Clinical Documentation –Why We Care

1. Clinical Documentation –Why We Care Shelley L. Oglesby, M.Ed, RHIT, CCS-P Manager, Coding & Reimbursement NancyIgnatowiczRN, BS, MBA, CCDS Manager Clinical Documentation July 24, 2013 Surgical Residents Orientation

2. Significance of Documentation • Acuity / severity of illness • Risk of mortality, O:E • Pt walks out alive, the hospital’s profile improves when comparing hospitals & outcomes. • QUALITY measures • Patient safety indicators • Physician profiles, research data & funding • Intensity of services provided => hospital receives the appropriate reimbursement. • Academically sound note writing. 7

3. Why Care? Proper documentation ensures appropriate severity of illness (SOI) and risk of mortality (ROM): • Substantiates Medical Necessity for • Appropriateness of admission/continued stay • Versus observation status or even outpatient Truly reflects how complex your patient is, how ill they are, and how likely they are to die • It’s the right thing to do 4

4. CDI • Clinical Documentation Improvement Team

5. The role of the Clinical Documentation Specialist (CDS) • RN’s review the medical record concurrently to ensure treated diagnoses are documented with specific terminology so the coder can code the most appropriate codes for Severity of Illness (SOI) & Risk of Mortality (ROM) • Clarifications are asked when an additional or more specific diagnosis may be present but not documented in verbiage that can be coded 7

6. The role of the Coder • Coder reviews the medical record post-discharge to assign the most appropriate ICD diagnosis(es) and procedure(s) codes to ensure accurate Severity of Illness (SOI) & Risk of Mortality (ROM) and appropriate MS-DRG assignment • Clarifications are asked when an additional or more specific diagnosis may be present but not documented in verbiage that can be coded Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive 8

7. Common opportunities for clarification Consider Documenting Acute Surgical Blood Loss Anemia Shock and Type Acute Respiratory Failure/ Acute Respiratory Distress Records indicate -..Post surgical anemia… -..Hypotensive, requires vasopressors, tachycardia, multiple fluid boluses… -..Intubated for airway protection… -In PACU patient unresponsive, desat to 88% requiring reintubation…

8. How to Avoid a Clarification/Query • With EVERY DIAGNOSIS consider: • Etiology • Severity • Type • Present or evolving on admission (POA) • Clinical manifestations • Treatment • Pathology findings

9. Valued Tips 1. Specify the diagnosis that best supports the principal reason for the inpatient admission to the hospital (condition established after study) 2. Use the following acceptable terms to describe uncertain diagnoses: Probable, suspected, likely, possible Avoid terms such as “concern for” or “VS” Diagnoses should be based on a physicians clinical judgment.

10. Valued Tips 3. Identify conditions/diagnoses that are present on admission (POA status)- present at the time the inpatient admission occurs, includes conditions that develop during an outpatient encounter (emergency room, observation, outpatient surgery) that result in an inpatient admission Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive

11. Valued Tips 4. List comorbid/complication diagnosis which are defined as: conditions that coexist at time of admission conditions that develop subsequently conditions that affect the treatment/care conditions that impact the length of stay Include chronic conditions such as hypertension, COPD etc Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive

12. Gaps in Documentation UNABLE TO CODE ACCEPTABLE TO CODE Hyponatremia UTI Acute Blood loss anemia due to trauma/ruptured aneurysm AKI or ARF LUL bacterial pneumonia Acute pulmonary edema • Na 130 -> fluid restriction • Dirty UA -> antibiotics • Post surgical anemia, will monitor/Blood loss-> PRBC • Elevated creatinine-> IVFs • LUL opacity -> Zosyn • Flash pulmonary edema

13. Avoid the TERM POST-OP

14. Gaps in Documentation UNABLE TO CODE ACCEPTABLE TO CODE Abscess/ intraperitoneal abscess/peritonitis Acute respiratory distress or acute respiratory failure Consider shock and type • Abdominal fluid • Dyspnea, SOB requiring BiPap/high flow O2 NC/intubation • Hypotension, vasopressors, EBL,temp, tachycardia, Tachypnea

15. Examples • Documentation of ALL secondary diagnoses present is how Severity of Illness (SOI) & Risk of Mortality (ROM) is captured • Do you think Loyola patients are sicker than patients in community hospitals?? • Patients are only as critical / complex as their documentation indicates

16. Inherent Diagnoses

21. Quality • Your notes get better from an academic standpoint • Explains reason for admission/readmission • Explains mortality • Low SOI/ROM score could be explained from review of records showing failure to document comorbidities • I.E. malnutrition, pre-op ileus, anxiety, obesity, Chronic systolic CHF, CKD stage 3, Acute blood loss anemia due to liver laceration from trauma, Shock, peritonitis, sepsis from pre-surgical rupture diverticulum, Respiratory failure from pulmonary fibrosis, toxic encephalopathy related to sepsis… • Present on admission (POA) • Define if condition was POA, evolving on admission/natural progression of disease • LINK symptoms to diagnosis determined after further diagnostics and evaluations

22. Inpatient Medical Record • History & Physical • Why inpatient admission necessary • Reason for inpatient surgical admission • Include diagnoses in assessment plan not just PMH • Progress Notes & Consultations • Link significance of findings/treatments (medications, diagnostics) to diagnoses • Discharge Summary • Should include all diagnoses addressed during this admission including chronic,resolved problems and any pathological findings(including post discharge)

23. ICD-10 • Lack of documentation is becoming a problem for acceptance.Wieste Venema

24. ICD-10- Prepare Now • For example, if a patient has a diagnosis of an abscess of bursa of the right shoulder, the appropriate code is M71.011 (abscess of bursa, right shoulder). • In ICD-9-CM, coders would report this condition with code 727.89 (disorder of synovium/tendon/bursa), which lacks site and laterality specificity.

25. ICD-10- Prepare Now • For 34 years, a closed, midcervical fracture of the femur has been coded as 820.02, using ICD-9,no other information needed • ICD-10-CM requires additional detail—Is it the right femur or the left femur? Is this an initial encounter or a subsequent encounter? Is the fracture healing nicely or delayed? ICD-10 has four codes and your documentation must note which femur, what type of encounter, and whether a complication exists.

26. Take Away • Document Who • Document What • Document Why • Document How • Document When

27. Contact Information • CDS – Michele E. Huguley RN • (9)646-9235 • mhuguley@lumc.edu • CDS – Gail Klotz RN BSN • (9)250-4108 • gklotz@lumc.edu • Manager - Nancy Ignatowicz RN, BS, MBA, CCDS • (9)646-9057 • nignatowicz@lumc.edu

28. Contact Information • Lead Coders – AnjieMarth • x64559 • amarth@lumc.edu • Lead Coders –Pattie Hise • x68542 • phise@lumc.edu • Manager – Shelley L. Oglesby, M.Ed, RHIT,CCS-P • x62132 • soglesb@lumc.edu