Transcript
UASI CDI/UR Services
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UASI CDI/UR Service Line Stats
▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement
• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs
• CONSULTANTS average 8 years in CDI and/or UR and 22 years in clinical nursing
• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing
UASI Lunch and Learn: CDI Management Series
“CDI Audit: Understanding the Keys to a Successful Process”
Staci Josten, BSN, RN, CCDSDirector, UASI CDI/UR Servicesstaci.josten@uasisolutions.com
Desired Outcomes
Describe the keys to a successful CDI Audit
Recognize the value of completing a CDI Audit
Understand the process for creating an effective CDI Audit
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Polling Question
Does your CDI Program currently perform CDI Audits
on the CDI staff?
1. Yes, one of our CDI program leaders performs routine internal CDI Audits
2. Yes, an outside vendor performs routine CDI Audits
3. Yes, we do peer to peer CDI Audits
4. No, we do not perform CDI Audits
5. Other
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Keys to a Successful CDI Audit Process
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Plan and Prepare
Communicate
Analyze ResultsProvide Feedback
Deliver Education
Why?
• Why perform a CDI audit on your team?
Who?
• Who will complete the audit?
When?
• When is the best time to complete?
What?
• What is reviewed?
How?
• How are records selected?
• How many reviews per CDS?
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Know the answer to these questions:
Plan and Prepare
Plan and Prepare
Why Perform a CDI Audit on your Team?
Advance CDI program to the next level
Assist in outlining CDI staff educational needs
Confirm CDI processes are followed
Evaluate compliance with standard query
language
Identify CDI Program opportunities
Validate documentation of care
and treatment is accurately reflected in
medical record
Assess quality of CDI Specialist performance
Identify potential shifts for risk of mortality
(ROM) and/or severity of illness scores (SOI)
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Internal
Pros:
• Part of the CDI Team
• Insider knowledge of team members
• Familiar with facility policies
Cons:
• May not be objective
• Audit may not be a priority
• Can cause hard feelings
• Don’t know what they don’t know
External
Pros:
• Objective 3rd person
• Experience from other organizations
• Fresh pair of eyes
Cons
• Cost
• Will need orientation on internal policies
Who Will Complete the CDI Audit?
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UASI CDI Quality Review (Audit) ROI
ROI:
Positive reimbursement of $1,157,980
Over $263 on average per record
UASI evaluated and provided feedback on over 4400 health
records.
Approximately 60% of potential DRG changes were realized
based on follow up queries and documented coding changes.
UASI CDI Reviewers evaluated health records and provided
feedback on key CDI performance elements such as
query compliance, query validity, additional query
opportunities, DRG changes, SOI/ROM changes, as well as
quality elements.
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When is the best time to complete?
Considerations for time of audit
▪ When time allows for evaluation and action on results
▪ Last time an audit was completed, ▪ minimally yearly, best is twice a year or ongoing
Avoid these times:
▪ Upcoming big projects (IT conversions or process changes)
▪ When selecting record reviews, avoid holidays or high PTO time (e.g. Christmas time)
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What is Reviewed in the Audit?
Consider and focus on your current areas of struggle
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Process
• Timing of initial reviews and subsequent reviews
• Reconciliation accuracy
General Understanding
• Correct working DRG and Final DRG
• CDI and Coder Mismatch
Clinical Concepts
• Missing query opportunities
• Other areas of program focus (e.g. SOI/ROM, PSI, HAC’s, Vizient, etc.)
Query Compliance
• Query validity
• Query compliance
Audit Tool Example
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Process CDI Understanding Query Compliance CDI Concepts Process
Name
Date Initial
Review
Date
Subsequent
Review
Discharge
Date
Working
DRGFinal DRG
Working
DRG ValidQuery Left
Query
Valid
Query
Compliant
Missed
Query
Missing Query
Opportunity Topic
Location of
information
Reconciliation
Completed
Accurately
Plan and Prepare
Record Selection Suggestions
▪ Narrow down criteria
▪ Random, but targeted
▪ LOS: > 3 days, < 7 days
▪ Discharged within the past 90 days, final coded
▪ Patients outside of GMLOS without CC/MCC
▪ Focus on troublesome DRGs for your team
▪ DRGs with high denial rates
▪ Similar number per CDS
▪ Minimally between 20-25 records per CDS twice a year
DRG Suggestions
Record Selection and DRG Suggestions
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MS DRGs Descriptions
189 Respiratory Failure
193, 194, 195 Pneumonia
290, 291 CHF
313 Chest Pain
330, 331 Major small and large bowel resection
640, 641 Misc. Disorders of Nutrition, Metab, Fluids/electrolytes
690 UTI
Polling Question
Approximately, how many record audits are
performed on your CDI staff each year?
1. Zero, not currently auditing
2. 1-36 records/year (1-3 reviews /per month)
3. 37-60 records/year (4-5 reviews/per month)
4. Greater than 50 records/year (>6 reviews/per month)
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Communicate before the audit starts
Share the why
Excite the staff
Convey anticipated timeline
Ease concerns
Convey how results will be used
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Communicate
Keys to Successful Communication to the CDI Team
Communicate
Additional Tip:It’s important to provide clear communication to the team, but it’s also imperative the auditors are clear on the objective of the audit as well.
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Analyze Results
What does the data show?
Are the results surprising?
What are the trends?
What are the opportunities?
Results are in, now what? Ask yourself these questions.
Analyze Results
What Does the Data Show?
uasisolutions.com | 19Analyze Results
Total cases reviewed 800
Cases with query opportunities 401
Total potential query opportunities 420
Potential MS-DRG changes 100
Potential SOI changes 301
Potential ROM changes 401
Client A Scenario: CDI Overall Review Results
Total cases reviewed 820
Cases with query opportunities 119
Total potential query opportunities 130
Potential MS-DRG changes 75
Potential SOI changes 57
Potential ROM changes 53
Client B Scenario: CDI Overall Review Results
Are the Results Surprising?
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Query Compliance Findings Count
Total Query Compliance Evaluated 606
Query Compliant 250
Query Enhancement Recommended 95
Query Non-Compliant 201
Query Non-Valid 60
Query Compliance Findings Count
Total Query Compliance Evaluated 606
Query Compliant 475
Query Enhancement Recommended 110
Query Non-Compliant 11
Query Non-Valid 10
Category Description
Query Enhancement
An educational opportunity to further strengthen query
language
Query Non-Compliance
Not adhering to the AHIMA “Guidelines for Achieving a Compliant Query Practice
(Update)"
Query Non-ValidNot meaningful; to ensure there is no “over-querying”
Client C Scenario: CDI Query Compliance Findings
Client D Scenario: CDI Query Compliance Findings
What are the Trends?
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Comparison of Insufficient Follow-up
Q1 90
Q2 40
Q3 2
Q4 10
Comparison of Non-Compliant Queries
Q1 48
Q2 28
Q3 5
Q4 0
Analyze Results
Client E Scenario: CDI Findings
Client F Scenario: CDI Findings
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CHF14%
Blood Disorders
11%
Clinical Validation
11%
Encephalopathy11%
Renal11%
CVA Related7%
Complication7%
Respiratory7%
Sepsis7%
Other14%
Abn. Lab Value3%
Blood Disorders
7%CHF5%
Clinical Validation
20%
Complication11%Conflicting Documentation
9%
Encephalopathy9%
Malnutrition2%
Other9%
Pneumonia2%
Renal3%
Respiratory16%
Sepsis4%
Client H ScenarioBreakdown of Query Opportunities
Analyze Results
What are the Opportunities?Client I Scenario
Breakdown of Query Opportunities
❑ Be thoughtful and prepared
❑ Give overall program feedback (no names identified) and then individual feedback
❑Provide information for review prior to meeting
❑ Celebrate the positives
❑ Anticipate constructive feedback will be challenging
❑ Consider “sandwich feedback”
❑Start with what they are doing well, provide areas of improvement and end meeting with more positive feedback
❑ Give specific examples
❑ Ask for response and recommendations on how to help them improve
❑ Expect defensiveness
❑ Remain calm
❑ Be clear on expectations
❑ Restate any action items, consider writing out
❑ Remember to follow up
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Provide Feedback
Keys to Successful Feedback
Provide Feedback
CDI Performance Feedback ExamplePerformance Review ResultTotal Cases Reviewed 16
Total Query Opportunity Missed
Breakdown:
Query Opportunity:
Complication
Query Opportunity: Sepsis
2
1
1
% Missed Query Opportunity 13%
CDS/Coder Mismatch 3
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Query Review ResultsTotal Queries Reviewed 13
Total Query Compliant 13
% Query Compliant 100%
Query Enhancement
Opportunity
4
Total Query Non-Compliant 0
% Query Non-Compliant 0%
Total Query Non-Valid 0
% Query Non-Valid 0%
Strengths:CDS is an effective reviewer and demonstrates a strong knowledge of CDI core principles along with a good foundation of coding knowledge with proper selection of Pdx. CDS is proactive and aggressively searches for potential impacting query opportunities. CDS looks for treatment or continued monitoring before submitting a query, complying with UHDDS standards for secondary diagnoses. Overall CDS demonstrates a solid foundation of core CDI principles, leaving valid, compliant queries on a variety of query topics which include ABLA, Malnutrition, CHF specificity, Hyponatremia, Shock specificity, Wound clarification, and rule in/rule out diagnoses.
Areas of Opportunities:1. Query Opportunity:Expand clinical knowledge and review all laboratory values, radiology reports, vital signs, MAR summary and PMH for clinical indicators that would support querying for additional diagnoses such as: Sepsis and Catheter Associated Urinary Tract Infection (CAUTI).2. Query Enhancement:Add additional clinical indicators, treatment & monitoring, and risk & related conditions to queries. Doing so helps support why a diagnosis is a reportable condition and helps establish the presence of the condition.3. Complications and Sequencing:Noted was one potential Query Opportunity and two CDS/Coder Mismatches related to complications. Be alert for complications of previous conditions/surgeries or condition(s) that occur while in the hospital to determine if the condition(s) was/were inherent to a procedure/condition, or outside the norm. If complication is already documented this could affect sequencing and DRG assignment, if not then a query may be needed for clarification.
Per Official Coding Guidelines Section 1.B.16 Documentation of Complication of Care:Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise
instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.
Become acquainted and refer to the Alphabetic Index regarding instructional notes for code sequencing of complications as this could affect DRG assignment. Also note any exclusion notes as these are fairly extensive in Chapter 33 and often will direct to elsewhere.
Provide Feedback
CDS Trends Example
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0
1
2
3
4
5
6
7
8
Occ
urr
en
ce
CDS Trend Report Example
Q1
Q2
Q3
Q1 Q2 Q3
DRG Change 4 1 0
Insufficient Follow Up Review 1 7 0
Late Initial Review 3 5 3
Query Non Compliant 0 0 4
Query Enhancement 1 0 0
Query Opportunity 3 1 0
Query Opportunity: Abnormal Lab
Values1 0 0
Query Opportunity: Blood Disorders 3 0 0
Query Opportunity: CHF 2 0 0
Query Opportunity: Clinical Validation 1 2 0
Query Opportunity: Respiratory Failure 1 1 0
Query Opportunity: Complication 0 4 0
Query Opportunity: Malnutrition 0 1 0
Query Opportunity: Renal 0 1 0
ROM Change- Query Opportunity 4 3 0
SOI Change- Query Opportunity 3 4 0
Provide Feedback
CDI Score Card Example
NameCases
ReviewedQuery Left
Case Count
Query Opportunities
Missed
%Missed Query
Opportunities
Query Accuracy
PointsQuery
Accuracy Points
Query Valid
%Valid Query
PointsQuery
Compliant %Compliant
QueryPoints
Total Points
Excellence Award Status
CDS A 27 22 0 0% 100% 3 6 22 100% 3 22 100% 3 12 Yes
CDS B 27 12 0 0% 100% 3 6 12 100% 3 12 100% 3 12 Yes
CDS C 36 36 0 0% 100% 3 6 36 100% 3 36 100% 3 12 Yes
CDS D 28 16 2 7% 93% 1 2 16 100% 3 16 100% 3 8
uasisolutions.com | 26Provide Feedback
Legend Excellent (3 points)
% Query Valid (needed) 100%
% Query Compliant 100%
Excellent (6 points)
% Query Accuracy >97
❑Education is imperative to ongoing improvement
❑Complete education prior to next audit to realize results
❑Keep education actionable
❑Share specific examples in audit findings
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Provide Education
Keys to CDI Education Success
Deliver Education
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Staci JostenBSN, RN, CCDS
Director, CDI/UR Services, UASIStaci.Josten@uasisolutions.com
Join us for the next UASI CDI Management Series Lunch and Learn:
Creating and Maintaining the Best CDI Teamon December 9, 2020 at 1:00 EST
email: info@uasisolutions.com for invite
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UASI CDI/UR Services
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UASI CDI/UR Services Stats
▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement
• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs
• CONSULTANTS average 8 years in CDI and/or UR and 22 years in clinical nursing
• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing
UASI at a Glance
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Headquarters:
Founded:
Clients:
Team:
Charts handled annually:
Solutions:
Experience
• Management: 22 years of HIM experience;
11 in CDI
• Coding staff: 8+ years
Quality
• 97% accuracy in coding
• 100% target for accuracy, certification and
meeting industry standards
Reliability
• 32+ years in business
• 40 clients in US News & World Report best
regional and honor roll hospitals
Culture
• People-centric, team-driven culture
• High employee satisfaction
• 20% new hires referred from current employee
• Industry-leading average employee tenure
Cincinnati, Ohio
1986
200+ hospitals/health systems nationwide
450+ employees, including AHIMA/AAPC-certified
coders, HIM and clinical documentation specialists
3.75 million coded; 200,000 audited
Coding Services, Coding Reviews, Clinical
Documentation Improvement, Revenue Integrity,
HIM Solutions, Strategic Consulting
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