Post on 18-Sep-2020
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Department of Quality
Documentation
Has anyone ever heard of
QD? CDI? Queries?
Quality Documentation’s
RoleWe review charts to find missing, conflicting documentation, and/or to specifydiagnoses to make sure there is a clear, accurate and complete picture of the patient’s hospital stay.
• Concurrently review the in-patient chart, usually by day 3-4 of hospital admission. We also do retrospective reviews for coders and for second level reviews (PSIs, HACs, Mortality).
• Seek to clarify any documentation that is unspecified, unclear, conflicting or missing.
• Send queries to providers to obtain any additional clarifying documentation.
• 95% of queries sent are quality impacting, only 5% financial.
• QD & Coding is a resource team that works in collaboration.
• Queries can be sent after discharge.
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Your documentation tells the patient’s
story.
H&P = Introduction
Progress/Op Notes = Body
Discharge summary = Conclusion
It is critical to paint a clear picture from start to finish
and cover the initial situation, changes through the
stay, and a clear summary that brings it all together.
How does your documentation
make a difference?
First and foremost, accurate documentation helps provide cohesive and collaborative care for the patient.
• Support medical necessity
• Helps support need for outpatient rehab and programs
• Accurately capture Severity of Illness and Risk of Mortality scores
• Length of stay
• Support CMI (case mix index) compensation
• Decrease denials
• Accurately reflect quality indicators and publicly published outcome measures
• Accurately reflects the conditions treated, monitored and resources utilized throughout that patients stay
• Represents the care you provided to your patient
• Provider quality scores
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Documentation Tips
• Document the diagnosis(es) rather than signs and symptoms.
Example: SOB due to Acute Respiratory Failure
• Be specific with type and acuity! Acute, chronic, acute on
chronic, or exacerbation.
Example: Acute on Chronic Systolic Congestive Heart
Failure; Acute Blood Loss Anemia; Chronic
Pancreatitis
• Link diseases /diagnoses to their underlying causes.
Example: Pancytopenia due to chemo; Anemia due to CKD
• Caution when using the term “postop” or “postoperative”. CMS
takes this as a postoperative complication and not a timeframe.
Documentation Tips continued…
• Use your consults! • Dietician notes- Malnutrition with severity
• Wound care- Pressure Injuries (be SPECIFIC)
• Clarify diagnoses that are present on admission (POA)
Example: Pressure Injuries, DVT, Fracture
• Avoid use of arrows/symbols and abbreviations (e.g. ↓low sodium, low plt, abnormal hgb, PNA, ARF)
Example: Hypernatremia, Thrombocytopenia, Iron Deficiency Anemia; Pneumonia; Acute Respiratory Failure
• Clarify the significance of laboratory, radiology and other procedures by summarizing these results in your documentation. Diagnoses can not be coded from these reports per CMS rules and guidelines.
*Do not copy and paste*
Terms of UncertaintyAll of the following documentation terms are considered “terms
of uncertainty” by CMS. This means diagnoses documented
with these terms do not generate an ICD-10 code and a query
will be sent for clarification or to rule in/out the diagnosis.
• Covering for, in the setting of Not acceptable as
confirmed or suspected per CMS guidelines
• Consistent with, compatible with, indicative of, concern
for, suggestive of, comparable with, probable,
suspected, likely, questionable, possible If this
documentation is followed through to DC Summary, a
query will not be sent.
Terms of Certainty
• Associated with
• Evidence of
• Treating as
• Treated as
These terms will all generate an ICD-10 code and a
query would not need to be sent.
Severity of Illness (SOI)
&
Risk of Mortality (ROM)
These are quality measures that affect population health. Risk of mortality and severity of illness are becoming a vital part of the
health record.
Hospital Acquired Conditions (HAC)
and Patient Safety Indicators (PSI)
– Foreign object retained after surgery– Air embolism– Blood incompatibility– Pressure injuries– Falls– Manifestations of poor glycemic control– Catheter-associated urinary tract infection– Vascular catheter-associated infection– DVT/ pulmonary embolism after lower extremity an operation– Surgical site infection– Post operative DVT/PE, Respiratory Failure & Sepsis
– If you are not able to determine present on admission status for these conditions- “unable to determine” choice does not code to a HAC.
Pneumonia Specificity• Even if no sputum cultures obtained or cultures are negative, you can
still document “Treating/treated as” to help accurately capture the treatment given for the pneumonia.
Example: “…Patient pneumonia treated as gram negative…” or “…treating as aspiration pneumonia…”
• Negative or inconclusive sputum cultures do not preclude a diagnosis of a specific bacterial pneumonia in patients with the clinical evidence of this condition. Pneumonia can be specified based on the treatment (per American Hospital Association Coding Clinic).
• If you are treating a suspected, possible or probable gram negative or other resistant pneumonia please document as such (must be carried to DC Summary).
• CAP and HCAP are not considered specified by CMS, and only code to Simple Pneumonia.
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Pneumonia
Observer A Observer B Observer C Observer D
Principal
Diagnosis
Simple
Pneumonia,
unspecified
Simple
Pneumonia,
unspecified
Simple
Pneumonia,
unspecified
Complex
Pneumonia:Treating Gram
Negative
Secondary
Diagnoses
w/o CC/MCC w/CC AKI w/MCC ARF w/MCC ARF
Medicare DRG 195 194 193 177
MS-DRG
AMLOS
3.3 4.4 5.8 8.2
Relative
Weights
0.7111 .9695 1.4261 2.0549
Severity of
Illness
Risk of
Mortality
Level 1/minor
Level 1/minor
Level 2/mod
Level 1/minor
Level 3/major
Level 3/major
Level 3/major
Level 3/major
Reimbursement $5,024.61 $6,541.63 $9,222.24 $12,023.79
COPDObserver A Observer B Observer C
Principal
DiagnosisCOPD
Exacerbation
COPD
Exacerbation
COPD
Exacerbation
Secondary
Diagnosesw/o CC/MCC w/CC Chronic
Diastolic/Systolic
CHF Oral Lasix -chronic
home medication
w/MCC Acute
Diastolic/Systolic
CHFIV Lasix
Medicare DRG 192 191 190
MS-DRG AMLOS 3.3 4.0 4.9
Relative Weights 0.7313 0.9321 1.1578
Severity of Illness
Risk of MortalityLevel 1/minor
Level 1/minor
Level 2/moderate
Level 2/moderate
Level 2/moderate
Level 2/moderate
Reimbursement $5,143.20 $6,322.03 $7,647.09
Common Queries Sent to ProvidersGen Med: Obesity/Morbid Obesity, Malnutrition, Pressure Injuries, CHF,
Sepsis, Respiratory Failure, Encephalopathy, CAUTI, Conflicting
Documentation “Captain of the Ship”
Pulmonary/ICU: Acute and/or Chronic Respiratory Failure, Pneumonia
Specificity, Shock, Sepsis
Cardiology: Afib/Aflutter Specificity, CHF, STEMI/NSTEMI/MI2/Demand
Ischemia
Neurology: Encephalopathy, Cerebral Edema, Brain Compression
ID: Pneumonia Specificity, HIV/AIDS
Surgery: Postop Complications, Acute Blood Loss Anemia,
Thrombocytopenia, Obesity/Morbid Obesity, Malnutrition, OP Note
Clarification
Top QueriesAcross the system (excluding Golisano’s), the top queries for all providers consistently are as follows:
• Obesity/Morbid Obesity ALWAYS clinically significant as it can impact nursing care, equipment, etc. BPA fires for BMI over 25.
• Malnutrition Look for your dietary consult notes, BPA will fire if noted by dietary. Must be specified. Patient can have malnutrition with BMI over 19.
• Pressure Injuries Often noted in nursing documentation flowsheets, but never mentioned in MD notes.
• Congestive Heart Failure Must be specified by type and acuity.
The Query Process• A query is an electronic question posed to a provider by a
QD Registered Nurse.
• Most queries are derived from a template bank and are
usually in a multiple choice format.
• All queries are meant to be non-leading and the best
judgment of the practitioner is advised.
• Once answered and signed, the query becomes a
permanent part of the medical record.
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Answering The Query
• If a query is sent, it will populate in your EPIC in-basket for
chart completion.
• A query that is sent on a template can be answered in just
a few clicks.
• Select a response from the drop down menu of options or
manually fill in the appropriate response as needed.
• A signed query becomes a progress note.
• Physicians can grant access to their EPIC in-basket to their
advanced practitioners to answer the queries. This can be
arranged through EPIC support staff.
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Notice the phone number! Always call if you have ANY questions!!!
What if I don’t answer?
• QD personnel are required to notify providers of existing queries 48 hours after being sent. This can be done through email, AMION/Voalte text, paging system, office messages or personally if seen on campus.
• After 72 hours, the query is then placed on a deficiency list for VPs and Physician Advisors to review.
• QD personnel are located on each campus M-F to provide assistance or answer questions. Every query has a QDS phone number you can call for any questions!
Are you going to be
documenting in EPIC daily?
• Tired of searching through HUNDREDS of diagnoses?
• Want to make sure your diagnosis generates an ICD-10 code and is CMS
APPROVED?
• Contact Quality Documentation to set up your EPIC preference list!
Health Park: Robin Krainer (239) 343-8118
Cape Coral: Jenna Prisciandaro (239) 343-8135
Lee: Jenna Prisciandaro (239) 343-8135
Gulf Coast: AnnMarie Perlmutter (239) 343-8173
Creating your preference list takes less than 10 minutes and allows you to chart faster with better accuracy.
Creating a Preference List in EPIC
Visit us on Intralee!
Physician Documentation Resources
Includes past education on a variety of topics.
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The following physicians serve as liaisons for the Quality Documentation Department:
William Carracino MD, Vice President & Chief Medical Information Officer
Michael Bolooki MD, Medical Director of Informatics
If you would like to reach out to Dr. Bolooki for a peer to peer discussion, please email him at michael.bolooki@leehealth.org
Thank you
Any Questions?
Last Updated 2/12/2020 JP
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