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
Things to Consider….. CVA • Hemorrhagic conversion • Cerebral edema or compression (look for terms on CT or MRI like sulcal effacement, shift, edema, etc) for a MCC
Things to Consider…… CHF • 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)
Things to Consider…… HIV • 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
Things to Consider Fracture • 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?
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