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3M Health Information Systems

© 3M 2014 All Rights Reserved. 3M provides these slides to promote a better understanding of 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only.

Advocate Health CareChrist Medical Center April 16, 2015

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3M provides these slides to better understand 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only.

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© 3M 2014. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.

Clinical Documentation Improvement Goals and Objectives

Clear concise accurate documentation

Across the continuum of care: inpatient and outpatient

Capture the severity of illness (SOI) and the Risk of Mortality (ROM)

Support hospital and physician reimbursement

Improve quality report cards and clinical outcomes

Prepare for ICD-10

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© 3M 2014. All rights reserved. 3M Confidential – Not for distribution


Impact of Accurate Complete Documentation

Profiling

Risk Management

Accountable Care

Critical Pathways

Case Management

Quality Managemen

t (CQI, TQM)

Core Measures

Regulatory Compliance

Validating LOS

Reimbursement

ICD-9-CMICD-10 Present-on-

Admission IndicatorsRAC Audits

2 Midnight

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General Rules for Documentation All diagnoses must be documented by a physician in the body of the

medical record

To report a diagnosis, it must meet one of the following criteria:― Clinical evaluation

― Therapeutic treatment

― Diagnostic procedures

― Extended length of hospital stay

― Increased nursing care and/or monitoring

Conditions cannot be coded from lab, x-ray, or other diagnostic reports without documentation by a licensed hands provider

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Documentation & Coding Issues

Physician Document in

CLINICAL terms

Documentation for coding, profiling &

compliance requires specificity in

DIAGNOSIS terms

This gap will be increased with ICD-10This gap will be increased with ICD-10

Two separate languages

Advocate System Documentation Improvement Program can help bridge the gap

Advocate System Documentation Improvement Program can help bridge the gap

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Basic Physician Documentation Requirements Document the reason(s) for the inpatient admission and the complex

medical judgment factors including:1) Severity of the signs and symptoms

2) Prediction of adverse event 3) Expectation of a two midnight length of stay

All medications, treatments and diagnostic studies, document the corresponding medical diagnoses

Document all conditions including probable, suspected or questionable based on your independent professional judgment and the clinical evidence and treatment provided.

Document if a condition was treated resolved or was considered probable at the time of discharge and include the medical decision making process and supportive clinical information.

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Liver failure, renal failure, resp failure

Respiratory failure : acute, acute on chronic

Hypotension, shock-cardiogenic/septic

Dehydration, hypovolemia

Ventricular tachycardia

Simple UTI

Hypokalemia

Right lower lobe pneumonia

Pancytopenia secondary Chemotherapy

Acute/Chronic Blood Loss Anemia

Dementia, Coma

Protein Calorie Malnutrition

Able to CodeUnable to Code

Multi-system organ failure

Severe respiratory distress

Hemodynamically unstable

Will rehydrate

Rhythm stable today

“Urosepsis”

↓ K = 2.0, will give KCL

Chest X pneumonia

↓ Platelets↓wbc ↓Hct

↓ HgB 5.2, Transfuse

Altered Mental Status

Emaciated, Total Protein/Albumin Low

Unable/Able to Code Examples

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Quality Report Cards

Profiles Hospital Profiles Physicians Healthcare Consumerism

Healthgrades.com Leapfroggroup.org CMS.gov

Patient Safety Initiatives

Copy Right 3M 2014 All Rights Reserved

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3M™ DRG Assurance Program

Assure all conditions are documented in the medical record

To promote the appropriate assignment of Severity Of Illness (SOI) & Risk Of Mortality (ROM) Based on CMS’s rules and

regulations Documentation Specialists “Real Time”

Physicians

Medical Record Professionals

Clin

ical

Doc

. Spe

cial

ists

Patient

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Concurrent Query Process

Query Opportunity

Query Posed to Physician

Physician Agrees?

Yes

Write Diagnosis inProgress Note

No No Response

Write “NO” on the Query Form

3M 360Medical Record

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Physician, Physician Assistant and Nurse Practioners Role

Focus remains on patient care Complete documentation – diagnostic terms Respond to written/verbal/electronic queries Do not need to learn coding Minimal impact on day-to-day routine Clinical Documentation Improvement Specialists

server as a Resource to the physician

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When should there be a query regarding clinical documentation?

“ whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure”

AHIMA Practice Brief “Managing an Effective Query Process” October 2008

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Impact of Responding to Query

Impact w/ Response to Query

RW = 2.9797

GLOS = 8.98

SOI = 3 Major

ROM = 2 Moderate

Impact w/o Response to Query

RW = 2.9797

GLOS = 8.98

SOI = 2 Moderate

ROM = 2 Moderate

Query:

“Patient had a magnesium level of 1.6 and received magnesium sulfate. Please provide a corresponding diagnosis for the treatment provided.”

** CDI seeks documentation of “ hypomagnesemia “

Cranial Procedure

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Appropriate Reimbursement And Profiles

Provider Documentation

Principal & Secondary DiagnosesPrincipal & Secondary Procedures

ICD-9-CM CodesICD-10-CM CodesICD-10-PS Codes

DRG AssignmentSeverity & Risk of Mortality

Classification

Profiling/Reimbursement (Providers/Hospitals)

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3M™APR DRG All Patient Refined DRGs

Developed by 3M Yale and the National Association of Children’s Hospitals – based on discharge data from 8.5 mil discharges, 1K hospitals, 10 states., all-payers, 47 Peds Hosps (updated every 2 years)Most widely used severity-of-illness and risk-of-mortality adjustment

U.S. News & World Report hospital rankings AHRQ Patient Inpatient quality Indicators 45 state and federal agencies JCAHO accreditation survey process Thomsen Reuter Utilized for reimbursement Medicaid Florida

© 3M 2011. All Rights Reserved.

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APR-DRG 3M™

Severity of Illness Subclasses

1. Minor

2. Moderate

3. Major

4. Extreme

Risk of Mortality Subclasses

1. Minor

2. Moderate

3. Major

4. Extreme

Mortality at < 4 suggests care, coding or documentation opportunities

Subdivide into subclasses

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Underlying Principle of 3M™ APR DRGs

Severity Of Illness (SOI) and Risk Of Mortality (ROM) are dependent on the

patient’s underlying problems.

High SOI and ROM are characterized by:

(a) multiple

(b) serious diseases and

(c) the interaction among those diseases.

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When do I document “other” diagnoses? What is the impact?

“additional conditions that affect patient care in terms of requiring at least one of the following”:― Clinical evaluation

― Therapeutic treatment

― Diagnostic procedures

― Extended length of hospital stay

― Increased nursing care and/or monitoring

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Principal Diagnosis "XYZ"Impact of Secondary Diagnosis

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“Diabetic Neuropathy” Non Specific code in ICD-10― Document :

• Diabetic mononeuropathy

• Diabetic polyneuropathy

• Diabetic autonomic neuropathy

• Diabetic amyotrophy

― Type of diabetes as Type 1 or Type 2 or drug induced

― Control status

Document :

• “inadequately controlled,”

• “out-of-control,” or

• “poorly controlled” and Type with hyperglycemia.

― Associated complications (atherosclerosis, peripheral angiopathy, PVD, gangrene― Document a cause and effect link (PVD due to diabetes, diabetic foot ulcer)

― )

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Medicare Risk-Adjusted Mortality AnalysisSystem Hospitals

Higher Than Expected (Unfavorable)

Lower Than Expected (Favorable)

Source: Risk Adjustment – by the 3MTM APR DRG Classification System and MEDPAR 2012; Expected deaths are based on the State of Illinois’s average death rate, risk adjusted by the 3M APR DRG Classification System.

Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study.

21 © 3M 2014 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M.

State Average

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Medicare Severity Index ComparisonsSystem Hospitals

Higher Than Expected (Favorable)

Lower Than Expected (Unfavorable)

Source: 3MTM APR DRG Classification System and MEDPAR 2012

22 © 3M 2014 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M.

State Average

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3M APR DRG Classification System Risk-Adjusted Mortality ExampleAPR-DRG 139 - OTHER PNEUMONIA


Data Source: 3M APR DRG Classification System utilizing MEDPAR 2012 data

Improved documentation may have increased the ROM to a higher level

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Document the Specific Type of Pneumonia

Diagnosis MCC CC Non-CC

Aspiration pneumonia X

E. Coli pneumonia X

Hemophilus Influenzae (H. Influenzae) pneumonia X

Hypostatic pneumonia X

Influenza with pneumonia X

Interstitial pneumonia (BOOP) X

Klebsiella pneumonia X

Legionnaires’ disease X

MCC vs. CC

Disease Progression Tables for Secondary Diagnoses

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Pneumonia: Complex vs. Simple Complex Pneumonia

Higher SOI; consume more resources RW = 1.9934― Anaerobic pneumonia― Aspiration pneumonia― Gram-negative pneumonia, which includes:

• E. coli pneumonia• Hemophilus parainfluenzae pneumonia• Legionnaires’ disease• Moraxella catarrhalis• Proteus pneumonia• Serratia marcescens pneumonia• Xanthomonas pneumonia

― Klebsiella pneumonia― Pseudomonas pneumonia― Staphylococcus pneumonia

• MRSA• MSSA

Simple Pneumonia Lower weight and SOI; consume less resources

RW = 1.4550― Chlamydia― Gram-positive pneumonia― Hemophilus influenzae pneumonia― Mixed bacterial pneumonia― Mycoplasma pneumonia― Pneumococcal pneumonia― RSV Pneumonia― Streptococcus pneumonia― Vancomycin resistant Enterococcus

(VRE)― Viral pneumonia― Unspecified pneumonia, CAP, HAP

Link causeof pneumonia

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"Probable" "Possible" "Suspected" "Unable to Rule Out"

Inpatient application:― Code these conditions as though they exist – applies to

hospital setting only― If condition is ruled out, it may not be coded

Outpatient application:― Must code signs/symptoms, not the suspected

condition

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Possible/Probable Cause of Chest Pain Cardiac Cath

MS-DRGs 286/287

RW = 1.9634

What’s new in ICD-10?

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Acuity:― Acute― Chronic― Healed/old

Specify “history of PE”― Patient has had the condition for a

while or patient no longer has the condition

― i.e.“chronic pulmonary embolism” vs. “healed PE” or “old PE”

Type:― Saddle― Septic― Postprocedural or due to a vascular

device

Cause/ other :― Atrial fibrillation― DVT (specify site and laterality)― Hypercoagulable state― Malignancy― Orthopedic surgery― Sepsis― Trauma

Presence of cor pulmonale (acute/chronic)

Documentation for Pulmonary Embolism: More Specificity

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ICD-10 Codes for STEMI: Increased Specificity

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3M APR DRG Classification System Risk-Adjusted Mortality ExampleAPR-DRG 720 - SEPTICEMIA & DISSEMINATED INFECTIONS



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Sepsis is classified in ICD-10 as: • Streptococcal or

• Other Sepsis (e.g., MRSA, Pseudomonas)

Severe sepsis

• Must document associated organ dysfunction and the basis for same and

• Document presence of septic shock (combination codes)

Sepsis/ Severe Sepsis

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Respiratory Failure Documentation

Document acuity:― Acute

― Chronic

― Acute on chronic

Document presence of:― With hypoxia

― With hypercapnia

Specify the etiology or cause of respiratory failure in progress notes and discharge summary

DISCHARGE DIAGNOSES:1. Acute respiratory failure secondary to MRSA pneumonia improved.2. Severe sepsis due to E. Coli treated and resolved.3. Anemia of chronic disease stable.4. Anasarca improving.5. Protein malnourishment mild improving.6. End-stage liver disease.

DISCHARGE DIAGNOSES:1. Acute respiratory failure secondary to MRSA pneumonia improved.2. Severe sepsis due to E. Coli treated and resolved.3. Anemia of chronic disease stable.4. Anasarca improving.5. Protein malnourishment mild improving.6. End-stage liver disease.

• Acute, chronic, acute on chronic?• With hypoxia, hypercapnia, or

both?• Etiology?

• Acute, chronic, acute on chronic?• With hypoxia, hypercapnia, or

both?• Etiology?

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Syncope Alternatives”: “possible” “probable” ArrhythmiaMS-DRGs

308/309/310RW = 1.2188

SyncopeMS-DRG 312 RW = .7215

Stroke or CVAMS-DRGs 64/65/66

RW = 1.8258

AnemiaMS-DRGs 811/812

RW = 1.2431

DehydrationMS-DRGs 640/641

RW = 1.0896

Heart FailureMS-DRGs

291/292/293 RW = 1.4609

HypotensionMS-DRGs

314/315/316 RW = 1.7589

Dig PoisoningMS-DRGs

917/918RW = 1.4449

Alcohol AbuseMS-DRGs 896/897

RW = 1.4155

.

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ICD-10 Cerebral Infarction Following Surgery What remains the same ICD-9 ? Etiology = thrombosis or embolism What’s new

― Site = precerebral, cerebral, or cerebellar arteries

If precerebral:

Vertebral, basilar, carotid, or other

― Laterality = right or left, when applicable

― Intraoperative or

― Post procedural

― During cardiac surgery or

― Another type of surgery

If cerebral:

Middle, anterior, or posterior

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3M APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 194 - HEART FAILURE



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ICD-10: Heart Failure

Specify Acuity acute, chronic, acute on chronic/exacerbation Type systolic and/or diastolic heart failure Etiology if known or suspected:

• Anemia

• Supraventricular tachycardia

• Myocarditis

• Cardiomyopathy: dilated, hypertrophic (obstructive vs. non obstructive), restrictive

• Structural heart disease

• Hypertension

• Renal failure

• Ischemia

Copy Right 3M 2014 All Rights Reserved

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Document The Reason for Drug Underdosing

New clinical terminology in ICD-10 Identifies intentionally or unintentionally taking less of a

medication than prescribed Document intentional versus unintentional or accidental

― Intentional• For example, due to financial hardship

― Unintentional or accidental• For example, due to age related disability

– Age-related dementia

– Rheumatoid arthritis of hands

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"Postoperative”: Complication or expected outcome

Clinical Definition

“A condition occurring in the postoperative period”.

Coder Definition

“A diagnosis related to the surgical procedure” Complication-900 code

“Coder cannot make the determination if it is a complication or an expected outcome”

(Coding Clinic 4/27/2011)

.

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Examples

Complication Postop ileus (997.4 + 560.1) Ileus secondary to surgery

(997.4 + 560.1)

Post op atelectasis (997.39 + 518.0)

Post op anemia (998.11 + 285.1)

Non-Complication Ileus

Prolonged ileus

Expected ileus

Incidental atelectasis

Atelectasis

Acute blood loss anemia

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Complications of Surgery ICD-10 for some complications, timeframe of when

complication occurred• Intraoperative or postoperative

• Body system of organ related to complication

• Body system on which the procedure was performed

Example:

– Colon resection :accidental puncture of artery resulting in postoperative hemorrhage status

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Complete and Accurate Documentation and Coding:Example: Patient with CA, syncope falls: Pathologic Fracture

Pathologic fracture documentation and coding will need to include: Exact location of fracture

• Site• Laterality• POA

Etiology of fracture

• Osteoporosis• Neoplastic disease (primary each secondary site)

Encounter type

• Initial encounter for fracture• Subsequent encounter for fracture• Subsequent encounter for fracture with delayed healing• Sequela

ICD-9-CMPathologic Fracture

8 Codes (733.13-733.19)

ICD-10-CMPathologic Fracture

150+ Codes (M80-M84)

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Require Documentation of Encounter Specificity:

Initial – patient is receiving active treatment for the condition such as:

― Surgical treatment

― Emergency department encounter, and

― Evaluation and treatment by a new physician

Subsequent – patient has received active treatment of the condition and is currently receiving routine care for the condition during the healing or recovery phase.

― Cast change or removal

― Removal of external or internal fixation device

― Adjustment of medication

― Other aftercare and follow-up visits following treatment of the injury or condition

Sequela – used for complications or conditions – late effects - that arise as a direct result of a condition.

ICD-10 Encounters

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0 2 7 B 3 4 Z0 2 7 B 3 4 Z

Med/SurgMed/Surg

Heart & Great Vessels

Heart & Great Vessels

DilatationDilatation

Coronary Artery

Coronary Artery

PercutaneousPercutaneous

Transluminal Device, Drug

Eluting

Transluminal Device, Drug

Eluting

NoneNone

SectionSectionBody

SystemBody

SystemRoot

OperationRoot

OperationBodyPart

BodyPart ApproachApproach DeviceDevice QualifierQualifier

ICD-10-PCS: Illustration only: stent

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End of Life/Palliative Care Documentation When further treatment is deemed futile and /or Patient/family has declined further treatment, the patient’s chart may document only the

following:― “Comfort measures”

― “Supportive care”

― “Condition grave” No aggressive treatment may be rendered…….but……. Document clinical all conditions and treatments required to accurately reflect patient’s

extreme severity of illness and risk of mortality. Examples:― Coma

― Agonal respirations

― Respiratory failure

― Brain Death

― Heart failure

― Renal failure Document the underlying terminal diagnosis (cancer, end-stage heart or renal failure)

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Pulmonary (Pocket card example)Clinical Terms

(Documentation needs clarification)Diagnostic Statement

(Accurate code may be assigned)

1. LUL infiltrate2. + sputum culture, productive cough

Pneumonia (specify type and organism, if known, such as Klebsiella pneumonia – must link responsible pathogen to the pneumonia; document cause such as aspiration pneumonia)

Fever, cough, infiltrates on CXR, suspect aspiration, abnormal swallow study, speech therapy consult, aspiration precautions

Aspiration pneumonia, aspiration pneumonitis, aspiration bronchitis

New onset fever, cough, productive sputum, fever Acute bronchitis (specify organism, if known), pneumonia (document causative organism, if known), pneumonitis

SOB, pO2 55, pCO2 64, pH 7.32, O2 sat 88%, BiPAP O2

Respiratory distress, cyanosis, ↑HR, labored respirations

Respiratory failure (specify acuity, if known: acute, chronic or acute on chronic; document if acute respiratory failure is hypoxemic, hypercapnic or both)

CXR shows chronic lung changes. Nurses’ notes indicate COPD. Home meds of inhalers and O2noted.

COPD (document if with acute exacerbation or decompensated, document if oxygen dependent)

History of asthma, continues marked wheezing, SOB, O2 sat 88%, ↓FEV1

Asthma (document severity and type [mild intermittent, mild persistent, moderate persistent, severe persistent], document status [uncomplicated, acute exacerbation, status asthmaticus])

A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

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Cardiology (Pocket Card example)


48



Infectious Disease (Pocket Card example)Clinical Terms

(Documentation needs clarification)Diagnostic Statement

(Accurate code may be assigned)

Chronic liver disease, now with altered mental status Viral hepatitis (document acuity such as acute or chronic; document hepatic coma when present; for hepatitis B patients, document any findings of delta agent)

History of IV drug use, HIV+, fever, cough, weight loss AIDS, symptomatic HIV infection

Endocarditis, SOB, CHF EF <40% Acute systolic heart failure due to endocarditis (document acuity)

Fever, headache, cough, weight loss +LP Meningitis (specify type such as bacterial or viral; document organism, if known; document acuity)

Abdominal pain, headache, fever, diarrhea Foodborne poisoning (specify type such as Salmonella)

Urosepsis, new cystostomy, + culture Cystitis (specify acuity; document if due to cystostomy tube; document organism if known such as E. coli)

Cellulitis, gangrene foot Document location, laterality, and organism; document underlying cause, if known, of gangrene such as diabetes, atherosclerosis


Tom Kravis

or suspected??

Tom Kravis

Type ??

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Impact of Documentation

MS-DRG 330 2.4981MS-DRG 330 2.4981

Bowel Procedurewith CC

PDx: Colon cancer

SDx:

Dehydration

Post-op ileus(codes to 997.4 + 560.1)

“Ulcer/Wound” noted by RN

PPx: Left hemicolectomy

MS-DRG 329 5.1396MS-DRG 329 5.1396

Bowel Procedurewith MCC

PDx: Colon cancer

SDx:

Acute Renal Failure – ATN

Expected ileus(560.1)

Pressure Ulcer, site unspecific


APR DRG: 221

SOI Level: 2

APR Weight: 1.7681

ROM Level: 1

Peer Group 0.0%

APR DRG: 221

SOI Level: 3

APR Weight: 2.9531

ROM Level: 3

Peer Group 2.5%

highest MS-DRG payment

highest MS-DRG payment

MS-DRG 329 5.1396MS-DRG 329 5.1396


PDx: Colon cancer

SDx:



Pressure Ulcer Stage IV on Sacrum


APR DRG: 221

SOI Level: 4

APR Weight:6.3732

ROM Level: 4

Peer Group 24.2%

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Impact of Documentation

MS-DRG 330 2.4981MS-DRG 330 2.4981

Bowel Procedurewith CC

PDx: Colon cancer

SDx:

Dehydration

Post-op ileus(codes to 997.4 + 560.1)

“Ulcer/Wound” noted by RN


APR DRG: 221

SOI Level: 2

APR Weight: 1.7681

ROM Level: 1

Peer Group 0.0%

APR DRG: 221

SOI Level: 4

APR Weight:6.3732

ROM Level: 4

Peer Group 24.2%

MS-DRG 329 5.1396MS-DRG 329 5.1396


PDx: Colon cancer

SDx:



Pressure Ulcer Stage IV on Sacrum


Not just about Not just about reimbursementreimbursementNot just about Not just about reimbursementreimbursement

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