3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. Ethics ENDS with the clarification Robert S. Gold, MD CEO, DCBA, Inc.

3. It's how you get there that can land you (and your docs) in jail

4. Don’t gamble with your charts How do you look in an orange jumpsuit?

5. We never promised it would be easy CDI World

6. Clinical documentation improvement definition • The process by which the medical record documentation produced by licensed providers of healthcare accurately reflects the diseases suffered by their patients in any encounter • ALL patients • ALL payers • ALL conditions

7. Clinical documentation improvement definition (cont.) • It does NOT imply “Medicare only” • It does NOT imply DRG payers only • It does NOT imply documenting for dollars • It does NOT imply overcoding for dollars

8. It’s help in documentation to save lives • When “pneumonia” is there rather than “infiltrate” or “LRTI,” Core Measures can intervene • When “chronic systolic failure” is there, ACE or ARB can be started for heart failure Core Measures • When “wound infection” rather than “soupy drainage” is there, SCIP can be effective • When “NSTEMI” is there rather than “ACS with ↑ troponin,” AMI Core Measures can be instituted

9. It’s documentation to justify resource utilization • When “persistent hypotension post CABG d/t diabetic autonomic neuropathy” is there, that extra day on the ICU is justified • When “embolic R MCA infarct occurring 1.5 hours ago” is there, TPA is justified • When “von Willebrand’s” is there, factor VIII administration is covered

10. What drives it all? Physician documentation!

11. It's documentation for severity of illness and risk of mortality!

12. All acute care hospitals All service lines at the hospitals All surgeons at the hospital All internists at the hospitals Who gets measured? Mortality = death rate Morbidity = complications and patient safety

13. Concentration on Medicare THE LAW: “Medicare has no obligation to pay for items and services if a provider treats Medicare beneficiaries differently from non-Medicare patients.”

14. Don’t code complications for dollars “Try to get surgeons to document postop ileus, postop urinary retention, postop atelectasis—that will change the DRG and bring the hospital more money.”

15. Everyone’s looking at us

16. It’s ALL payers

17. Hi, Remember I told you a few weeks ago about Blue Cross going to pay us a visit? Well, guess what - they did. We got a 9% increase in payment and Mr. Betz says that’s about a million dollars we are looking at. Across the river in Memphis they got a 16% cut in payment. What does that tell you about their million dollar program?

18. Everyone with blood pressure over 180/100 has malignant hypertension

19. Accelerated hypertension • Just because a blood pressure is high does NOT mean accelerated or malignant hypertension • Hypertensive urgency definition • Hypertensive emergency definition—with an organ dysfunction!

20. Accelerated hypertensionTarget organs • Heart • Acute diastolic heart failure (acute pulmonary edema) • Stress MI • Kidneys • Acute renal failure • Brain • Stroke • Hypertensive encephalopathy

21. Everyone with blood sugar over 200 or placed on sliding scale insulin has uncontrolled diabetes

22. Definitions of uncontrolled • HbA1C over 7.0 (goal 6.0 American Diabetes Association, 6.5 American Association of Clinical Endocrinologists) or … • Persistent refractory hyperglycemia associated with metabolic deterioration • Recurring fasting hyperglycemia greater than 300 mg/dl refractory to outpatient therapy, or a glucose greater than or equal to 100% above the upper limit of normal • Recurring episodes of severe hypoglycemia (i.e., less than 50 mg/dl, or 2.8 mmol/l), despite intervention • Metabolic instability manifested by frequent swings between hypoglycemia (less than 50 mg/dl) and fasting hyperglycemia (greater than 300 mg/dl) • Recurring diabetic ketoacidosis without precipitating infection or trauma • Repeated absence from school or work due to severe psychosocial problems, causing poor metabolic control that the patient cannot manage on an outpatient basis

23. ESRD patients with high creatinine on admission that comes down to normal range after dialysis have acute renal failure on ESRD

24. Acute on chronic • Decried by nephrologists • Chronic kidney disease has its causes • Acute kidney injury (acute renal failure) has its causes • They’re NOT exacerbations of the same condition—name each • But …

25. Acute on ESRD? • Coding guidelines set us WRONG • There is NO acute renal failure on ESRD Kidneys

26. Acute renal failure • If the physician documents “acute renal insufficiency,” that ALONE is NOT reason to ask for documentation of acute renal failure • The history, clinical circumstances, and lab support must be there before you bother the doc

27. "Possible," "probable," or "likely" diagnoses on admission can be—SHOULD BE— coded as though they exist

28. Official coding guidelines • If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” code the condition as if it existed or was established. • The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.”

29. Impossible, improbable, or unlikely “The patient in 322 is from a nursing home and is 72 years old and has COPD. Is this gram negative pneumonia?” “I don’t know.” “Is it possible that it’s gram negative pneumonia?” “I don’t know.” “But is it POSSIBLE?” “Sure, it’s possible.” 7/26/2005 Barbara told me to write that this is possible gram negative pneumonia

30. Impossible, improbable, or unlikely (cont.) • If the usual treatment for all pneumonia is Rocephin and Zithromax, and this patient was treated with Rocephin and Zithromax, it was NOT: • Gram negative pneumonia • Aspiration pneumonia • Mixed bacterial pneumonia • “Hypostatic pneumonia”

31. Possible, probable, or likely • 57 year old WM with painless jaundice. CT shows 8 cm mass at head of pancreas with dilated common and hepatic ducts, paraaortic lymphadenopathy, multiple foci of metastases in liver, lungs, and brain. Refused PTBD for symptomatic relief. No chemo can help. Palliative care through hospice. • Imp: Probable cancer of head of pancreas

32. When a patient is maintained on a ventilator over 24 hours after surgery, it's acute respiratory failure

33. Acute respiratory failure • Patients being purposely maintained on the ventilator after surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure • Just because the patient is on oxygen is NOT a reason to ask the doc for acute respiratory failure

34. Preventive maintenanceon respirator • Abdominal compartment syndrome is a well-known complication after abdominal trauma and is increasingly recognized as a potential risk factor for renal failure and mortality after adult orthotopic liver transplantation (OLT). • The techniques of temporary abdominal closure (TAC) are varied. All techniques face a similar challenge: the management of the open abdomen. • These data consistently show that maintaining the open abdomen protocol in high-risk groups has been effective in reducing mortality in a clinical setting.

35. Preventive maintenanceon respirator (cont.) • Postop issues in the morbidly obese patient. • Patients who have obesity-related comorbidities carry a dramatically greater risk of perioperative complications. Therefore, any obese patient undergoing major surgery, or those with a history of comorbidities, should be nursed in an appropriate level 2 or level 3 facility.

36. Code pulmonary infiltrate rather than pneumonia when there is no CC

37. Infiltrate reasoning • 518.3 as principal diagnosis with no CC leads to DRG 198 (Interstitial lung disease w/o CC/MCC) with RW = 0.8137 • 486 as principal diagnosis with no CC leads to DRG 195 (Simple pneumonia w/o CC/MCC) with RW = 0.7095

38. Pulmonary infiltrate • A finding on a chest x-ray 793.1 is NOT a disease • Pulmonary eosinophilia 513.8 is NOT the code for pulmonary infiltrate—it is the code for allergic (eosinophilic) pneumonia • If a pulmonary infiltrate is worked up and no finding identified, you must assign the symptom code—it’s an abnormal x-ray finding, not Loeffler’s

39. Be sure to code 514 for patients with lung congestion. Pneumonia after atelectasis is hypostatic pneumonia.

40. Rationale for 514 • 514 as principal diagnosis leads to DRG 189 (Respiratory failure and pulmonary edema) with RW = 1.3455 • 486 as principal diagnosis leads to DRG 195 (Simple pneumonia without CC/MCC) with RW = 0.7095

41. Lung congestion is NOT 514 • Lung congestion on physical exam is a physical finding and is NOT to be assigned a code • Pulmonary edema on a chest x-ray is an x-ray finding and is NOT to be assigned a code

42. Hypostatic pneumonia • Code was developed for passive lung congestion in 1800 – it was NOT an infection, but hepatization of the lungs due to prolonged position in a malnourished patient • Hypostatic pneumonia: Pulmonary congestion due to the stagnation of blood in the dependent portions of the lungs in old persons or in those who are ill and lie in the same position for long periods. • “Hypostatic pneumonia” is a disease of large farm animals • Pneumonia treated with antibiotics is 486

43. Teach your physicians to document SIRS when the patient has two of the four criteria and has an infection

44. Infection with two criteria for SIRS is NOT sepsis Encoders may lead you down the garden path—DON’T be fooled How good do YOU look in orange? • Sepsis has a higher RW than UTI or pneumonia • Surgery for sepsis has a higher RW than appendicitis

45. Jonathan Ball, St. George’s Hospital “Sepsis syndrome has been, and remains, a major focus of intensive care research and the subject of a large number of international multicentre trials. Despite these facts, there is limited awareness of the condition among the general public and health care providers. One of the explanations for this is felt to be the confusing definitions and terminology surrounding the condition, in particular the SIRS diagnostic criteria, which have been the standard diagnostic tool employed, especially in therapeutic trials. However, SIRS has multiple deficiencies, not least that two of the criteria are met performing normal daily activities such as running for a bus (tachycardia and tachypnoea).” 45

46. More dissatisfaction “Vincent began by asking the panel to define sepsis. Artigas proposed the view that sepsis is a syndrome of systemic inflammation, which occurs in response to infection. He felt that the SIRS criteria were too vague, failed to include vital parameters, failed to consider the site of infection and failed to usefully assess severity of illness. In response, Bakker felt that the SIRS criteria are a useful concept in the early identification of patients who may have or are developing sepsis, a view supported by Schroeder and Sherry. However, there appeared to be unanimous agreement that the SIRS criteria were overly sensitive and insufficiently specific to be used as diagnostic criteria for sepsis in clinical practice or therapeutic trials.” 46

47. Arthur Baue, MD from Yale • “Systemic inflammatory response syndrome was defined by a consensus conference of the American College of Chest Physicians and the Society of Critical Care Medicine as a clinical syndrome that is thought to be the result of an overly active inflammatory response. Vincent, Bone, Opal, and others believe that the concept of SIRS does not help, and I agree.” • “I have no problem with the use of SIRS as a nonspecific description of being sick. I do have a problem with going beyond that such as using SIRS criteria for randomized trials of therapy. No one has reported on the appearance of patients with SIRS. Don't they look sick? Can't clinical observation also tell you that they are sick?” 47

48. Baue (cont.) “Anyone with SIRS is sick. Systemic inflammatory response syndrome has been highly touted as a way to define and measure sickness. Has it helped? Is it worthwhile? Let us go beyond the hype of those who have a vested interest in SIRS because they invented the concept. The trained clinician observes his patients beyond just vital signs. I recommend to my students and residents that during rounds, they should go into the patient's room or cubicle in the intensive care unit or elsewhere and observe and talk to the patient before they check the chart and the vital signs. This allows them to determine the patient's state as the patient feels it or experiences it.” 48

49. Urosepsis is NOT sepsis • Unless it is • Dorland’s definition changed about 1992 • Sepsis due to … a named infectious process is the way to adequately address it • If the patient has NO signs/ symptoms consistent with sepsis, leave it alone

50. Urge the physicians to use the term encephalopathy rather than altered mental status