Documentation for the Modern Healthcare System

1. Documentation for the Modern Healthcare System Amanda Peppercorn, M.D. Physician Advisor, Medical Information Management Assistant Professor, Division of Infectious Diseases University of North Carolina at Chapel Hill

2. What is the Medical Record? • A means for healthcare providers to communicate to each other and explain medical events • A legal document • A way to track emerging diseases, epidemics, healthcare utilization, population shifts • The basis for accurate medical billing, compliance (avoidance of being audited!) • Health care quality improvement • Outcomes—cost, mortality

3. Outpatient and Inpatient Billing are Different • Outpatient: • Procedures • evaluation/ management (CPT-4) based on complexity, history/physical, time spent doing E/M • Inpatient: • Hospital Pay: DRG system (Diagnosis-related Group) based on ICD-9 Codes • Based on Principal diagnosis, procedures, complicating conditions (CC’s and MCC’s) • Case Mix Index (CMI) • Physician: procedures, E/M

4. Impact of Hospital Payment • Maintain the physical plant • Provision of services for PATIENTS • Local and National Competition • Community employment/local economy • Support Graduate Medical Education “Fiscal health of the hospital and the scope of the physician’s patient care delivery are directly intertwined”

5. Why documentation & coding are important • Payment (Reimbursement) • Profiling (Outcome Analysis) • Physician • Institution • Performance (Quality of Care Initiatives) • Core Measures • Present on Admission

9. PRINCIPAL DIAGNOSIS • The condition after study chiefly responsible for admission to the hospital • It is NOT: • Cause of death • Underlying disease process • Most morbid condition • Always the reason for OP procedure • Ex. Crohn’s disease, admitted for TPN due to malnutrition

10. Documentation Guidelines Specificity • Clarify if reason for admission is a direct complication of medical care—post op wound infection, ileus • Specify reason for admission following operative procedure • Pain control • Arrhythmia • Respiratory failure • Blood loss • Avoid if possible using nonspecific signs and symptoms as principal diagnoses • Chest paincostochondritis, GERD, chronic angina • TIAatrial fibrillation with embolism • Syncopeorthostatis • Abdominal painsmall bowel obstruction, diverticulitis with abscess

13. Clarify Procedures Debridements (not I&D) • Excisional • Deepest tissue layer debrided Re-operations of previous amputation sites • Re-amputation • Revision • Debridement only

14. Documentation Guidelines Document all sites/extent of trauma Type of skin ulcer and complications Delineate wound complications Define the extent of burns/inhalation injury

16. Wound Complication • Surgical Wound dehiscence Infection • Traumatic (“Complicated Open Wound”) Infected—type (bone, soft tissue, muscle) Delayed healing Foreign body

18. “Other Diagnoses” “All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.”

19. “Other Diagnoses” • Chronic active systemic medical diseases • Any condition that occurs that affects patient care: • Evaluation/treatment • Extended length of stay • Increased level of care

20. BILIARY TRACT DISORDERS Cholangitis Pancreatitis Sepsis SKIN ULCER Cause Cellulitis Osteomyelitis Sepsis/SIRS TRAUMA Hypovolemia Blood loss anemia Hypoxemia DIVERTICULAR DISEASE Abscess Obstruction Sepsis/Sirs All interrelated conditions that impact patient care

21. Renal Insufficiency Acute vs Chronic Renal failure Stage of CKD Stage IV-V ESRD LV dysfunction/CHF Left/right/biventricular Systolic/diastolic Acute/chronic SPECIFICITY

22. COPD Chronic respiratory failure Diabetes Mellitus type and control Heart failure Chronic kidney disease Active Cancer including sites Malnutrition (TPN, severe, BMI<20) HIV infection Obesity (BMI>40) All chronic systemic diseases

23. Postoperative Conditions • Exacerbation of chronic disorders COPD, Left heart failure, atrial fibrillation • Occurrence of unexpected conditions Postoperative myocardial infarction • Expected conditions associated Blood loss anemia; ileus; atrial flutter; wound infection

25. An 69 WF presents following a MVA with multiple injuries including chest and pelvis. The patients oxygen saturations were 70% requiring Bipap. Hematocrit dropped from 38 to 21 requiring 3 units of blood. Patient was initially hypotensive requiring fluids and low dose vasopressors. The BUN and creatinine increase to 50 and 4.0 during the first week of hospitalization but returned to normal by the time of transfer to Rehab on hospital day 21. The final principal diagnosis was multiple rib and pelvic fractures . Additional diagnoses included: hypoxemia, anemia, hypotension, and renal insufficiency.

26. Clinical vs.Coding Specificity • Renal Insufficiency • Hypoxemia • Hypotension • Anemia Level 0 Severity • Acute renal failure • Acute respiratory failure • Shock • Acute blood loss anemia Level 3 Severity

27. Documentation Guidelines Completeness • Significance of all abnormal laboratory and imaging testsneed treating MD translation • Can’t use primary data to support DRG (includes ECHOs, X-rays, path reports, labs) • Ex “sodium of 125”hyponatremia • Ex Path reports to document infection, malignancy • Ex interpretation of chest CTprobable aspiration pneumonia, malignancy, tuberculosis • OPERATIVE NOTES, PROCEDURE NOTES (ex colonoscopy) COUNT AS MD DOCUMENTATION

33. PERFORMANCE ANALYSIS

34. Medicare POA, October 2008 • Present on Admission • Object left in during surgery • Air embolism • Blood incompatibility • Catheter-related infections (foley) • Pressure ulcers • Vascular catheter-associated infections • Mediastinitis after CABG • Hospital associated injuries—fractures, dislocations, falls, burns • Manifestations of poor glycemic control • Surgical site Infections following Bariatric Surgery for obesity • DVT & PE following knee and hip procedures • Surgical site infections following fusions of spine, elbow and shoulder • Cigna, BC/BS, other insurance providers to adopt this

35. Summary • Accurate coding data is dependent on specificity and completeness of the physician’s documentation • Inpatient coding data is important for payment, profiling, and patient care • Documenting co-morbidities and specific manifestations of disease processes • Adds to re-imbursement directly through CCs and MCCs • Impacts interpretation of hospital quality