S

Clinical Documentation Improvement

Langley Provider GroupColleen Garry RN, BS

Mary Beth Genovese RN, BS, CCS, CCDS

JAMA: April 26, 2006 p. 1918

“The era of accountability defined as measured performance with consequences, is rapidly arriving in the US for medical practitioners and health care facilities. Soon, both reputations and incomes of practitioners and health care facilities may well be altered depending on how one scores on a limited set of performance metrics”

Hospital Life Today

Affordable Care ACT Changes Decreased reimbursement Bundled payments Pay for Performance/VBP EMR Implementation ICD 10 Pay for Outcomes

Deficit Reduction Act of 2005

SECTION 501 c of PL 109-71

Congress authorizes CMS to adjust for Medicare IPPS hospital payments to encourage the prevention of certain conditions (VBP)

Requires CMS to choose at two conditions; High volume high cost or both Condition is a cc or MCC Reasonably preventable thru evidenced based

guidelines No addition payment when these conditions develop

after admission (when condition is the only one to bring to the higher RW tier)

Who’s Profiling Physicians?

Federal State and Regulatory agencies Joint Commission CMS Peer Review Organizations Managed Care organizations/Profiling Agencies Prospective Payment Systems Hospitals

(one of the major indices is based on SOI)

Is your profile accurate?

How complex is the care being delivered? What overall severity is being reported and

collected? What risk of mortality is being reflected? How do secondary diagnoses affect reflection of

severity and risk? Do I have any control over my profile?

WIKIPEDIA DEFINITIONS

Severity of illness (SOI) is defined as the extent of organ system derangement or physiologic decompensation for a patient. It gives a medical classification into minor, moderate, major, and extreme. The SOI class is meant to provide a basis for evaluating hospital resource use or to establish patient care guidelines.

The risk of mortality (ROM) provides a medical classification to estimate the likeli-hood of in-hospital death for a patient. The ROM classes are minor, moderate, major, and extreme. The ROM class is used for the evaluation of patient mortality.

Flow of Documentation

MD DOCUMENTATION

Converts into ICD 9 Codes NOW And

ICD 10 codes

OCTOBER 1, 2014

FEDERAL GOVT.

RACS

INSURANCE COMPANIES

HEALTHGRADESLEAPFROG

RANKING REIMBURSEMENT

OVERSIGHT RECOVERY

TIER STATUS CREDENTIALING

INTERNET PATIENT

BALTIMORE SUN

Governmental AUDITS

NAME OF AUDIT Governmental AGENCY

RAC POST BILL DCS INC. FOR CMS

RAC PRE-BILL DCS INC. FOR CMS

RAC A to B RE-BILL CMS

NGS PRE-BILL AUDIT 1 DAY STAY

NGS

CMS PART B PHYSICIAN AUDIT CMS

RAC’s: YOUR BEST DEFENSE: A GOOD OFFENSE

(CDI) To Assess:

Level of Acuity Severity of Illness Clinical Indicators Utilization of resources

LANGUAGE INCOMPATABILITIES

Clinical Language vs. Diagnostic Statements

CLINICAL LANGUAGE CODING LANGUAGE

↓ NA HyponatremiaFluid resuscitation Dehydration, hypovolemia,

hypovolemic shockEnzymes + St elevation V leads Acute anterior MI (STEMI vs.

NSTEMI)↓ HGB transfuse 2 units Acute blood loss anemia Urosepsis Urinary tract infection Urosepsis Sepsis from a urinary source

Effective CDI

LEADERSHIP

SUPPORT

DATA TRACKIN

G

COMMUNICATION &

COLLABORATION

ONGOING EDUCATIO

N

ACCOMPLISHED BY:

CDI team fully trained in CDI (clinical, coding, compliance)

Concurrent “real” time record reviews Ensure proper assignment of: DRG/CC/MCC/POA

Status/ HAC’s Tracking tool to report on vital data Scheduled reports to CDI Steering Committee with

regularly scheduled meetings Continuous feedback to Mid Level Providers and

Physicians

Benefits of CDI:

Regulatory Compliance Improved outcome indicators

Thorough documentation enhances accurate hospital and physician profiles

Enhanced support for the patient’s treatment plan LOS and medical necessity are supported by SOI Fewer Denials Added support for E&M coding levels Risk management tool

What are the drivers for change?

Accurate and Comprehensive clinical documentation is essential for:

Safe, high quality patient care Accurate performance data Appropriate reimbursement

revenue Regulatory compliance e.g.,

MS DRG . POA, HAC’s, Core Measures, PSI’s, RAC

????

Critical Success Factors

To ensure accurate comprehensive clinical documentation:

Provide Strong Medical and Administrative Leadership Support

Communicate and Collaborate Perform Robust Data Tracking Offer ongoing education Implement an effective CDI program

Improvement Activities Benchmarking

Regularly monitor

performance

Determine processes to be studied

Identify relevant

performance data /gather

data

Comparediscover critical success factors

Adopt/adapt successful strategies

COUNTDOWN TO ICD 10

OCTOBER 1, 2014

MAY 17, 2013

502 DAYS 71 WEEKS +

5 days

CHANGES TO VOLUME

DIAGNOSIS CODESICD-9-CM14,025 CODES

ICD-10-CM 68,069

Thank you

QUESTIONS ?

mgenovese@langleyprov.com cgarry@langleyprov.com