Driving a Successful Documentation Improvement Program LHIMA - - PowerPoint PPT Presentation

Driving a Successful Documentation Improvement Program

LHIMA Presentation Presented by: Trudy Rioux

Is a Program Needed?

• What is the baseline CMI (Case Mix Index)

compared to other facilities within your peer group? For starters, review Med Par.

• How well is facility doing on risk of

mortality?

• How well is facility doing on severity of

illness?

• Can we create our own program or do we

need to consult with a company that has software/reporting metrics/etc.?

Point of a Documentation Program: Bridging the Gap

Bridging the gap between the physician's language and what is recognized in the code format and by Centers for Medicare and Medicaid Services (CMS) to reflect the severity and complexity of illness.

Before Starting a Program

You need the following:

• Administrative buy in is a must and will

aid in physician compliance.

• Alignment to meet the goals.
• Accountability for the physicians to

answer clarifications/queries …. Unanswered queries are assigned a medical record completion deficiency post‐discharge.

A Physician Champion

• It’s necessary to have a physician champion

to teach the clinical information to the coders and documentation specialists as needed.

• A Task Force meeting consisting of the

documentation specialists, inpatient coding team, VP of revenue cycle, and the physician champion should be held monthly – quarterly (depending on the need) which makes a strong team.

A Physician Champion

• Assists educating the physicians on staff

about the upcoming program.

• Can keep a program alive by continuous

education about the program at the monthly Medical Executive Committee Meetings.

Physician Documentation Equals

• Physician Documentation = ICD 10 codes
• ICD 10 codes = 1 MS‐DRG (Medicare

Severity Diagnostic Related Group) per inpatient encounter

• MS‐DRG = Length of stay
• MS‐DRG = severity of illness, risk of

mortality, physician profile, hospital profile

• MS‐DRG = Facility Reimbursement

Physician Pocket Card

• Creating a Physician pocket card with

the top things clarified for is essential.

• As a documentation specialist works

with a physician concurrently it’s something tangible that can be distributed to include the clinical indicators for the condition.

Internal Organization Marketing

• There needs to be marketing about the

documentation improvement program.

• This marketing/education needs to

include physicians, nursing, ancillary care, etc.

• The organization as a whole needs an

understanding as to why a documentation specialist might be clarifying about a diagnosis.

Which Population of Patients Should be Reviewed?

• Review just Medicare?
• Review Medicare Advantage?
• Review all payers that reimburse on the

MS‐DRG > 55 years of age?

• Review all payers that reimburse on the

MS‐DRG regardless of age?

Documentation Specialist Staffing

• 1 FTE for every 1,800 discharges
• This amount could depend on how pure

the program is related to the working DRG, follow‐up and the other duties.

Duties of the Documentation Specialist Staff in addition to Clarifying for MS‐DRG Movement

• Identifying quality of care issues, HACs, PSIs
• Assisting with quality measures CHF,

Pneumonia, MI, CVA

• Following queries post‐discharge if not

answered concurrently

• Severity clarifications that have no impact
• n the MS‐DRG but potentially impact risk
• f mortality and severity of illness

New Documentation Specialist Training

What has worked? 1 week of intense classroom training

• Learning the MS‐DRG system
• Learning the official coding rules
• Begin learning documentation strategies

New Documentation Specialist Training

• 6 weeks of rounding with a mentor (an

existing documentation specialist; very beneficial to have the new person rotate with each existing documentation specialist)

• Following those 7 weeks, constant

feedback to the new documentation specialist

• It takes 9 months to a year to yield a

seasoned documentation specialist

Documentation Specialists Working with HIM Coders

• Include both the Documentation

Specialist and the Coders in all continuing education meetings.

• Pairing each coder and doc spec for a

coder/doc spec buddy system so they can use each other as a resource.

Scrubbing Charts Post‐Discharge

• Charts are sent to a supervisor review Q

pre‐bill that do not have a CC or MCC prior to final coding.

• Even if the chart has a CC and the DRG

could still use a MCC, the account will get scrubbed.

• A CC is good but a MCC is BETTER!

Scrubbing Charts Post‐Discharge

• If an opportunity is sited by the

supervisor this is shared with the documentation specialist and coder.

• A determination is made whether a

post‐discharge query will be generated.

Creating a Think Fast Documentation Opportunity Sheet is Helpful

• A think fast Document are tips on what

the documentation specialist or coder should automatically consider when they see certain diagnoses documented.

• Just because a diagnosis is documented

does not mean you will automatically be able to generate a clarification/query.

Creating a Think Fast Document

• Before clarifying you always have to

have justification in the form of all of these:

• Risk factor
• Clinical indicators
• Treatment/monitoring

Things to Consider…..

CVA

• Hemorrhagic conversion
• Cerebral edema or compression (look for

terms on CT or MRI like sulcal effacement, shift, edema, etc) for a MCC

Things to Consider……

CHF

• The acuity (acute/decompensated

and/or chronic)

• CHF in the setting of HCVD and HTN/CKD
• The type of heart failure

(systolic/diastolic)

Things to Consider……

Pulmonary Condition (pneumonia, COPD, etc…) or CHF

• Acute respiratory failure for a mcc

Pneumonia

• Aspiration, gram negative or other

specified organism Bronchitis

• Aspiration

Things to Consider……

Localized infection (Pneumonia, Cellulitis, UTI, etc..)

• Clinical Sepsis (PDX)

Dehydration, Volume Loss, Blood loss, diarrhea, vomiting, poor intake

• Acute Renal Failure or Acute Renal

Failure w/ATN

Things to Consider……

Altered Mental Status (AMS)

• Encephalopathy (mcc)

Bedridden/Contracted Patient

• Functional Quad (mcc)

PTCA/Stent

• coronary artery dissection (mcc)

Things to Consider…..

More than one diagnosis meeting definition of pdx

• Can I flip it? One may be a mcc for the
• ther

Anemia

• GI bleed site (gastritis w/bleed,

diverticulitis w/bleed, duodenal ulcer w/bleed)(MCC)

Things to Consider……

Post Surgery

• Hemoglobin/hematocrit ‐ Acute blood

loss anemia (cc)

• Chest x‐ray – atelectasis (cc)

Cardiac conditions w/atrial fib as secondary

• Atrial flutter (cc)
• Persistent atrial fibrillation (cc)

Things to Consider…..

All Patients Peruse

• Lab ‐ Sodium (hyponatremia ‐ cc)
• Lab ‐ Creat (AKI‐ cc)
• Last Nursing Notes – (skin for stage III or

IV decubitus present on admission ‐ mcc)

Things to Consider……

HIV

• AIDS (B20)
• HIV manifestation currently or

previously (B20) Injury (fracture, SDH, Internal injury, open wound)

• Multiple injured sites for MST(multiple

significant trauma) MS‐DRG

Things to Consider

Fracture

• Pathologic (non‐surgery patient could

impact DRG) Chemo Patient

• Pancytopenia due to chemo (mcc)

The role of a Documentation Specialist

• Generating a worksheet on a patient is

not beneficial if it’s just a worksheet with no fruit.

• Yielding results by way of an impact

clarification to improve the MS‐DRG or a severity clarification to appropriately reflect risk of mortality and severity of illness.

The role of the Documentation Specialist

• Yielding results by way of insuring the

documentation meets the quality measure/core measure requirements.

• Yielding results by way of clarifying

documentation around HACs (CMS hospital acquired conditions and PSI (patient safety indicators) to insure accurate reporting.

Monthly Measures for Each Documentation Specialist

• How many DRG matches have they had

for the month? Meaning the documentation specialist’s MS‐DRG matches the coders final MS‐DRG.

Monthly Measures for Each Documentation Specialist

• How many DRG changes based on

additional documentation after their last review? A documentation specialist reviewing the chart daily or at a minimum every other day is essential to a successful program

Monthly Measures for Each Documentation Specialist

• How many DRG changes due to an

incorrect code, a coding rule, or misinterpreting the documentation?

Monthly Measures of Program Success

• Overall CMI
• Medical CMI – for a hospital with the

majority being medical cases will be a good measure of how robust the program

• Surgical CMI

Monthly Measures of Program Success

• CC capture rate – a cc is good but a mcc

is better

• MCC capture rate
• Top 10 DRG
• Physician Agree Rate

Continuing Physician Education

• New Physician Orientation
• Hospital Medicine Group Orientation

(HMG)

• Stay connected to HMG
• Monitor their query responses
• Is there one or two physicians not

complying?

Physician Buy In/Participation

• Watching each physician’s agree rate is a

key factor

• A physician will not typically agree with

every clarification

• However, we only generate clinically

significant clarifications that meet risk factors, clinical indicator and treatment/monitoring.

Physician Buy In/Participation

• A solid program should strive for > 80%

physician agree rate

• If a physician is declining 100% of good

substantiated clarifications then the physician champion should review the cases to identify whether he needs to meet with the physician declining.

Physician Buy In/Participation

• If there is a hospital medicine group

seeing the majority of all the patients then you need to make sure the whole group is engaged.

• Constant communication with the

hospital medicine team leader is key.

• Attending their monthly or quarterly

meetings providing documentation

• pportunities is important.

Other Program Measures

Quarterly PEPPER Reports

• # of cases with only one CC/MCC; a solid

bullet proof chart has 2 or more.

• CC/MCC capture

External Audit Results – don’t be audit scared

External Audits

• RAC
• Payer Audits
• OIG Audits

The majority of payers are on the band wagon of MS‐DRG validation. The auditors data mine to identify potentially problematic MS‐DRGs.

External Audits

• The auditors data mine accounts that

contain only a CC or MCC.

• While a CC or MCC is good, 2 or more

can potentially protect against being pulled for an audit.

External Audits

• An account with only one CC or MCC will be

dissected apart to find a loop hole to discredit it.

• Auditors may not always know the coding

rules.

• Always appeal as appropriate using the

record documentation, coding conventions,

• fficial guidelines, and coding clinics to

support the codes on the claim.

External Audit Follow‐up

• Realize when the coder simply made a

mistake, misinterpreted, jumped to a conclusion too quickly, etc.

• Use these mistakes as education for the

entire team and track it.

• Otherwise when what the auditor is

citing is just not right, FIGHT with all you MIGHT!!

Goal

• Reflect the severity and complexity of

each patient’s illness.

• Get credit for the good care provided.
• Get paid for resource consumption.

Driving a Successful Documentation Improvement Program Trudy Rioux, CCS Manager, Coding and Documentation Baton Rouge General Medical Center