The Impact Physician Documentation on Hospital Reimbursement and Metrics.

The Impact Physician Documentation on Hospital Reimbursement and

Metrics

Integration of CDIPhysician documentation

Clinical Documentation Improvement (CDI)/Concurrent Review

Coding

(identify/validate principal and secondary diagnoses & procedures)May refer back to CDI as needed or may query provider

ICD-9 codes

Grouping of ICD-9 diagnosis codes

(APR-DRG, MS-DRG, or DRG)

Submission of hospital bill

Disclaimer

The following information is educational and based on estimates of MS-DRG distribution against current practicesThis organization has a policy against DRG creeping

and/or DRG “upcoding”Physicians have the freedom to disagree with

CDI/coding recommendations without concern for any reprisal

Important Terms

• Principal Diagnosis • Secondary Diagnoses• Diagnostic Related Group (DRG)• Medicare Severity - Diagnostic Related Group

(MS-DRG)• Concurrent/Complicating Condition• Major Concurrent/Complicating Condition• GLOS – geometric/global length of stay

How Do Hospitals Get Paid by Medicare?

Each MS-DRG has a unique RELATIVE WEIGHT (RW)

XThe hospital’s annual BASE RATE

=Hospital Payment ($)

Ensuring the Highest RW

The principal diagnosis and the principal procedure (if applicable) establishes the base MS-DRGCo-morbidities (a.k.a. complicating or concurrent

conditions) can adjust the MS-DRG to a higher relative weight = $

THEREFORE, a systemic, full body approach is more effective than a focused assessment, which requires a comprehensive H & P, identifying all body systems impacted by the disease process

Principal Diagnosis

Establishes the base MS-DRGThe condition, after study, which occasioned the

inpatient admission to the hospital – Not necessarily what brought the person to the

hospital• ER c/o abdominal pain• Admitted for SIRS 2/2 chronic pancreatitis (principal dx)

– Should be a disease process or condition rather than a symptom i.e., CAD vs. chest pain

Principal Diagnosis

Coders can’t infer a cause/effect relationship– The physician doesn’t have to state the condition in the

H&P for it to be the principal dx HOWEVER– The presenting symptomology necessitating the

admission MUST be linked to the final disease process diagnosis by the physician • Usually this occurs in the discharge summary; therefore,

discharge summaries should be completed as soon as possible following discharge for accurate coding• The provider needs to clearly state the diagnosis was

present on admission (POA) as evidence by the presenting symptoms of . . .

Co-morbidities (CC/MCC)

Additional conditions that affect patient care in terms of requiring:• Clinical evaluation AND/OR• Therapeutic treatment AND/OR

– Continuation or adjustment of home medications– Initiation of new medications or IVF

• Diagnostic procedures AND/OR• Extended length of hospital stay AND/OR

– Focus on GLOS – global length of stay• Increased nursing care and/or monitoring

Co-morbiditiesCC = concurrent condition

Patients who are more ill than a “healthy” person with the same principal condition i.e., many chronic conditions add a CC

MCC = major concurrent conditionRepresent the highest severity of illness to identify the

“sickest of the sick” i.e., acute episodes (exacerbation) of chronic conditions e.g., acute on chronic systolic or diastolic HF and/or potentially lethal conditions i.e., acute respiratory failure, shock, encephalopathy, ESRD, open fracture of a major bone, etc.

Secondary ConditionsSome DRGs differentiate between “ill” and

“sickest of the sick” patients – One tier• no differentiation among patients

– Two tier• With a CC/MCC or without a CC/MCC

Differentiate between ill and more ill/sickest of the sick Easiest to move the MS-DRG

• With a MCC or without a MCCDifferentiate between ill and sickest of the sickMost difficult to move the MS-DRG

– Three tier • Without a CC or MCC (ill)

– Medicare estimates 41% of total patient population• With a CC (more ill)

– Medicare estimates 37% of total patient population• With a MCC (sickest of the sick)

– Medicare estimates 22% of total patient population

MS-DRGs GroupingsSubgroups

# base MS-DRGs

# of MS-DRGs

Single no CC/MCC option 53 53

Two tiered

w/CC/MCC43 86

w/o CC/MCC

w/MCC63 126

w/o MCC

Three tiered

w/MCC

152 456w/CC

w/o CC or MCC

RecommendationsProvide more extensive H & P

• CCs and MCCs are based on the secondary conditions that occur with the principal dx

• Many problematic cases are elective admissions• Specify which “history of” conditions are being treated

compared to those that are resolved• Note when a chronic condition is exacerbated

Assign a diagnosis to abnormal lab values i.e., “acute blood loss anemia” or “posthemorrhagic anemia” when transfused due to low H&H

Document identified or suspected organism leading to antibiotic selection for all infections, especially pneumonia

Documentation Hints

• Chronic conditions: – Last 12 months or longer AND– Places limitations on self-care, independent living, &

social interactions– Results in the need for ongoing intervention w/medical

products, services, and special conditions• Always note when the patient is experiencing an

acute exacerbation of a chronic condition• Describe how the patient’s current condition

differs from their normal baseline

Weight Issues

Add BMI to your H & P– BMI > 40 + morbid obesity = CC• Provider must document the BMI and the diagnosis of

obesity or morbid obesity– Protein-calorie malnutrition = CC– BMI < 16 + severe malnutrition = MCC– Cachexia = CC• Note under general impressions

– Emaciated = MCC• Note under general impressions

Substance Dependence• Substance dependence is not the same as

substance abuse and can occur with prescription medications

• Document any withdrawal symptoms associated with substance use i.e., alcohol or drugs (specify substance if known).– Alcohol or drug withdrawal = CC– Toxic encephalopathy = MCC

• Link the treatment of a “banana bag” with the diagnosis of thiamine deficiency in alcoholics– Thiamine deficiency = CC

Mental Status

Altered Mental Status (AMS) does not convey severity in ICD-9Consider acute delirium – confusion accompanied

by agitation or other behavioral disturbances rather than “confusion,” or “altered mental status” secondary to Alzheimer’s, late effect of stroke, Lewy body dementia, vascular dementia, anoxic encephalopathy, alcohol withdrawal, etc. = CC

Consider encephalopathy (toxic or metabolic) especially with acid/base or electrolyte imbalances

Renal Function

Be sure to distinguish between acute and chronic Renal Failure and specify Acute Tubular Necrosis (ATN) when applicable:–Acute Renal Failure (A.K.A. non-traumatic

Acute Kidney Injury or AKI) = CC–ATN = MCC

Renal Function

Chronic Kidney Disease (Chronic Renal Failure)• Always specify the applicable stage• Use the National Kidney Foundation’s

standardized staging of progressive kidney disease – add a CC–CKD stage IV (severe) • GFR = 15-29 SCr = 2.5 – 4.5

–CKD stage V (cardiovascular disease) • GFR = <15 SCr = > 4.5

Renal Failure

Chronic Renal Failure (CKD IV & V) = CC

End Stage Renal Failure = MCC • specify the known or suspected underlying

cause of ESRD i.e., HTN, DM, renal cystic disease, systemic lupus erythematosus, glomerulomephritis, etc.

Renal Failure

• The known or suspected etiology of kidney disease should be specified

• Coding assumes a casual relationship b/t HTN and CKD – The presence of essential hypertension and CRF is

classified as “Hypertensive Kidney Disease” which is not inclusive of renal manifestations due to secondary HTN – so add the documentation/diagnoses

Renal Insufficiency

• Codes to “unspecified disorders of the kidney and ureter” and is considered by coding as an early stage of renal impairment

• Chronic renal insufficiency codes to “CKD, unspecified”

• AVOID using renal insufficiency and renal failure interchangeably

Fluid Volume Overload

Determine the cause of Fluid Volume Overload• Fluid volume overload is always attributed to

CHF if it is listed as a secondary diagnosis unless another cause is clearly specified e.g., ESRD, as the cause of the fluid volume overload– This can lead to failures on CMS Quality Measures

for HF as the provider does not realize the principal diagnosis will be HF on these patients

– Remember to have heart failure, the heart must have pathology

Heart Failure

Avoid the use of term “CHF” (congestive heart failure) – Classify to the type of heart failure whenever

possible• Systolic • Acute• Diastolic • Chronic• Combined • Acute on chronic

(exacerbation or decompensated)

– Use presenting symptomology when ECHO results are not available

Heart Failure

Systolic – most common type of HFEF < 40% Dilated on Echo Cardiomegaly on CXR S3 gallop

DiastolicEF usually normal LVH on EKGS4 gallop Often hypertensiveAbnormal relax on ECHO

Acute Heart Failure

SymptomsRales CVP > 16 cmNeck vein distensionParoxysmal nocturnal dyspneaAcute pulmonary edema or BNPWeight loss => 4.5 kg in 5 days in response to CHF

treatment

Electrolyte Imbalances

Interpret abnormal lab valueshyponatremia/ hyposmolality = CC

SIADH = CCMetabolic encephalopathy = MCC

Hyperkalemia (not a CC)Hypoaldosteronism = CC

ACE-Inhibitors, Angiotensin Receptor Blockers, Spironolactone

Hypercalcemia (not a CC) Metabolic encephalopathy = MCC

Electrolyte Imbalances

Are there acid/base imbalance?Acidosis = CC

HCO3<18

Alkalosis = CCHCO3 >28

Rather than Altered Mental Status or Confusion - consider Metabolic encephalopathy = MCC