ACDIS day1-6 track1-2 pres 0515 Haik f · [email protected] In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation

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Coding and Physician Self‐Defense: Engaging Docs in CDI

William E. Haik, MD, FCCP, CDIP, AHIMA‐Approved ICD‐10‐CM/PCS Trainer

Consultant

Huff DRG Review Services

Fort Walton Beach, Florida

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Explain how medical chart documentation aids in accurate ICD‐9‐CM code assignment

– Demonstrate how ICD‐9‐CM coding and accurate clinical data collection can impact future patient care and funding

– Discuss how ICD‐9‐CM coding and accurate clinical data collection can impact physician performance profiling and reimbursement for physician services


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Coding and Physician Self‐DefenseGeneral

• How physicians are affected by coding

• Examples of incomplete documentation

• How to avoid these documentation pitfalls in the future

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How Are Physicians Affected by Coding?Performance Profiling

• Hospital cost

• Hospital length of stay Related to

• Mortality/readmission rate severity of

• Patient Safety Indicators illness

• Hospital‐acquired conditions

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• Severity of illness = DRG relative weight (RW)

• Physician quality of care = Actual hospital cost of care

(report card) Predicted hospital cost of care(DRG severity level)

• cost for severity of illness = poor quality of care


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Profiling Agencies

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Performance

Core measures

Hospital‐acquired conditions

Mortality measures

Readmission measures

Patient safety

measures

Cost measures

Patient satisfaction

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• The DRG severity level is determined by ICD‐9‐CM codes

– Antiquated coding system

– Coding dependent on physician documentation


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GIGO!

Garbage in, garbage out

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Physician Payment ICD‐9‐CM/CPT

Admission diagnosis

ICD‐9‐CM code CPT‐5 code Limited charge

Bronchitis 466.0 99221 $108

Bronchitis w/COPD

491.21 99222 $144

Bronchitis w/COPD w/ARF

518.81/491.21 99291 $291

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Physician Payment Value‐Based Physician Payment

• As per section 3007 of the Patient Protection and Affordable Care Act, CMS implemented a value‐based payment modifier for the Medicare physician fee schedule based on the “quality of care compared to cost.” Beginning in 2013, Medicare started collecting ICD‐9‐CM codes to reflect severity of a patient’s illness (HCC bundles) and, therefore, cost efficiency with implementation beginning in 2015.


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Physician PaymentRelative Risk

Scenario 1 CMS relative risk factor

Female age 75 0.457

DM unspecified 0.102

UTI 0.0

Total 0.619

Scenario 2 CMS relative risk factor

Female age 75 0.457

DM with renal manifestation 0.508

CKD3 0.368

DM nephropathy Excluded by CKD3

UTI 0.0

Malnutrition, mild 0.856

Old MI 0.244

BKA status 0.678

Total 3.111

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Physician Value Modifier

Quality/cost Low cost Average cost High cost

High quality +2.0%** +1.0%** +0.0%

Average quality

+1.0%** +0.0% <0.5%>

Low quality +0.0% <0.5%> <1.0%>

**These tiers can get an additional +1% if the HCC risk score of your population is in the top 25% nationally

Value modifier amounts using quality tier method for CY 2015

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Physician Payment ACO/BPI

• The physicians and the hospital are merged into accountable care organizations (ACO), and their payments are bundled [bundled payment initiative (BPI)] based on the final DRG assignment and the attainment of specific quality measures

• Example: A patient admitted for hip replacement who is under treatment for the comorbidity of chronic systolic heart failure is considered more resource intensive; therefore, this patient results in a higher global payment to the physicians and the hospital than a patient admitted for hip replacement without the comorbidity of chronic systolic heart failure


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Hospital Value‐Based PurchasesFY 2015 Finalized Domains and Measures/Dimensions

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PSI 03 – Pressure Ulcer RateExcludes: Hemiplegia, monoplegia, neurogenic bladder, etc.

PSI 06 – Iatrogenic Pneumothorax RateExcludes: Pleural effusion

PSI 07 – Central Venous Catheter–Related Bloodstream Infection RateExcludes: Immunocompromised state (cancer [present or past history]), neutropenia, severe malnutrition, etc.

PSI 08 – Postoperative Hip Fracture RateExcludes: PDx of syncope, CVA, dementia, etc., or any diagnosis of MSsystem (e.g., osteoporosis)

PSI 12 – Postoperative Pulmonary Embolism or Deep Vein Thrombosis RateExcludes: PDX of PE or DVT

PSI 13 – Postoperative Sepsis RateExcludes: PDX of infection or immunocompromised state (cancer [present orpast history]), neutropenia, severe malnutrition, etc.

PSI 14 – Postoperative Wound Dehiscence RateExcludes: Immunocompromised state (cancer [present or past history]), neutropenia, severe malnutrition, etc.

PSI 15 – Accidental Puncture or Laceration RateExcludes: Spinal surgery

Patient Safety for Selected Indicators (PSI 90)

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Patient Care

• The financial health of the hospital and the patient's health are directly intertwined

• The physician is the first and last patient advocate

nursing ratio

DRG severity latest medications

advanced technology


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DRG Definition With Examples of Incomplete Documentation

DRG

(diagnostic related group)

The thousands of diagnoses and procedures that occur in DRG hospitalized patients are bundled into approximately 750 clinically related and resource (cost) related groups.

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• Hypertension

– Renovascular hypertension

– 1° hyperaldosteronism

– Essential hypertension

• GI diagnosis with large bowel resection

– Colon polyp with partial bowel

resection

– Pancolitis with total colectomy

On average, similar LOS, cost mortality

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Principal Dx (PDx)

+

DRG Other (additional) Dx (ODx)

+

OR procedures


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Principal diagnosis (PDx) – condition after study that was chiefly responsible for occasioning the patient's admission to the hospital

Chest pain → endoscopy → PUD → lacerated esophagus → medias ni s → sepsis → ARDS

(admit dx) (PDx) (not PDx)

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Coequal conditions – if two or more conditions are present on admission, required in‐hospital care, and are equally addressed, then either condition may be reported as the principal diagnosis

– Principal Dx – acute systolic heart failure

– Additional Dx – staphylococcal pneumonia

– Principal Dx – staphylococcal pneumonia

– Additional Dx – acute systolic heart failure

DRG 291 (RW 1.5174)

DRG 177 (RW 2.0549)

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• Coequal conditions

– Atrial fibrillation/acute systolic heart failure

– Acute exacerbation of COPD/atrial tachycardia

– Diabetic ketoacidosis/pneumonia


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• Other (additional) diagnoses – conditions other than the principal diagnosis

– Comorbid conditions

– Complications

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• Comorbid conditions – conditions which are “present on admission” (pre‐existing) may be chronic, but active, even if not acutely symptomatic

Examples:

1. Cardiomyopathy/chronic systolic/diastolic heart failure

2. Stage III decubitus ulcer of hip

3. Malnutrition/cachexia

4. CAD of venous bypass graft

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DRG Definition With Examples of Incomplete Documentation (Comorbid Condition)

• Example

PDx – diverticulitis PDx – diverticulitis

ODx – none ODx – chronic systolic heart failure

OR procedure – sigmoidectomy OR procedure – sigmoidectomy

DRG 331 DRG 330

(RW 1.6361) (RW 2.5731)


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• Complications – clinically significant conditions that occur during the hospital stay that impact patient care in terms of requiring evaluation, treatment, increased level of care (e.g., nursing care, telemetry, etc.), or increased length of stay

Examples:1. Acute blood loss anemia/drop in hematocrit

2. Hyponatremia

3. Thrush

4. Paroxysmal ventricular tachycardia

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DRG Definition With Examples of Incomplete Documentation (Complication)

• Example

PDx – GI bleed PDx – GI bleed

ODx – none ODx – acute blood loss anemia

OR procedure – none OR procedure – none

DRG 379 DRG 378

(RW 0.7015) (RW 1.0168)

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• Operating room procedures – procedures that require increased hospital resource use or serve as a marker for increased hospital resource use

Examples:

1. Hip replacement

2. Excisional debridement (removal of devitalized tissue by excision)


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DRG Definition With Examples of Incomplete Documentation (OR Procedure)

• Example

PDx – decubitus ulcer PDx – decubitus ulcer

ODx – chronic systolic heart failure ODx – chronic systolic heart failure

OR procedure – non‐excisional debridement

OR procedure – excisional debridement

DRG 593 DRG 571

(RW 0.9912) (RW 1.4969)

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• Specificity of diagnosis reporting – at the time of discharge, qualify symptoms or conditions to the highest level of specificity with such terms as suspected, probable, or still to be ruled out if there is supportive chart documentation to suspect their existence

– Outpa ent dx → dyspnea ( certainty)

– Inpatient dx → probable COPD ( specificity)

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• Examples of specificity of inpatient diagnosis reporting 1. Syncope, probably secondary to paroxysmal ventricular tachycardia

2. Chest pain? – angina/CAD, esophagitis, Tietze syndrome, etc.

3. Pneumonia, secondary to "probable" aspiration, "suspected" gram‐negative bacterial organisms, etc.

4. Urosepsis? – UTI vs. sepsis from urinary origin

5. Acute renal insufficiency? – acute renal failure or injury, ATN

6. Congestive heart failure? – systolic/diastolic, acute/chronic

7. Hypoxia? – acute respiratory failure, chronic respiratory failure, acute respiratory insufficiency

8. AMS ? – encephalopathy, acute confusion, etc.

9. ↓ Na – hyponatremia, merely abnormal Na level

10. Decubitus ulcer? – stage/site

11. Malnutrition? – severity

12. Chronic renal failure? – stage

13. Schizophrenia? – acute, chronic, etc.

14. Fracture? – traumatic versus osteoporotic (pathologic)


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Physician Self‐Defense Tools

• Prompt and complete dictation

– H&P

– Discharge summary

– Operative report

• SOAP notes

– The assessment and plan should particularly be emphasized

– The quality of the note is more important than the quantity

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Physician Self‐Defense Tools

• Coder/CDI specialist/physician advisor

– These internal subject experts are not the problem, they are the solution to the problem

• External auditor correspondence

– Answer all external auditor inquiries regarding DRG modifications, admission denials, necessity of procedures, or quality of care

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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

Documents

ACDIS day1-6 track1-2 pres 0515 Haik f · [email protected] In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation