3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. Bridging the CDI gap: Bringing the clinical/coding reconciliation process together Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS Lynne Spryszak, RN, CCDS, CPC-A

3. Objectives of this presentation: • Identify successful CDI infrastructure models • Learn how to use each other’s strengths to build a strong process • Use differences to “close the gap” • Develop a “full-circle” reconciliation process

4. Program Foundation/Infrastructure

5. Who needs to be involved? • Build a solid foundation of support • Administrative support/Steering Committee • CEO • CFO • CMO/VP Medical Affairs/Chief of Staff • VP Nursing • HIM Director • Director of CDI

6. Who has responsibility? • CDI Program Reporting structure • HIM and CDI reporting to same level of administration • Facilitates decision-making • Eliminates barriers d/t differing facility goals • Understands global effect of program • Support for change • Champions growth – invested in success • Promotes program within organization • Ability to approve program changes • Staffing • Focus of program

7. Importance of program leaders • CFO (Chief Financial Officer) • Understands: • Financial impact of program • Payer benefits • Impact on operating budget • DNFB, A/R • How improved profiling affects business • Fiscal responsibility • Approves budget/spending • CDI FTEs

8. Importance of program leaders • CEO (Chief Executive Officer) • Hospital’s “top dog” • Top level of Administrative Tree • Influence • Medical Staff • Nursing • HIM • All other departments

9. Importance of program leaders • CMO (Chief Medical Officer)/VPMA (Vice President of Medical Affairs)/Chief of Medical Staff • Responsibilities: • Support/facilitate physician education • Support physician participation • Access to staff meetings • Support CDI Process • Medical staff involvement • Inclusion on medical staff agendas • Physician compliance • Final medical authority in query follow-up process

10. Importance of program leaders • CNO (Chief Nursing Officer)/VP of Nursing/ Director of Nursing • May have responsibility for CDS • Understanding of CDI goals • Documentation drives data • Nursing documentation • Impacts data • Patient care • Ability to effect change • Required documentation: forms, templates, EMR fields, etc. • Participation of Nurse Practitioners, other second level providers with documentation privileges • Support goals of documentation improvement

11. Importance of program leaders • HIM Director • Approves CDI/Coding policies and procedures • May have responsibility for CDS as well as coders (overall program administrator) • Approves procedural changes • Final responsibility for actions of HIM department • Coder participation • Coding turnaround time • Compliance

12. Importance of program leaders • CDI Director • Provides guidance • Access to resources • Liaison between CDS and upper management • Responsible for • Program outcomes • Meeting goals • Staffing • Training

13. Importance of program leaders

14. Importance of program leaders • Key Points • Success depends upon involvement of the executive committee • Collaboration within and between administrative levels essential • Program organizational structure not as important as strong leadership at each level • Ongoing communication is pivotal to success

15. The “Blended” Model: HIM and RN teams The blended model

16. What each profession brings to the team The blended model

17. The blended model • HIM Strengths • Knowledge of coding rules and regulations • Training/Education 2 - 4 (or >) years of formal learning including: • Anatomy & Physiology • Pharmacology • Medical Terminology • Health Information Management • Inpatient coding/billing • Physician (Professional) coding/billing • Specialty training • Legal/Ethical Issues in Healthcare • Reimbursement Methodology • Outpatient coding/billing • ED coding/billing • Health Data Management • Computer Systems • Clinical Data Management

18. The blended model • RN Strengths • Clinical (hands-on) assessment experience • Training/Education 2 – 4 (or >) years of formal learning including: • Anatomy & Physiology • Pharmacology • Medical Terminology • Pathophysiology • Nutrition • Microbiology • Pediatric/Adult Growth and Development • Psychology • Ethics • Clinical Practice • Chemistry

19. The blended model 100 % Success = 50% + 50% Effort!

20. The blended model • Teams • Respect differing values & viewpoints • Share the “load” • Define goals • Develop processes • Avoid blame/shame • Focus on the problem, not the people • Persistent • Work together…

21. The blended model Success depends on everyone knowing their job and then doing it!

22. The blended model • Responsibilities of the Coder: • Ethical behavior • Accurate code assignment • Productivity benchmarks • Data management • Confidentiality • Adherence to internal policies and procedures • Facility • Coding • Employee • Adherence to rules and regulations • AHIMA Code of Ethics • “Official Coding Guidelines for ICD-9” • Coding Clinic • State regulations • Continuing education • Training and development

23. The blended model • Responsibilities of the CDS • Ethical behavior • Facilitate improvements in provider diagnostic documentation • Collaborate in data reporting (diagnoses) • Specificity • Clinically appropriate • Supported by medical record • Ensure “complete” record • Adherence to internal policies and procedures • Coding • CDI • Employee • Adherence to external rules and regulations • AHIMA? • ???? Are there any?

24. The blended model While CDI team members may be subject to the same internal policies (employee, safety, body mechanics, etc.), determining whether the CDS’ are governed by coding rules and regulations and whether their goals are the same as the coders’ has been much disputed and the subject of controversy. • This “double standard” creates an “us” versus “them” mentality. • Impedes or eliminates trust • Creates conflict • Prevents collaboration • Diminishes credibility • Team working as individuals rather than partners

25. Perspective: Do you see what I see?

26. Case study The patient is a 78-year-old female who presented with a 2-day history of black tarry stools. This patient denied any abdominal pain, nausea, vomiting or diarrhea, also, no chest pain, no fevers or chills.  The patient denied any recent trauma or change in medication.  The patient had a significant history of use of aspirin, Plavix, and Coumadin.  The patient denied any gross blood in stool or history of any ulcers in her GI tract or cancers of the GI tract.  Initial laboratory work revealed hemoglobin level of 8.1 and hematocrit of 24.8, which was down from a baseline level of 10.4 hemoglobin in August 2009.  Her INR was 4.4 as well.  Troponins were negative x3 sets and chest x-ray was clear.  Upon admission, warfarin, Plavix, and aspirin were held and she was transfused 2 units of packed red blood cells followed by H and H q.6 hours.  She was also given IV fluids and placed on a Nexium drip. 

27. Case study On April 3rd, she was again found to be weak, tired, and also experienced a bowel movement that was positive for blood.  Her hemoglobin had initially responded to the first 2 units of blood to a level of 9.6 but had again decreased to 8.6.  She was given 1 more unit of packed red blood cells and GI was consulted for endoscopy.  EGD was performed, which revealed no active source of bleeding.  Also, colonoscopy was performed which revealed no source of bleeding as well. 

28. Case study • DISCHARGE DIAGNOSES:1.  Osteoporosis2. Dementia3. Osteoarthritis (OA)4. Coronary artery disease (CAD)5. Type 2 diabetes6.  Gastroesophageal reflux disease (GERD)7.  Peripheral vascular disease (PVD)8.  Depression9.  Hyperlipidemia10. Hypertension11. Acute gastrointestinal (GI) bleed

29. How good are your ‘eyes’? Through a coder’s eyes: • Acute GI bleed • Due to ? • H/H low – • Query needed for • ?anemia & type • ?blood loss • ?acute on chronic • GERD • Hx aspirin use • (Code the rest of discharge diagnoses listed) • EDG • Colonoscopy • Transfusion

30. How good are your eyes? Through a nurse’s eyes: • Why was the patient on Plavix and Coumadin? • Was patient taking her medication appropriately – she has dementia • Was this then a “poisoning” or is it an “averse effect”? • Pt placed on Nexium drip – did the doctor suspect an upper GI bleed? • Should I ask the GI guy if he suspects a cause of bleeding even though the scopes were negative? • Did the patient have blood loss anemia or was it a combination – blood loss, iron deficiency, other?

31. The medical record • Coders: • Identify documented conditions (diagnoses) • Focus on what IS documented, not what isn’t • Focus on “who” documented • Identify and interpret conflicting information • Interpret operative reports • Understand the difference between what is apparent and what is “code-able” • Process records efficiently and within defined time frames (can’t get bogged down in one record)

32. The medical record • Nurses: • Synthesize random bits of information into a diagnosis • Pulmonary infiltrates + Levaquin = Pneumonia • Absent bowel sounds = Ileus • Increased pulse, edema, and “wet” breath sounds = CHF • “Leap to conclusions” • Don’t need to see the word to know it exists • Aren’t necessarily concerned with specificity • Bronchitis or COPD – what’s the difference – it’s all SOB • Altered mental status = more work! • Why do I care if it’s systolic heart failure? They all get Lasix! • I can’t read the progress notes either - when in doubt, I guess!

33. The medical record • Coders typically • Review thousands of records each year • Look at all the documentation, while thinking coding, guidelines, and is it all supported? • All clinician documentation, all reports, progress notes, orders … • Are happy to have a discharge summary at the time of coding. • Compares the discharge summary to the body in the chart to make sure all is consistent. • Have the “whole enchilada” available for coding • Well, maybe half an enchilada if there’s no d/c summary… • Reviews all other information and digs into the nursing notes when searching for a missing link… • Generally don’t place a lot of emphasis on the ED notes, (for coding purposes), but use for the introduction (framework of the patient – what occasioned the admission to the hospital) • Take pride in their work

34. The medical record • Nurses typically • Focus on the abnormals: lab results, vital signs, mental status, x-rays • Focus on the clinical, not the record • Don’t see things as contradictions • Renal failure = renal insufficiency • Rarely “challenge” a physician’s diagnosis • Only use the progress notes if there’s no “check box” • Are task-oriented • Assess patient • Pass medications • Sign-off orders • Document by exception • Take pride in their work

35. What’s the answer? • Respect our similarities • Appreciate our differences • Share what we know • Be willing to admit what we don’t know and ask for help • Appreciate each other’s limitations • Time • Opportunity • Expertise • Keep our “eyes on the prize” – accurate data! • Collaborate in devising solutions

36. Comprehensive approach • CDS perform concurrent reviews and Coders perform retrospective reviews to: • Identify opportunities • Diagnosis specificity/accuracy • Request clarification as needed • Priorities – align, but the scope or focus may be a little different • CDS • Physician documentation: accurate, specific, clinically supported • HACs • CORE measures • Medical Necessity • Coders • Coding the record: accurate, specific, clinically supported, also meeting the above (to an extent)

37. Observations • Neither group can do it alone – • or should have to • What one person misses, another one may catch – “have each others’ backs” • Wearing different “glasses” makes us see things differently • One group can help the other – “many hands make light work”

38. One solution? • Never only one solution • Process is dynamic • Enlist support: • Medical staff • Nursing • Ancillary care • Quality • Finance • Managers • Be willing to compromise on the small issues and collaborate on the big issues

39. Assigning the DRG Drawing the circle

40. DRG/MS-DRG assignment Aiming for the most accurate … 40

41. The principal diagnosis (PDx) is the initial “driver” to the (one) MDC…. Then driving on to the most specific DRG/MS-DRG With of course several factors involved The driver = The principal diagnosis

42. PDx: Principal diagnosis • Coding guideline for inpatient hospital cases for the Principal diagnosis = “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” • How does the term “principal” dx differ from the clinician’s definition? (Most severe? most acute?)

43. MDC listing

44. The bucket list Medical Diagnosis

45. Start with medical first • The starting point is always the medical diagnosis. • Determines the correct MDC • Medical diagnoses are grouped to DRGs within that MDC • MDC assignment does not change d/t surgical procedure • Correct starting point “drives” the DRG assignment • Incorrect starting point, incorrect ending point 45

46. DRG bucket options

47. Procedures Surgical Procedure

48. Is there a surgical procedure? • If a procedure is done, you then drive from medical to the surgical side of the MDC. • However; not in all cases. • Not all procedures will drive to the surgical side: • Example: Biopsy • Closed, percutaneous, open …

49. Chest tube Cystoscopy Defibrillation EGD Electroshock therapy Endotracheal intubation ERCP Foley catheter Non-surgical procedures CMS non -surgical procedures are coded, but does not impact the DRG assignment • Gastric tube • I&D • Intrathecal catheter • Lumbar puncture • Paracentesis • Peritoneal dialysis • Spinal tap • Subclavian line • Swan-Ganz catheter • Temporary pacemaker • Thoracentesis 49

50. Procedures: One too many • The PDx as the driver is still the determining factor in many cases for a surgical DRG/MS-DRG. • There are procedures common for multiple diagnoses in many MDCs. • IVC or Greenfield filter placement • Excisional debridement • While these procedures are included in several surgical DRGs/MS-DRGS, the PDx will drive to the most specific choice. 50