ACDIS Chapter Meeting

1. A teaching hospital of Harvard Medical School ACDIS Chapter Meeting January 25, 2017

2. Agenda • Malnutrition: Nutrition Assessment Tools and Severity Levels/Risk Litsa Georgakilas, RD, LDN, CNSC • Pressure Ulcers: Staging and Differentiation of Unstageable Pressure Ulcers vs. Deep Tissue Injury Maureen Lira, RN, BSN, CWCN, CHI

3. Agenda • Clinical Documentation Challenges and Best Practices for Malnutrition and Pressure Ulcer Code Capture Nancy Friedlander-Hosken RN, MEd, CCDS Clinical Documentation Specialist • Coding Guideline Review, I10 Requirements and Quality Reporting Considerations for Malnutrition and Pressure Ulcer Staging and Progression Luisa DiIeso RHIA, MS, CCS Coding Training Manager

4. Clinical Documentation Challenges: Malnutrition • Malnutrition • Service Specific Clinical Correlation and Recognition • Source Documentation • BMI – Multiple Conflicting Sources and Variations • Retrospective Clinical Denials: RAC Examples • OIG and Internal Compliance Screens; Data Mining – Severe Malnutrition vs. Kwashiorkor

5. Best Practices: Malnutrition • Nutrition Forms Template Re-Design: Physician Co-Sign • Internal Data Mining: Compliance • Pre-Bill Validation: Kwashiorkor • Internal BMI Policy and Procedure: Source Documentation Hierarchy

6. Clinical Documentation Challenges: Pressure Ulcers • Pressure Ulcers • Staging Variations • Timely Physician Clinical Documentation of Specific Ulcer and Anatomic Site(s) • Pressure Ulcers vs. DTIs • POA-Present on Admission Documentation • Pressure Ulcer Stage Progression

7. Best Practices: Pressure Ulcers • CDI Clarification and Education • Internal Pressure Ulcer Staging Policy and Procedure: Source Documentation Hierarchy

8. Coding Guidelines and I10 Requirements: Malnutrition • Malnutrition: • Dx. And Severity: Physician Documentation • BMI Documentation: Other (Nursing, Anesthesia, Nutrition) • Hierarchy • Retrospective Appeals: RAC; Other • Kwashiorkor Dx- Inpatient: Pre-bill Validation • Kwashiorkor Dx- Outpatient: Internal Compliance Data Mining and Validation • Coding Clinic Highlights: Severity and BMI

9. Coding Guideline Review; I10 Requirements; Quality- Pressure Ulcer Staging and Progression • Pressure Ulcers Stage/Progression: • Diagnosis- Physician Documentation • I10: Laterality; Anatomic Site Code Expansion • Stage and Progression: “Other” Non-MD • Coding Guideline Updates 10/1/16: Progression of Stage with Corresponding POA Assignments • Multiple Codes; POA Differences • Coding Clinic Advice and Changes: 3Q, 2016

10. Coding Guideline Review; I10 Requirements; Quality- Pressure Ulcer Staging and Progression • Pressure Injury= Pressure Ulcer • Deep Tissue Injury- Meaning Pressure Ulcer – See Ulcer pressure, unstageable, by site • PSI; Quality Reporting Considerations • Importance of POA assignments • Internal Source Documentation Hierarchy: Wound Care, Bed Side Nursing