What is Clinical Documentation Integrity? A daily scavenger hunt.

What is Clinical Documentation Integrity?

A daily scavenger hunt

• More accurate documentation reflective of true acuity and services provided

• More accurate profiling data for both Hospital and medical staff

• More appropriate case mix and reimbursement• Reduced compliance risk• Potential reduction in denials• More appropriate patient severity, mortality,

outcomes and resource consumption data • Increased cooperation between physicians and

hospital

Benefits of Clinical Documentation

• A consulting group reviewed the appropriateness of the DRG assignment for a sample of inpatient Medicare cases at HPRHS based on the clinical documentation in the Medical Record.

• Based on their findings, there was a potential financial impact of approximately $1.8 million in missed opportunities, contributed to documentation.

• Documentation was the key factor, not the quality of care or service.

• We know that we deliver exceptional health care services to the people of our region!

• Many times the documentation doesn’t support the true severity of illness of our patients.

HPRHS Data Analysis: Why Does Data Matter?Hospital and physician profiling data is available

to the public

Research& ComparePhysicians

HPRHS Data Analysis: Why Does Data Matter?Hospital Report Cards

www.abouthealthtransparency.org

POA vs. Hospital-acquired Conditions

Present on admission (POA) is defined as present at time the order for inpatient admission occurs - - conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

Hospital-acquired conditions (HACs) are those that developed / occurred during an inpatient hospital stay.

Purpose of POA

• Intention of this new concept is to reduce increased payments for complications that occurred after admission / during the hospitalization.

• Hospitals have to submit data on all Medicare claims indicating whether the diagnoses were POA.

• Coders indicate (Y or N) beside the principal diagnosis and all secondary diagnoses.

The 10 categories of HACs include:

• Foreign Object Retained After Surgery • Air Embolism • Blood Incompatibility • Stage III and IV Pressure Ulcers • Falls and Trauma • Manifestations of Poor Glycemic Control • Catheter-Associated Urinary Tract Infection          (UTI) • Vascular Catheter-Associated Infection • Surgical Site Infection Following

– Orthopedic Procedures • Spine Neck,Shoulder,Elbow

• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)•  Total Knee and Total Hip Replacement• Payment implications began October 1, 2008, for these 10

categories of HACs.

Medicare 101DRG (Diagnosis Related Groups) Basics

• How are DRGs used:– Calculating Hospital reimbursement– Evaluate quality of care– Evaluate utilization of resources

• Each DRG represents the average resources utilized to care for a patient within the grouping

• Every DRG has a relative weight (RW) assigned to it• The RW is used in the calculation of the Hospitals

Case Mix Index

www.hcup-us.ahrq.gov

Medicare 101DRG Basics

– Major enhancement is revision of the CC list and development of MCC list

– With the development of MS-DRGs, CMS reduced the CC capture rate from 77% to 40%

– CC’s are categorized:• MCC (Major complication/comorbidity)• CC (complication/comorbidity)• Non CC

www.hcup-us.ahrq.gov

MS-DRG’s

• Heart failure with no MCC/CC DRG 293 = RW 0.7220 = $3,699 CHF LOS 3.7days TX O2 and IV Lasix

• Heart Failure with CC DRG 292 = RW 1.0069 = $5,155 CHF LOS 5 days TX O2, IV Lasix, echo, med adjustment, Chronic obstructive bronchitis acute exacerbation

• Heart Failure with MCC DRG 291 = RW 1.4601 = $7,481 CHF LOS 6.5 days intubated ED, admit to ICU, In ICU 7 days, IV Dobutamine, multiple tests, multiple med adjustment, critical care, complicated by acute renal and respiratory failure

CMS DRGs vs. MS-DRGs

• The Goals of Clinical Documentation Integrity (CDI) Process are as follows:

– Drive appropriate coding for accurate reimbursement

– Reflect accurate patient acuity levels– Meet standards– Reduce compliance risks– Provide accurate data for quality indicators and

other hospital metrics– Reduce coding turnaround time– Decrease post-discharge queries to the physicians

by utilizing concurrent physician queries when indicated

Clinical Documentation Analysts

• Nita Campbell, RN ICU/CCU/OCU• Janice Davis, RN 6S/7N/PJC• Alletheia Fitzgerald, RN 6N/7N/5N• Tamika Jones, RN CPU/MTU• Elinore Poindexter, RN 5S/CTU

• Medical Records x 2938