What is Clinical Documentation Integrity?

1. What is Clinical Documentation Integrity? A daily scavenger hunt

2. Benefits of Clinical Documentation • More accurate documentation reflective of true acuity and services provided • More accurate profiling data for both Hospital and medical staff • More appropriate case mix and reimbursement • Reduced compliance risk • Potential reduction in denials • More appropriate patient severity, mortality, outcomes and resource consumption data • Increased cooperation between physicians and hospital

3. A consulting group reviewed the appropriateness of the DRG assignment for a sample of inpatient Medicare cases at HPRHS based on the clinical documentation in the Medical Record. • Based on their findings, there was a potential financial impact of approximately $1.8 million in missed opportunities, contributed to documentation.

4. Documentation was the key factor, not the quality of care or service. • We know that we deliver exceptional health care services to the people of our region! • Many times the documentation doesn’t support the true severity of illness of our patients.

5. HPRHS Data Analysis: Why Does Data Matter?Hospital and physician profiling data is available to the public Research& ComparePhysicians

6. HPRHS Data Analysis: Why Does Data Matter?Hospital Report Cards www.abouthealthtransparency.org

10. POA vs. Hospital-acquired Conditions Present on admission (POA) is defined as present at 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 (HACs) are those that developed / occurred during an inpatient hospital stay.

11. Purpose of POA • Intention of this new concept is to reduce increased payments for complications that occurred after admission / during the hospitalization. • Hospitals have to submit data on all Medicare claims indicating whether the diagnoses were POA. • Coders indicate (Y or N) beside the principal diagnosis and all secondary diagnoses.

12. The 10 categories of HACs include: • Foreign Object Retained After Surgery • Air Embolism • Blood Incompatibility • Stage III and IV Pressure Ulcers • Falls and Trauma • Manifestations of Poor Glycemic Control • Catheter-Associated Urinary Tract Infection          (UTI) • Vascular Catheter-Associated Infection • Surgical Site Infection Following • Orthopedic Procedures • Spine Neck,Shoulder,Elbow • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) •  Total Knee and Total Hip Replacement • Payment implications began October 1, 2008, for these 10 categories of HACs.

13. Medicare 101DRG (Diagnosis Related Groups) Basics • How are DRGs used: • Calculating Hospital reimbursement • Evaluate quality of care • Evaluate utilization of resources • Each DRG represents the average resources utilized to care for a patient within the grouping • Every DRG has a relative weight (RW) assigned to it • The RW is used in the calculation of the Hospitals Case Mix Index www.hcup-us.ahrq.gov

14. Medicare 101DRG Basics • Major enhancement is revision of the CC list and development of MCC list • With the development of MS-DRGs, CMS reduced the CC capture rate from 77% to 40% • CC’s are categorized: • MCC (Major complication/comorbidity) • CC (complication/comorbidity) • Non CC www.hcup-us.ahrq.gov

15. CMS DRGs vs. MS-DRGs • MS-DRG’s • Heart failure with no MCC/CC DRG 293 = RW 0.7220 = $3,699 CHF LOS 3.7days TX O2 and IV Lasix • Heart Failure with CC DRG 292 = RW 1.0069 = $5,155 CHF LOS 5 days TX O2, IV Lasix, echo, med adjustment, Chronic obstructive bronchitis acute exacerbation • Heart Failure with MCC DRG 291 = RW 1.4601 = $7,481 CHF LOS 6.5 days intubated ED, admit to ICU, In ICU 7 days, IV Dobutamine, multiple tests, multiple med adjustment, critical care, complicated by acute renal and respiratory failure

16. The Goals of Clinical Documentation Integrity (CDI) Process are as follows: • Drive appropriate coding for accurate reimbursement • Reflect accurate patient acuity levels • Meet standards • Reduce compliance risks • Provide accurate data for quality indicators and other hospital metrics • Reduce coding turnaround time • Decrease post-discharge queries to the physicians by utilizing concurrent physician queries when indicated

17. Clinical Documentation Analysts • Nita Campbell, RN ICU/CCU/OCU • Janice Davis, RN 6S/7N/PJC • Alletheia Fitzgerald, RN 6N/7N/5N • Tamika Jones, RN CPU/MTU • Elinore Poindexter, RN 5S/CTU • Medical Records x 2938