AbstractionValidation Updates Changes effective with 712006 discharges

1
Abstraction/Validation Updates Changes effective
with 7/1/2006 discharges

• Acute Myocardial Infarction (AMI)
• Congestive Heart Failure (HF)

2
Specifications Manual for National Hospital
Quality Measures

• Abstractor Resources
• Resources that support joint alignment
  information between CMS and JCAHO for the core
  measures
• Primary source for abstractors to help in data
  abstraction and quality improvement efforts
• Keep up to date with changing guidelines or rules
  in data elements
• Helps to achieve good validation scores

3
Specifications Manual for National Hospital
Quality Measures

• Use the correct version of the Specifications
  Manual for National Hospital Quality Measures for
  the following
• Correct time frame for date of patients
  discharge
• Data Dictionary
• General Abstraction Guidelines
• Tables and Appendices
• Measure Information Form/Flowcharts

4
Specifications Manual for National Hospital
Quality Measures

• Specifications Manuals for National Quality
  Measures now available are as follows
•  Version 2.0 discharges beginning 7/1/06
• Version 2.0a addendum for discharges beginning
  7/1/06
• Version 2.0b addendum for discharges beginning
  7/1/06
• Version 2.1 discharges beginning 10/1/06
•  
• Release notes for each version are available on
  QualityNet.

5
(No Transcript)
6
Abstraction Resources

• Specifications Manual for National Hospital
  Quality Measures. http//xrl.us/stcp
• QNetQuest, http//xrl.us/s4yv
• GMCF Hospital Team

7
Specifications Manual for National Hospital
Quality Measures
Case Selection

• Initial selection of medical records must meet
  the following criteria
• Acute inpatient hospitalization ONLY
• All payor sources
• For topic specific populations, refer to Section
  2 (Measurement Information) and Section 4
  (Sampling Methods) of the Specifications Manual

8
Acute Myocardial Infarction

• Changes effective with 07/01/2006 discharges

9
Data DictionaryVersion 2.0 - 7/1/06

• Arrival Time
• Medical record documentation from all of the
  only acceptable sources should be carefully
  examined to determine the most correct time of
  arrival.
• If documentation suggests that the earliest
  date/time in acceptable sources does not reflect
  the time the patient arrived at the hospital,
  this time should not be used

10
Data DictionaryVersion 2.0 - 7/1/06

• Arrival Time cont
• For ED Arrivals to the hospital, use any ED
  documentation
• Includes ED vital sign record, ED/Outpatient
  Registration forms/Face Sheet, Triage record,
  Nursing/Physician documentation and ancillary
  services documentation if these services were
  rendered while the patient was an ED patient.

11
Data DictionaryVersion 2.0 - 7/1/06

• Arrival Time cont
• For Outpatient Services if the patient is in an
  outpatient setting of the hospital and is
  subsequently admitted to the hospital, use the
  time the patient presents to the ED or arrives on
  the floor as the arrival time.
• Arrival time is not the time that care or
  treatment was initiated.

12
Data DictionaryVersion 2.0 - 7/1/06

• Arrival Time cont
• For Direct Admits the Face Sheet has been added
  as an allowable source.
• Use the earliest time that the patient arrived at
  the hospital.
• If the patient is a direct admit to the cath
  lab, as a transfer from another ED or acute care
  hospital, use the time the patient presents to
  the cath lab.

13
Data DictionaryVersion 2.0 - 7/1/06

• Comfort Measures Only
• If DNR-CC documented, select No, unless there
  is documented clarification the CC stands for
  Comfort care.
• If any inclusions are documented, select Yes
  regardless of other documentation

14
Data DictionaryVersion 2.0 - 7/1/06

• Comfort Measures Only cont.
• If continue supportive care is documented in the
  context of patients age, chronic illness or
  terminal/grave prognosis, select Yes.
• Guidelines for Abstraction, Inclusions Remove
  continue supportive care.

15
Data DictionaryVersion 2.0 - 7/1/06

• Contraindications to Both ACEI and ARB at
  Discharge
• Clarification In the absence of explicit
  documentation that the patient has
  moderate/severe aortic stenosis, this should be
  inferred when there is documentation of a history
  of moderate/severe aortic stenosis without
  mention of repair or replacement, valvuloplasty,
  or commissurotomy.

16
Data DictionaryVersion 2.0 - 7/1/06

• Contraindications to Both ACEI and ARB at
  Discharge cont.2
• Guidelines now to include pre-procedure and
  post-procedure holds.
• Add clarification to 1x hold exception guideline
  MD/NP/PA order for a one-time hold.

17
Data DictionaryVersion 2.0 - 7/1/06

• Contraindications to Both ACEI and ARB at
  Discharge cont.2
• One-time holds include the holding of just one
  dose of a medication or holding of a medication
  for a defined period of time
• The physician order of the one-time hold needs to
  be explicit and able to stand on its own (Do not
  cross-reference with other medical record
  documentation to determine one-time holds.

18
Discharge Status - 66

• Discharged/Transferred to a Critical Access
  Hospital (CAH)
• Applicable if the medical record reflects that
  the patient was transferred to a critical access
  hospital for inpatient care.
• Discharges/transfers to a CAH swing bed should
  still be coded with patient status code 61.

19
Discharge Status - Case Scenarios

• The medical record reflects that the patient was
  transferred to XYZ Critical Access Hospital, the
  discharge status would be 66. But, if the
  medical record reflects only that the patient was
  transferred to XYZ Hospital then the discharge
  status would be 02.
• The medical record reflects that the patient was
  discharged to ABC Nursing Home to the Skilled
  Care Unit, the discharge status code would be 03.
  But, if the medical record reflects only that
  the patient was discharged to ABC Nursing Home,
  the discharge status code would be 04.

20
Discharge Status Case Scenarios

• The medical record reflects that the patient was
  transferred to ABC Skilled Nursing Facility for
  Rehab, the discharge status would be 03. But, if
  the medical record reflected only that the
  patient was transferred to rehab, then the
  discharge status would be 62 (Transferred to an
  Inpatient Rehabilitation Facility including
  Distinct Part Units of a Hospital).

21
Discharge Status Basic Guidelines

• A basic rule of thumb is to code to the highest
  level of care that is known.
• For conflicting information, within the medical
  record, use the best source to code.
• Appendix H, Table 2.5 Discharge Code Status,
  http//xrl.us/q6o9

22
Data DictionaryVersion 2.0 - 7/1/06

• First PCI Time
• Guideline changed Abstractors to use the
  earliest time from allowable times (Time of first
  balloon inflation, Time of first treatment of
  lesion).
• The earliest time from the above allowable times
  should be used regardless of how many vessels
  were treated or which ones were successful vs.
  unsuccessful

23
Data DictionaryVersion 2.0 - 7/1/06

• Initial ECG Interpretation
• Read Specifications Manual, Version 2.0 pages
  1-174 1-178 for complete detail.
• Guidelines for Abstraction
• Inclusions for Left Bundle Branch Block Remove
  Intermittent LBBB
• Exclusions MIs where age is documented as
  undetermined, ST abnormality, ST changes or ST
  segment described as consistent with ischemia, ST
  elevation clearly described as confined to one
  lead, minimal.

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Data DictionaryVersion 2.0 - 7/1/06

• Non-primary PCI AMI-8 8a
• Question Does the MD, NP, or PA describe the
  first percutaneous coronary intervention (PCI)
  done after hospital arrival as not primary?
• Definition A percutaneous coronary intervention
  (PCI) is considered non-primary when it is used
  for reasons that are not emergent in nature.

25
Data DictionaryVersion 2.0 - 7/1/06

• Non-primary PCI AMI-8 8a cont.
• Allowable Values
• Yes, MD, NP, or PA documentation describes the
  first PCI done after hospital arrival as not
  primary.
• No, MD, NP, or PA documentation describes the
  first PCI done after hospital arrival as primary
  or does not describe the PCI in
  primary/non-primary terms, or unable to determine
  from medical record documentation.

26
Data DictionaryVersion 2.0 - 7/1/06

• Reason for Delay in Fibrinolytic Therapy AMI-7
  AMI-7a
• Question Is there a reason documented by a MD,
  NP, or PA for a delay in initiating fibrinolytic
  therapy after hospital arrival?
• Definition Documentation of a reason for a
  delay in initiating fibrinolytic therapy after
  hospital arrival by a MD, NP, or PA.

27
Data DictionaryVersion 2.0 - 7/1/06

• Reason for Delay in PCI AMI-8 AMI-8a
• Question
• Is there a reason documented by a MD, NP or PA
  for a delay in doing the first percutaneous
  coronary intervention (PCI) after hospital
  arrival?
• Definition Documentation of a reason for a
  delay in doing the first percutaneous coronary
  intervention (PCI) after hospital arrival by a
  MD, NP, or PA.

28
Data DictionaryVersion 2.0 - 7/1/06

• Reason for Delay in PCI AMI-8 AMI-8a
• Allowable Values
• Yes, Reason documented by a MD, NP, or PA for a
  delay in doing the first PCI after hospital
  arrival.
• No, No reason documented by a MD, NP, or PA for a
  delay in doing the first PCI after hospital
  arrival.

29
Transfer From Another ED

• Documentation that the patient was received as a
  transfer from another hospital emergency
  department.
• The emergency department of another hospital
  includes both emergency room AND observation
  bed/unit stays at that hospital.

30
Transfer From Another ED

• If a patient is transferred in from the emergency
  department or observation unit of ANY outside
  hospital, option Yes should be selected
  regardless of whether the two hospitals are close
  in proximity, part of the same hospital system,
  have a shared provider number or have a shared
  medical record number.

31
Transfer From Another ED

• Added new Note for Abstraction
• If a patient is transferred in from a Disaster
  Medical Assistance Team (DMAT), which provides
  emergency medical assistance following a
  catastrophic disaster or other major emergency,
  select Yes.

32
Congestive Heart Failure

• Changes effective 7/1/2006

33
Data DictionaryVersion 2.0 - 7/1/06

• Discharge Instructions Address Activity, Diet,
  Follow-up, Symptoms Worsening or Weight
  Monitoring
• Teaching sheets now classified with brochures and
  no longer classified with patient discharge
  instruction forms.
• When a teaching sheet, brochure, booklet, or
  other instruction material is present in the
  medical record and there is no explicit
  documentation that a copy was given to the
  patient/caregiver, the inference should be made
  that the patient/caregiver was given a copy IF
  the patients name or medical record number
  appears on the material AND the hospital staff or
  patient/caregiver has signed the material.

34
Data DictionaryVersion 2.0 - 7/1/06

• Discharge Instructions Address Medications
• Clarification Discharge medication information
  included in the discharge summary date after
  discharge should be used as long as it was added
  during the hospitals normal course of completing
  a medical record per organization policy, or
  within 30 days after discharge, whichever is
  sooner.

35
Data DictionaryVersion 2.0 - 7/1/06

• LVF Assessment
• Suggested Data Sources Add Excluded Data
  Sources Any documentation dated/times after
  discharge, except discharge summary and
  operative/procedure/diagnostic test reports (from
  procedure done during hospital stay).

36
Data DictionaryVersion 2.0 - 7/1/06

• LVSD
• Guidelines for Abstraction, Exclusions for
  moderate or severe systolic dysfunction Add
  Hypokinesis described as diffuse, generalized or
  global and mild.

37
Issues in Validation Appeal

• Commonly Seen Errors In
• The Validation Appeal Process

Courtesy of

Beverly BowersValidation
SupervisorClinical Data Abstraction Center (CDAC)
38
Heart Failure

• LVSDD/C Instructions Address Medications

39
LVSD

• Definition
• a left ventricular ejection fraction less than
  40 or a narrative description consistent with
  moderate or severe systolic dysfunction.

40
LVSD

• When there are two or more documented LVF
  numeric/narrative results, abstract the LVF
  closest to discharge
• OR closest to hospital arrival, if only
  pre-arrival LVF results are documented.

41
LVSD

• If unable to determine which LVF is closest to
  discharge (or closest to arrival if only
  pre-arrival LVF results are documented) abstract
  yes if any of the documented LVF results in an
  EF less than 40 or a narrative description
  consistent with moderate or severe systolic
  dysfunction.

42
LVSD

• If there is conflicting documentation between a
  numeric value and a narrative description in
  reference to the same test, abstract yes.
• For numeric values, if both calculated and
  estimated value is documented, use the calculated
  value.
• If the EF is documented as a range, use the
  midpoint and consider this an estimated value.

43
LVSD

• If the severity of systolic dysfunction is not
  specified, assume it is moderate or severe.
• Test reports are not priority or the only
  acceptable sources. Remember to look for
  conflicting documentation in physician progress
  notes and reports.

44
Discharge Instructions Address Medications

• Definition
• Written discharge instructions or other
  documentation of written material given to the
  patient/caregiver addressing the names of all
  discharge medications

45
Discharge Instructions Address Medications

• Abstraction for this element is a 2-step process
• Determine all of the medications being prescribed
  at discharge, based on available documentation
  elsewhere in the record.
• Check the list against written discharge
  instructions given to the patient to ensure that
  these instructions addressed at least the names
  of all discharge medications prescribed.

46
Discharge Instructions Address Medications

• If a list of discharge meds is not documented
  elsewhere in the record and the completeness of
  the medication list in the written discharge
  instructions cannot be confirmed, abstract No.
• When general references to laxatives, antacids,
  vitamins and herbs are made and the patient may
  choose their product of preference, specific
  names are not required.

47
Discharge Instructions Address Medications

• Any general references to a medication regimen
  (continued home meds, same meds, see MAR) that is
  listed in the medication section of the written
  discharge instruction sheet given to the patient
  is an exclusion if the meds are not all listed
  specifically by name.

48
Myocardial Infarction

• Initial ECG InterpretationContraindications

49
Initial ECG Interpretation

• Definition
• ST segment elevation or a left bundle branch
  block (LBBB) based on the documentation of the
  ECG performed closest to hospital arrival.

50
Initial ECG Interpretation

• Use the 12-lead ECG performed closest to the time
  of hospital arrival, whether it was done prior to
  arrival or after arrival.
• Do not use ECGs done more than one hour PTA.
• If there is no interpretation available from the
  ECG performed closest to arrival, abstract no.
• Do not use an interpretation from another ECG if
  it is not the initial ECG.

51
Initial ECG Interpretation

• The interpretation must be taken from the actual
  ECG that is signed by the physician, NA or PA or
  documentation of the initial ECG findings on
  other sources by the physician, NA or PA.

52
Initial ECG Interpretation

• If both an inclusion and exclusion are documented
  for the same ECG or the documentation is
  conflicting, abstract no.
• Consider documentation as conflicting if there is
  documentation of both an included term and
  excluded term or documentation clearly
  contraindicates the inclusion term.

53
Contraindications

• Definition
• documentation of a reason for not prescribing a
  medication (by specific name or category

54
Contraindications

• The following should be captured as
  contraindication for the applicable category of
  medicine. This will apply if the category of drug
  is referenced or only a particular drug within
  the category.
• No Aspirin
• No Beta Blockers
• No ACEI
• No ARB

55
Contraindications

• Do not capture stops or D/Cs on medications as
  contraindications when done for substitution of
  type of medication.
• Do not capture stops or D/Cs on medications as
  contraindications when done for a change in the
  dose or the route of medication.

56
Contraindications

• If the physician writes an order for a medication
  but then crosses out the order, consider this a
  contraindication.
• If a medication is printed on a standing order
  form and is crossed out by the physician,
  consider this a contraindication that is clearly
  implied.

57
Contraindications

• Remember
• The contraindication elements are to be
  answered independently and irrespective of
  whether the patient was prescribed the medication
  on admission or at discharge.

58
OTHER

• Invalid Record SelectionSuggested Data Sources

59
Invalid Record Selection

• What makes a record an invalid record selection?
• Wrong patient Date of birth on the cover sheet
  does not match the record received by the CDAC.
• Pediatric patients are excluded from the sample
  and considered invalid if received by the CDAC.
• Wrong dates of stay Provider submits a
  different admission than what was requested on
  the coversheet.

60
Invalid Record Selection

• What makes a record an invalid record selection?
• Wrong admission or discharge date Dates on the
  coversheet include the acute care admission plus
  the swing bed admission.
• For example coversheet has a discharge date of
  7/10/06 but documentation in the record states
  patient was discharged from acute care on 7/05/06
  and was discharged from swing bed on 7/10/06.

61
Invalid Record Selection

• What makes a record an invalid record selection?
• Wrong type of admission Stay is not acute care
  admission. The following are all examples
• ER visits only
• 23-hour observation only
• Swingbed admission
• Rehab stays

62
Invalid Record Selection

• Information on the green coversheets (those sent
  with the request) must match the documentation in
  the record.
• Information on the green coversheets and case
  selection listing is from the data the hospital
  or their vendor submits to the warehouse.
• It is extremely important that the patient
  identifiers and admission/discharge dates are
  entered correctly.

63
Suggested Data Sources

• What are Suggested Data Sources?
• They are a list of recommended sources/locations
  to provide guidance to the Abstractor as to where
  the information needed to abstract a data element
  may most likely be found.

64
Suggested Data Sources

• What are Suggested Data Sources?
• The Abstractor is not limited to the sources
  unless the data element specifically restricts
  what sources may be used to gain the information.
• If so, these sources will be identified in the
  data element instruction.
• Some elements may have a list of excluded
  sources, which are unacceptable sources for
  abstracting information.

65
Suggested Data Sources

• What are Suggested Data Sources?
• The sources are listed in alphabetical order, NOT
  priority order, unless otherwise specified.
• If conflicting information is found within the
  suggested sources or on a source other than the
  suggested sources, abstract this information if
  it more accurately answers the data element,
  unless otherwise specified in the data element.

66
Suggested Data Sources

• What are Suggested Data Sources?
• The sources are listed by their commonly used
  titles. Many hospitals use different label/name
  for their forms/reports. Information may be
  abstracted from any source that is equivalent to
  those listed, unless otherwise specified.

67
Questions?

• For Validation records requests
• Contact CDAC at 717-767-7400 ext. 201

68
Additional Identified Issues in Validation

• Arrival Time
• Admission Source
• Discharge Status

69
Arrival Time

• The earliest time that the patient arrived at the
  hospital, not the time that care or treatment
  was initiated.
• This time may differ from the admission time.
• Medical record documentation from all of the
  only acceptable sources should be reviewed to
  determine the most correct time of arrival.
• Should NOT be abstracted as the earliest time
  without substantiating documentation.

70
Admission Source

• The intent of the admission source is to look at
  where the patient was admitted from.
• The values for admission source are taken from
  the National Uniform Billing Committee (NUBC)
  manual which is used by billing to complete the
  UB-92.
• For validation purposes it is important that the
  medical record reflect the admission source, as
  the CDAC does not have access to the UB and can
  only validate from the medical record.

71
Discharge Status

• The values for discharge status are taken from
  the National Uniform Billing Committee (NUBC)
  manual which is used by billing to complete the
  UB-92.
• For validation purposes it is important that the
  medical record reflect the discharge status, as
  the CDAC does not have access to the UB and can
  only validate from the medical record.

72
Discharge Status - 03

• Discharged/transferred to a Skilled Nursing
  Facility (SNF)
• Used if the medical record reflects that the
  patient was discharged to a skilled nursing bed
  or facility
• Includes transfers to a rehabilitation unit that
  is located within a skilled nursing facility
• Includes transfers to a Transitional Care Unit
  (TCU)

73
Discharge Status - 04

• Discharged/transferred to an Intermediate Care
  Facility (ICF)
• Should be used when the medical record reflects
  that the patient was discharged to a non-skilled,
  custodial or residential level of care
• Includes Extended Care Facility, Intermediate
  Care Facility, and Nursing Homes

74
Admission SourceDischarge Status

• If utilizing the UB-92 for abstracting these
  elements, the abstractor should NOT assume that
  the UB-92 is correct.
• If the abstractor determines through chart review
  the UB-92 is incorrect, they should correct and
  override the downloaded value.

75
Validation Requirements
76
Validation Requirements

• Ensure that you and involved staff are aware of
  the deadline date for chart submission.
• Identify the charts requested for validation
  sampling by a V after the patient ID number.
• Pull medical records and verify
• - Patient ID information
• - Date of admission
• -Date of discharge
• The chart matches the green, barcoded CDAC face
  sheet.

77
Validation Requirements

• Before photocopying, verify that the following
  are included
• All pages of the record (e.g., all diagnostic
  test reports)
• Printouts of electronic medical records (e.g.,
  lab and radiology reports, nursing documentation)
• After photocopying, go through the entire medical
  record to make sure
• All information is legible (e.g., photocopied
  stickers are clear and do not appear as black
  boxes)
• All information is visible (e.g., no information
  is concealed by folded paper or separate notes)

78
Validation Requirements

• Attach the correct green, bar-coded CDAC face
  sheet to each medical record.
• Ship to CDAC via FedEx prior to the deadline date
  to ensure charts arrive on time.
• If you have questions, call CDAC prior to the
  chart submission deadline at [phone].
• Track CDACs receipt of the medical record on
  QualityNet.
• Case Selection Report

79
Case Selection Report
80
Known Q4 2006 Changes

• Undated MAR
• Illegible Handwriting

81
Undated Medication Administration Records

• Effective with 10/01/2006 discharges
• If, in the course of abstraction an undated MAR
  is found in the medical record, it cannot be
  used.
• Handwritten MARs must have the administration
  date documented on the form.
• Handwritten MARs that only have the start/stop
  dates of each medication will not be sufficient
  as they would not reflect the actual
  administration date.

82
Illegible Handwriting

• Effective 10/01/2006 discharges
• All documentation in the medical record must be
  legible and complete, and identified by name and
  discipline by the person who is responsible for
  ordering, providing, or evaluating the service
  provided.
• When abstracting a medical record, if the CDAC is
  unable to verify an answer due to illegible
  handwriting, the documentation in question will
  not be used.

83
Illegible Handwriting - cont

• Example
• Patients admission orders state Admit to ICU
  for diagnosis of ?? and sepsis. The abstractor
  is unable to determine what the letters are that
  the question marks are representing. After
  reviewing the ED documentation, the CDAC
  abstractor identifies that the patient was being
  admitted for pneumonia ant the letters in
  question were PN.
• If no additional information is located that
  shows the patients diagnosis, this information
  will not be taken into consideration, as the
  documentation was illegible and could not be
  verified.

84
The Right Care for Every Person Every Time
This material was prepared by GMCF under contract
with the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not
necessarily reflect CMS policy. Publication No.
8SOW-GA-HOSP-06-126