Clinical Documentation –Why We Care

Shelley L. Oglesby, M.Ed, RHIT, CCS-P

Manager, Coding & Reimbursement

Nancy Ignatowicz RN, BS, MBA, CCDS Manager Clinical Documentation

July 24, 2013 Surgical Residents Orientation

7

Significance of Documentation

Acuity / severity of illness

Risk of mortality, O:E Pt walks out alive, the hospital’s profile improves when comparing hospitals & outcomes.

QUALITY measures

Patient safety indicators

Physician profiles, research data & funding

Intensity of services provided => hospital receives the appropriate reimbursement.

Academically sound note writing.

Why Care?

Proper documentation ensures appropriate severity of illness (SOI) and risk of mortality (ROM):

Substantiates Medical Necessity for Appropriateness of admission/continued stay Versus observation status or even outpatient

Truly reflects how complex your patient is, how ill they are, and how likely they are to die

It’s the right thing to do

4

CDI

Clinical Documentation Improvement Team

7

The role of the Clinical Documentation Specialist (CDS)

RN’s review the medical record concurrently to ensure treated diagnoses are documented with specific terminology so the coder can code the most appropriate codes for Severity of Illness (SOI) & Risk of Mortality (ROM)

Clarifications are asked when an additional or more specific diagnosis may be present but not documented in verbiage that can be coded

The role of the Coder

Coder reviews the medical record post-discharge to assign the most appropriate ICD diagnosis(es) and procedure(s) codes to ensure accurate Severity of Illness (SOI) & Risk of Mortality (ROM) and appropriate MS-DRG assignment

Clarifications are asked when an additional or more specific diagnosis may be present but not documented in verbiage that can be coded

Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive 8

Common opportunities for clarification

Records indicate

-..Post surgical anemia…

-..Hypotensive, requires vasopressors, tachycardia, multiple fluid boluses…

-..Intubated for airway protection…

-In PACU patient unresponsive, desat to 88% requiring reintubation…

Consider Documenting

Acute Surgical Blood Loss

Anemia

Shock and Type

Acute Respiratory Failure/

Acute Respiratory Distress

How to Avoid a Clarification/Query

With EVERY DIAGNOSIS consider:

Etiology

Severity

Type

Present or evolving on admission (POA)

Clinical manifestations

Treatment

Pathology findings

Valued Tips

1. Specify the diagnosis that best supports the principal reason for the inpatient admission to the hospital (condition established after study)

2. Use the following acceptable terms to describe uncertain diagnoses: Probable, suspected, likely, possible Avoid terms such as “concern for” or “VS”

Diagnoses should be based on a physicians clinical judgment.

Valued Tips

3. Identify conditions/diagnoses that are present on admission (POA status)- present at the time the inpatient admission occurs, includes conditions that develop during an outpatient encounter (emergency room, observation, outpatient surgery) that result in an inpatient admission

Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive

Valued Tips

4. List comorbid/complication diagnosis which are defined as: conditions that coexist at time of admission conditions that develop subsequently conditions that affect the treatment/care conditions that impact the length of stay Include chronic conditions such as hypertension, COPD etc 

Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive

Gaps in Documentation

UNABLE TO CODENa 130 -> fluid restriction

Dirty UA -> antibiotics

Post surgical anemia, will monitor/Blood loss-> PRBC

Elevated creatinine-> IVFs

LUL opacity -> Zosyn

Flash pulmonary edema

ACCEPTABLE TO CODEHyponatremia

UTI

Acute Blood loss anemia due to trauma/ruptured aneurysm

AKI or ARF

LUL bacterial pneumonia

Acute pulmonary edema

Avoid the TERM POST-OP

Gaps in Documentation

UNABLE TO CODE

Abdominal fluid

Dyspnea, SOB requiring BiPap/high flow O2 NC/intubation

Hypotension, vasopressors,

EBL,temp, tachycardia,

Tachypnea

ACCEPTABLE TO CODE

Abscess/ intraperitoneal abscess/peritonitis

Acute respiratory distress or acute respiratory failure

Consider shock and type

Examples

Documentation of ALL secondary diagnoses present is how Severity of Illness (SOI) & Risk of Mortality (ROM) is captured

Do you think Loyola patients are sicker than patients in community hospitals??

Patients are only as critical / complex as their documentation indicates

16

Inherent DiagnosesSigmoidectomy Sigmoidectomy

PDx: DiverticulitisSigmoidectomy

PDx: DiverticulitisSigmoidectomyPeritonitis present on

admission

RW LOS SOI ROM RW LOS SOI ROM

1.6361 5.0 1 1 5.2599 14.9 2 1

With post op Ileus

2.5731 8.6 2 1

If Acute Kidney Injury added If Acute Kidney Injury added

RW2.5731

LOS 8.6

SOI 2

ROM 2

RW5.2599

LOS 14.9

SOI 3

ROM 2

Admitted with colon cancer

52 yo with esophageal cancer with left hemicolectomy

RW LOS SOI ROM

1.6361 5.0 2 1

Documented: Stage 3 colon cancer 1.6361 5.0 2 1

With confirmation of path findings for positive lymphadenectomy: lymph nodes positive for metastatic carcinoma

2.5731 8.6 2 2

18

Admitted for Lumbar Spinal Fusion

63 yo with chronic back pain s/p lumbar/sacral fusion T10 to S1 EBL 1000cc

RW LOS SOI ROM

3.8783 3.6 1 1

Clinical: history of diastolic heart failure hold lasix

3.8783 3.6 2 2

Documented: overnight Pt hemodynamics unresponsive to fluid resuscitation requiring pressors

3.8783 3.6 2 2

With complete documentation: Overnight Pt hemodynamics unresponsive to fluid resuscitation requiring multiple pressors. Hypovolemic shock

6.5390 9.1 2 2

19

Admitted for removal of renal mass/lesion

52 yo with enhancing lesion right kidney, suspicious for solid lesion

RW LOS SOI ROM

1.3335 2.9 2 1

Clinical: history of atrial fibrillation

1.3335 2.9 2 1

Documented: underwent right robotic assisted retroperitoneal partial nephrectomy without complication

1.3335 2.9 2 1

With complete documentation: Right renal cell carcinoma

1.4836 3.2 2 1

20

Admitted with esophageal cancer

52 yo with esophageal cancer for surgical resection

RW LOS SOI ROM

5.6118 15.4 3 2

Documented: celiac lymphadenectomy also performed 5.6118 15.4 3 2

With confirmation of path findings for lymphadenectomy: celiac lymph nodes positive for metastatic carcinoma

5.6118 15.4 3 3

QualityYour notes get better from an academic standpoint

Explains reason for admission/readmissionExplains mortalityLow SOI/ROM score could be explained from review of records showing failure to document comorbidities I.E. malnutrition, pre-op ileus, anxiety, obesity, Chronic systolic CHF, CKD stage 3, Acute blood loss anemia due to liver laceration from trauma, Shock, peritonitis, sepsis from pre-surgical rupture diverticulum, Respiratory failure from pulmonary fibrosis, toxic encephalopathy related to sepsis…

Present on admission (POA)Define if condition was POA, evolving on admission/natural progression of diseaseLINK symptoms to diagnosis determined after further diagnostics and evaluations

Inpatient Medical Record

History & PhysicalWhy inpatient admission necessary

Reason for inpatient surgical admission

Include diagnoses in assessment plan not just PMH

Progress Notes & ConsultationsLink significance of findings/treatments (medications, diagnostics) to diagnoses

Discharge SummaryShould include all diagnoses addressed during this admission including chronic,resolved problems and any pathological findings(including post discharge)

ICD-10

Lack of documentation is becoming a problem for acceptance.

Wieste Venema

ICD-10- Prepare Now

For example, if a patient has a diagnosis of an abscess of bursa of the right shoulder, the appropriate code is M71.011 (abscess of bursa, right shoulder).

In ICD-9-CM, coders would report this condition with code 727.89 (disorder of synovium/tendon/bursa), which lacks site and laterality specificity.

ICD-10- Prepare Now For 34 years, a closed, midcervical fracture of the femur has been coded as 820.02, using ICD-9,no other information needed

ICD-10-CM requires additional detail—Is it the right femur or the left femur? Is this an initial encounter or a subsequent encounter? Is the fracture healing nicely or delayed? ICD-10 has four codes and your documentation must note which femur, what type of encounter, and whether a complication exists.

Take Away

Document Who

Document What

Document Why

Document How

Document When

Contact Information

CDS – Michele E. Huguley RN (9)646-9235 mhuguley@lumc.edu

CDS – Gail Klotz RN BSN (9)250-4108 gklotz@lumc.edu

Manager - Nancy Ignatowicz RN, BS, MBA, CCDS (9)646-9057 nignatowicz@lumc.edu

Contact Information

Lead Coders – Anjie Marth x64559 amarth@lumc.edu

Lead Coders –Pattie Hise x68542 phise@lumc.edu

Manager – Shelley L. Oglesby, M.Ed, RHIT,CCS-P x62132 soglesb@lumc.edu