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Documentation Enhancement Case Management and Utilization Review

Documentation Enhancement Case Management and Utilization Review. Prepared by: Sherry A. Milton, RHIA Milton & Associates P.O. Box 683 Erin, Tennessee October 13, 2011. Measures of Excellence. Quality Measures Public Health Research Organized Monitoring and Performance

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Documentation Enhancement Case Management and Utilization Review

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  1. Documentation EnhancementCase Management and Utilization Review Prepared by: Sherry A. Milton, RHIA Milton & Associates P.O. Box 683 Erin, Tennessee October 13, 2011

  2. Measures of Excellence • Quality Measures • Public Health • Research • Organized Monitoring and Performance • Information System Advances • Reimbursement

  3. Current Environment • Medical • Constant • W/O CC/MCC • W/CC • W/CC/MCC • W/MCC • Surgical • Constant • W/O CC/MCC • W CC • W/CC/MCC • W/MCC

  4. CURRENT EXAMPLE • Congestive Heart Failure • CHF without CC/MCC – Wt. .6853 - $3,769.15 • CHF with CC – Wt. 1.0302 - $5,666.10 • CHF with MCC – Wt. 1.4943 - $8,218.65 DIASTOLIC/SYSTOLIC ACUTE/CHRONIC

  5. CHF – Secondary Diagnosis • Pneumonia – as principal – Wt. .7096 - $3,902.80 • CHF – Unspecified (W/O CC/MCC) • Pneumonia as principal – Wt. 1.0152 - $$5.583.60 • CHF – Chronic, diastolic/systolic/both (W CC) • Pneumonia – as principal – Wt. 1.4796 - $8,137.80 • CHF – Acute, diastolic/systolic/both (W MCC)

  6. Reason for Change ToInternational Classification Disease 10-CM • No longer meet the demands of healthcare’s data needs • Cannot accurately describe the diagnoses and inpatient procedures for care delivered • Coded data is well beyond the purposes of ICD-9-CM • Greater need for coding accuracy and specificity • ICD-9-CM initially was not used for reimbursement purposes • ICD-9-CM procedures are outdated and inadequate • ICD-9-CM cannot support many of the IT and data exchange initiatives.

  7. The BenefitsInternational Classification Disease 10-CM • Quality measures and medical error reduction (Patient safety) • Outcomes measurement • Clinical, financial and administrative performance improvement • Health Policy planning • Payment systems design and claims processing • Provider profiling • Refinements to current reimbursement systems, such as severity-adjusted DRG systems • Pay-for Performance programs • Educating consumers on costs and outcomes of treatment options

  8. Cost/Benefit Analysis • More accurate payment for new procedures • Fewer rejected claims • Fewer fraudulent claims • Better understanding of new procedures • Improved disease management

  9. New Features Combination Codes for conditions and common symptoms or manifestations E10.21 -Type I diabetes mellitus with diabetic nephropathy I125.110 - Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris K50.112 - Crohn’s disease of large intestine with intestinal obstruction

  10. New Features Combination codes for poisonings and external causes • T36.0x1D – Poisoning by penicillin, accidental (unintentional), subsequent encounter • T42.4x5A – Adverse effect of benzodiazepines, initial encounter

  11. New Features Added Laterality • H60.332 – Swimmer’s ear, left ear • M94-211 – Chondromalacia, right shoulder • S40.259A – Superficial foreign body of unspecified shoulder, initial encounter

  12. New Features Added seventh-character extensions for episode of care • M80.051A – Age related osteoporosis with current pathological fracture, right femur, initial encounter for fracture • S06.0x1A – Concussion with loss of consciousness of 30 minutes or less, initial encounter • S52-132B – Displaced fracture of neck of left radius, initial encounter for open fracture, Type I or II or initial encounter for open fracture NOS

  13. New Features Expanded codes (injuries, diabetes, alcohol and substance abuse, postoperative complications • E11.341 – Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema • F14.221 – Cocaine dependence with intoxication delirium • K91.71 – Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure.

  14. New Features Inclusion of trimesters in obstetrical codes (and elimination of fifth digits for episode of care) • 010.012 – Pre-existing essential hypertension complicating pregnancy, second trimester • O99.013 – Anemia, complicating pregnancy, third trimester

  15. New Features Changes in timeframes specified in certain codes • Acute myocardial infarction – time period changed from 8 weeks to 4 weeks • Time frame for abortion versus fetal death changed from 22 weeks to 20 weeks.

  16. CASE MANAGEMENT ROLE DOCUMENTATION DOCUMENTATION DOCUMENTATION DOCUMENTATION DOCUMENTATION

  17. Credentials • Anatomy and Physiology • Microbiology • Pharmacology • Coding rules understanding • DRG Payment Methodology

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