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Copy-Paste usage in the EHR
- 1. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. . All Rights Reserved.9 November 2015© 3M 1 Clinical Documentation Copy-Paste usage in the EHR Provider EHR Documentation Prior Visits Current Visit 20–60% Average % of note content that is copied (i.e. duplicated) text from prior notes Copy-Paste
- 2. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. . All Rights Reserved.9 November 2015© 3M 2 Pneumonia, HTN, Diabetes Type II, UTI DRG: 194 Simple Pneumonia & Pleurisy w/CC $4,069 Risks of Copy-Paste: Coding and Reimbursement Patient details Admitting diagnoses Documentation Duplicate text Coded diagnoses Coding outcome Reimbursement 76 year old male Pneumonia Physician creating H&P copies information from prior admission’s H&P “...patient has HTN, diabetes type II and a UTI…”High-risk issue Incorrect coding results in $1,110 over- payment UTI is not a current problem for this admission DRG should be: 195 Simple Pneumonia & Pleurisy without CC/MCC $2,959 Patient Overview Documentation & Coding Copy-Paste Issue & Impact
- 3. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. . All Rights Reserved.9 November 2015© 3M 3 Risks of Copy-Paste: Patient Care Patient details Admitting diagnoses Initial Lab Tests Documentation Duplicate text Patient care decision 62 year old woman Admitted in AM due to CHF Potassium level: 5.1 (Normal range: 3.7- 5.2) BNP was elevated at 2000 Patient Overview Documentation & Patient Care Copy-Paste Issue & Impact High-risk issue High risk for an adverse patient care event Potassium level is normal, copied text implies it is low Adverse Event Risk: Administering potassium supplements to a patient with normal potassium level could have devastating impacts on the patient Avoidable Cost: Ordering recheck of the potassium level is additional cost that could have been avoided Admitting physician creating H&P copies information from a prior admission’s H&P “…patient has a potassium level of 2.9…” Hospitalist covering patient on evening shift reads H&P. Based on potassium level of 2.9 orders: 1. Potassium supplements 2. Recheck of potassium level next day
Editor's Notes
- The Takeaway Message: Specificity queries make are impactful and can result in big changes to the final coding of a patient visit, and thus impacts reimbursement and quality/outcomes reporting. Opening: Here is a patient case example to highlight the importance and impact of getting additional specificity. Click One: For this patient the principle diagnosis is Acute Kidney Failure, with secondary diagnoses of Urosepsis (which codes to a UTI), Heart Failure, Chronic Kidney Disease and an old Myocardial Infarction. You can then see the DRGs and Severity of Illness and Risk of Mortality based on these diagnoses. Click Two: These diagnoses are the ones that will trigger a specificity query with 360MD, as they are currently classified as “un-specificied diagnoses” meaning there is a more specific, detailed version of this diagnosis. Click Three: By querying a physician for more specificity on this patient, we can clarify that the patient has Sepsis, Acute Systolic Heart Failure and CKD Stage 4. This additional detail not only changes the MS-DRG by capturing an MCC, it also changes the ROM, changes the DRG weighting and the National Mortality Rate score. Transition to Next Slide: In order to capture all of the needed specificity and diagnosis information for each visit to achieve appropriate reimbursement and accurate reporting for the care provided in your hospital, this requires a full team approach…
- The Takeaway Message: Specificity queries make are impactful and can result in big changes to the final coding of a patient visit, and thus impacts reimbursement and quality/outcomes reporting. Opening: Here is a patient case example to highlight the importance and impact of getting additional specificity. Click One: For this patient the principle diagnosis is Acute Kidney Failure, with secondary diagnoses of Urosepsis (which codes to a UTI), Heart Failure, Chronic Kidney Disease and an old Myocardial Infarction. You can then see the DRGs and Severity of Illness and Risk of Mortality based on these diagnoses. Click Two: These diagnoses are the ones that will trigger a specificity query with 360MD, as they are currently classified as “un-specificied diagnoses” meaning there is a more specific, detailed version of this diagnosis. Click Three: By querying a physician for more specificity on this patient, we can clarify that the patient has Sepsis, Acute Systolic Heart Failure and CKD Stage 4. This additional detail not only changes the MS-DRG by capturing an MCC, it also changes the ROM, changes the DRG weighting and the National Mortality Rate score. Transition to Next Slide: In order to capture all of the needed specificity and diagnosis information for each visit to achieve appropriate reimbursement and accurate reporting for the care provided in your hospital, this requires a full team approach…