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Quality Brand & Documentation
Helping your physicians look as good as they are
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• Quality is generally measured as:
• For Risk Adjusted Mortality Index (RAMI), expected is based on coding which is based on documentation
• A lack of specific or accurate documentation will result in a gap between the clinical picture known by the physician and the clinical picture based on ICD-10 coding
March 19, 2019
Quality Brand & Documentation
Observed outcome
Expected outcome
3March 19, 2019
Quality Brand & Documentation
Confusion
Frustration
Mistrust in the process
The Documentation Gap
• How do we start this work?
• How do we address the gap?
• How do we make this a priority?
• How do we know it’s working? (measure improvement)
4March 19, 2019
Quality Brand & Documentation
Our goals for today’s discussion
5March 19, 2019
Quality Brand & Documentation
Coding & CDI
Compliance
Epic
Quality
Medical Informatics
Physicians & APPs
Finance
How do we get started: you need a team
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
6March 19, 2019
Quality Brand & Documentation
Documentation occurs
Quality and Coding/CDI reviews
Opportunities presented to
monthly Physician Champion meeting
Physician Champion provides
department education
Coding tip sheets updated
Epic preference lists optimized
Learning system is ready for the “next”
patient
Clinical guideline is created
Workflow pilot developed
Biweekly Documentation
SWAT Team meetings
Quality Assurance
Monthly QBD Core Team meeting
How do we address the gap: you need a plan
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
7March 19, 2019
Quality Brand & Documentation
Monthly Physician Champion meetings
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Leveraging knowledge and experience from Coding & CDI experts
• Focus is on accounts that are already billed• Doesn’t impact current inpatients
• Allows for freedom of discussion
• Could use LOS>GMLOS without CC/MCC as an indicator for chart review (requires Case Management involvement)
• Champions can be MDs or lead APPs but must be engaged to be successful
8March 19, 2019
Quality Brand & Documentation
Monthly Physician Champion meetings
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
9March 19, 2019
Quality Brand & Documentation
Clinical guidelines and coding tip sheets
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Coordination of language
• Coding tip sheets are used to help identify indicators and understand variations in physician language
• Example: cerebral edema; “salt bomb”
• Clinical guidelines are used for conditions that benefit from added structure
• Heart failure – acute, chronic, systolic, diastolic
• Renal failure – kidney injury, renal insufficiency, ATN
• Encephalopathy – dementia, delirium, AMS
• Respiratory failure – acute, chronic, hypoxic, hypercapnic
• Can be inserted into query templates
10March 19, 2019
Quality Brand & Documentation
Clinical guidelines and coding tip sheets
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Very misunderstood• Why are you asked to agree with pathology or
radiology?
• Myth: just pick the first choice
• Myth: always say clinically undetermined
• “Queries are your friend!”• A necessary tool
• Helps physicians to use CMS coding language based on indicators
• Last opportunity to clarify your documentation
11March 19, 2019
Quality Brand & Documentation
Queries
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
12March 19, 2019
Quality Brand & Documentation
The Documentation Gap
Clinical guidelines
Coding tip sheets & Queries
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
13March 19, 2019
Quality Brand & Documentation
Tools
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Adding common diagnoses to Epic’s diagnosis preference list with specificity “built in”
• Working with Physician Champions to bring concepts back to their departments and share learnings
• Identifying opportunities where a change in workflow could have a positive impact
• How do we address queries most timely and efficiently?
• How do we leverage documentation done in the clinic?
• How do we capture most accurate and specific documentation for short LOS?
14March 19, 2019
Quality Brand & Documentation
Tools
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Difference between E&M and Inpatient coding
• Need for MEAT criteria for each diagnosis• Measure, Evaluate, Assess, Treat
• Threshold for MEAT• Generally a low threshold
• “Chronic systolic heart failure stable, will continue same dose of Lasix and ACE inhibitor”
• “Hyperlipidemia, lipid profile ordered”
• Can’t just list problems
• Using terms like suspected, likely, probable
• Impact of secondary diagnoses to expected mortality
• Importance of Present on Admission status
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Quality Brand & Documentation
Documentation education
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
16March 19, 2019
Quality Brand & Documentation
Quality assurance
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Bi-weekly meeting to build strategy and vision• Includes senior leadership from HIM, Epic, Compliance, Finance,
Medical Informatics, Quality
• Monthly Core Team Meeting• Larger group of stakeholders
• Focus is on updates, pushing data out
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Quality Brand & Documentation
Quality assurance
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Improvement can be very hard to measure• Case Mix Index (CMI)
• Can fluctuate due to medical/surgical mix or variations in patient acuity
• Comorbid and Major Comorbid Conditions (CC/MCC) capture rate• Only one diagnosis needed to maximize rate which undercuts importance of secondary diagnoses
• Normalized CMI (nCMI)
• Created by Cleveland Clinic to help control differences in relative weights across DRGs
• Similar to CC/MCC capture rate in that it only needs one diagnosis to maximize score
18March 19, 2019
Quality Brand & Documentation
How do we know it’s working: measurements
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
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Quality Brand & Documentation
• Each Diagnosis Related Group (DRG) has a relative weight assigned by CMS
• Most DRGS have 3 “levels” (MCC, CC, or neither) but some only have 2 (MCC, no MCC)
• CMI is based on this weight
• Weight variations or medical/surgical mix significant impact CMI even if there is no CC or MCC captured
Case Mix Index (CMI)
DRGs 001 and 002Heart Transplant or Implant of Heart Assist System W MCC = 29.7170Heart Transplant or Implant of Heart Assist System W/O MCC = 16.9233
DRGs 077, 078, 079Hypertensive Encephalopathy W MCC = 1.7449Hypertensive Encephalopathy W CC = 1.1544Hypertensive Encephalopathy W/O CC/MCC = 0.8529
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• CC or MCC coded will result in 100% capture for that patient
• No CC or MCC coded will result in 0% capture
• Primary diagnosis generally cannot be a CC or MCC, it must be a secondary diagnosis
• Some DRGS only have two options (MCC or no MCC)
• Only one diagnosis needed to maximize rate which undercuts importance of secondary diagnoses
20March 19, 2019
Quality Brand & Documentation
Comorbid and Major Comorbid Conditions (CC/MCC) capture rate
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• MCC coded results in nCMI of 100
• CC coded results in score of 1-99 depending on where relative weight of DRG with CC is between other two DRGs
• No CC or MCC coded results in nCMI of zero
• Normalizes out relative weights across DRGs
• Only one diagnosis needed to maximize rate which undercuts importance of secondary diagnoses
21March 19, 2019
Quality Brand & Documentation
Normalized CMI (nCMI)
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
22March 19, 2019
Quality Brand & Documentation
Month 1:
2 patients: #1 is not sick at all, #2 is very sick
• Pt #1 is healthy 25 y/o marathon runner and has no CC/MCC diagnoses
• Pt #2 is intubated due to acute respiratory failure
nCMI = 50MCC/CC capture = 50%
Month 2:
2 patients: #1 is not sick at all, #2 is very sick
• Pt #1 is healthy 25 y/o marathon runner and has no CC/MCC diagnoses
• Pt #2 is intubated due to acute respiratory failure but MD spends more time documenting 2 other CC/MCC diagnoses that are present
nCMI = 50MCC/CC capture = 50%
Lots of documentation improvement
work in between month
1 and 2
CMI would also not change
The improvement doesn’t show up in these measurements
How do we know it’s working: measurements
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• Average number of CC/MCC diagnoses per discharge that are Present on Admission (POA)
• Adult inpatients only
• Excludes SNF, rehab, psych, primary diagnosis, and diagnoses with POA status other than Y/W/1
23March 19, 2019
Quality Brand & Documentation
Coding Density
Coding Density © Ochsner Health System 2019
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
24March 19, 2019
Quality Brand & Documentation
Coding Density
Month 1:
2 patients: #1 is not sick at all, #2 is very sick
• Pt #1 is healthy 25 y/o marathon runner and has no CC/MCC diagnoses
• Pt #1 is intubated due to acute respiratory failure
Coding Density = 0.5
Month 2:
2 patients: #1 is not sick at all, #2 is very sick
• Pt #1 is healthy 25 y/o marathon runner and has no CC/MCC diagnoses
• Pt #2 is intubated due to acute respiratory failure but MD spends more time documenting 2 other CC/MCC diagnoses that are present
Coding Density = 1.5
Lots of documentation improvement
work in between month
1 and 2
Coding Density © Ochsner Health System 2019
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
• nCMI and CC/MCC capture provide a 2D image of documentation improvement
• Both max out with 1 CC/MCC
• Both are heavily affected by acuity of patient population
• Coding Density provides 3rd dimension• Sicker patients often have more than 1 CC/MCC
• Capturing more secondary POA diagnoses generally improves expected mortality
25March 19, 2019
Quality Brand & Documentation
No
rma
lize
d C
MI (y
)
CC/MCC Percent Capture (x)
Coding Density
Coding Density © Ochsner Health System 2019
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
26March 19, 2019
Quality Brand & Documentation
How do we make this a priority: show the changing landscape
How do we start this work?How do we address the gap?How do we know it’s working?How do we make this a priority?
27March 19, 2019
Quality Brand & Documentation
Look as good as you are!Your inpatient documentation is your inpatient quality
• Expected mortality
• Expected complication rate
• Complications “in documentation only”
Your inpatient documentation
Inpatient coding (based on
documentation)
MEDPAR(CMS National
Database)
How do we make this a priority: show the changing landscape
Complication Review/ Hardwiring Documentation Improvement
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Quality Brand & Documentation
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Complication Review
- AHRQ (Agency for Healthcare and Research Quality) has a list of diagnoses that are
interpreted as “harm” and they should never happen to patients while in our care. (Patient Safety
Indicators)
- Inclusion codes are the “harm” codes
- Exclusion codes can explain the reason for the “harm” code, and prevent an artificial complication
- We have developed a review process that ensures that if the inclusion code is present, the exclusion
code is also present, if applicable
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Complication Review
- Complication review is coordinated at the system level by a subject matter expert
- PI Coordinators and VPMA’s assist with reviews on each campus
- The subject matter expert is being trained to submit queries directly to physicians/APP’s
- There is a focus group at Jeff Highway working to reduce PSI-03 (Hospital Acquired Pressure Injuries)
- Spreadsheet with thorough review of each case is on Nursing G drive
- SOS reports are cross checked to the pressure injuries
- Mini RCA’s completed on each pressure injury
- Regular feedback at UBMD meeting
- Working with EPIC team on continuous documentation improvement
- Coding Collaborative team is working together to resolve many issues; example: rebill process
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Are queries always our friends?
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Working together, we built a better query
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Quality Brand & Documentation
QUESTIONS