Clinical Documentation Improvement

1
Clinical Documentation Improvement

• Preparing Physicians for ICD-10

2
Background

• A program implemented by Mary Washington Hospital
  in 2001 to improve the clinical documentation on
  a concurrent basis with 3 nurses.
• In 2007, the program grew to 4 clinicians and 1
  manager. (All RNs)
• May 2013, the program consists of 6 FTEs
  (including 1 manager) at Mary Washington Hospital
  and 0.5 FTE at Stafford Hospital.
• The CDMP Nurses clarify with physicians the
  documentation guidelines that will accurately
  reflect the severity of illness and the intensity
  of service provided to patients.

3
Background cont.

• The program provides the public, third party
  payors and managed care entities with accurate
  profiles of the types of patients treated at our
  hospital and the physicians providing the care.
  More accurate profiles should result in
• 1. Improved market share positioning for
  managed care contracts.
• 2. Appropriate DRG assignments physician
• payments.
• 3. Improved severity-adjusted quality outcomes.

4
CDMP Review

• The Clinical Documentation Specialists (CDS)
  clarify the documentation concurrently to
  reflect
• Severity of illness
• Intensity of service
• Provide clear and concise documentation for
  coding accuracy and reimbursement
• The program supports an opportunity for
• Increased CMI.
• Collaboration with Coder for appropriate DRG
  assignments
• Clear, concise

5
Why should it be important to Physicians?

• CMS, as well as private payors, are clearly
  moving toward Pay For Performance iniatives to
  determine physician payment for care rendered.
• HealthGrades are beginning to publish physician
  profile information.
• These sites use severity of illness (measured by
  Case Mix Index), mortality rates, length of stay
  information, and complication rates to judge
  physician performance.

6
Importance to Physicians cont.

• Failure to fully document the severity of the
  patients illness makes the length of stay,
  mortality, and complication rate look higher,
  because it appears that patients had bad outcomes
  despite being less sick.
• Internal physician profiling within the
  organization fails to give adequate credit for
  how sick the patient really was unless
  documentation is accurate.

7
Physician Champion

• Letter to all Physicians
• You have probably met the Clinical Document
  Improvement (CDI) nurses reviewing your patients
  charts and seen the queries they leave for you
  asking such questions as whether this acute
  respiratory insufficiency could also be called
  acute respiratory failure, or whether this GI
  bleeding with drop in Hct could also be called
  acute blood loss anemia. While these questions
  often seem trivial, and while you can rest
  assured that in many cases the nurses asking the
  questions already know the answers, the queries
  reflect CMS Medicare Coding Guidelines.

8
Physician Champion

• Once the patient is discharged, certified
  coders are allowed to use only certain words and
  terms to code diagnoses. If the answer to the
  CDI query is no, that language does not reflect
  what is really going on, check the no box. If
  the answer is that the suggested language would
  be accurate, please reflect this in your Progress
  Notes and Discharge Summary. Accurate
  documentation helps us all.
• If you have questions or would like additional
  information, please contact Kathy Harkness at
  XXX-XXXX or Becky Bigoney at XXX-XXXX.

9
Communication with Physicians
Dr. Mc Dreamy
Dr. Mc Steamy
10
Criteria

• The Three-legged Stool
• Risk Factors
• Clinical Evidence
• Treatment

11
Example Sepsis

• Mary Washington Healthcare
• PHYSICIAN QUERY
•  Sepsis
•  Dr.
•  Per the guidelines of the MWHC Coding
  Documentation Improvement Program, the following
  clinical indicators found in this patients
  record indicate a query is appropriate to clarify
  documentation for Sepsis
• The patient meets the following SIRS criteria
  ?N/A
• ?Temp gt 100.4F or lt 98.6F ? RR gt 20 breaths/min.
  ?HR gt 90 bpm
• ?WBC gt 12,000 or lt 4,000 or gt 10 bands
•  The patient has the following documented
  infection(s)
• ?Positive culture results ?Pneumonia ?UTI
  ?Intrabdominal perforated organ?
• ? Wound ?Central Line Infection ?Joint
  Infection
• ?Is the patient currently receiving antibiotics?
• Response
• -Sepsis secondary to __________________, Present
  On Admission
•  -Sepsis secondary to __________________, Not
  Present On Admission
• -Septicemia without SIRS
• -Bacteremia without SIRS
• -Other (please specify)___________________________
  ____________
• -Clinically Unable to Determine

12
Example Anemia

• As documented in the progress notes,
• The H/H decreased from 9.5/29 to 7.4/23
• The patient was transfused with 2 units PRBCs,
  2 unit FFP and IV vit K.
• Documentation in the progress notes
  anemia-transfuse 2 units PRBCs
• Please, if possible, specify the type of anemia,
  acuity and the cause of your documentation of
  anemia in the progress notes. If due to a
  specific blood loss related to a specific
  diagnosis, please correlate the two conditions in
  your progress note and discharge summary.
• The term "anemia" is considered somewhat vague
  and may not capture the clinical severity.
• Examples of specified types of anemia include but
  are not limited to
• refractory anemia
• iron deficiency anemia/nutritional anemia
• acute blood loss anemia
• chronic blood loss anemia
• hemolytic anemia
• anemia associated with chronic disease

13
Example Renal Failure

• The medical record reflects the following
  clinical findings, treatment and risk factors
• --Pt s/p cardiac cath, CABG x3 and MVR
• --BUN preop 24 increased to 49 on 9/26
• --Cr preop 1.2 increased to 3.9 on 9/26
• --Documentation in PN "continue to monitor u/o
  increase BUN/Cr
• --Treated with IVF and daily labs
• Please clarify and document your clinical opinion
  in the progress notes and discharge summary, the
  definitive and/or presumptive diagnosis related
  to the above clinical findings.
• Acute Renal Failure
• Acute on Chronic Renal Failure
• Chronic Renal Failure
• Other explanation of clinical findings (Please
  specify)
• No explanation for clinical findings (Please
  state)

14
Example Renal Failure (Chronic)

• Please clarify, if possible, the stage of this
  patient's documented Chronic Kidney Disease.
• Calculated GFR with Creat. 4.2 18
• Chronic Kidney Disease (CKD), stages 1-5
  specifically code to the documented stage.
  Documenting the stage of CKD will improve data
  integrity and will help clarify vague terms such
  as "renal insufficiency" or "chronic renal
  failure."
• The stages of CKD according to the National
  Kidney Foundation are as follows
• Stage I GFR gt90
• Stage II GFR 60-89
• Stage III GFR 30-59
• Stage IV GFR 15-29
• Stage V GFR lt15

15
Example Malnutrition

• The medical record reflects the following
  clinical findings, treatment, and risk factors.
• --Pt adm with general weakness and abd/back pain
• --Total Protein on adm 6.1 down to 4.3 on 6/29
• --Albumin on adm 3.8 down to 2.5 on 6.29
• --Cardiac Diet
• --Recent history of nausea and poor PO intake
• Please clarify and document your clinical opinion
  in the progress notes and discharge summary the
  definitive and/or presumptive diagnosis,
  (suspected or probable), related to the above
  clinical findings. Please include clinical
  findings supporting your diagnosis.
• Protein Calorie Malnutrition
• Mild, Moderate or Severe Malnutrition
• OTHER explanation of clinical findings
• Unable to determine (no explanation for
  clinical findings)

16
Example Debridement

• After review of your OR/ Procedure Note,
  additional documentation is needed to fully
  capture the complexity of procedure performed.
  Please clarify in your progress notes and
  Procedure Note whether the debridement performed
  was
• Sharp/ Excisional / Non excisional
• Instrument Used (ie scalpel, scissors,
  VersaJet)
• Depth of the debridement
• Types of Debridement
• Sharp Debridement - Minor removal of loose
  fragments by scissors
• Excisional Debridement - Scalpel used to
  remove devitalized tissue cutting outside or
  beyond wound margins
• Non Excisional Debridement - Whirlpool,
  Waterscalpel, Versajet
• Depth of Debridement
• Partial Thickness
  
• Full thickness
• Skin and Subcutaneous Tissue
• Subcutaneous Tissue and Muscle
• Subcutaneous Tissue, Muscle and bone

17
Example Hypertension

• The medical record reflects the following
  clinical findings, treatment, and risk factors.
• --Documentation in PN of Hypertension with
  medication changes for BP control
• --Adm for Acute CVA with hx of CVA
• --TX includes CVA protocol
• --Diastolic BPs in 90's
• Please clarify and document your clinical opinion
  in the progress notes and discharge summary the
  definitive and/or presumptive diagnosis,
  (suspected or probable), related to the above
  clinical findings.
• Essential Hypertension
• Benign Hypertension
• Malignant Hypertension
• OTHER explanation of clinical findings
• Unable to determine (no explanation for
  clinical findings)

18
Example Congestive Heart Failure

• The medical record reflects the following
  clinical findings, treatment and risk factors
• --Pt adm with COPD/Asthma, hx of CM EF 25-30
• --ProBNP 2780
• --Cardiology documents "mildly elev. BNP may be
  chronic level rather than acute indicator of CHF
• --Treatment includes IV Lasix, ACEI, daily
  weights, strict IO
• Please clarify and document your clinical opinion
  in the progress notes and discharge summary, the
  definitive and/or presumptive diagnosis related
  to the above clinical findings.
• Acute Diastolic/Systolic/Combined Heart Failure
• Acute on Chronic Diastolic/Systolic/Combined
  Heart Failure
• Chronic Diastolic/Systolic/Combined Heart Failure
• Other explanation of clinical findings (Please
  specify)
• No explanation for clinical findings (Please
  state)

19
Hospital Acquired Conditions (HAC)

• Conditions not documented as present on admission
  (POA). CMS has identified specific conditions
  that will not result in assignment of a higher
  weighted DRG
• Foreign objects retained after surgery
• Air embolism
• Blood incompatibility
• Stage III and IV pressure ulcers
• Catheter associated UTI
• Surgical site infections of specific surgeries
• Specific Injuries from falls and trauma
• Poor hyperglycemic control
• DVT/PE following total hip or total knee
  replacement
• Vascular Catheter-Associated Infections

20
Physician Education

• New physician orientation
• Flyers
• Pocket cards
• Newsletters
• Department Meetings
• Evidence-based DocuPrompters
• Transcription-based Automated Queries
• Beta Project

21
Physician Query Policy

• The purpose of the query process is to clarify
  provider documentation whenever there are
  conflicting, ambiguous, or incomplete information
  in the medical record regarding any significant
  reportable condition or procedure.
• a. Reportable conditions are defined by Official
  Coding Guidelines as those that affect patient
  care in terms of requiring
• Clinical evaluation
• Therapeutic treatment
• Diagnostic procedures
• Extended length of hospital stay
• Increased nursing care and/or monitoring.
• b. Clinically significant conditions include
  those listed above as well as those conditions
  that have implications for future health care
  needs.

22
Query Policy

• Queries may be initiated by either the Clinical
  Documentation Specialist (CDS) or Coding.
• Query Types
• Concurrent for patients currently in an
  inpatient bed
• Retrospective (Post) for patients who have been
  discharged

23
Query Policy

• Providers will be queried for clarification prior
  to final billing whenever possible.
• a. Written queries will be made using standard
  forms.
• b. Verbal and telephonic queries will follow the
  same format as written queries.
• c. All queries will be
• 1. Clear and not leading.
• 2. Simple and direct
• 3. State the issue in as few words as possible
• 4. Itemize the clinical elements or clues from
  the medical record

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27
(Post) Query Policy

• Coder request for Post Query.
• Coder emails Inpatient Coding Compliance Auditor
  or CDI Nurse if CDI case.
• Coding Compliance Auditor or CDI Team Leader
  write Post Query if need is determined.
• Query is emailed to HIM Training Coordinator
  imports into ChartView, deficiency entered, query
  printed and placed in bin.
• HIM clerical associate picks up query and enters
  information into post query log.
• Transcription coordinator notifies physician by
  faxing Post Query to physicians office on day
  Post Query imported into ChartView.
• Transcription coordinator reviews log daily and
  determines if Day 7 and Day 12 action needs to be
  taken and updates log as necessary.

28
Query Escalation Time Line

• On Day 7 if query remains unanswered,
  Transcription coordinator faxes letter and query
  to physician and the physicians Service Chief is
  notified via email. .
• On Day 12 if query remains unanswered,
  Transcription coordinator calls physician.
• Coding Data Specialist reviews log daily to
  determine if query has been answered or is
  expired.
• Coding Data Specialist removes deficiency and
  alerts coder and CDI Team Leader if CDI case that
  chart is ready to be coded.
• On Day 14 if the query remains unanswered, the
  chart will be coded as is unless coder determines
  response is needed and escalates to Inpatient
  Coder Compliance Auditor.
• Coder Compliance Auditor finalizes account or
  determines response is needed and emails Vice
  President of Medical Affairs and Chief of
  Medicine for MWH or SH.

29
Query Policy

• Reports
• 1. Reports will be provided to service chiefs on
  a periodic basis for their areas, but at least
  quarterly on the number of queries and response
  rate. The report will, if applicable, also
  include any changes that were made in coding as a
  result of the
• query.
• 2. Reports will also be provided to other
  members of hospital administration as requested.
• References
• 1. AHIMA. Managing an Effective Query Process
  Journal of AHIMA 79, no. 10
• (October 2008) 83-88.

30
CDMP Clarification Post Query Worksheet
Dr Stewart Kohler
Clinical Documentation Clarification --HP Sepsis most likely 2nd to pneumonia --Pnote 1/5 sepsis/pneumonia --WBC 16, HR 139, RR 33 respiratory failure --Levaquin, Zosyn, and Vancomycin --No further mention of sepsis on pnotes, ICU admit note, or discharge summary Please clarify the sepsis documentation ---Sepsis, present on admission, ruled in ---Sepsis, ruled out ---Other explanation, please state
Thank you. Please document in the Discharge Summary or a work type 98 addendum to answer query.
Thank you. Please document in the Discharge
Summary or a work type 98 addendum to answer
query.
Admitted 1/5/13 Discharged 1/10/13
Name Physician Stewart Kohler
Account 6220000000 ? Tara Norbeck, CDI Team Leader 741-6555 ? Vanessa South, Coding Compliance Auditor 804-794-4307 ? Tara Norbeck, CDI Team Leader 741-6555 ? Vanessa South, Coding Compliance Auditor 804-794-4307
MRN 444444 ? Tara Norbeck, CDI Team Leader 741-6555 ? Vanessa South, Coding Compliance Auditor 804-794-4307 ? Tara Norbeck, CDI Team Leader 741-6555 ? Vanessa South, Coding Compliance Auditor 804-794-4307
Location-MWH/SH MWH 2North ? Tara Norbeck, CDI Team Leader 741-6555 ? Vanessa South, Coding Compliance Auditor 804-794-4307 ? Tara Norbeck, CDI Team Leader 741-6555 ? Vanessa South, Coding Compliance Auditor 804-794-4307
31
Sample Email to MD

• Subject Unanswered Post Query
•  Dr. ________,
•  
• Please, if possible, answer the Post Query on the
  account below in your Discharge Summary (if not
  already dictated) or dictate as a work type 98
  addendum to answer query. The Post Query can be
  found under CDMP in ChartView.
• Acct _________
• MRN_________ with admit date of _________
• Query scanned_______
• Today is day 7 (email reminder to physician)
• Day 12 will be _______(phone call to physician or
  physicians office)
•  
• No answer to Post Query as of today. Chart will
  be coded as is on _______.
•  Respectfully,
• xxxxx
•  

32
Sample Fax to MD (Day 1)

• Date __________________
• Subject Unanswered Post Query
•  
• Dr._________________________________
•  Please, if possible, answer the attached Post
  Query as soon as possible. Account information
  is included below.
•  Please dictate a work type 98 Addendum to answer
  the Post Query.
•  
• The Post Query can be found under CDMP in
  ChartView.
• Account Number _____________________ Patient
  Name __________________________
• Medical Record Number _______________ Visit
  admission date _____________________
•  
• Query Scanned __________________
• Chart will be coded as is on
  __________________
•  
• Respectfully,
• Health Information Management Department

33
Sample Fax to MD (Day 7)

• Date __________________
• Subject Unanswered Post Query
• 2nd Attempt
•  
• Dr.__________________________________
•  
• Please, if possible, answer the attached Post
  Query as soon as possible. Account information
  is included below.
•  
• Please dictate a work type 98 Addendum to answer
  the Post Query.
•  
• The Post Query can be found under CDMP in
  ChartView.
• Account Number _____________________ Patient
  Name __________________________
• Medical Record Number _______________ Visit
  admission date _____________________
•  
• As of today, the Post Query has not been
  dictated.
•  
• Query Scanned __________________
• Chart will be coded as is on
  __________________.

34
Sample Fax to MD (Day 12)

• Date __________________
• Subject Unanswered Post Query
• 3rd and Final Attempt
•  
• Dr.__________________________________
•  
• Please, if possible, answer the attached Post
  Query as soon as possible. Account information
  is included below.
•  
• Please dictate a work type 98 Addendum to answer
  the Post Query.
•  
• The Post Query can be found under CDMP in
  ChartView.
• Account Number _____________________ Patient
  Name __________________________
• Medical Record Number _______________ Visit
  admission date _____________________
•  
• As of today, the Post Query has not been
  dictated.
•  
• Query Scanned __________________
• Chart will be coded as is on
  __________________.

35
Post Query Log Post Query Log Post Query Log Post Query Log Post Query Log
Query from     Patient MD   Day 1 Day 7 Day 12   Day 15 Final Outcome Responded YES
CDI or Coder Type of Query Acct. Last, First Last, First Date Allocated Fax Physician Fax to Physician cc Chief Fax to Physician Call Office Query Answered, Coder notified Def deleted, if needed Responded Yes or No DRG change YES or No
CODER SEPSIS 6221126227     4/3/13 4/3/13 Query answered Query Answered 4/5/2013   yes yes
CDI ACUTE RESPIRATORY FAILURE 6221108821     4/3/13 4/3/13 4/10/2013 Query Answered 4/12/2013   yes no
CDI RESPIRATORY FAILURE SHOCK 6221130038     4/4/13 4/4/13 Query answered 4/8/13 Tara forwarded to Dr. Bigoney 4/9/2013   yes  
CDI PNEUMONIA 6221117236     4/4/13 4/4/13 Query answered Query Answered 4/9/2013   yes yes
CODER MISSING DOCUMENTATION 5010001003     4/4/13 4/4/13 4/11/2013 MD called said no procedure so therefore no query needed removed allocation 4/12/2013 yes yes no
CDI LINK BETWEEN CHF HTN 6221131710     4/4/13 4/4/13 Query answered Query Answered 4/9/2013   yes yes
CDI PNEUMONIA 6221125654     4/4/13 4/4/13 4/11/2013 Query Answered 4/12/2013   yes yes
CDI SEPSIS 6221122260     4/4/13 4/4/13 Query answered Query Answered 4/8/2013   yes  
CDI CHF UTI 6221131810     4/4/13 4/4/13 4/11/2013 Query Answered 4/12/2013   yes yes
CDI ANEMIA 6221125830     4/4/13 4/4/13 4/11/2013 Query answered in Discharge Summary 4/19/2013   yes  
CDI PNEUMONIA 6221140432     4/5/13 4/5/13 Query answered Query Answered 4/8/2013   yes no
CDI POST OP COMPLICATION 6221134344     4/5/13 4/5/13 4/11/2013 4/17/2013 Query Answered 4/19/2013   yes yes
36
Outcomes

• October 2012 (old process) 44 Post Queries with
  a 50 Response Rate
• March 2013 (new process) 52 Post Queries with
  an 87 Response Rate (Hospitalist Response Rate
  100)
• Hospitalists 62 of Post Queries
• Non-Hospitalists 38 of Post Queries
• Post Query response changed the DRG in 47 of the
  cases

37
More Data

• CDI generated - 69
• Coder generated-31
• Of the CDI cases
• 22 of 36 Post Queries were unanswered concurrent
  queries (61)
• 11 of 36 Post Queries there was no concurrent
  query (31)
• 3 of 36 Post Queries were written the day of
  discharge (8)

38
Top Five Topics

• Sepsis
• Anemia
• CHF
• UTI
• Debridement

39
Opportunities for Improvement

• Hospitalist Response Rate was 100 while
  Non-Hospitalist was 87---Engage non-hospitalists
  in answering Post Queries
• 61 of CDI generated Post Queries were unanswered
  concurrent queries---Improve Response Rate to
  concurrent queries
• 31 of the time, CDI could have written a
  concurrent query---missed opportunities
• Physician Education around Sepsis, Anemia, CHF,
  UTI, and Debridement

40
Whats Next?

• Education
• Education
• Education

41
Questions?
42
Contact Information

• Kathleen R. Harkness, BSN, RN
• Manager CDI and Revenue Integrity
• Mary Washington Healthcare
• Health Information Management
• 1001 Sam Perry Blvd.
• Fredericksburg, VA 22401
• 540-741-3193
• Kathleen.harkness_at_MWHC.com