
associated with infarct.
425.4
Cardiomyopathy
Sub-type. Identify whether dilated versus restrictive
423.9
Pericardial Disease
Clarify effusion status.
427.1
Ventricular Tachycardia
Re-entry variant status. Identify whether ‘re-entry’ type was documented
424.1
Aortic Valve Disorder
Clarify type. I.e., Stenosis, insufficiency, regurgitation
424.0
Mitral Valve Disorder
Clarify type. Stenosis, insufficiency, regurgitation
427.5
Cardiac Arrest
Etiology. Depending upon whether or not the underlying reason for the cardiac
arrest is known and if known, whether it is due to cardiac disease may
significantly influence patient care and can also influence severity of illness
considerations.
997.1
Cardiac Complications
Type and Episode of Care. Several cardiac complications previously reported
using a ‘catch-all’ complication code are now captured using specific ICD-10
codes (e.g., cardiac arrest, functional disturbance. Relevant cases will be
reviewed to determine the nature of the complication and the episode of care
involved (e.g. intraoperative vs. postoperative).
427.81
Bradycardia
Sick sinus Syndrome status. Identify whether ‘sick sinus syndrome’ was
documented
428.0
Congestive Heart Failure
Identify the severity of the CHF. Document the acuity (acute, chronic,
Source: Advisory Board Analysis; ICD-10 Compass analysis.
exacerbation) and dysfunction (systolic, diastolic, combined)
of the CHF
©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM
21
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