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Clinical Documentation Improvement . Langley Provider Group Colleen Garry RN, BS Mary Beth Genovese RN, BS, CCS, CCDS. JAMA: April 26, 2006 p. 1918. - PowerPoint PPT Presentation
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Clinical Documentation Improvement
Langley Provider GroupColleen Garry RN, BS
Mary Beth Genovese RN, BS, CCS, CCDS
JAMA: April 26, 2006 p. 1918
“The era of accountability defined as measured performance with consequences, is rapidly arriving in the US for medical practitioners and health care facilities. Soon, both reputations and incomes of practitioners and health care facilities may well be altered depending on how one scores on a limited set of performance metrics”
Hospital Life Today
Affordable Care ACT Changes Decreased reimbursement Bundled payments Pay for Performance/VBP EMR Implementation ICD 10 Pay for Outcomes
Deficit Reduction Act of 2005
SECTION 501 c of PL 109-71
Congress authorizes CMS to adjust for Medicare IPPS hospital payments to encourage the prevention of certain conditions (VBP)
Requires CMS to choose at two conditions; High volume high cost or both Condition is a cc or MCC Reasonably preventable thru evidenced based
guidelines No addition payment when these conditions develop
after admission (when condition is the only one to bring to the higher RW tier)
Who’s Profiling Physicians?
Federal State and Regulatory agencies Joint Commission CMS Peer Review Organizations Managed Care organizations/Profiling Agencies Prospective Payment Systems Hospitals
(one of the major indices is based on SOI)
Is your profile accurate?
How complex is the care being delivered? What overall severity is being reported and
collected? What risk of mortality is being reflected? How do secondary diagnoses affect reflection of
severity and risk? Do I have any control over my profile?
WIKIPEDIA DEFINITIONS
Severity of illness (SOI) is defined as the extent of organ system derangement or physiologic decompensation for a patient. It gives a medical classification into minor, moderate, major, and extreme. The SOI class is meant to provide a basis for evaluating hospital resource use or to establish patient care guidelines.
The risk of mortality (ROM) provides a medical classification to estimate the likeli-hood of in-hospital death for a patient. The ROM classes are minor, moderate, major, and extreme. The ROM class is used for the evaluation of patient mortality.
Flow of Documentation
MD DOCUMENTATION
Converts into ICD 9 Codes NOW And
ICD 10 codes
OCTOBER 1, 2014
FEDERAL GOVT.
RACS
INSURANCE COMPANIES
HEALTHGRADESLEAPFROG
RANKING REIMBURSEMENT
OVERSIGHT RECOVERY
TIER STATUS CREDENTIALING
INTERNET PATIENT
BALTIMORE SUN
Governmental AUDITS
NAME OF AUDIT Governmental AGENCY
RAC POST BILL DCS INC. FOR CMS
RAC PRE-BILL DCS INC. FOR CMS
RAC A to B RE-BILL CMS
NGS PRE-BILL AUDIT 1 DAY STAY
NGS
CMS PART B PHYSICIAN AUDIT CMS
RAC’s: YOUR BEST DEFENSE: A GOOD OFFENSE
(CDI) To Assess:
Level of Acuity Severity of Illness Clinical Indicators Utilization of resources
LANGUAGE INCOMPATABILITIES
Clinical Language vs. Diagnostic Statements
CLINICAL LANGUAGE CODING LANGUAGE
↓ NA HyponatremiaFluid resuscitation Dehydration, hypovolemia,
hypovolemic shockEnzymes + St elevation V leads Acute anterior MI (STEMI vs.
NSTEMI)↓ HGB transfuse 2 units Acute blood loss anemia Urosepsis Urinary tract infection Urosepsis Sepsis from a urinary source
Effective CDI
LEADERSHIP
SUPPORT
DATA TRACKIN
G
COMMUNICATION &
COLLABORATION
ONGOING EDUCATIO
N
ACCOMPLISHED BY:
CDI team fully trained in CDI (clinical, coding, compliance)
Concurrent “real” time record reviews Ensure proper assignment of: DRG/CC/MCC/POA
Status/ HAC’s Tracking tool to report on vital data Scheduled reports to CDI Steering Committee with
regularly scheduled meetings Continuous feedback to Mid Level Providers and
Physicians
Benefits of CDI:
Regulatory Compliance Improved outcome indicators
Thorough documentation enhances accurate hospital and physician profiles
Enhanced support for the patient’s treatment plan LOS and medical necessity are supported by SOI Fewer Denials Added support for E&M coding levels Risk management tool
What are the drivers for change?
Accurate and Comprehensive clinical documentation is essential for:
Safe, high quality patient care Accurate performance data Appropriate reimbursement
revenue Regulatory compliance e.g.,
MS DRG . POA, HAC’s, Core Measures, PSI’s, RAC
????
Critical Success Factors
To ensure accurate comprehensive clinical documentation:
Provide Strong Medical and Administrative Leadership Support
Communicate and Collaborate Perform Robust Data Tracking Offer ongoing education Implement an effective CDI program
Improvement Activities Benchmarking
Regularly monitor
performance
Determine processes to be studied
Identify relevant
performance data /gather
data
Comparediscover critical success factors
Adopt/adapt successful strategies
COUNTDOWN TO ICD 10
OCTOBER 1, 2014
MAY 17, 2013
502 DAYS 71 WEEKS +
5 days
CHANGES TO VOLUME
DIAGNOSIS CODESICD-9-CM14,025 CODES
ICD-10-CM 68,069
