Why ED Documentation matters to Inpatient coders/CDI specialists

1. Why ED Documentation matters to Inpatient coders/CDI specialists

2. Bernard H. Ravitz MD, PAC-CDI Board Certified in Emergency Medicine Physician Advisor Medical Director of Observation Unit/ Heart Care Unit MedStar Good Samaritan Hospital bernard.ravitz@medstar.net

3. Needed For Quality of Patient Care • Key to exchanging critical information with all members of the clinical team. • Describes clinical conditions in order to assist in developing a plan of care. • Paramount to the continuity of care.

4. Essential For Business Of Health Care • Shows that the service was medically necessary to justify payment • Provides diagnosis and procedure information to determine the coding that leads to the correct prospective payment • Drives the quality of data within the healthcare system

5. It’s The Law • Section 1156(a) of the Social Security Act and regulation at 42 CFR 1004.10 - Supported by appropriate evidence of medical necessity and quality in the form and fashion (and at such time) that the reviewing QIO may reasonably require

6. Medical Necessity • “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease or it’s symptoms.

7. Medical Necessity - in accordance with the generally accepted standards of medical practice; - clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and

8. Medical Necessity - not primarily for the convenience of the patient or physician - and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease

9. Medical Necessity Begins In The ED • Emergency Room record: - should demonstrate the true acuity of a case - include patient’s risk factors and other medical concerns substantiating building a case for the attending physician’s decision to admit the patient to the hospital for further work-up and management

10. ED Physician Clinical Documentation • Equally as important as the clinical documentation in the History & Physical, Progress Notes, Consults, Discharge Summary • Importance of succinct, complete, accurate and effective clinical documentation by the ED physician cannot be underestimated

11. Diagnostic Specificity • Utilizing clinical terminology that appropriately corresponds to ICD-9-CM and CPT codes that properly capture diagnostic complexity and severity of illness (SOI). This will justify the consumption of resources and demonstrate the quality of care provided.

12. Diagnostic Specificity • For a presenting problem with an established diagnosis, the record should reflect whether the problem is: - Acute or chronic - Due to something known - Improved, controlled, resolving, or resolved - Inadequately controlled, worsening or failing to change as expected.

13. Diagnostic Specificity • For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible”, “probable”, “suspect” or “can not rule out” diagnosis.

14. ED Documentation • Coding professionals need clinical documentation from ED that clearly states “possible”, “probable” diagnoses, rather than merely listing acute symptoms • Increased specificity and detail in ICD-10-CM codes is expected to be particularly relevant for the types of conditions treated in the ED.

15. ICD-10-CM • Increased clinical documentation will be needed to code in ICD-10 • Frequent ED condition – sprains & strains - ICD-9 classified to same code - ICD-10 classified separately

16. Code Assignment ICD-9-CM ICD-10-CM 847.0 513.4xxA Sprains & Strains of other Sprain of ligaments of C spine unspecified parts of back; neck. 516.1xxA Strain of muscle, fascia & tendon Documentation: site at neck level, initial encounter Documentation: site; sprain (ligament) or strain (muscle,tendon)

17. Templates • Commonly used in Emergency Room • Are complaint-driven and are designed to capture common ED conditions, such as chest pain, back pain, injury, URI • Lack detail to prompt documentation of definitive diagnoses.

18. ICD -10-CM • Clinical documentation should be as comprehensive as possible to ensure: - quality of patient care - reflection of severity of illness - ensure appropriate reimbursement - sufficient to support specificity

19. Present on Admission (POA) ED Physicians capture crucial information that inpatient coders need to ensure correct Present on Admission (POA) indicator assignment.

20. In Summary • Reimbursement enters the facility through ICD-9-CM (soon to be ICD-10) codes, CPT codes or HCPCS codes • Coding professionals ensure that correct codes are assigned • Precise provider documentation is required for accurate code assignment • Physician documentation needs to be legible, accurate, clear, complete & as specific as possible

21. THANK YOU

22. Any Questions ????