A day in the life of a Clinical Documentation Improvement Specialist

1. A day in the life of a Clinical Documentation Improvement Specialist

2. What Killed

3. Was it urosepsis? • A urinary tract infection? or • Sepsis resulting from the decomposition of extravasated urine?

4. Was it pneumonia? • Pneumonia, unspecified? or • Pneumonia related to aspiration?

5. Was it an appendicitis? • Appendicitis, unspecified? or • Appendicitis with rupture & peritonitis?

6. These are just a few questions a Clinical Documentation Improvement Specialist may ask

7. Why do we ask and why does it matter? Let’s investigate…..

8. Coders must rely on physician documentation • They cannot assume or interpret what is in the medical record Code Assignment Physician Documentation Sometimes there is a “broken link” between the clinical and “codeable” documentation

9. Any time documentation in the medical record is: • ambiguous • conflicting • incomplete or missing • lacks specificity • unclear whether a condition was present on admission Clarification is necessary to ensure accurate assignment of codes, severity of illness & risk of mortality scores, length of stay targets, and appropriate reimbursement for utilization of resources

10. One solution….. A Clinical Documentation Improvement Program aka – Master Detective Agency

11. Clinical Documentation Improvement Program (CDIP) What is a CDIP? – An initiative which focuses on improving the documentation concurrently or at the point of service to the patient.

12. A 2007 HCPro survey found that 50% of US hospitals have a CDIP • CDIP Models: • HIM • CM • Quality • Finance

13. Why have a CDIP? – • Effect on Quality of Care • Identifying a condition by your thoughts permits others who follow to know what you’re thinking - • What is the patient’s clinical picture during your assessment • What work-up has been done so far • What were the results • What treatment has been started • What is the plan of care

14. Why have a CDIP? – • Effect on Legal Risk Reduction • The better the documentation reflects the complexity and the risks, the easier it is to explain morbidity and mortality – and the likelihood of frivolous liability claims is reduced. • If it’s not documented – it didn’t happen including excellent patient care!

15. Why have a CDIP? – • Effect on Public Quality Measures • Results in better physician and hospital outcomes on consumer-oriented health care websites such as: • Health Grades • US News & World Report • Consumer Reports

16. According to a 2009 PricewaterhouseCoopers consumer survey, 48% of consumers said they use health websites to find information to make decisions about their healthcare.

20. Why have a CDIP? – • Impact on Mortality Risk Adjustment • Provides a more accurate illustration of patient acuity and the care provided. • Impacts Severity of Illness (SOI) and Risk of Mortality (ROM) statistics. • Severity adjusted expected mortality rate depends on ICD-9 codes being assigned that demonstrate SOI & ROM

21. Two of the most common metrics used for mortality risk adjustment: • Severity of Illness • How sick is the patient? • Risk of Mortality • What is the likelihood of death? • The four levels of SOI & ROM are: • 1 = minor • 2 = moderate • 3 = major • 4 = extreme

22. Why have a CDIP? – Contributes to appropriate and timely reimbursement for utilization of resources • More appropriate payment for the hospital and physicians. • Accurate severity-adjusted Case Mix Index (CMI) • Reduces number of retrospective queries which negatively impacts the revenue cycle.

23. How are questions communicated? Either verbally on the patient care floors, or written via a Physician Documentation Query Form. To maintain a paper trail for verbal queries, the CDIS will document a brief synopsis of the discussion on a concurrent query form.

24. Where will the query forms be found? - When appropriate, a query form is placed in the progress notes. Where should physician document response? -Query response may be documented in the progress, consultation, or procedure notes, and/or the discharge summary. Responses then become a permanent part of the medical record. Who may respond to query? - Any physician (or physician extender) who provides “face to face” care.

25. What happens if the concurrent query is not addressed while the patient is in-house? A retrospective or post-discharge electronic query is sent to the Attending Physician

26. Disadvantages of a Post-Discharge Query Since the Post-Discharge query is sent a week or more after the patient is discharged: • The details of the patient’s condition are not as clear • The record is scanned so the physician must access the electronic record • For physicians who rotate, they may be out of town or even out of the country • Negatively impacts the DNFB (Discharged Not Final Billed)

27. Query Guidelines for Concurrent & Post-Discharge QueriesThe query should not: • Sound presumptive, directing, prodding, probing, or as though the physician is being led to make an assumption • Give only choices that increase the reimbursement • Indicate the financial impact of the response to the query • Be designed so that all that is required is a physician signature

28. Physician Documentation Education • One-on-one • Small groups – on the nursing units • Large groups – Departmental Grand Rounds • New Housestaff Orientation • Pocket cards

29. What Killed

30. Mr. Boddy, a 64-year-old male was found on his living room floor. On arrival to the ED - • Altered mental status • RLQ abdominal pain • Elevated temperature • Hypotensive • Tachypnea & tachycardia • Positive UA & BC – e coli • Chest x-ray revealed bilateral lower lobe infiltrates

31. Mr. Boddy was taken to the OR and underwent an appendectomy. Thick, purulent pelvic fluid was encountered. He was kept in the SICU for eight days where he received IV antibiotics and Vasopressin.Unfortunately, he did not survive.

32. Physician documented cause of death as: • Urosepsis • Pneumonia • Appendicitis s/p appendectomy

33. To a coder, this = UTI GMLOS=3.5 days SOI=1 ROM=1 Reimbursement=$5,883 To a physician, this = sepsis from a urinary source GMLOS=4.6 days SOI=1 ROM=1 Reimbursement=$8,514 Urosepsis…

34. Pneumonia, unspecified = GMLOS=3.3 days SOI=1 ROM=1 Reimbursement=$5,415 Pneumonia due to aspiration = GMLOS=4.3 days SOI=1 ROM=2 Reimbursement=$7,700 Pneumonia…

35. Appendicitis, unspecified = GMLOS=1.7 days SOI=1 ROM=1 Reimbursement=$7,144 Appendicitis with rupture & peritonitis = GMLOS=3.4 days SOI=2 ROM=1 Reimbursement=$9,310 Appendicitis (with appendectomy)

36. Without the investigative services (concurrent query) of the CDIS (aka – Master Detective) it would appear thatMr. Boddy died from a simple urinary tract infection, pneumonia, and an appendicitis. • GMLOS = 5.1 days • SOI = 2 (moderate) • ROM = 1 (minor) • Reimbursement = $ 16,875

38. After receiving clarification from the physician in response to a concurrent query, it was determined that Mr. Boddy died from septic shock related to a urinary tract infection and aspiration pneumonia. In addition, he had a ruptured appendix with peritonitis. • GMLOS = 12.5 days • SOI = 4 (extreme) • ROM = 4 (extreme) • Reimbursement = $41,938

40. Impact of CDI Investigation and intervention • Greater specificity of existing conditions • Appropriate severity of illness score • The patient was extremely ill • Appropriate risk of mortality score • The patient died – his ROM should be extreme • Increased length of stay allowance • Appropriate reimbursement for utilization of resources

41. Questions Donna Fisher, CCS, CCDS Lead Clinical Documentation Improvement Specialist Shands at the University of Florida fishdl@shands.ufl.edu 352-265-0680 extension 48769 aka – Master Detective