The Impact Physician Documentation on Hospital Reimbursement and Metrics

1. The Impact Physician Documentation on Hospital Reimbursement and Metrics

2. Integration of CDI Physician documentation  Clinical Documentation Improvement (CDI)/Concurrent Review  Coding (identify/validate principal and secondary diagnoses & procedures) May refer back to CDI as needed or may query provider  ICD-9 codes  Grouping of ICD-9 diagnosis codes (APR-DRG, MS-DRG, or DRG)  Submission of hospital bill

3. Disclaimer The following information is educational and based on estimates of MS-DRG distribution against current practices This organization has a policy against DRG creeping and/or DRG “upcoding” Physicians have the freedom to disagree with CDI/coding recommendations without concern for any reprisal

4. Important Terms • Principal Diagnosis • Secondary Diagnoses • Diagnostic Related Group (DRG) • Medicare Severity - Diagnostic Related Group (MS-DRG) • Concurrent/Complicating Condition • Major Concurrent/Complicating Condition • GLOS – geometric/global length of stay

5. How Do Hospitals Get Paid by Medicare? Each MS-DRG has a unique RELATIVE WEIGHT (RW) X The hospital’s annual BASE RATE = Hospital Payment ($)

6. Ensuring the Highest RW The principal diagnosis and the principal procedure (if applicable) establishes the base MS-DRG Co-morbidities (a.k.a. complicating or concurrent conditions) can adjust the MS-DRG to a higher relative weight = $ THEREFORE, a systemic, full body approach is more effective than a focused assessment, which requires a comprehensive H & P, identifying all body systems impacted by the disease process

7. Principal Diagnosis Establishes the base MS-DRG The condition, after study, which occasioned the inpatient admission to the hospital • Not necessarily what brought the person to the hospital • ER c/o abdominal pain • Admitted for SIRS 2/2 chronic pancreatitis (principal dx) • Should be a disease process or condition rather than a symptom i.e., CAD vs. chest pain

8. Principal Diagnosis Coders can’t infer a cause/effect relationship • The physician doesn’t have to state the condition in the H&P for it to be the principal dx HOWEVER • The presenting symptomology necessitating the admission MUST be linked to the final disease process diagnosis by the physician • Usually this occurs in the discharge summary; therefore, discharge summaries should be completed as soon as possible following discharge for accurate coding • The provider needs to clearly state the diagnosis was present on admission (POA) as evidence by the presenting symptoms of . . .

9. Co-morbidities (CC/MCC) Additional conditions that affect patient care in terms of requiring: • Clinical evaluation AND/OR • Therapeutic treatment AND/OR • Continuation or adjustment of home medications • Initiation of new medications or IVF • Diagnostic procedures AND/OR • Extended length of hospital stay AND/OR • Focus on GLOS – global length of stay • Increased nursing care and/or monitoring

10. Co-morbidities CC = concurrent condition Patients who are more ill than a “healthy” person with the same principal condition i.e., many chronic conditions add a CC MCC = major concurrent condition Represent the highest severity of illness to identify the “sickest of the sick” i.e., acute episodes (exacerbation) of chronic conditions e.g., acute on chronic systolic or diastolic HF and/or potentially lethal conditions i.e., acute respiratory failure, shock, encephalopathy, ESRD, open fracture of a major bone, etc.

11. Secondary Conditions Some DRGs differentiate between “ill” and “sickest of the sick” patients • One tier • no differentiation among patients • Two tier • With a CC/MCC or without a CC/MCC Differentiate between ill and more ill/sickest of the sick Easiest to move the MS-DRG • With a MCC or without a MCC Differentiate between ill and sickest of the sick Most difficult to move the MS-DRG • Three tier • Without a CC or MCC (ill) • Medicare estimates 41% of total patient population • With a CC (more ill) • Medicare estimates 37% of total patient population • With a MCC (sickest of the sick) • Medicare estimates 22% of total patient population

12. MS-DRGs Groupings

13. Recommendations Provide more extensive H & P • CCs and MCCs are based on the secondary conditions that occur with the principal dx • Many problematic cases are elective admissions • Specify which “history of” conditions are being treated compared to those that are resolved • Note when a chronic condition is exacerbated Assign a diagnosis to abnormal lab values i.e., “acute blood loss anemia” or “posthemorrhagic anemia” when transfused due to low H&H Document identified or suspected organism leading to antibiotic selection for all infections, especially pneumonia

14. Documentation Hints • Chronic conditions: • Last 12 months or longer AND • Places limitations on self-care, independent living, & social interactions • Results in the need for ongoing intervention w/medical products, services, and special conditions • Always note when the patient is experiencing an acute exacerbation of a chronic condition • Describe how the patient’s current condition differs from their normal baseline

15. Weight Issues Add BMI to your H & P • BMI > 40 + morbid obesity = CC • Provider must document the BMI and the diagnosis of obesity or morbid obesity • Protein-calorie malnutrition = CC • BMI < 16 + severe malnutrition = MCC • Cachexia = CC • Note under general impressions • Emaciated = MCC • Note under general impressions

16. Substance Dependence • Substance dependence is not the same as substance abuse and can occur with prescription medications • Document any withdrawal symptoms associated with substance use i.e., alcohol or drugs (specify substance if known). • Alcohol or drug withdrawal = CC • Toxic encephalopathy = MCC • Link the treatment of a “banana bag” with the diagnosis of thiamine deficiency in alcoholics • Thiamine deficiency = CC

17. Mental Status Altered Mental Status (AMS) does not convey severity in ICD-9 Consider acute delirium – confusion accompanied by agitation or other behavioral disturbances rather than “confusion,” or “altered mental status” secondary to Alzheimer’s, late effect of stroke, Lewy body dementia, vascular dementia, anoxic encephalopathy, alcohol withdrawal, etc. = CC Consider encephalopathy (toxic or metabolic) especially with acid/base or electrolyte imbalances

18. Renal Function Be sure to distinguish between acute and chronic Renal Failure and specify Acute Tubular Necrosis (ATN) when applicable: • Acute Renal Failure (A.K.A. non-traumatic Acute Kidney Injury or AKI)= CC • ATN = MCC

19. Renal Function Chronic Kidney Disease (Chronic Renal Failure) • Always specify the applicable stage • Use the National Kidney Foundation’s standardized staging of progressive kidney disease – add a CC • CKD stage IV (severe) • GFR = 15-29 SCr = 2.5 – 4.5 • CKD stage V (cardiovascular disease) • GFR = <15 SCr = > 4.5

20. Renal Failure Chronic Renal Failure (CKD IV & V) = CC End Stage Renal Failure = MCC • specify the known or suspected underlying cause of ESRD i.e., HTN, DM, renal cystic disease, systemic lupus erythematosus, glomerulomephritis, etc.

21. Renal Failure • The known or suspected etiology of kidney disease should be specified • Coding assumes a casual relationship b/t HTN and CKD • The presence of essential hypertension and CRF is classified as “Hypertensive Kidney Disease” which is not inclusive of renal manifestations due to secondary HTN – so add the documentation/diagnoses

22. Renal Insufficiency • Codes to “unspecified disorders of the kidney and ureter” and is considered by coding as an early stage of renal impairment • Chronic renal insufficiency codes to “CKD, unspecified” • AVOID using renal insufficiency and renal failure interchangeably

23. Fluid Volume Overload Determine the cause of Fluid Volume Overload • Fluid volume overload is always attributed to CHF if it is listed as a secondary diagnosis unless another cause is clearly specified e.g., ESRD, as the cause of the fluid volume overload • This can lead to failures on CMS Quality Measures for HF as the provider does not realize the principal diagnosis will be HF on these patients • Remember to have heart failure, the heart must have pathology

24. Heart Failure Avoid the use of term “CHF” (congestive heart failure) • Classify to the type of heart failure whenever possible • Systolic • Acute • Diastolic • Chronic • Combined • Acute on chronic (exacerbation or decompensated) • Use presenting symptomology when ECHO results are not available

25. Heart Failure Systolic – most common type of HF EF < 40% Dilated on Echo Cardiomegaly on CXR S3 gallop Diastolic EF usually normal LVH on EKG S4 gallop Often hypertensive Abnormal relax on ECHO

26. Acute Heart Failure Symptoms Rales  CVP > 16 cm Neck vein distension Paroxysmal nocturnal dyspnea Acute pulmonary edema or  BNP Weight loss => 4.5 kg in 5 days in response to CHF treatment

27. Electrolyte Imbalances Interpret abnormal lab values hyponatremia/ hyposmolality = CC SIADH = CC Metabolic encephalopathy = MCC Hyperkalemia (not a CC) Hypoaldosteronism = CC ACE-Inhibitors, Angiotensin Receptor Blockers, Spironolactone Hypercalcemia (not a CC) Metabolic encephalopathy = MCC

28. Electrolyte Imbalances Are there acid/base imbalance? Acidosis = CC HCO3<18 Alkalosis = CC HCO3 >28 Rather than Altered Mental Status or Confusion - consider Metabolic encephalopathy = MCC