PART 3 - DOCUMENTATION · ICD-9-CM vol. 1 & 2 (Diagnosis Codes) ICD-10-CM (Diagnosis Codes) 3-5...
Transcript of PART 3 - DOCUMENTATION · ICD-9-CM vol. 1 & 2 (Diagnosis Codes) ICD-10-CM (Diagnosis Codes) 3-5...
PART 3 - DOCUMENTATION
Presented by
Steve Wirth, Esq., CAC, CACO, CAPO
Dan Pedersen, Esq., CAC, CACO, CAPO
www.pwwemslaw.com
5010 E. Trindle Road, Suite 202 Mechanicsburg, PA 17050
717-691-0100 717-691-1226 (fax)
[email protected] [email protected]
© COPYRIGHT 2015, PAGE, WOLFBERG & WIRTH, LLC. ALL RIGHTS RESERVED. REPRODUCTION BY ANY MEANS EXPRESSLY PROHIBITED WITHOUT
THE WRITTEN CONSENT OF PAGE, WOLFBERG & WIRTH, LLC.
ICD-10 FOR THE
AMBULANCE INDUSTRY
2015
Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050
www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226
Stephen R. Wirth, Partner [email protected]
Steve Wirth is a founding partner of Page, Wolfberg & Wirth, LLC, and is one of the best known EMS attorneys and consultants in the United States. Widely regarded as the nation’s leading EMS law firm, PWW represents private, public and non-profit EMS organizations, as well as billing companies, software manufacturers and others that serve the nation’s ambulance industry. In a distinguished public safety career that spans four decades, Steve has worked in virtually every facet of EMS – as a first responder, firefighter, EMT, paramedic, flight paramedic, EMS instructor, fire officer, and EMS executive – and was one of central Pennsylvania’s first paramedics. Steve brings a pragmatic business-oriented perspective to his diverse legal practice having served for almost a decade as senior executive of a mid-sized ambulance service, helping to build the company from the ground up.
Steve is a dynamic and sought after speaker at regional, state and national conferences on a variety of EMS and public safety subjects. He has authored numerous articles and book chapters on a wide range of EMS leadership, reimbursement, risk management, corporate compliance and workplace law topics. A contributing writer for JEMS, (where he serves on the editorial board), EMS Insider and EMS World, Steve has co-authored the highly acclaimed and popular compliance manuals and video training programs produced by PWW. He enjoys teaching and is an adjunct instructor for the University of Pittsburgh EMS degree program.
Steve graduated cum laude from Duquesne University School of Law and was a member of the school’s national trial and appellate advocacy competition teams. He is admitted to all Pennsylvania state courts, all federal district courts in Pennsylvania, and the United States Court of Appeals for the Third Circuit. Steve also holds a Master of Science degree in Health Services Administration with an emphasis in organizational behavior.
Steve remains in touch with patient and field provider issues as an active EMS provider and nationally certified firefighter with Hampden Township Fire Rescue where he serves as Incident Safety Officer and Medical Officer. He is a life member of the Nippenose Valley Fire Co. near Jersey Shore, PA, where he started his public safety career as a junior firefighter and served as Deputy Fire Chief. Steve has volunteered for many charitable organizations and is currently on the board of the Pennsylvania Fire and Emergency Services Institute and the Pennsylvania EMS Providers Foundation. Steve is a Certified Ambulance Coder (CAC) and a founder of the National Academy of Ambulance Coding (NAAC). He is a past Commissioner for the Commission on Accreditation of Ambulance Services (CAAS), and served as Chair of the Panel of Commissioners. Steve was the recipient of the prestigious James O. Page Leadership Award in 2013.
2015
Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050
www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226
Daniel J. Pedersen, Esquire [email protected] Daniel Pedersen is a Senior Associate Attorney with the nationally recognized law firm of Page, Wolfberg & Wirth, LLC. The firm represents ambulance services, municipalities, fire departments, hospitals, and other organizations in a wide range of medical transportation issues.
Daniel joined PWW in 2005, after spending several years at a health care firm in Harrisburg, PA. At Page, Wolfberg & Wirth, Daniel concentrates his legal practice in the areas of compliance, Medicare reimbursement, HIPAA, and federal and state regulatory issues that affect ambulance services, including the false claims act and anti-kickback statute. Daniel spends much of his time performing compliance and claim reviews, including on-site visits and training sessions, and handling Medicare appeals on behalf of clients around the country. Daniel is admitted to practice law in Pennsylvania.
A 1998 Graduate of Franklin & Marshall College in Lancaster, PA, Daniel majored in Biology and English before attending law school. While at Franklin & Marshall, Daniel was involved with the yearbook, Pep band, golf team, Biology club, and served as an Orientation Advisor. He earned his J.D. from Pace University School of Law in White Plains, NY in 2002, and spent his third year of studies as a visiting student at Widener School of Law in Harrisburg, PA. While at both Widener and Pace, Daniel was a research assistant for law professors. While on sabbatical from law school in 1999, Daniel worked as a Quality Assurance Analyst for Wyeth-Ayerst Laboratories in Marietta PA. Daniel resides in Hummelstown, PA with his wife and three children. As a family, they enjoy such activities as reading, swimming, playing golf and tennis, and vacationing in Myrtle Beach.
IMPORTANT NOTICE FOR SEMINAR ATTENDEES The information presented in this seminar and these supporting materials does not constitute legal advice or a definitive statement of the law. These materials are for educational purposes only and to provide a general overview of the issues discussed. The information contained in these materials and discussed at this seminar are subject to change at any time by new laws or regulations, repeals or modifications of existing laws and regulations, court and agency decisions, and in numerous other ways. While our materials are, whenever possible, based on official sources of information from Medicare and other government agencies, you must consult the official sources of materials from those agencies – including regulations, manuals, policies, advisory opinions, etc. – for official statements of the law and government policy. Of course, we cannot be responsible to update these materials for you, nor are we responsible for any documentation, billing, compliance, reimbursement, legal or other decisions you make based in whole or in part upon these materials. We use examples of documentation, billing scenarios and other teaching illustrations throughout this seminar, and they are just that – examples. Do not use any wording in your own documentation unless it is truthful and accurate. While we believe the information presented in this seminar and in these materials to be accurate, errors (such as typographical or other content errors) are possible. Ensure that your agency’s legal counsel is aware of any specific legal issues you may have. All materials are the Copyright of Page, Wolfberg & Wirth, LLC unless otherwise noted. No part of this material may be duplicated, reproduced or distributed by any means. No audio, video and/or digital recording of any type is permitted at this conference. By attending this seminar, and/or utilizing these materials, you agree to these terms and conditions.
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ICD-10 for the Ambulance IndustryPart 3 of 3: Documentation
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Today’s Webinar New Era of “Documenting for Detail” Clinical Documentation Improvement
(CDI) for EMS Documentation Compliance Checklists
(DCCs) CDI Queries CDI Implementation, Training, Auditing
and Evaluation Documentation Examples
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PLEASE NOTE Any examples of documentation used in this
presentation are strictly for illustrative purposes only. These examples should not be used as “templates” or
“scripts.” Your agency’s documentation must be based on an objective assessment of the patient by your crews, accurately reflect the patient’s clinical condition, and should be honest, complete, and
accurate at all times!
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New Era of “Documenting for Detail”
Essential with ICD-10
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Clinical Documentation
Defined: a digital or analog record detailing the EMS patient encounter to include accurate, timely and specific descriptions of the patient assessment, condition of the patient, and treatments/services provided
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The Goal
Clinical documentation that accurately and precisely as possible reflects the patient’s condition and services performed, so we can have…
Billing codes that accurately and precisely reflect that patient’s condition and the services performed
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We Are All in This Together!
Partnership between field providers, billing staff, dispatch, quality assurance, training, and management
Develop standards for documentation – then communicate, train, evaluate, provide feedback – and improve!
Communication and training are the key
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ICD-10 is not just a coding challenge.
It’s a documentationchallenge.
ICD-9-CM and ICD-10-CM Comparison
ICD-9-CM vol. 1 & 2 (Diagnosis Codes) ICD-10-CM (Diagnosis Codes)
3-5 characters in length 3-7 characters in length
Approximately 13,000 codes Approximately 68,000 available codes
First digit may be alpha (E or V) or numeric; Digits 2-5 are numeric
First digit is alpha; Digits 2-3 are numeric; Digits 4-7 are alpha or numeric
Limited space for adding new codes Flexible for adding new codes
Lacks detail Very specific
Lacks laterality Has laterality
Example: 453.41 Venous embolism and thrombosis of deep vessels of proximal lower extremity
Example: I82.411 Embolism and thrombosis of right femoral vein
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Identified in the January 16, 2009 – HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS Final Rule © Copyright 2015 PWW Media, Inc.
Diagnosis Code Structure
S52.311A Greenstick fracture of shaft of radius, right arm, initial encounter for closed fracture
Root Root Root Site Severity Etiology Extension
S 5 2 3 1 1 A
Injury, poisoning and certain other
consequences of external
causes
Injuries to the elbow and
forearm
Fracture of
Forearm
Radial Shaft
Greenstick Right Initial Encounter
22
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“New” Documentation Concepts
Specificity – more detail as to types of injuries, anatomic location, location of incident, etc.
Laterality – accurately describing which side of the body is affected by the insult or injury (left, right, bilateral)
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Specificity Example - Fracture
ICD-10-CM ICD-9-CM
S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture
82002 Fracture of midcervical section of femur, closed
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The “Clinical Documentation Improvement” (CDI) Process
for EMS
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Why EMS Documentation Is So Difficult
Because each health care consumer has his or her own unique combinations of medical conditions that your EMS agency must somehow standardize for data comparison and to ensure compliant reimbursement
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CDI Bridges the Gap!
Field Providers Document in Clinical Terms
Billers Code Claims in Diagnostic Terms
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Goal of Clinical Documentation Improvement (CDI)
ICD-10 is an opportunity to improve clinical documentation and enhance patient care for all patient conditions
CDI is a team process that does that – sharpening the focus on obtaining the highest level of documentation possible
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What is CDI?
A process for improving the quality of clinical documentation – to facilitate an accurate representation of the services provided through complete and accurate reporting of patient assessment, procedures, and transport performed
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Role of CDI
Impacts quality measures and data used in health care reform and other initiatives that requires more specificity in clinical documentation
Improves accuracy of clinical documentation to reduce compliance risks, minimize audit vulnerability, and provide insight into legal quality of care issues
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CDI Promotes . . .
Positive patient outcomes through improved continuity of care
Accurate reflection of the level of care provided to the patient
More precise information for quality improvement measures and for public health purposes
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In Today’s Audit and Enforcement Climate a Clinical Documentation Improvement (CDI) Program is Absolutely
Essential!
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The Key to High Quality PCR Documentation is a Complete,
Thorough and Well Documented Patient
Assessment!
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A Systematic Approach to Patient Assessment Leads to a
Systematic Approach to Patient Documentation
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Assessment Elements
Scene evaluation and size-up Initial patient assessment
• Identify/assess life threats• General impression of patient’s
condition Rapid Trauma or Medical Assessment
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Assessment Elements
Focused History and Physical Exam Detailed Physical Exam Ongoing Patient Assessment
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Acronyms Can Help Crews Remember Key Assessment
Elements
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A.V.P.U.
A = awake, alert and oriented x4 V = alert to voice but not oriented x4 P = responsive to pain stimulus only U = unresponsive to both voice or
painful stimulus
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D.C.A.P. – B.T.L.S.
D = Deformities C = Contusions A = Abrasions P = Punctures or penetrations B = Burns T = Tenderness L = Lacerations S = Swelling
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D.O.T.S
D = Deformities O = Open injuries T = Tenderness S = Swelling
• Addressed for each area of the body
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S.A.M.P.L.E.for Patient History
S = Signs and symptoms A = Allergies M = Medications P = Pertinent past medical history L = Last oral intake E = Events that led up to the situation
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O.P.Q.R.S.T
O = Onset P = Provocation Q = Quality R = Radiation S = Severity T = Time
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Documentation Narrative Formats
S.O.A.P. C.H.A.R.T. C.H.E.A.T.E.D.
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S.O.A.P.
S = Subjective O = Objective A = Assessment P = Plan
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C.H.A.R.T.
C = Chief Complaint H = History (Present and Past) A = Assessment R = Rx or Treatment T = Transport and condition enroute
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C.H.E.A.T.E.D.
C = Chief complaint or concern H = History E = Examination A = Assessment T = Treatment E = Evaluation/effectiveness of
treatment D = Disposition
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Elements of the CDI Process
Identify Common
Conditions
Define Documentation Requirements
Communicate Documentation
Standards
Constantly Review the CDI Process
Audit Documentation
Practices
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1. Identify the Most Common EMS Patient Conditions
ALS and BLS treatment protocols CMS Condition Code list Evaluate historical run data by chief
complaint Statewide or regional protocols
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Examples - Emergency
Chest pain Abdominal pain Nausea and vomiting Emergency childbirth Hemorrhage Possible stroke Fall victim
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Examples - Nonemergency
Inter-facility transport Discharge from hospital to SNF Transport ESRD patient for dialysis Transport for specific treatments
(rehab, radiation, etc.) Transport from SNF to hospital for
direct admission Psych transports
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2. Define the Documentation Requirements for Each Condition
Review national texts, curricula, treatment protocols
Obtain medical review committee and medical director input
Involve field staff
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Bottom Line
Develop list of key elements that must be assessed and documented for each primary patient condition encountered
Audit PCRs based on these elements Provide feedback, constructive
counseling and training to promote improvement
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If You Don’t Measure It . . .
You can’t MANAGE it You can’t CONTROL it You can’t IMPROVE it
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3. Communicate the Documentation Standards
Communicate documentation elements for key patient conditions
Integrate CDI training into all aspects of leadership and staff training• Initial orientation• Continuing education• Remedial education
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4. Audit Documentation Practices by Patient Condition
Audit PCRs using standard documentation elements necessary to document each condition
Identify documentation strengths and weaknesses • On an individual basis• On an agency basis using “trends” to target
additional documentation training
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Audit Documentation Practices
Provide follow up concurrently –initiate a CDI Query on inadequate PCR documentation
Provide follow up retrospectively –communicate audit stats and model additional training based on common issues of weakness
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5. Constantly Review the CDI Process
Evaluate common strengths and weaknesses and modify approach as necessary
Evaluate appropriateness of CDI Queries to ensure focus is on the clinical documentation
CDI Oversight Team to meet quarterly
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Developing “Documentation Compliance Checklists” (DCCs)
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Develop “Documentation
Compliance Checklists” for
Each Primary Patient Condition
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EMS Patient Conditions
Every primary patient condition encountered by a field provider should have an established checklist of issues that must be addressed in the documentation
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Example Condition: “Pain”
Issues that should be documented:• O nset• P rovocation• Q uality• R adiation• S everity• T ime
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Example Documentation Compliance Checklist –
Abdominal Pain
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Abdominal Pain
Initial Assessment?• ABCs and Chief Complaint
Focused History and P.E.?• How and where was patient found?• Skin color, temp, condition• Location and quality of pain
Associated Symptoms PQRST
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Abdominal Pain
Abdominal Assessment• Tenderness• Rebound tenderness• Rigidity• Guarding• Pulsatile masses• Surgical scars
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Abdominal Pain
Back pain? (location, quality, radiation, etc.)
Female – menstrual period normal? Nausea and vomiting? Bowel movements? Urination (pain, color, amount,
frequency) Position of comfort?
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Abdominal Pain
Oral intake and meals? Fever? Other signs and symptoms? Allergies? Medications? Pertinent past medical history? History of present illness? Vital signs
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Abdominal Pain
Interventions?• Oxygen• Cardiac monitor• IVs or saline lock• Medication administration• Position of transport
Response to treatments? Condition enroute and at hospital?
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Example Documentation Compliance Checklist –Altered Mental Status
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Altered Mental Status
Patient oriented to time?• Knows time of day?
Patient oriented to place?• Knows where they are?
Patient oriented to person?• Knows who they are and others around
them? Patient oriented to situation?
• Knows what is happening?
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Altered Mental Status
Syncopal episodes? Glasgow Coma Score assessed and
documented at intervals? Neurological assessment completed? HPI and PMH obtained?
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Example Documentation Compliance Checklist –Refusals of Transport or
Treatment
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Refusals of Transport/Treatment
Complete patient assessment documented?• Past history of mental issues?• Medications that impact mental status?• Suicidal ideations?• Risk to self or others?
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Refusals of Transport/Treatment
Patient’s mental status? (“A&Ox4”?) Glasgow coma score? Attempts to persuade patient and
patient’s response? Communication with family members
at scene?
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Refusals of Transport/Treatment
Patient’s understanding of possible injuries/illness?
Discussion of the risks and consequences of non-transport explained?
Patient’s understanding of the risks? Alternatives for care and transport
suggested by the crew?
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Refusals of Transport/Treatment
Contact with Medical Command? Recommendation to seek medical care
in some way? Offer to return if patient changes
mind? Providing follow-up instruction?
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Refusals of Transport/Treatment
Actual refusal form read to and understood by patient?
Obtain patient/witness signature
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DCCs apply to demographic documentation as well as
clinical documentation
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Example Documentation Compliance Checklist –Patient Information and
Demographics
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Patient Information/Demographics
Full patient name documented accurately
Pt DOB recorded in mm/dd/yyyy format Complete address of P.O.P. and patient
home address documented
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Patient Information/Demographics
SSN documented Signature of patient obtained If patient incapable of signing,
specific reason documented and signature of authorized representative obtained
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When You Need More:Proper Use of “CDI Queries”
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CDI Query Process
Key element of CDI is provider communication
A “CDI Query” is a routine communication and education tool used to advocate complete and compliant documentation and to ensure accuracy of the PCR
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Types of CDI Queries
Written Queries• Based on established documentation
elements for specific patient condition• Helps avoid miscommunication on “why”
the query is being made
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Types of CDI Queries
Verbal Queries• Usually for elements that are simply
missing or for minor issues• More likely to be “misconstrued”
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When to Query?
Lack of clinical indicators of an undocumented condition (e.g., suspected shock as a “provider impression”)
Need for further specificity or degree of severity of a documented condition (e.g., pain)
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When to Query?
Clarifying a potential cause and effect relationship
Missing fundamental information necessary for that particular “condition” or “chief complaint”
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The Proper Query
When additions, clarifications or amendments are required, it is critical to reinforce that proper documentation is the goal
Avoid even the appearance of “suggestive” documentation
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Compare“Suggestive”
“Your PCR fails to document medical necessity. Please document bed confined status so we can bill this.”
Proper
“This PCR does not document whether the patient could ambulate, sit in a chair/wheelchair or get out of bed unassisted. Please complete accurately according to observed pt condition.”
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The Effective “CDI Query”
It is critical to be precise, not only in what you say but how you say it
Be sure to communicate these requests in a way that your intent cannot be misconstrued
Always emphasize importance of accuracy and honesty in documentation
Why Must You Emphasize Honesty,
Accuracy and Completeness?
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Billing Investigations
Investigators may interview your crew members
This often happens even before your agency knows of the investigation
“Have you ever been asked to change your patient care reports for billing purposes?”
“Have you ever been asked to put down that the patient was bed confined when the patient was not bed confined?”
“Have you ever been asked to write an addendum to add things that you knew were not true?”
“Have you ever been told never to write that a patient walked to the stretcher?”
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Points for Providers
Being asked to clarify, amend or append your documentation does not mean you are being asked to falsify documentation
Providers should never be told to document anything that isn’t true, and they should not be directed on what to write for billing purposes
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Points for Providers
The focus of any documentation query must be on improving clinical documentation
If a PCR is incomplete or unclear, field providers should be asked to make it complete and accurate – that is the provider’s job
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Points for Providers
Having a complete and accurate PCR that paints a clear picture is an essential part of patient care
If you didn’t do that the first time, we have every right to ask you to do it the second time
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SAMPLE “Clinical Documentation Query Form –
Non-Emergency Transport”
Model form only! You will need to decide how to use this form – e.g., part of patient record, or worksheet to be used for crews to complete an addendum
Only implement after you establish a policy on use of queries and you train your personnel
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CDI Tips for Implementation, Training, Auditing and Evaluation
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Training Must Change!
QA staff and supervisors need to focus on CDI
Communicate the documentation standards for each key condition
Involve front line staff in finalizing the Documentation Compliance Checklists (DCCs) before they are implemented
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Training Must Change!
CDI must be incorporated into the feedback and evaluation process –the 360 degree feedback loop
This re-emphasizes the critical importance of CDI in your agency!
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Conducting CDI Audits
Consistently track compliance with DCCs over time
These key elements can be quantified into numbers• E.g., “26% of the time, your PCRs with
a chief complaint of “abdominal pain” failed to document whether guarding or rigidity were present”
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Conducting CDI Audits
Tracking these objective documentation indicators over time is critical
That which is observed is improved
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Evaluating the CDI Program
The CDI program itself must constantly evolve and adapt
Changes in clinical practice, new protocols, new providers, new medical directors, etc. can all necessitate changes in your CDI program
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Examples of “Inadequate” and “Adequate” PCR Documentation
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Inadequate Narrative . . .
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“We had a 56 y/o patient with no chief complaint. Patient states he had chest pain earlier in the day. His wife said she saw him turn blue and called an ambulance. Past history of heart attack. Patient placed on oxygen and transported to hospital. Transport uneventful”
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Adequate Narrative . . .
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“Dispatched by 911 for a reported possible heart attack. Upon arrival, we found a 56 y/o obese male
C: Chest pain.
H: Patient states the pain began at around 8 a.m. this morning while he was lying in bed. He states the pain felt “crushing” and lasted for about 30 minutes. He states the pain has subsided somewhat and that it “comes and goes” over the last 4 hours. Pain does not radiate and is centered substernally. He has no SOB, nausea or vomiting, or any other complaints. Wife states that patient appeared to turn blue and she called 911.
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Patient states he had a “mild” heart attack 5 years ago and on multiple meds since then. Current meds: Inderal, Lasix, Aspirin and a BP med.
A: Appx. 300 lb. patient found in his recliner laying back, in no obvious distress, but appeared ashen in color holding his chest. Paramedic assessment was performed by Paramedic Jones. Pt was A&O x4. Skin was moist to touch. Capillary refill delayed. O2 saturation 90% room air. Lungs clear in all fields. No tenderness to the chest or abdomen.
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Rx: Patient placed on cardiac monitor which revealed atrial fibrillation. Placed on O2, IV established (see treatment section). Litter was brought to the side of recliner and patient was lifted onto stretcher by 2 person lift.
T: Patient loaded into ambulance and vital signs monitored enroute to ABC hospital. Patient complained of a 5 minute episode of chest pain while enroute, described as “dull” and non-radiating with pain level an 8 on a 1-10 scale. Skin color improved enroute. Patient had no other complaints. Patient was transferred to Bed 10 and report given to Sally Jones RN.
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Specificity - Trauma
Inadequate Specificity
“Pt has possible fracture to the right tib/fib”
Adequate Specificity
“Pt has possible fx of R tibia after falling down approximately 6 steps at home. Pt has a 3” hematoma mid right anterior lower leg, appx. 2” above the ankle. No angulation or deformity. Distal pulses intact. Good skin color and capillary refill above and below injury site and sensation. Pain upon movement rated 8 on a 1-10 described as sharp
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Specificity – Mobility
Inadequate Specificity
“Pt found in bed. Transferred pt from bed to stretcher. Moved pt via stretcher to ambulance and transport to hospital uneventful”
Adequate Specificity
“Pt found in hospital bed in living room supine with oxygen running at 2 lpm via nasal cannula. Pt unable to sit up without passing out. Pt moved to stretcher via 3 person sheet pull with pt unable to assist due to severe weakness. Transported pt supine to hospital with no change in pt condition”
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Specificity – Mobility
Inadequate Specificity
“Pt was transported in position of comfort”
Adequate Specificity
“Pt was transported in a semi-seated position and denied any pain or discomfort during transport”
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Specificity - Medical
Inadequate Specificity
Pt complains of chest pain and says the pain comes and goes
Adequate Specificity
Pt complains of chest pain. Pain started 3 hours ago while mowing grass. Describes pain as “dull” centered under sternum. States pain comes and goes at intervals of 10-15 min and does not radiate to arms or neck. Severity 8 on a 1-10 scale. No complaints of SOB, nausea or vomiting
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Specificity – Non Emergency
Inadequate Specificity
Pt was found in bed and transferred from bed to stretcher
Adequate Specificity
Pt was found in hospital bed in hospital room in supine position unresponsive to voice with arms and legs flaccid. Pt was log rolled onto side and then back onto a sheet. Moved to stretcher via a sheet pull and secured in a supine position on the stretcher with four cot straps
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Specificity – Abdominal Pain
Inadequate Specificity
Pt complains of abdominal pain since 8 a.m. this morning.
Adequate Specificity
Pt complains of abdominal pain since 8 a.m. this morning. Pt states pain is in the right lower quadrant and is sharp in nature. Describes pain as very severe at 10 on a 1-10 scale. Pt denies nausea, vomiting or fever
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Specificity – Decubitus Ulcers
Inadequate Specificity
Pt has a decubitus ulcer on left side of buttocks
Adequate Specificity
Pt has a decubitus ulcer on left side of buttocks that is bandaged. SNF staff state the wound is Stage 3 approximately 4 inches across. Staff state that severity of wound and pain upon movement make it impossible for patient to sit up in a chair or wheelchair
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Non-Emergency Specificity
MLN Matters Number: SE1514, “Overview of the Repetitive Scheduled Non-Emergent Ambulance Prior Authorization Model”
What needs to be addressed in “medical documentation” to support the PCS
A preview of things to come!
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What CMS is Looking For . . .
“Only conditions specific for the beneficiary should be noted and all applicable comments should concern the beneficiary’s current condition”
“…a clear picture of the beneficiary’s current condition requiring ambulance transport”
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What CMS is Looking For . . .
“Capture the “what” and “why” of a beneficiary’s condition that necessitates the transports”
“Support the diagnosis or the ICD codes on the PCS with clinical assessment data and objective findings”
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What CMS is Looking For . . .
“Documentation must contain statements that capture the “what” and the “why” (for example, if a patient’s condition is bed confined, documentation must indicate why the patient is bed confined”
“Documentation should not contradict the PCS (for example, patient is indicated as bed confined on PCS, however medical records document the patient uses a wheelchair”
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What Can We Learn from the Following Example? . . .
“Patient is an 80 y/o white male with history of ESRD being treated with hemo-dialysis at ABC Dialysis Center. Wegener’s Disease, Atrial Fibrillation, severe osteoporosis, and spinal stenosis all treated by Dr. Smith. Recently, patient has had “bouts” of pneumonia. Patient has extremely fragile bones, to the point that any lifting of the patient even with a “Hoyer Lift” can and has resulted in dislocations and fractures. Patient has a bilateral elbow fusion of 30 degrees, reduced plantar strength with a max of 1 out of 5 bilaterally and 0 degree max hip flexion bilaterally. Bilateral knee flexion is 0 degree. Patient is alert and oriented x4 at baseline with a GCS of 15.
Patient requires assistance in the areas of bathing, dressing, toileting and cleaning himself, transferring, unable to get up from bed, and feeding. Patient does not exercise any control over urination or defecation.”
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According to CMS, This Documentation Identifies the
“What” and “Why” of the Patient’s Condition that
Necessitates Ambulance Transport!
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Summary
Specificity in documentation and ICD-10 coding go “hand in hand”
Key to success is a renewed focus on “CDI for EMS”
Top down commitment is essential Renewed documentation training is a
must - And PWW can help you with that!
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Happy EMS Week!
We salute you for all that you do for your communities!
“EMS is truly among the most noble of all professions.”
- James O. Page
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1) In what physical location (room, department, etc.) did you find the patient at the point of pickup?
(Examples: Hospital room, ED bed, bedroom, waiting room)
2) Please provide a description of the position the patient was in when you found the patient.
(Examples: Supine in bed, sitting on edge of bed, sitting in wheelchair, standing with assistance of a walker)
3) Please describe the patient's mobility status in more detail:
Is the patient able to walk/ambulate? Yes No
Please describe:
Is the patient able to sit in a chair or wheelchair? Yes No
Please describe:
Is the patient able to get up out of bed without assistance? Yes No
Please describe:
4) Please describe how the patient was moved to the stretcher:
5) Please describe any physical limitations or patient conditions that would require transport by ambulance:
6) Please describe any medical conditions (including pertinent medical history and current medications) of the
patient that would require transport by ambulance:
7) Please describe any medical treatments provided to the patient during transport (Examples: oxygen,
suctioning, wound vacs, splints, IVs etc.):
8) Please describe the specific reason that the patient was being transported from the point of pickup to the
destination:
Crew Members:
A review of the PCR for this incident revealed that pertinent information may be missing or is incomplete. A complete
and accurate PCR of the patient transport is essential for a complete patient record. Please review the PCR attached
and provide additional information or clarification as indicated by the sections checked below. Please ensure that all
responses are complete, accurate and honest. Do not make anything up and do not provide information that is false
or untrue. If you do not remember or cannot recall then indicate that as appropriate. If you have any questions
please contact ________________________________________.
Documentation Requirements
©Copyright 2015, Page, Wolfberg & Wirth, LLC. This Form Does Not Constitute Legal Advice.
Clinical Documentation Improvement (CDI) Query Form ‐ Non‐Emergency Transport
User Bears All Responsibility for Proper Documentation and Billing and Releases PWW From Any and All Liability for Use.
Call/Run #: Call Time:Date of Query: Date of Incident:
Page 1 of 2
9) Please describe the patient's level of consciousness and mental status upon arrival and during transport:
10) Please describe any relevant patient assessment or current patient condition/medical history that related to
this transport:
11) Do you have any other additional information about the transport of this patient that would be helpful to
other healthcare providers who will care for this patient?
I verify that the information I have provided on this form is accurate, complete, and truthful to the best of
my knowledge.
Signature: _________________________________________________ Date: _________________________
Name: (Please print) ____________________________________________________
Credentials/Certification Level (EMT‐B, EMT‐P, etc.) ___________________________
Page 2 of 2
this
CCeerrttiiffiiccaattee ooff CCoommpplleettiioonn is presented as evidence of completion, by the Certified Ambulance Coder®, Certified Ambulance
Compliance Officer™ or Certified Ambulance Privacy Officer™ whose Signature and Certification
Number appear below, of the NAAC® approved Continuing Education course entitled
PWW - 2015 - ICD-10 Part III - Documentation
Course ID: 1579 Vendor Code: 6 Topic Code: 2 CEU Units: 1.5
Education Provider: Page, Wolfberg & Wirth Presenter: PWW Staff
Jason J. Leet NAAC
® Program Coordinator
5/20/2015 Date of Training
I hereby certify that I have completed the continuing education training as represented on this certificate.
Signed: ______________________________________________________ NAAC® Certification Number ________________________________
Certificate is invalid without the signature and certification number of the attendee.