Auditing & Monitoring

1. Donald A. Butler, RN, BSN Manager, Clinical Documentation Vidant Medical Center Auditing & Monitoring

2. Auditing & Monitor • What is the overall desired goal? • Are there sources of guidance or references? • What is auditing? • What is monitoring? • How does auditing fit in? • What are some of the tools & resources?

3. Auditing & Monitor The General Goal:

4. Auditing & Monitor • What is being achieved by our CDI program • How well is it being done • What are the improvement opportunities • Where are the areas that need special focus • Focus topics for education • What are your program’s goals?

5. AHIMA 2010 CDI Tool kit • What Are CDI Goals? • Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures • Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement • Promote health record completion during the patient‘s course of care • Improve communication between physicians and other members of the healthcare team • Provide education • Improve documentation to reflect quality and outcome scores • Improve coders‘ clinical knowledge • Tracking the CDI program results is key to demonstrating that the goals of the program are being achieved

6. Auditing & Monitor • Tools & Resources • Internal data gathering, processing & analysis • Consultant engagements • CMS annual data • UHC & other organizations to benchmark • ACDIS surveys • AHIMA standards

7. Auditing & Monitor • Monitoring: Outcomes & measures • Data & Metrics • Measures • Compare to benchmarks • Should drill down to individual staff • Useful flags to identify trends, excellence, areas of concern • Identify areas of focus or special studies

8. Items Monitored 71% Origin of query 78% Name of query author 88% Name of physician 58% Method (written,verbal) 46% Paraphrase verbal query & response 64% Focus of query (DRG, SOI/ROM, etc.) 84% Physician agreement 60 – 70% DRGs (initial, potential, working, final) 58% CDS / Coding agreement 59% # reviews per day 44% # re-reviews per day 63% CC/MCC capture rate 70% Query rate by CDS 58% Query rate by physician 73% Financial impact of queries 43% SOI / other impact 75% rate for positive & negative responses ACDIS 2010 Physician Query Benchmarking Report

9. Auditing & Monitor • Basic Benchmarks: • 18% Query Rate (10 – 30%) • 87% Physician Response (>70%) • 88% Physician Agreement ( 70 – 95%) • 12 New charts per day (6 – 20) • 92% target < = 48 hours • 12 Re-reviews per day (6 – 20) • 58% daily, 24% every other day • Staffing basis 152 discharges per CDS per month • 50% CDI Programs have a Physician Advisor • Variable time, about 50% good or better effectiveness • 3-5% CDI programs 10 years or older

10. Auditing & Monitor • Auditing: Doing the right thing at the right time in the right way • Active examination • Application & comparison standards • Benchmarking data • P&P • Available guidance

11. Auditing & Monitor • Key Guidance (AHIMA): • Managing an Effective Query Process • Guidance for CDI Programs • CDI Tool Kit • Background of current state (2010) • ACDIS Physician Query Benchmarking Report • ACDIS CDI Program Benchmarking Survey • ACDIS White paper: CDI Staffing Survey • ACDIS On-line polls

12. Auditing & Monitor Critical importance: • Establishing written policies & procedures to establish expectations and standards • Ensure consistent CDI practices • Define among other elements: • Compliant query practices • Indications of when to query • Process • Who / how / when • Resolution • Background of individuals who do query

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14. ACDIS 2010 Physician Query Benchmarking Report

15. AHIMA Query Brief: P&P • The healthcare entity’s documentation or compliance policies can address situations such as: • unnecessary queries, • leading queries, • repetitive overuse of queries without measureable improvement in documentation, • and methods for provider education • Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy • policy should specify whether the completed query will be a permanent part of the patient’s health record • query policy should address the question of who to query (could include the attending physician, consulting physician, or the surgeon) • address the issue of yes/no queries in their policies

16. AHIMA 2010 CDI Program Guidance: P&P • The CDI department must be governed by written policies and procedures. These policies and procedures should be developed with the assistance of other departments affected by clinical documentation, including compliance, case management, and HIM. CDI policies can include (but are not limited to) education, experience, and credentials for hiring CDI professionals; initial orientation and training; ongoing education and training; compliant query practices; and a CDI quality assurance process • Organizations require comprehensive, facility-specific policies and procedures that govern the CDI clarification process. These should include, but are not limited to, when and how to format an appropriate question to a provider (verbal and written queries), query retention, and conducting audit and monitoring activities to determine the appropriateness and effectiveness of the CDI program.

17. AHIMA 2010 CDI Program Guidance: P&P • Organizations should also outline the following procedures for written queries: • A protocol to identify where queries are placed in the medical record • A process for notifying the medical staff of the presence of a query in the medical record • A protocol to address open (concurrent) queries, including: • How frequently open queries will be addressed • How long queries are allowed to remain unanswered or open • How queries opened under concurrent review are addressed when the patient is discharged • without a response • A protocol for query maintenance • A QA process of written queries, including: • Who will monitor the written queries • How many queries will be reviewed for compliance and how often • The feedback and corrective action needed, including who will take corrective action and when • Reporting documents for CDI QA processes

18. AHIMA 2010 CDI Program Guidance: P&P • Organizations should outline the following procedures for verbal queries: • When verbal queries are appropriate • An initial and ongoing training process that includes mentoring and testing trainees and a process for ongoing compliance monitoring • A process for documenting the verbal queries • A QA process of verbal queries, including: • Who will monitor the verbal queries • How many queries will be reviewed for compliance and how often • The feedback and corrective action needed • Reporting documents for CDI QA processes

19. AHIMA 2008 Managing an Effective Query Process • Since the query process has become a tool to improve provider documentation, it is critical that the design of these processes be maintained with legal, regulatory, and ethical issues in mind. Healthcare entities can create and maintain a compliant query process by: • Creating comprehensive policies and procedures for query processes • Generating queries only when documentation is conflicting, incomplete, or ambiguous • Conducting auditing and monitoring activities to determine the effectiveness of the query process • Providing education and training for the staff involved in conducting provider queries

20. AHIMA 2008 Managing an Effective Query Process • Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes • Queries can be reviewed retrospectively to ensure that they are completed according to documented policies • That the query was necessary • That the language used in the query was not leading or otherwise inappropriate • That the query did not introduce new information from the health record • the healthcare entity may need to identify follow-up actions • codes be corrected • tracked and trended • appropriate education and training

21. AHIMA 2008 Managing an Effective Query Process • reviewing both performance measures and compliance monitors, the errors related to documentation will become apparent • Healthcare entities should have a process in place to support and educate the staff involved in conducting provider queries. Ongoing education and training is a key component of the auditing and monitoring process

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26. ACDIS 2010 Physician Query Benchmarking Report

27. ACDIS 2010 Physician Query Benchmarking Report

28. ACDIS 2010 Physician Query Benchmarking Report

29. ACDIS 2010 Physician Query Benchmarking Report

30. AHIMA 2008 Managing an Effective Query Process • conducted on a regular basis. • include a representative sample of total queries • as well as a sampling by individuals initiating the query • Effective elements of an auditing and monitoring program include • percentage of negative and positive provider responses • high negative response rate • may indicate overuse of the query by the coding staff; a high positive response rate may indicate a • pattern of incomplete documentation that needs further investigation • format of query forms – may lead to specific education • individual providers to indicate improvement in health record documentation…result in a decreased number of queries for an individual provider • high-risk or problem diagnoses. The results may determine whether additional • education resulted in a decreased number of queries for a particular diagnosis

31. Reasons to Query: AHIMA Query Brief • Queries may be made in situations such as the following: • Clinical indicators of a diagnosis but no documentation of the condition • Clinical evidence for a higher degree of specificity or severity • A cause-and-effect relationship between two conditions or organism • An underlying cause when admitted with symptoms • Only the treatment is documented (without a diagnosis documented) • Present on admission (POA) indicator status • A query should be initiated when there is conflicting, incomplete, or ambiguous documentation in the health record or additional information is needed for correct assignment of the POA indicator. • whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure

32. Reasons to Query: AHIMA Query Brief • consider a policy in which queries may be appropriate when documentation in the patient’s record fails to meet one of the following five criteria: • 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). • 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).

33. AHIMA 2008 Managing an Effective Query Process • Queries should not be used to question a provider’s clinical judgment … a healthcare entity’s policies can provide guidance on a process for addressing the issue without querying the attending physician

34. AHIMA 2008 Managing an Effective Query Process • A query generally includes the following information: • Patient name • Admission date and/or date of service • Health record number • Account number • Date query initiated • Name and contact information of the individual initiating the query • Statement of the issue in the form of a question along with clinical indicators specified from the chart • The preferred formats for capturing the query include facility-approved query form, facsimile transmission, electronic communication on secure e-mail, or secure IT messaging system • Verbal queries have become more common as a component of the concurrent query process … entities should develop specific policies to clearly address this practice and avoid potential compliance risks

35. AHIMA 2008 Managing an Effective Query Process • Queries be written with precise language, identifying clinical indications from the health record and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case. The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption. • The introduction of new information not previously documented in the medical record is inappropriate in a provider query • In general, query forms should not be designed to ask questions about a diagnosis or procedure that can be responded to in a yes/no fashion. The exception is present on admission (POA) queries when the diagnosis has already been documented. • Multiple choice formats that employ checkboxes may be used as long as all clinically reasonable choices are listed, regardless of the impact on reimbursement or quality reporting. The choices should also include an “other” option, with a line that allows the provider to add free text. Providers should also be given the choice of “unable to determine.” This format is designed to make multiple choice questions as open ended as possible. • A single query form can be used to address multiple questions. If it is, a distinct question should be asked for each issue • the query should never indicate that a particular response would favorably or unfavorably affect reimbursement or quality reporting

36. AHIMA 2010 CDI Program Guidance: Queries • the term “query” will be used to identify any physician communication tool • A query is a routine communication and education tool used to advocate complete and compliant documentation. Although AHIMA refers to this communication to providers as a “query,” CDI programs may use different names, such as clinical clarification, documentation alerts, and documentation clarification. Regardless of what the communication is called, the query should adhere to the guidance outlined in the 2008 practice brief “Managing an Effective Query Process” and this current practice Guidance for Clinical Documentation Improvement Programs brief. • Typical situations addressed by a query include presenting clinical indicators of an undocumented condition, requesting further specificity or the degree of severity of a documented condition, clarifying a potential cause and effect relationship, and addressing present on admission issues.

37. AHIMA 2010 CDI Program Guidance: Queries • the standard query [template] should be individualized to each patient and contain clinical evidence specific to the case • Template queries should not be titled with a diagnosis that has not already been documented in the health record, as this may prejudice the provider’s response • CDI professionals must craft their queries skillfully. The query should assist the physician in understanding the documentation problem without leading the provider to a particular conclusion. • The advantage of a verbal query is the ability to interact with the provider to facilitate understanding of the issues that need to be addressed. However, caution must be used to ensure that the provider is allowed to make his or her own conclusions • One of the main challenges of a verbal query is accurate documentation of the interaction. What, where, and how it should be documented are all issues to be addressed by policies and procedures

38. AHIMA 2010 CDI Program Guidance: Queries • All written queries should include the following standard elements: • Patient name • Admission date and time • Account number • Medical record number • Date the query is initiated • Contact information of the CDI professional • Individualized diagnosis-specific templates to the particular patient, which provide clinical evidence relevant to the particular patient

39. AHIMA 2010 CDI Tool kit: CDI Quality Assurance Audit Tool CDI Quality Assurance Audit Tool • helps monitor the work of the CDI professional • checks and balances in place to ensure the highest level of integrity as CDI programs are likely to be scrutinized during external audits … aid in achieving a successful and compliant program • no recommendations as to how often these reviews should be completed and what volume of cases should be reviewed … each organization specify the frequency and volume of audits within its departmental policy

40. AHIMA 2010 CDI Tool kit: CDI Quality Assurance Audit Tool • support the appropriateness of the query • evidence of a missing or incomplete diagnosis to illustrate the query is not an attempt to introduce new information • issued query did not rely on a yes/agree or no/disagree response • ensure the revised documentation is present in the health record • physician response is twofold: did the physician respond, and if so, what was the physician‘s response. • Lack of response represents a different problem than a lack of agreement. • A low agreement rate by the physicians may be an indicator of inappropriate queries or poorly constructed queries. • Conversely, an agreement rate of 100 percent may also be indicative of a problem, as physicians may not perceive the ability to disagree with queries • focus on the ability of the CDI professional to correctly identify the need for additional documentation and additional reviews • identify differences between the final working DRG as determined by the CDI professional and the billed DRG • CDI professional is not a coder may expect DRG disagreements due to coding rules, inadequately capturing procedures • complicating conditions that arise after the CDI review • other causes of disagreements may be learning opportunities for the CDI professional

41. Clinical Documentation Improvement Quality Assurance Audit Tool Name of CDI staff: ___________________________ Review date: __________________ MR# of reviewed chart: _________________ Admission Date: ________ D/C Date: _______ Date of Initial CDI review: _______________ Date of subsequent review(s) ____________ Which of the following was the rational for issuing the query? The documentation was (circle all that apply): Illegible Incomplete Unclear Inconsistent Imprecise Conflicting documentation Did the query contain relevant medical evidence? Could the query be perceived as leading? Did the physician respond to the query? Did the physician agree with the recommendation? Was the additional documentation added to the health record? Were all opportunities for Present on Admission (POA) clarified? Was there clinical evidence of a diagnosis, which did not result in a query? Was there clinical evidence of a procedure, which did not result in a query? Were subsequent reviews performed? If more than one review occurred, were the subsequent reviews at appropriate intervals? Was the working DRG revised during the review process? Was the final working DRG the same as the billed DRG? If not, what was the difference between the two DRGs i.e., CC found, CC not verified, etc.? What were the medical evidence and the possible diagnosis and/or procedure? AHIMA 2010 CDI Tool kit: CDI Quality Assurance Audit Tool

42. Auditing & Monitor • Based on medical record information & physician documentation at the time of the Final DRG assignment… CDS Review Process • Initial and Poss PDX assignment supported with tx, monitoring, and/or evaluation etc. • Initial and Poss Secondary Diagnoses (CC/MCC) supported with tx, • DRG assignment was reflective of the highest documented severity i.e most optimal and within the appropriate MDC? • Identified query opportunity initiated? Query • Was the query necessary, based on the need for Present On Admission status, clinical indicators for a higher degree of specificity, conflicting, incomplete, or ambiguous (diagnoses that may have multiple impressions) documentation? • Was the query language appropriate, based on clinical S&S, treatment, or other information from the medical record? * • Was the query addressed to the appropriate provider (based on the query policy) • Did the query allow the provider options: The query allowed the physician to render his own clinical judgment?

43. Auditing & Monitor • How to apply – varies by size, staff, organization… • Audit even for standard query forms without customization