Clinical Quality Measures (CSI) Electronic Copy of Health Information

Clinical Quality Measures (CSI) Electronic Copy of Health Information

Presenters David Taylor, MHS, RPh, PA-C, RN Deborah Alcorn, MSN, RN, CPC Chris Lamer, PharmD, MHS, BCPS, CDE Electronic Copy of Health Information 2

Objectives At the end of this session, participants will be able to: Identify the SNOMED, LOINC, and CPT codes for meeting the clinical quality measures that follow. Identify the Clinical Documentation Improvement (CDI) principles, practices, and techniques to meet the measure. Perform a Computer Scene Investigation (CSI) to improve documentation of clinical quality measures impacted by HIM professionals. Electronic Copy of Health Information 3

Clinical Quality Measures Overview New CQM reporting requirements: Electronic submission to CMS in QRDA. Need for new measure tool (not CRS). Alignment of National Quality Measure Reporting: CQM, PQRS, others. Status of CQM module (part of BMW). CQM measure logic: Differences between what we code and what we document. Meeting CQM measures and effects on other functions: Auditing (BUSA). Electronic Copy of Health Information 4

Clinical Quality Measures EH CMS 32. Median time from ED arrival to ED departure for discharged patients (ERS). CMS 55. Median time from ED arrival to ED departure for admitted ED patients (ERS). CMS 111. Admit decision time to ED departure time for admitted patients (Delayed Admission Order). CMS 110. VTE discharge instruction (SNOMED, RX Norm, ICD-10). CMS 31. Hearing screening prior to hospital discharge (SNOMED). Electronic Copy of Health Information 5

CMS 32 & CMS 55 Median Time from ED Arrival to Departure for Admitted and Discharged ED Patients Admit your assigned demo patient to the ED through the ERS. Discharge your assigned demo patient from the ED through the ERS. Examine your demo patient through the coding queue for the arrival and discharge times. Electronic Copy of Health Information 6

CMS 111 Admit Decision Time Admit your assigned demo patient to the ED using the ERS. Write an admission order to the hospital using Delayed Order Option. Discharge your assigned demo patient from the ED using the ERS. Admit your assigned demo patient to the hospital using ADT (BMW). Compare and contrast decision to admit time with actual ED and inpatient admission times. Electronic Copy of Health Information 7

CMS 110 VTE Discharge Instructions Document VTE discharge instructions using the EHR Patient Education component. Examine the Patient Education Code through the EHR coding queue for a SNOMED Term. Locate the Discharge Instruction Note title. If VTE instructions were to be documented in this note title, is there an appropriate ICD Code to be assigned? Electronic Copy of Health Information 8

CMS 31 Hearing Screening Document hearing screening using the EHR exam codes. Examine the hearing exam code through the EHR coding queue for a SNOMED Term. Assign the appropriate CPT code for hearing screening. Electronic Copy of Health Information 9

Clinical Quality Measures EP CMS 155. Weight Assessment & Counseling for Nutrition and Physical Activity for Children and Adolescents (Measurements, SNOMED, and CPT for MNT) CMS 50. Closing the Referral Loop: Receipt of Specialist Report CMS 90. Functional Status Assessment for Complex Chronic Conditions (Minnesota Living with Heart Failure Questionnaire, MLH-FQ) Electronic Copy of Health Information 10

CMS 155 Weight Assessment & Counseling Document Nutrition Counseling through the EHR Patient Education Code. Examine the Patient Education Code through the EHR Coding Queue: Is there a SNOMED Term associated with this Patient Education Code? Is there an appropriate CPT Code associated with this Patient Education Code? Assign the appropriate CPT MNT Code to this visit. Compare and contrast the difference between Medical Nutrition Therapy and Nutrition Therapy. Electronic Copy of Health Information 11

CMS 50 Closing the Referral Loop Discuss your RCIS and CHS practices at your facility. Are you closing the referral loop? Considerations: How are reports received from outside providers? What happens to the reports after they are received? How does the referring provider receive the report? Who is responsible to assure the referring provider receives the report? Electronic Copy of Health Information 12

CMS 90 Functional Status Assessment How would a provider document results on the Minnesota Living with Heart Failure Questionnaire (MLH-FQ)? What would be the appropriate CPT Code to document this type of assessment? Electronic Copy of Health Information 13

Implications Do these measures and the use of SNOMED terminology impact the physician query process for coders? Integrated problem list. Provider narrative. Electronic Copy of Health Information 14

Questions and Discussion Electronic Copy of Health Information 15