TEAMING FOR DOCUMENTATION INTEGRITY

1. TEAMING FOR DOCUMENTATION INTEGRITY PHYSICIAN ORIENTATION 2008

2. Dr. N. Dodhia Physician Advisor TDI, UM Mary Ellen Totzke RN BBA Quality Documentation Coordinator

3. PMMC Teaming for Documentation Integrity (TDI) Program • Quality Documentation Coordinator (QDC) • Link between physicians and coders from a documentation clarification standpoint • Coding language and requirements often differ from the clinical thought processes and documentation • Code to the highest degree of specificity • Improve data accuracy • Case Mix Index accurately reflects the intensity of service provided, severity of illness or resource utilization • Publicly available data increasingly scrutinized to measure hospital and physician performance

4. Ulcers: Type of i.e. Pressure Ulcers/Stage, Skin Tears, Venous Stasis Ulcers etc. Urosepsis = “UTI unspecified” in the Coding World If clinically applicable please document “sepsis due to urinary tract source” CHF: Acute, Acute on Chronic or Chronic? Systolic, Diastolic or both? Post Op Anemia: “Post op blood loss anemia” Debridement: “Excisional” or “Non excisional” Type of tissue debrided Documentation Clarification

5. Documentation Clarification cont’d • Please do not use arrows to indicate hyper or hypo. • Patient admitted with signs & symptoms (S&S) as diagnosis: • Link S&S to an etiology, if known • “Syncope due to hypovolemia” • “Abdominal pain due to diverticulitis”

6. POA Present at the time the order for inpatient admission occurs - - conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission Hospital Acquired Conditions (HAC’s) High cost or high volume or both Higher payment when present as a secondary diagnosis Could reasonably have been prevented through the application of evidence – based guidelines Definitions Source: www.cms.hhs.gov/HospitalAcqCond/06_Hospital -Acquired_Conditions.asp

7. POA Indicator Reporting Options

8. New from Federal Government • “Hospital Acquired Conditions” (HAC’s) POA (if not POA=possible reduction in reimbursement; possible future performance measures? ) - Stage III and IV Pressure Ulcers • Catheter Associated UTI • Vascular Catheter Associated Infection • Blood Incompatibility • Air Embolism • Foreign body left in • DVT and PE post Certain Ortho Procedures • Total Knee Replacement, Hip Replacement • Falls and Trauma (HA injuries)

9. New from Fed Gov (cont) • Manifestations of Poor Glycemic Control • DKA, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity (Secondary Diabetes-Cushing’s syndrome, genetic disorders, drugs, chemicals, infections etc.) • Surgical Site Infection-mediastinitis • SSI post certain ortho procedures • Spine, neck, shoulder, elbow • SSI post Bariatric Surgery

10. QUESTIONS?