Driving a Successful Documentation Improvement Program LHIMA Presentation Presented by: Trudy Rioux
Is a Program Needed? What is the baseline CMI (Case Mix Index) compared to other facilities within your peer group? For starters, review Med Par. How well is facility doing on risk of mortality? How well is facility doing on severity of illness? Can we create our own program or do we need to consult with a company that has software/reporting metrics/etc.?
Point of a Documentation Program: Bridging the Gap Bridging the gap between the physician's language and what is recognized in the code format and by Centers for Medicare and Medicaid Services (CMS) to reflect the severity and complexity of illness.
Before Starting a Program You need the following: Administrative buy in is a must and will aid in physician compliance. Alignment to meet the goals. Accountability for the physicians to answer clarifications/queries. Unanswered queries are assigned a medical record completion deficiency post discharge.
A Physician Champion It s necessary to have a physician champion to teach the clinical information to the coders and documentation specialists as needed. A Task Force meeting consisting of the documentation specialists, inpatient coding team, VP of revenue cycle, and the physician champion should be held monthly quarterly (depending on the need) which makes a strong team.
A Physician Champion Assists educating the physicians on staff about the upcoming program. Can keep a program alive by continuous education about the program at the monthly Medical Executive Committee Meetings.
Physician Documentation Equals Physician Documentation = ICD 10 codes ICD 10 codes = 1 MS DRG (Medicare Severity Diagnostic Related Group) per inpatient encounter MS DRG = Length of stay MS DRG = severity of illness, risk of mortality, physician profile, hospital profile MS DRG = Facility Reimbursement
Physician Pocket Card Creating a Physician pocket card with the top things clarified for is essential. As a documentation specialist works with a physician concurrently it s something tangible that can be distributed to include the clinical indicators for the condition.
Internal Organization Marketing There needs to be marketing about the documentation improvement program. This marketing/education needs to include physicians, nursing, ancillary care, etc. The organization as a whole needs an understanding as to why a documentation specialist might be clarifying about a diagnosis.
Which Population of Patients Should be Reviewed? Review just Medicare? Review Medicare Advantage? Review all payers that reimburse on the MS DRG > 55 years of age? Review all payers that reimburse on the MS DRG regardless of age?
Documentation Specialist Staffing 1 FTE for every 1,800 discharges This amount could depend on how pure the program is related to the working DRG, follow up and the other duties.
Duties of the Documentation Specialist Staff in addition to Clarifying for MS DRG Movement Identifying quality of care issues, HACs, PSIs Assisting with quality measures CHF, Pneumonia, MI, CVA Following queries post discharge if not answered concurrently Severity clarifications that have no impact on the MS DRG but potentially impact risk of mortality and severity of illness
New Documentation Specialist Training What has worked? 1 week of intense classroom training Learning the MS DRG system Learning the official coding rules Begin learning documentation strategies
New Documentation Specialist Training 6 weeks of rounding with a mentor (an existing documentation specialist; very beneficial to have the new person rotate with each existing documentation specialist) Following those 7 weeks, constant feedback to the new documentation specialist It takes 9 months to a year to yield a seasoned documentation specialist
Documentation Specialists Working with HIM Coders Include both the Documentation Specialist and the Coders in all continuing education meetings. Pairing each coder and doc spec for a coder/doc spec buddy system so they can use each other as a resource.
Scrubbing Charts Post Discharge Charts are sent to a supervisor review Q pre bill that do not have a CC or MCC prior to final coding. Even if the chart has a CC and the DRG could still use a MCC, the account will get scrubbed. A CC is good but a MCC is BETTER!
Scrubbing Charts Post Discharge If an opportunity is sited by the supervisor this is shared with the documentation specialist and coder. A determination is made whether a post discharge query will be generated.
Creating a Think Fast Documentation Opportunity Sheet is Helpful A think fast Document are tips on what the documentation specialist or coder should automatically consider when they see certain diagnoses documented. Just because a diagnosis is documented does not mean you will automatically be able to generate a clarification/query.
Creating a Think Fast Document Before clarifying you always have to have justification in the form of all of these: Risk factor Clinical indicators Treatment/monitoring
CVA Things to Consider.. Hemorrhagic conversion Cerebral edema or compression (look for terms on CT or MRI like sulcal effacement, shift, edema, etc) for a MCC
CHF Things to Consider The acuity (acute/decompensated and/or chronic) CHF in the setting of HCVD and HTN/CKD The type of heart failure (systolic/diastolic)
Things to Consider Pulmonary Condition (pneumonia, COPD, etc ) or CHF Acute respiratory failure for a mcc Pneumonia Aspiration, gram negative or other specified organism Bronchitis Aspiration
Things to Consider Localized infection (Pneumonia, Cellulitis, UTI, etc..) Clinical Sepsis (PDX) Dehydration, Volume Loss, Blood loss, diarrhea, vomiting, poor intake Acute Renal Failure or Acute Renal Failure w/atn
Things to Consider Altered Mental Status (AMS) Encephalopathy (mcc) Bedridden/Contracted Patient Functional Quad (mcc) PTCA/Stent coronary artery dissection (mcc)
Things to Consider.. More than one diagnosis meeting definition of pdx Can I flip it? One may be a mcc for the other Anemia GI bleed site (gastritis w/bleed, diverticulitis w/bleed, duodenal ulcer w/bleed)(mcc)
Things to Consider Post Surgery Hemoglobin/hematocrit Acute blood loss anemia (cc) Chest x ray atelectasis (cc) Cardiac conditions w/atrial fib as secondary Atrial flutter (cc) Persistent atrial fibrillation (cc)
Things to Consider.. All Patients Peruse Lab Sodium (hyponatremia cc) Lab Creat (AKI cc) Last Nursing Notes (skin for stage III or IV decubitus present on admission mcc)
HIV Things to Consider AIDS (B20) HIV manifestation currently or previously (B20) Injury (fracture, SDH, Internal injury, open wound) Multiple injured sites for MST(multiple significant trauma) MS DRG
Fracture Things to Consider Pathologic (non surgery patient could impact DRG) Chemo Patient Pancytopenia due to chemo (mcc)
The role of a Documentation Specialist Generating a worksheet on a patient is not beneficial if it s just a worksheet with no fruit. Yielding results by way of an impact clarification to improve the MS DRG or a severity clarification to appropriately reflect risk of mortality and severity of illness.
The role of the Documentation Specialist Yielding results by way of insuring the documentation meets the quality measure/core measure requirements. Yielding results by way of clarifying documentation around HACs (CMS hospital acquired conditions and PSI (patient safety indicators) to insure accurate reporting.
Monthly Measures for Each Documentation Specialist How many DRG matches have they had for the month? Meaning the documentation specialist s MS DRG matches the coders final MS DRG.
Monthly Measures for Each Documentation Specialist How many DRG changes based on additional documentation after their last review? A documentation specialist reviewing the chart daily or at a minimum every other day is essential to a successful program
Monthly Measures for Each Documentation Specialist How many DRG changes due to an incorrect code, a coding rule, or misinterpreting the documentation?
Monthly Measures of Program Success Overall CMI Medical CMI for a hospital with the majority being medical cases will be a good measure of how robust the program Surgical CMI
Monthly Measures of Program Success CC capture rate a cc is good but a mcc is better MCC capture rate Top 10 DRG Physician Agree Rate
Continuing Physician Education New Physician Orientation Hospital Medicine Group Orientation (HMG) Stay connected to HMG Monitor their query responses Is there one or two physicians not complying?
Physician Buy In/Participation Watching each physician s agree rate is a key factor A physician will not typically agree with every clarification However, we only generate clinically significant clarifications that meet risk factors, clinical indicator and treatment/monitoring.
Physician Buy In/Participation A solid program should strive for > 80% physician agree rate If a physician is declining 100% of good substantiated clarifications then the physician champion should review the cases to identify whether he needs to meet with the physician declining.
Physician Buy In/Participation If there is a hospital medicine group seeing the majority of all the patients then you need to make sure the whole group is engaged. Constant communication with the hospital medicine team leader is key. Attending their monthly or quarterly meetings providing documentation opportunities is important.
Other Program Measures Quarterly PEPPER Reports # of cases with only one CC/MCC; a solid bullet proof chart has 2 or more. CC/MCC capture External Audit Results don t be audit scared
RAC Payer Audits OIG Audits External Audits The majority of payers are on the band wagon of MS DRG validation. The auditors data mine to identify potentially problematic MS DRGs.
External Audits The auditors data mine accounts that contain only a CC or MCC. While a CC or MCC is good, 2 or more can potentially protect against being pulled for an audit.
External Audits An account with only one CC or MCC will be dissected apart to find a loop hole to discredit it. Auditors may not always know the coding rules. Always appeal as appropriate using the record documentation, coding conventions, official guidelines, and coding clinics to support the codes on the claim.
External Audit Follow up Realize when the coder simply made a mistake, misinterpreted, jumped to a conclusion too quickly, etc. Use these mistakes as education for the entire team and track it. Otherwise when what the auditor is citing is just not right, FIGHT with all you MIGHT!!
Goal Reflect the severity and complexity of each patient s illness. Get credit for the good care provided. Get paid for resource consumption.
Driving a Successful Documentation Improvement Program Trudy Rioux, CCS Manager, Coding and Documentation Baton Rouge General Medical Center