Improving Revenue, CMI and Quality Care with Documentation · Improving Revenue, CMI and Quality Care with Documentation Wilbur Lo, MD, CDIP, CCA AHIMA World Congress Faculty

©2017 AHIMA’s Intellectual Property. All rights reserved.

Improving Revenue, CMI and Quality Care

with Documentation

Wilbur Lo, MD, CDIP, CCA

AHIMA World Congress Faculty

AHIMA


OBJECTIVES

• Discuss two definitions of case mix index (CMI)

• Differentiate CMI concept with sample calculations

• Discuss complex, clinical case scenarios

– Provide examples of inappropriate vs. appropriate

documentation and the impact on CMI

– Offer insight on analyzing CMI trends, with respect to revenue

and quality care

2


Clinical Definition of CMI

Clinical Definition: For each inpatient facility, CMI reflects

level of sickness of patient population, with respect to the

following:

• Severity of illness

• Risk of mortality

• Prognosis

• Treatment difficulty

• Need for intervention

3


Reimbursement Definition of CMI

Reimbursement Definition: For each inpatient facility, CMI

is a direct measure of amount of resource consumption and

cost to provide patient care

• CMI is a calculation, based on average of sum of relative

weights (values) of DRGs (e.g., IR-DRGs, AR-DRGs,

MS-DRGs) of all patients treated during a specific time

period

• Higher CMIs correspond to increased consumption of

resources, increased cost of patient care and increased

reimbursement to facility from government and private

payers

4


Calculation of CMI: Scenario #1

• Scenario #1: Hospital “X” discharged 200 patients in

August 2017; all discharge diagnoses were documented

correctly

– 100 patients had discharge diagnosis of “sepsis”

[DRG relative weight (value) of 1.05; MS-DRG “872”]

– 100 patients had discharge diagnosis of “septic

shock” [DRG relative weight (value) of 1.81; MS-DRG

“871”]

– CMI calculations for Scenario #1 discussed in next

slide

5


Calculation of CMI: Scenario #1

Scenario #1: CMI Calculation for Hospital "X"

DRG # of Discharges (Aug 2017) DRG Value Composite

DRG

872 100 1.05 105

871 100 1.81 181

TOTAL 200 286

CMI (Total composite DRG/Total

Discharges) 1.43

6


Impact of Clinical Documentation

Improvement on CMI

• In Scenario #1, Hospital “X” discharged 200 patients in August 2017

– 100 patients were discharged with diagnosis of “sepsis” [DRG

relative weight (value) 1.05; MS-DRG “872”]

– 100 patients were discharged with diagnosis of “septic shock”

[DRG relative weight (value) 1.81; MS-DRG “871”]

• In Scenario #2, assume that improper documentation led to

discharge diagnoses of “sepsis” in 150 patients (instead of 100

patients) and “septic shock” in 50 patients (instead of 100 patients)

• CMI calculations for Scenario #2 discussed in next slide

7



Improvement on CMI


DRG # of Discharges (August 2017) DRG

Value Composite

DRG

872 150 1.05 157.5

871 50 1.81 90.5

TOTAL 200 248.0

CMI (Total composite DRG/Total

Discharges) 1.24

8



Improvement on CMI



DRG 872 100 1.05 105 871 100 1.81 181

CMI 1.43



DRG

872 150 1.05 157.5 871 50 1.81 90.5

CMI 1.24

9


CDI Case Studies with CMI

• Seven Characteristics of High Quality Clinical

Documentation

• Case Studies with Working DRGs and Target DRGs

• Calculation of CMI

10


Best Practice: Seven Characteristics of

High Quality Clinical Documentation

Legibility Required by government and regulatory agencies

Reliability Treatment provided without documentation of condition being treated

Precision Diagnosis lacks specificity

Completeness Abnormal test results without documentation of clinical significance

Consistency Disagreement between two or more treating physicians about diagnosis

Clarity Vague or ambiguous documentation; symptom without diagnosis

Timeliness Documentation that is not complete within the guidelines set by the facility, government and regulatory agencies *Hess, Pamela. Clinical Documentation Improvement: Principles and Practice. AHIMA Press: 2015

11


Case Study #1

SYNOPSIS:

• Admitted 21 hours ago for STEMI involving left main coronary artery

• Treated with aspirin, reteplase, ticagrelor, enoxaparin, morphine sulfate, carvedilol and captopril

• Appears confused with cold extremities, decreased urinary output and blood pressure 84/52, despite fluid resuscitation

• Echocardiography with no papillary muscle or left ventricular rupture

• Ejection fraction 27%

• Pulmonary capillary wedge pressure 17 mm Hg

• Cardiac index 1.9 L/min/m2

• Treated with intra-aortic balloon pump, coronary angiography, revascularization with percutaneous coronary intervention, dopamine

• DISCUSSION: Physician documents “STEMI”

• Which characteristics of high quality clinical documentation are missing?

• Target Diagnoses: Are the aforementioned clinical indicators integral to conditions that should be queried by the CDI specialist?

12


Case Study #1- DRG

Analyses

WORKING

DIAGNOSIS:

STEMI, unspecified

TARGET DIAGNOSES:

STEMI of left main coronary artery with cardiogenic shock

MS-DRG Description Weight

272 Other Major Cardiovascular Procedures

w/o CC/MCC

2.2508

MS-DRG Description Weight

270 Other Major Cardiovascular

Procedures w/ MCC

4.7349



Improvement on CMI

Scenario #1: CMI Calculation (with target diagnoses)

DRG # of Discharges DRG Value Composite

DRG 272 100 2.2508 225.08 270 100 4.7349 473.49

CMI 200 3.49285

Scenario #2: CMI Calculation

DRG # of Discharges DRG Value Composite

DRG 272 150 2.2508 337.62 270 50 4.7349 236.745

CMI 200 2.871825


Case Study #2

Synopsis: • Admitted for paralysis and sensory loss of right face

and right upper extremity; bilateral visual loss in right hemifields

• Drowsiness, slurring of speech, unable to speak complete sentences; episode lasts 85 minutes; BP 158/96

• Diagnostic Tests:

• computed tomography- no acute intracranial hemorrhage

• electrocardiogram- no AMI or erratic atrial activity

• magnetic resonance angiography scheduled

• Treatment: recombinant tissue plasminogen activator, mannitol, anti-hypertensive medications

DISCUSSION: Physician documents “stroke”.

• Which characteristics of high quality clinical documentation are missing?

• Target Diagnoses: Are the aforementioned clinical indicators integral to conditions that should be queried by the CDI specialist?


DRG Description Weight

MS DRG: 063 ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W/O CC/MCC

1.5098

Case #2- DRG Analyses


MS DRG: 062 ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W CC

1.8555

Stroke, unspecified

r/o thrombotic CVA of left middle cerebral artery; right hemiplegia, hemisensory loss, homonymous

hemianopia; global aphasia, hypertension



Improvement on CMI

Scenario #1: CMI Calculation (with target diagnoses)

DRG # of Discharges DRG Value Composite DRG

63 50 1.5098 75.49

62 100

1.8555

185.55

CMI 150 1.7403



63 100 1.5098 150.98

62 50

1.8555 92.78

CMI 150 1.6251


Case Study #3

Synopsis: • Admitted for multiple episodes of witnessed seizures,

headaches, chills, high fever, sweats, myalgias, arthralgias, abdominal pain, nausea, vomiting and diarrhea during past 2 days

• dyspnea, tachypnea, jaundice and blood pressure 84/52; recent travel to Africa

• Diagnostic Tests:

• Arterial blood gases: pH 7.21, PaCO2 53 mm Hg (millimeter mercury), PaO2 55 mm Hg, HCO3 24 mmol/L (millimole/liter)

• Chest x-ray: pulmonary edema and bilateral pulmonary infiltrates

• Giemsa-stained blood smears: Plasmodium malariae trophozoites

• Hemoglobin 9.8 g/dL, hematocrit 32%, total bilirubin 4.3 mg/dL

• Treatment:

• intravenous artesunate, 100% oxygen via non rebreather mask

• neurology, pulmonology and hematology consults

• Which characteristics of high quality clinical

documentation are missing?


Case Study #3

CDI Discussion

• Working Diagnosis: “malaria” documented as

reason for admission • Symptoms/signs (POA):

• multiple episodes of witnessed seizures, headaches, chills,

high fever, sweats, myalgias, arthralgias, abdominal pain,

nausea, vomiting and diarrhea during past 2 days

• dyspnea, tachypnea, jaundice and blood pressure 84/52;

recent travel to Africa

• Diagnostic Tests: • Arterial blood gases: pH 7.21, PaCO2 53 mm Hg (millimeter

mercury), PaO2 55 mm Hg, HCO3 24 mmol/L

• chest x-ray: pulmonary edema and bilateral pulmonary

infiltrates

• Giemsa-stained blood smears: Plasmodium malariae

trophozoites

• hemoglobin 9.8 g/dL, hematocrit 32%, total bilirubin 4.3

mg/dL

• Management: • intravenous artesunate, 100% oxygen via non rebreather

mask

• neurology, pulmonology and hematology consults

• Target Diagnoses: Are the aforementioned clinical

indicators integral to conditions that should be

queried by the CDI specialist?



MS DRG: 869 Other Infection & Parasitic Disease Diagnoses w/o CC/MCC 0.6640

Case #3- DRG Analyses


MS DRG: 867 Other Infectious & Parasitic Disease Diagnoses w/MCC 2.6467

malaria, unspecified

Severe malaria, due to plasmodium malariae, seizures (r/o cerebral malaria), acute hypercapneic & hypoxic respiratory failure, respiratory

acidosis, acute non-cardiogenic pulmonary edema, hypotension, jaundice with hyperbilirubinemia (r/o hemolytic anemia)



Improvement on CMI Scenario #1: CMI Calculation (with target diagnoses)


869 1000 0.6640 ? 867 5000 2.6467 ?

CMI 6000

?



869 5000 0.6640 ? 867 1000 2.6467 ?

CMI 6000 ? 21



Improvement on CMI Scenario #1: CMI Calculation (with target diagnoses)


869 1000 0.6640 664.00 867 5000 2.6467 13233.50

CMI 6000

2.3163



869 5000 0.6640 3320.00

867 1000 2.6467 2646.70

CMI 6000 0.9945 22


Summary of Key Points

• CMI with clinical and reimbursement definitions

• Proper calculation of CMI is crucial

• Inappropriate documentation adversely impacts CMI

• Slight shifts in CMI have tremendous financial impact

• Analyses of CMI trends utilized for revenue, patient complexity,

patient care and documentation practices

23


References

• AHA Coding Clinic® for ICD-10-CM/PCS. Chicago: AHA Central Office, 2017.

• Casto, Anne B. ICD-10-CM Code Book, 2017. Chicago: AHIMA Press, 2017.

• Casto, Anne B. ICD-10-PCS Code Book, 2017. Chicago: AHIMA Press, 2017.

• Casto, Anne B. and Forrestal, Elizabeth. Principles of Healthcare

Reimbursement, Fifth Edition. Chicago: AHIMA Press, 2015.

• Hess, Pamela Carroll. Clinical Documentation Improvement- Principles and

Practice. Chicago: AHIMA Press, 2015.

• Kasper, Dennis et al. Harrison'sTM Principles of Internal Medicine, Nineteenth

Edition. Columbus: McGraw-Hill Education, 2015.

• Leon-Chisen, Nelly. ICD-10-CM and ICD-10-PCS Coding Handbook 2017.

Chicago: AHA Central Office, 2017.

• Papadakis, Maxine A. et al. 2017 Current Medical Diagnosis & Treatment- Fifty

Sixth Edition. Columbus: McGraw-Hill Education, 2017.

24


Questions?


Contact Information

Wilbur Lo, MD, CDIP, CCA

AHIMA-Approved ICD-10-CM/PCS Trainer

AHIMA World Congress Faculty

[email protected]

Thank you for participating!

mailto:[email protected]


Thank You!

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Improving Revenue, CMI and Quality Care with Documentation · Improving Revenue, CMI and Quality Care with Documentation Wilbur Lo, MD, CDIP, CCA AHIMA World Congress Faculty