Learning Objectives. Medical University of South Carolina. Leap Frog to Pediatrics: Implementing a Successful Pediatric CDI Program

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1 Leap Frog to Pediatrics: Implementing a Successful Pediatric CDI Program Medical University of South Carolina, Charleston: Karen Bridgeman, MSN, RN Clinical Documentation Specialist David Habib, MD Medical Director Children s Hospital 2 Learning Objectives Medical University of South Carolina Explain motivating factors at MUSC to implement pediatric review Identify basic steps of initiating a pediatric CDI committee Develop targets and opportunities for clinical documentation improvement Translate CDI concepts (e.g., severity of illness & risk of mortality) into clinical practice Identify methods for sustaining the project Major academic and tertiary patient referral center for all of South Carolina Three hospitals: University Hospital Institute of Psychiatry Children s Hospital 709 beds Teaching hospital Level 1 Trauma Center 3 4 For questions please contact HCPro customer service at

2 MUSC Children s Hospital 186 licensed beds Service lines targeted 11 Pediatric ICU 12 Pediatric Cardiology ICU Peds ICU Peds Cardiology 10 Cardiovascular/telemetry Peds Hospitalists 65 Pediatric General Med-Surg Peds Hem-Oncology 22 Hematology/Oncology Neonatal Services 29 Level III Neonatal ICU Peds Pulmonary 09 Level II Nursery Peds Neurology 28 Newborn Nursery Peds Emergency Dept. MUSC Clinical Documentation Program Begun in 2005 for adult services Expanded 2007; additional staff and reviews Currently 12 CDI nurses Pediatric CDI program began January pediatric CDI nurses (1.5 FTE) Concurrent reviews 5 6 Motivating Factors at MUSC Department of Pediatric divisions supported in part by hospital funding Emergency, Sedation, Child Abuse, Gastroenterology, Hematology, and Hospitalists are supported financially in part by the hospital Increasingly scarce hospital resources for new personnel, equipment, and renovations Accurate documentation and coding sustains appropriate hospital reimbursement and funding Early planning and development for new Children s Medical Center Department of Pediatrics and Children s Hospital Services are viewed as one entity 7 Phase 1: Assessment High-Level Data Analysis UHC and NACHRI data indicated that compared to benchmarks our severity of illness, mortality, and case-mix index were not accurately reflecting our patients acuity MUSC financial data suggested a higher level of clinical complexity than represented by clinical documentation Clinical practice and resource utilization were undervalued by clinical documentation 8 For questions please contact HCPro customer service at

3 Phase 1: Assessment Identify Targets & Opportunities Data analysis Review of top and bottom 25 pediatric DRGs by discharge Identified DRGs with LOS index > 1.0 and/or DRGs with direct cost index >1.0 MUSC volume by case severity to expected volume for a tertiary academic medical center were incongruent Two categories of DRGs: High-volume, low-potential reimbursement yield Low-volume, high-potential reimbursement yield Medicaid Blue Cross Commercial Phase 1: Assessment Analysis of Data: Example 1 SOI Original Volume Asthma & Bronchitis Redistribution Volume redistribution Payment ($8,200) Totals Minor = % 38 ( 76) $2,822 $107,236 Moderate = % 77 (+11) $4,116 $316,932 Major = % 57 (+49) $6,385 $363,945 Extreme = % 19 (+16) $11,859 $225, $1,013,434 ($679,391) $ Phase 1: Assessment Analysis of Data: Example 2 Phase 1: Assessment Goals and Initial DRG Targets Primary goals of pediatric CDI program Fiscal = Reimbursement Quality = SOI/ROM High volume/low yield Asthma and bronchitis Seizures Neonatal High yield/low volume Cardiothoracic Other opportunities Respiratory failure and postoperative respiratory failure Cystic fibrosis Sickle cell Chemotherapy For questions please contact HCPro customer service at

4 Phase 2: Planning Committee Structure & Tactical Considerations Phase 2: Planning Pediatric CDI Committee Pediatric CDI Committee: Physician champion Core inpatient service physicians Pediatric CDI reviewers, director of hospital CDI Hospital finance Coding and compliance CDI reviewers and physician champion meet, exchange ideas, review subject matter, and develop instruction techniques & materials Other important tactics Committee meetings every other week Pocket cards Formal & informal rounding Resident education 13 Physician champion Dr. David Habib, Vice Chair of Clinical Operations CDI specialists (2) Karen Bridgeman, RN, and Tina Smith, RN Pediatric hospitalist (2) Pediatric intensive care physician (2) Pediatric cardiology physician (2) Pediatric emergency department physician (2) Children s Hospital director business operations Coding supervisor Compliance officer Ad hoc groups: Pulm/CF, Neurology, Neonatal, Hem-Onc Meets every two weeks for first 3 4 months 14 Phase 2: Planning Presentation Design Phase 2: Planning Presentation Basic Agenda Pre-meeting(s) to design/refine the presentation Focus presentation on single clinical entity Epilepsy & seizures or asthma & respiratory failure Translate into single DRG examples Review the literature on the diagnosis for complications and comorbidities (CCs/MCCs) Identify documentation issues that lead to inaccurate coding Focus on documentation that leads to highest impact on SOI or ROM Create two or four block diagrams from lowest to highest weighting Define key CDI terminology Discuss reimbursement with different payers Identify the MCCs and CCs pertinent to the diagnosis along with diagnoses that impact the SOI Show examples of missing and/or ambiguous documentation Focus on insufficient documentation that can lead to coding omissions For questions please contact HCPro customer service at

5 Role of the Pediatric CDI Specialist The pediatric CDI specialist should be proficient in CDI with a knowledge of pediatrics Needs to commit time and resources Learning the pediatric terminology Pediatric diseases and conditions Age-related diagnoses Pediatric treatments Developing educational materials Frequent meetings Understanding pediatric coding The Basics Initial pediatric CDI program overview: Who are the hospital CDI staff & rules of coding Familiarize faculty with appropriate CDI terminology to translate clinical practice into clinical documentation Hospital reimbursements & quality are derived from ICD-9 and ICD-10 diagnosis codes Payment types (e.g., APR-DRG, MS-DRG) MUSC payer distribution Query forms Determining Principal vs. Secondary Diagnosis Basic factors Severity of illness and risk of mortality Secondary diagnosis & final patient subgroups Principal diagnosis e.g., asthma exacerbation vs. respiratory failure Definition of respiratory failure Acute respiratory distress or insufficiency CCs & MCCs Examples of how clinical documentation impacts the hospital s principal vs. secondary diagnosis, reimbursements, severity of illness, mortality index, and case-mix index Basic Terminology for MS-DRG Medicare severity diagnostic-related groups MS-DRG payer Payment is fixed flat rate per case Based on the DRG wgt x base rate Medicare Blue Cross/Blue Shield Tricare For questions please contact HCPro customer service at

6 Basic Terminology for APR-DRG All patient refined diagnosis-related groups Medicaid reimbursements Expands the basic DRG system Three descriptors Base APR-DRG Severity of Illness subclass Risk of Mortality subclass Reimbursement Severity of illness is used for payment Based on APR-DRG SOI level weight X base rate Basic Coding Terms Principal diagnosis The reason after study that occasioned the admission CC Complication and comorbidity MCC Major complication and comorbidity SOI Severity of illness ROM Risk of mortality Key CDI Definitions Severity of illness (SOI) is a means to measure the impact or loss of the patient s physiological function or organ system failure. It is classified into: 1 Minor 2 Moderate 3 Major 4 Extreme Severity of Illness The SOI class is a means for assessing the resources used by the hospital to provide patient care. The SOI is determined by specific diagnoses and procedures that occur during the patient s hospitalization. Patients with a higher SOI (major or extreme) consume more hospital resources and generally will have a longer length of stay than patients with the same DRG with a lower SOI (minor or moderate). Key Terms & Clinical Correlates Epilepsy: Documentation that directly impacts SOI Intractable Pharmacological treatment resistant Poorly controlled or refractory While these terms do not move the DRG, they will impact the severity of illness For questions please contact HCPro customer service at

7 Definition of Key Terms Intractable Epilepsy Intractable epilepsy is defined as a patient who has been under the care of a physician with recurrent seizures that do not respond to the current medical therapy as prescribed by the physician. Recurrent seizures occur regardless of compliance with the prescribed medication therapy. Intractable epilepsy must be clearly documented by the physician. Query for Missing Documentation The CDI Committee read this H&P and stated they felt this met the criteria for intractable epilepsy Key Terms Impacting Severity of Illness or DRG Documentation & Coding Omissions Complications and Comorbidities of Seizures and Other Neurological Conditions Encephalopathy Hydrocephalus Respiratory failure Acidosis Aspiration pneumonia Hyper/hyponatremia Cerebral palsy w/quadriplegia Paraplegia Meningismus Cerebral edema Papilledema Vasogenic edema Acute renal failure Compression of brain Malnutrition Herniation of brain Developmental delay Quadriplegia Red = MCCs Blue = CCs ATN Black = Impacts SOI (not considered a CC/MCC) 27 Can you find encephalopathy? Neither could coding. Led to discussion to include key clinical findings in H&P and the hospital discharge summary to assist coding. 28 For questions please contact HCPro customer service at

8 Mapping of Documentation to Coding Phase 3: Presentation APR-DRG 053 Seizures, Status Epilepticus Develop clinical examples that the physicians and residents can recognize in their everyday practice Demonstrate the impact of clinical documentation on DRG mapping and weighting Build maps in two or four steps Build from lowest to highest weight Demonstrate changes in weight, SOI, ROM, and/or DRG with increasing documentation of CCs and MCCs Do not overwhelm Keep it simple, specialist! APR-DRG Seizure GLOS 1.90 Wgt SOI 1 APR-DRG Seizure GLOS 3.36 Wgt SOI 3 ROM Respiratory Failure w/vent APR-DRG Seizure GLOS 2.34 Wgt SOI 2 APR-DRG Seizure GLOS 7.01 Wgt SOI 4 ROM Respiratory Failure w/vent Aspiration pneumonia Phase 3: Presentation MS-DRGs Seizures w/wo MCC Status Epilepticus Phase 3: Presentation APR-DRG 053 Seizures w/ VEEG Monitoring MS-DRG 101 Seizures w/o MCC MS-DRG 100 Seizures w/mcc APR-DRG Seizures APR DRG Seizures GLOS 2.6 Wgt SOI Status Epilepticus GLOS 4.3 Wgt SOI 2 GLOS 1.90 Wgt SOI Complex partial seizures w/o intractable epilepsy VEEG GLOS 2.34 Wgt SOI Complex partial seizures w/o intractable epilepsy Developmental Delay VEEG MS-DRG 100 Seizures w/mcc GLOS 4.3 Wgt SOI 3 ROM Respiratory Failure w/vent MS-DRG 100 Seizures w/mcc GLOS 4.3 Wgt SOI 4 ROM Respiratory Failure w/vent Aspiration pneumonia APR-DRG Seizures GLOS 3.36 Wgt SOI Complex partial seizures w/ intractable epilepsy VEEG APR-DRG Seizures GLOS 3.36 Wgt SOI Complex partial seizures w/ intractable epilepsy Developmental Delay VEEG For questions please contact HCPro customer service at

9 Tips for Success Pre-meet with physician champion to review presentations Include mid-levels and residents Follow up by rounding formally and informally Design pocket guides that cover basic definitions and mapping Utilize DRG summary sheets so physicians can see the impact of their documentation on concurrent reviews Develop a website for easy access to presentations, minutes, and pertinent CDI information Make your presence known on your units Phase 4: Evaluation Outcome and Impact Review progress through data analysis of metrics: Impact on hospital reimbursement Severity of illness, risk of mortality Case-mix index & benchmarks Physician scorecards for query responses Query rates should decrease as impact of education is demonstrated with improved clinical documentation Ongoing education into infinity and beyond! Phase 4: Evaluation Outcomes From Pediatric CDI Program Phase 4: Evaluation Impact of Pediatric CDI Program For questions please contact HCPro customer service at

10 Phase 4: Evaluation MUSC Children s Hospital Case-Mix Index Phase 4: Evaluation MUSC Children s Hospital Mortality Index Thank you. Questions? 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 workbook. 39 For questions please contact HCPro customer service at