3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. Gray Areas in CDI: Negotiating the Relationship James S. Kennedy, M.D., C.C.S. Managing Director FTI Healthcare

3. Speaker • James S. Kennedy, M.D., C.C.S. • Managing Director, FTI Healthcare • CDCI Practice Leader • Medical School – University of Tennessee • Private Practice – General Internal Medicine, 1983–1998 • CCS Certification – 2001 • Publications: • 2007–current – “Minute for the Medical Staff” in Medical Records Briefing • 2008 – Severity-Adjusted DRGs, an MS-DRG Primer • 2009 – Physician Query Handbook

4. Disclaimer • The information presented reflects Dr. Kennedy’s understanding of the ICD-9-CM and his wish that all medical conditions addressed during a clinical encounter are documented accurately in the medical record by providers and coded compliantly by the coding staff. • Dr. Kennedy and FTI Healthcare wholeheartedly support ICD-9-CM, its Guidelines, its interpretations through Coding Clinic for ICD-9-CM, and other applicable laws or practice standards. Coders, clinical documentation specialists, and physicians are expected to be familiar with applicable rules, regulations, and laws, implementing them in their daily work.It is not the speaker’s nor FTI’s intent or desire that any physician, case manager, or coder promote diagnosis terminology that is not supported by a reasonable standards of care or appropriate physician literature, nor is it their intent to encourage coding or query practices that fraudulently or abusively incur incorrect payments under government or private insurance programs. • This lecture is highly clinical and reflects the opinions of a clinician discussing clinical syndromes. Nothing said in this lecture should be construed as medical advice. • The audience is strongly encouraged to discuss the content of this lecture with their compliance officer prior to submission of claims for payment to any healthcare insurer or government entity. Dr. Kennedy, FTI Healthcare or other entities affiliated with this lecture will not assume responsibility for any misunderstanding or misapplication of the material presented in this lecture.

5. Goals • Review certain “gray” areas surrounding concurrent and retrospective provider query • Principal diagnosis sequencing • Coding of uncertain diagnoses • Coding and query in the absences of a discharge summary • Definitions of “leading queries” • Differing roles of licensed and unlicensed personnel in provider query • Postoperative complications Note – Due to time limitations, other topics outlined in the promotional brochure may not be covered. If there are any questions, please contact the author directly for further support.

6. Clinical Scenario #1 • An 80-year-old white female presents to the hospital as an inpatient for pneumonia. She currently lives in a skilled nursing facility due to a left hemispheric stroke sustained two weeks prior to admission resulting in a dense right hemiparesis and an expressive aphasia. She is being fed with a nasogastric feeding tube.

7. Clinical Scenario #1 (cont.) • Her past history is otherwise insignificant. Current medications consist of tube feeding, aspirin, Plavix, and multi-vitamins. • Physical examination on admission has a temperature of 100.5°F, pulse of 90, RR of 24, and BP of 135/70. Generally, she is aphasic and has some raspy respiratory and requires suctioning, producing purulent sputum. She has rales and bronchial breath sounds in the RLL. NG tube is in place. There is a dense right hemiparesis with hyperreflexia. The rest of her examination is noncontributory.

8. WBC 9,800 with 10% Bands. O2 sat – 98% on RA Sputum gram-stain shows multiple organisms. Chest X-ray with RLL infiltrate Admitting impression: Healthcare-associated pneumonia Recent stroke with right hemiparesis and aphasia Dysphagia Rx: Zosyn, vancomycin, tobramycin. Pulmonary toilet (e.g., CPPD, aerosols) Continued stroke rehabilitation Clinical Findings Photo source: CDC – Emerging Infectious Diseases – Public Domain Available at: http://www.cdc.gov/ncidod/eid/vol6no1/scrimgeourG2.htm

9. Patients with healthcare-associated pneumonia had: • higher fatality rates (17.8% vs. 6.7%) • longer mean hospital stay (18.7 days vs. 14.7 days) • S. aureus and gram-negative bacilli were significantly more frequent • The selection of empirical antibiotics include coverage of methicillin-resistant S. aureus and multidrug-resistant gram-negative rods (such as linezolid or glycopeptides plus an antipseudomonal β-lactam)

10. Physician Query • Dear Dr. Jones. This patient is documented to have healthcare-associated pneumonia treated with Zosyn, vancomycin, and tobramycin. If possible, please document the infectious cause of this patient’s HCAP, given the antibiotics selected. Thank you for your assistance. • Answer documented in the progress notes: The patient’s pneumonia is probably (or appears to be) due to a multi-resistant gram-negative rod in the setting of likely aspiration pneumonia. Same answer repeated three times in the progress notes. • Diagnosis documented at the time of discharge: • Healthcare-associated pneumonia

11. Question • Based on the physician’s documentation, what DRG should this group to? • MS-DRG 178 – Respiratory Infection & Inflammations with CC – R.W. 1.4860 • APR-DRG 137 – Major Respiratory Infection • SOI 2 – R.W. 0.9102 • MS-DRG 194 – Simple Pneumonia & Pleurisy with CC – R.W. 0.9976 • APR-DRG 139 – Other pneumonia • SOI 2 – RW 0.6393 • Is further query necessary?

12. Physician Query • Dear Dr. Jones. This patient is documented to have healthcare-associated pneumonia treated with Zosyn, vancomycin, and tobramycin. If possible, please document the infectious cause of this patient’s HCAP given the antibiotics selected. Thank you for your assistance. • Answer documented in the progress notes: There is evidence of the patient’s pneumonia being due to a multi-resistant gram-negative rod in the setting of likely aspiration pneumonia. Same answer repeated three times in the progress notes. • Diagnosis documented at the time of discharge: • Healthcare-associated pneumonia

13. Question • Based on the physician’s documentation, what DRG should this group to? • MS-DRG 178 – Respiratory Infection & Inflammations with CC – R.W. 1.4860 • APR-DRG 137 – Major Respiratory Infection • SOI 2 – R.W. 0.9102 • MS-DRG 194 – Simple Pneumonia & Pleurisy with CC – R.W. 0.9976 • APR-DRG 139 – Other pneumonia • SOI 2 – RW 0.6393 • Is further query necessary?

15. Documented at the Time of Discharge • Discharge note • Discharge order • Discharge summary

16. Coding Clinic Support • Question: The attending physician for an inpatient admission has included conditions listed with terms such as "consistent with," "compatible with," "indicative of," "suggestive of," and "comparable with" in the final diagnosis. How should these conditions be coded? • Answer: Code these conditions as if they were established. These terms fit the definition of an uncertain diagnosis. According to the Official Guidelines for Coding and Reporting (Sections II and III), in short-term, acute, long-term care, and psychiatric hospitals, if the diagnosis documented at the time of dischargeis qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," code the condition as if it existed or was established. • This advice should not be applied to admitting or interim diagnoses.

17. Coding Clinic Support (cont.) • CC, 3rd Quarter, 2009, page 7. • Question: Is it appropriate to report codes for diagnoses recorded as "evidence of cerebral atrophy" and "appears to be a nasal fracture" when documented on outpatient radiology reports? • Answer: The phrase "appears to be," listed in the diagnostic statement, fits the definition of a probable or suspected condition and would not be coded in the outpatient setting. • However, when the provider documents "evidence of" a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported in the outpatient setting.

18. Bottom Line • Uncertain diagnoses may not be coded unless documented at the time of discharge • “Evidence of” = certain • “Appears to be,” “possible,” “probable,” and other similar language = uncertain • If uncertain diagnoses are documented in the record and there are clinical indicators supporting that diagnosis, a nonleading query to clarify or to bring forward the uncertainty to the discharge note is compliant.

19. Clinical Scenario #2 • An 80-year-old white female fell out of bed at home and fractured her hip. En route to the hospital, she develops substernal chest pain and abnormal EKG changes. While the troponin was normal initially at the emergency department, three hours later, it rises above the 99th percentile, suggesting a non-ST segment elevation MI. • The patient is admitted, her pain subsides, she is stabilized, and undergoes a hip pinning on the 8th hospital day. • Final diagnosis • Osteoporotic hip fracture POA • Non ST-segment elevation MI POA

20. Clinical Scenario #2 (cont.) • What’s the correct DRG? • Principal diagnosis – hip fracture • MS-DRG 480 – Hip and Femur Procedure except Major Joint w MCC – RW 2.8752 • APR-DRG 309 – HIP/FEM Proc Except Joint Replacement – Nontraumatic – SOI 3 – RW 2.5005 • Principal diagnosis – acute MI • MS-DRG 982 – Extensive OR Procedure Unrelated to Principal Diagnosis with CC – RW 2.8954 • APR-DRG 950 – Extensive Procedure Unrelated to the Principal Diagnosis – SOI 2 – APR-DRG RW 2.2273

21. Principal Diagnosis AssignmentICD-9-CM Official Guidelines • The circumstances of inpatient admission always govern the selection of principal diagnosis. • The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” • In determining principal diagnosis, the coding conventions in the ICD-9-CM, Volumes I and II, take precedence over the official coding guidelines.

22. Principal Diagnosis AssignmentICD-9-CM Official Guidelines (cont.) • Two or more diagnoses that equally meet the definition for principal diagnosis • In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, and the Alphabetic Index, Tabular List, or other coding guidelines do not provide sequencing direction, any one of the diagnoses may be sequenced first.

23. Coding Clinic – 3rd Q, 2002, Page 14Physician Intent for Admission • Question: A patient is admitted with severe dental caries and periodontal disease. She has been on Coumadin in the past for clotting of her dialysis access. This had to be stopped prior to her dental procedure and she needed to be switched to IV Heparin. The documentation states that the patient was admitted for anticoagulant adjustment prior to her surgery. In addition, the history of present illness specifies, "the primary reason for admission is not for her teeth extraction but because she has had chronic clotting problems of her vascular access for dialysis. Every time her Coumadin is stopped, the patient's access clots." It appears that the dental extraction would have been carried out as an outpatient if the patient had not had clotting problems. What should be the principal diagnosis in this case, the dental condition or V58.61 or V07.8? • Answer: Assign code 521.09, Other dental caries, as the principal diagnosis. The dental condition required care, and the patient's medications had to be adjusted in preparation for the dental surgery.

24. Coding Clinic, 3rd Quarter 2009Severe Medical Condition Presence • Question: A patient with an acute ST elevation lateral wall myocardial infarction (STEMI) was initially seen at Hospital A and was immediately transferred to Hospital B for an emergency cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA) with stent insertion. What is the appropriate principal diagnosis for Hospital B? • Answer: Assign code 410.51, Acute myocardial infarction, of other lateral wall, initial episode of care, as the principal diagnosis. The acute STEMI of the lateral wall had not resolved and was still being treated at Hospital B. Assign code 414.01, Coronary atherosclerosis, of native coronary artery, as a secondary diagnosis. This advice is consistent with that previously published in Coding Clinic Fifth Issue 1993, page 14.

25. Other Guidelines CriteriaPrincipal Diagnosis Assignment • Codes for symptoms, signs, and ill-defined conditions • Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established. • Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis • When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

26. Other Guidelines CriteriaPrincipal Diagnosis Assignment(cont.) • Two or more comparative or contrasting conditions • In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed, and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first. • A symptom(s) followed by contrasting/comparative diagnoses • When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.

27. Other Guidelines CriteriaPrincipal Diagnosis Assignment (cont.) • Original treatment plan not carried out • Sequence as the principal diagnosis the condition that, after study, occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances. • Complications of surgery and other medical care • When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the 996–999 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.

28. Other Guidelines CriteriaPrincipal Diagnosis Assignment (cont.) • Admission following medical observation • When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.

29. Other Guidelines CriteriaPrincipal Diagnosis Assignment (cont.) • Admission following postoperative observation • When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

30. Other Guidelines CriteriaPrincipal Diagnosis Assignment (cont.) • Admission from outpatient surgery • When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission: • If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. • If no complication or other condition is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. • If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.

31. Bottom Line • Either the hip fracture or the MI can be the principal diagnosis and still be compliant with ICD-9-CM • “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.” – ICD-9-CM Guidelines • “(The) determination of the appropriate principal diagnosis is not always an easy task.” – Coding Clinic, 3rd Quarter, 2002

32. Clinical Scenario #3 • A patient with a known history of ASCAD and previous myocardial infarction is admitted as an inpatient on a Saturday evening for chest pain to rule out a myocardial infarction. Initial troponin studies and ECG are negative for acute myocardial ischemia. Due to the lack of radionuclide, the nuclear stress test is not conducted until Monday, which was negative. • Due to the patient being seen promptly, the patient was discharged at 11:00 a.m. prior to the CDS seeing the patient. No CDS encounter was generated. • Final diagnosis on the progress note – noncardiac chest pain, ASCAD, old MI – which was coded by HIM. • Discharge medications – aspirin, Protonix.

33. Clinical Scenario #3 (cont.) • The medical staff bylaws require a discharge summary on all inpatient admissions (outpatient and observation admissions do not require a discharge summary). The attending physician, Dr. Johnny Come Lately, dictated the summary two weeks post-discharge. • Final diagnosis: • Noncardiac chest pain probably due to GERD • ASCAD • History of old MI

34. What’s the Appropriate DRG? • Chest pain • MS-DRG 313 – Chest Pain – 0.5404 • APR-DRG 198 – Angina Pectoris & Coronary Atherosclerosis – SOI 1 – 0.4692 • GERD • MS-DRG 392 – Esophagitis, Gastroenteritis, & Misc. Digestive Disorder w/o MCC – 0.6921 • APR-DRG – Other Esophageal Disorder – 0.4695

35. Inquiring Minds Want to Know • Is it OK to code a record without a discharge summary? • Hospitals wish to maintain a Discharge Not Final Billed average of less than 4 days, whereas most medical staff bylaws allow a physician up to 30 days to complete his or her medical records (including performance of the discharge summary). • How can CDI participants help if a coder has a record without a DC summary?

36. Coding Without a Discharge Summary • ICD-9-CM Official Guidelines for Coding and Reporting • A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. • The Definition of CDCI/CDI • These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. • The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. • The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

37. AHIMA Practice Brief – July 2001Coding Compliance Policy • Medical records are analyzed and codes selected only with complete and appropriate documentation by the physician available. According to coding guidelines, codes are not assigned without physician documentation. If records are coded without the discharge summary or final diagnostic statements available, processes are in place for review after the summary is added to the record. • Example: When records are coded without a discharge summary, they are flagged in the computer system. When the summaries are added to the record, the record is returned to the coding professional for review of codes. If there are any inconsistencies, appropriate steps are taken for review of the changes.

39. CDCI’s Role in Support of the Discharge Summary • Reminders to providers of • CMS’ requirement that the record be complete within 30 days of discharge • The requirement to code from the COMPLETE medical record, which includes the discharge summary • The allowance to code uncertain diagnoses, given the discharge summary is a “time of discharge” document • The role that the discharge summary plays in the minds of some retrospective reviewers

40. Bottom Line • While records may be coded without a discharge summary, they should be flagged so that they may be rereviewed upon the performance of the discharge summary. • CDCI specialists have a role in supporting the rereview and physician query in the event of inconsistent, incomplete, imprecise, or conflicting documentation.

41. Clinical Scenario #4 • A patient is admitted for nausea and vomiting. The patient’s admitting creatinine increases is 1.8 mg/dl. The CDS who is an RN writes the following: • The patient was admitted with a creatinine of 1.8 mg/dl with a documented baseline of 1.2 mg/dl. The chart documents “ARI” and “volume depletion” and treatment “followed with volume repletion.” • Please render your clinical opinion if the patient has acute renal failure based on these indicators by checking the box below. If you agree, I will update the problem list and prepare a clarification for your signature. (x) Agree ( ) Disagree Adapted from Source: Payne T. “Improving Clinical Documentation in an EMR World.” hfm magazine. Published in February 2010.

42. Definitions of Acute Renal Failure or Acute Kidney Injury RIFLE AKI Network Acute Kidney Injury* Stage 1 ↑in SCr ≥ 0.3 mg/dl or ↑ 150%–200% from baseline Stage 2 ↑in SCr ≥ 200%–300% from baseline Stage 3 ↑in SCr ≥ 300% from baseline or SCr ≥ 4.0 mg/dl with acute ↑ of 0.5 mg/dl *Assumes volume repletion has occurred • Risk – ↑ SCr x 150% • UOP < 0.5 ml/kg x 6 hours • Injury – ↑ SCr x 200% • UOP < 0.5 ml/kg x 12 hours • Failure – ↑ SCr x 300% or SCr ≥ 4.0 mg/dl with acute ↑ of 0.5 mg/dl • UOP < 0.5 ml/kg x 24 hours or anuria for 12 hours • Loss – Persistent loss of renal function > 4 weeks • ESRD – Persistent loss of renal function > 3 months

43. 2011 IPPS Proposed Rule • Code (584.9) is being widely used to capture degrees of renal failure ranging from that which is caused by mild dehydration with only minor laboratory abnormalities all the way through severe renal failure that requires dialysis. • There are no clinical criteria for assigning diagnosis code 584.9 (Acute renal failure, unspecified). The attending physician must simply document the presence of acute renal failure for the diagnosis code to be assigned. • The concern is that the diagnosis code for Acute renal failure, unspecified (diagnosis code 584.9) is being assigned to patients with a low clinical severity level.

44. 2011 IPPS Proposed Rule • Coders are observing the terminology of “acute renal failure” being applied to patients who are simply dehydrated. • These patients do not require renal dialysis and they do not appear to be severely ill. • Coders have stated that there appears to be an increase in the use of the terminology of acute renal failure for patients who were previously referred to as acute renal insufficiency.

45. Coding Clinic1st Quarter 2008, p. 3 • The establishment of clinical parameters for code assignment is beyond the scope of authority of the Editorial Advisory Board for Coding Clinic for ICD-9-CM. • All code assignment is based on provider documentation.

46. Indications for Query2008 AHIMA Practice Brief • Legibility. This might include an illegible handwritten entry in the provider’s progress notes, and the reader cannot determine the provider’s assessment on the date of discharge. • Completeness. This might include a report indicating abnormal test results without notation of the clinical significance of these results (e.g., an x-ray shows a compression fracture of lumbar vertebrae in a patient with osteoporosis and no evidence of injury). • Clarity. This might include patient diagnosis noted without statement of a cause or suspected cause (e.g., the patient is admitted with abdominal pain, fever, and chest pain, and no underlying cause or suspected cause is documented).

47. Indications for Query2008 AHIMA Practice Brief • Consistency. This might include a disagreement between two or more treating providers with respect to a diagnosis (e.g., the patient presents with shortness of breath. The pulmonologist documents pneumonia as the cause, and the attending documents congestive heart failure as the cause.). • Precision. This might include an instance where clinical reports and clinical condition suggest a more specific diagnosis than is documented (e.g., congestive heart failure is documented when an echocardiogram and the patient’s documented clinical condition on admission suggest acute or chronic diastolic congestive heart failure).

48. Is This an Appropriate Circumstance? • The CDS who is an RN writes the following: • The patient was admitted with a creatinine of 1.8 mg/dl with a documented baseline of 1.2 mg/dl. The chart documents “ARI” and “volume depletion” and treatment “followed with volume repletion.” • Please render your clinical opinion if the patient has acute renal failure based on these indicators by checking the box below. If you agree, I will update the problem list and prepare a clarification for your signature. (x) Agree ( ) Disagree Source: Payne T. “Improving Clinical Documentation in an EMR World.” hfm magazine. Published in February 2010.

49. Inappropriate Use of Query Forms2001 AHIMA Practice Brief • Query forms should NOT: • “Lead" the physician • Is allowing only the option of acute renal failure “leading” given that other options of “renal risk” or “renal insufficiency” are not offered? • Sound presumptive, directing, prodding, probing, or as though the physician is being led to make an assumption • What about the option of hypovolemia? Why was that not offered? • Ask questions that can be responded to in a yes-or-no fashion • Is “Agree” or “Disagree” the same as “Yes” or “No”? • Indicate the financial impact of the response to the query • Be designed so that all that is required is a physician signature Resource: Prophet, Sue. "Developing a Physician Query Process (AHIMA Practice Brief)." Journal of AHIMA 72, No. 9 (2001): 88I-M.

50. Is This Leading?Rendered by an RNDS • The patient was admitted with a creatinine of 1.8 mg/dl with a documented baseline of 1.2 mg/dl. The chart documents “ARI” and “volume depletion” and treatment “followed with volume repletion.” • Please render your clinical opinion if the patient has acute renal failure based on these indicators by checking the box below. If you agree, I will update the problem list and prepare a clarification for your signature. (x) Agree ( ) Disagree Adapted from: Payne T. “Improving Clinical Documentation in an EMR World.” hfm magazine. Published in February 2010.