Cerebral Palsy Infographic- Cerebral Palsy: A Gude For Parents
ACDIS | - How Via Web · Cerebral Palsy Example • 8 yo female, ex 34 weeker with history of...
Transcript of ACDIS | - How Via Web · Cerebral Palsy Example • 8 yo female, ex 34 weeker with history of...
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Pediatric CDI: Lessons Learned From a Tertiary, Freestanding Children's Hospital
Jodi P. Carter, MD, CDI Physician Champion
Nancy C. Rush, RN, BSN, CCM, CDI Manager
Mary Ellen Fee, RN, CCDS, CDI Specialist
Phoenix Children’s Hospital
Phoenix, Arizona
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Learning Objectives
• At the completion of this educational activity, the learner will be able to:
– Identify opportunities commonly found in pediatric tertiary medical centers
– Describe documentation opportunities found in the inpatient pediatric surgical population
– List two documentation opportunities found in pediatric ICU settings
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Practice Poll
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Phoenix Children’s Hospital
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Phoenix Children’s Hospital
• 385 licensed beds
• More than 70 subspecialty fields of pediatric medicine
• Over 18,000 inpatient admissions per year
• Over 16,000 surgical cases per year
©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
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Phoenix Children’s Hospital
• Provides approximately 60% of Arizona’s pediatric tertiary medical and surgical care for cardiac, orthopedic, neurologic, and oncologic populations
• Transplant services: Heart, renal, bone marrow, liver
• ECMO capability
• Level one trauma center
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Phoenix Children’s Hospital
• Payer mix = approximately 60% Medicaid
• 2014–2015 U.S. News & World Report Best Children’s Hospitals
– Cancer
– Cardiology/heart surgery
– Neurosurgery/neurology
– Orthopedics
• Leapfrog Group Top Children’s Hospital
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Phoenix Children’s Hospital CDI Program
• Established 2011
– Hospital CMI = local community hospital pediatric care
– Only one major DRG payer, but other contracts in active negotiation to convert to DRG
– 3 CDI specialists
– 1 physician champion
– Housed in finance with direct report to CFO
©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
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Get Your Cell Phones Ready!
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Phoenix Children’s Hospital CDI Program
• Our perception of critical success factors:
– All team members share equal responsibility for project success
– Engage providers in a personal and professional manner
– Develop a user‐friendly program
– Create specific queries for individual diagnoses
– Choosing to retain all queries as a permanent part of the medical record
• Includes concurrent and retrospective queries
• Includes queries generated by either CDI or coding
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Pediatric CDI Program Success
2011 2015
Hospitalwide CMI equivalent to local community hospitals’ pediatric care
CMI now in top quartile of freestanding children’s hospitals
Nonspecific documentation leading to lower reimbursement
Consistent financial contribution through improved documentation
Growing importance of public quality metric reporting
Improved public quality metrics (Leapfrog Group Top Children’s Hospital; U.S. News and World Report)
Only one major payer reimbursing by DRG, but actively renegotiating active commercial contracts
90% of payers reimbursing by DRG, including Arizona Medicaid (APR‐DRG)
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DRG Systems
• MS‐DRG– Used by Medicare
– Identify the sicker patient with:
• CC = Complications and comorbidities– Example: Salmonella gastroenteritis
• MCC = Major complications and comorbidities– Example: Salmonella septicemia
– CCs AND MCCs ARE IDENTIFIED BY PROVIDER DOCUMENTATION
• APR‐DRG– Used by Arizona Medicaid
– Identify the sicker patient with:
• SOI = Severity of illness (1–4)
• ROM = Risk of mortality (1–4)
– SOI AND ROM INCREASE WHEN PROVIDERS DOCUMENT THE INTERACTION BETWEEN MULTIPLE DISEASE PROCESSES AND COMORBIDITIES
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Pediatric CDI Program Success
CDI metric 2014
Physician response rate 99% average/year
Physician concurrence rate 75% average/year
DRG reassignment rate 34% average/year
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Pediatric Hospitals ≠ Adult Hospitals
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Get Your Cell Phones Ready!
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Top Performing Pediatric Opportunities
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Pediatric Hospital Medicine
Children with complex chronic illness
• Multiple comorbidities
• Potential for long LOS
• Example: Cystic fibrosis
Healthy children with acute illness
• Few comorbidities
• High intensity/short stay
• High volume of respiratory disease
• Top 2 admissions by volume each year:
– Asthma
– Bronchiolitis
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Maximizing Common Respiratory Illnesses
Common respiratory illnesses
• Asthma– Acute respiratory failure (MCC)
– Acute on chronic respiratory failure (MCC)
– All comorbid secondary conditions
• Bronchiolitis– Acute respiratory failure (MCC)
– Acute on chronic respiratory failure (MCC)
– All comorbid secondary conditions
• Capture isolation precautions (increases SOI)
Our definitions of respiratory failure
• Acute respiratory failure– Blood gas with pCO2 > 50,
pH < 7.35, pO2 < 60
– Initiation of positive pressure ventilation to maintain gas exchange
• Acute on chronic respiratory failure – Patient chronically on positive
pressure ventilation
– Blood gas with pCO2 > 50, pH < 7.35
– Increase in positive pressure ventilation
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Cystic Fibrosis: A Challenge in Sequencing
• For a patient admitted with a CF exacerbation, should the exacerbation of CF always be sequenced first?
• Not always …– Ask yourself, “Is the reason for admission the cystic fibrosis itself
(e.g., poor compliance with home respiratory therapies has led to difficulty breathing) or a cystic fibrosis complication (e.g., an infectious bronchitis has led to difficulty breathing)?”
– If the reason is the cystic fibrosis itself, the principal diagnosis will be “cystic fibrosis with pulmonary manifestations” (277.02)
– If the reason is an infectious bronchitis, the principal diagnosis will be “infectious bronchitis” (466.0) and the CF will be a secondary diagnosis
• Reminder: Capture isolation precautions (increases SOI)
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Get Your Cell Phones Ready!
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Pediatric Surgical Opportunities
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Pediatric Surgical Opportunities
• Neurosurgery
– Brain compression
– Cerebral edema
• Orthopedic surgery
– Cerebral palsy
• General surgery
– Anemia from acute blood loss around the time of surgery
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Neurosurgery
• Brain compression
INSTEAD OF DOCUMENTING PLEASE CONSIDER
Mass effectMidline shift
Brain compression (MCC)
Note: Incidental findings on an imaging study with no clinical impact should not be coded. There must be clinical impact.
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Brain Compression Example
• 15‐mo‐old female with history of brainstem PNET. Despite chemotherapy tumor has grown. Admitted to hospital for surgical debulking.
• Pre‐op brain MRI: “There has been marked interval increase in size of irregular exophytic brainstem mass … with mass effect upon the optic nerves …”
• Progress note: “… s/p suboccipital craniotomy for resection of posterior fossa PNET …”
Mass effect with compression of the brain
Mass effect on imaging without clinical significance
Other Unable to determine
ORIGINAL REVISED
Weight 2.977 4.6927
SOI/ROM 1/1 3/4
Reimbursement Over $25,000
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Neurosurgery
• Cerebral edema
INSTEAD OF DOCUMENTING PLEASE CONSIDER
Brain swelling Cerebral edema (MCC)Brain edema (MCC)
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Cerebral Edema Example
• 6‐month‐old male presented to ER with fever, lethargy, and emesis. LP done in ER was concerning for gram‐negative bacterial meningitis. Patient admitted to PICU.
• Brain MRI demonstrated intra‐ventricular debris (that was concerning for pus) as well as some small loculated collections in the subdural space, and patient was started on Decadron.
• CSF culture ultimately grew H. flu.
H. flu meningitis with ventriculomegaly and cerebral edema
H. flu meningitis with ventriculomegaly and compression of the brain
H. flu meningitis with ventriculomegaly without compression or edema
Other
Unable to determine
ORIGINAL REVISED
Weight 2.2787 3.4974
SOI/ROM 3/2 4/3
Reimbursement Over $40,000
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Orthopedic Surgery
INSTEAD OF DOCUMENTING PLEASE CONSIDER
CP Specific type of cerebral palsy (plegia = paralyzed; paresis = weakened)
Cerebral palsy Topography: Monoplegia/monoparesis
Diplegia/diparesis (CC)
Hemiplegia/hemiparesis (CC)
Paraplegia/paraparesis (CC)
Triplegia/triparesis (CC)
Tetraplegia/tetraparesis (MCC)
Quadriplegia/quadriparesis (MCC)
Spasticity: Spastic
Non‐spastic
Note: When a CP patient has quadriplegia, you should not look for an additional code of “functional quadriplegia.” It is inherent to the code of CP quadriplegia.
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Cerebral Palsy Example
• 8 yo female, ex 34 weeker with history of cerebral palsy and GERD admitted for Nissen fundoplication
Congenital quadriplegic cerebral palsy
Congenital diplegic cerebral palsy
Congenital paraplegic cerebral palsy Other
Unable to determine
ORIGINAL REVISED
Weight 1.38 5.68
SOI/ROM 2/1 2/2
Reimbursement Over $50,000
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Surgery
• Acute blood loss anemia
INSTEAD OF DOCUMENTING PLEASE CONSIDER
Low hemoglobin Anemia due to acute blood loss from a disease (name the disease) (CC)
Low hematocrit Anemia caused by acute blood loss from surgical complication (name the complication) (CC)
Decreased RBC count Low hematocrit from hemodilution (not a CC)
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Acute Blood Loss Anemia Example
• 16 yo female with a history of idiopathic scoliosis that is now > 50 degrees
• Admitted for posterior spinal fusion, T3 ‐> L3
• EBL = 1000 cc; 525 cc cell saver given
• H/H 10.0/30.2 7.2/20.4
• Postoperatively patient becomes tachycardic, PRBCs given
• Note: You must account for the expected dilutional effect on H/H when making the decision to query for this diagnosis postoperatively
Acute blood loss anemia Chronic blood loss anemia
Acute on chronic blood loss anemia Other
Unable to determine
ORIGINAL REVISED
Weight 5.0565 6.3425
SOI/ROM 1/1 2/1
Reimbursement Over $16,000
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Pediatric ICU Opportunities
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Pediatric ICU Opportunities
• PICU
• NICU
• CVICU
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Pediatric ICU Opportunities
• Respiratory failure
INSTEAD OF DOCUMENTING PLEASE CONSIDER
Tracheostomy dependentVentilator dependentBiPAP dependentCPAP dependent
Chronic respiratory failure (CC)
Increased work of breathing Acute respiratory failure (MCC)
Acute on chronic respiratory failure (MCC)
Note: Clinical correlation needed to confirm appropriateness of these CCs and MCCs
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Example: Respiratory Failure
• 6 mo female with hx of type I SMA (on BiPAP at all times) admitted to PICU with increased thoracic/abdominal asynchrony and increased work of breathing
• ABG shows pCO2 = 60
• In PICU BiPAP settings increased above baseline and aggressive airway clearance initiated
• Provider queried for respiratory failure:
Acute respiratory failure Acute on chronic respiratory failure
Chronic respiratory failure Other
Unable to determine
ORIGINAL REVISED
Weight 0.9091 2.0549
SOI/ROM 3/2 3/3
Reimbursement Over $10,000
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Pediatric ICU Opportunities
• Shock
INSTEAD OF DOCUMENTING PLEASE CONSIDER
Hypotension Shock (CC)
SPECIFIED shock (MCC)
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Example: Shock
• 13 yo female with hx of a “genetic syndrome,” global developmental delay, spastic quadriplegic CP, epilepsy, GERD, and neuromuscular scoliosis admitted for posterior spinal fusion.
• L pleural space entered while dissecting to the spine. Pt became hypotensive. Dopamine drip started. Crystalloid, albumin, PRBCs, FFP, and cell saver given in OR. Transferred to PICU on dopamine drip, intubated, and hypothermic with a SBP in the 50s.
ORIGINAL REVISED
Weight 1.8091 3.0782
SOI/ROM 3/2 3/2
Reimbursement Over $20,000
Hypotension without shock Postoperative cardiogenic shock during/resulting from surgery
Postoperative hypovolemic shock Postoperative shock during/resulting from surgery
Other Unable to determine
Note: This example assumes the CDI specialist is aware of the connection between the pneumothorax and the shock state. In this example, there is also a coding opportunity for iatrogenic pneumothorax.
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Neonatal ICU Opportunities
• Neonatologists forget how sick their patients are
– Acute respiratory failure (MCC)
– Cardiogenic shock (MCC)
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Cardiovascular ICU Opportunities
• Hypoplastic left heart syndrome (MCC)
• Three phase surgical correction
– Norwood
• Performed within the first 2 weeks of life
– Bi‐directional Glenn shunt
• Performed between the ages of 4 and 6 months
– Fontan
• Performed between 18 months of age and 3 years of age
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Hypoplastic Left Heart Syndrome
INSTEAD OF DOCUMENTING PLEASE CONSIDER
“s/p Norwood” Hypoplastic left heart syndrome (MCC)
“s/p Glenn”
“s/p Fontan”
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Thank you. Questions?
[email protected]@[email protected]
In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.