This document discusses the importance of clinical documentation improvement (CDI) programs in both inpatient and outpatient settings. It provides several examples showing how more thorough documentation can result in more accurate coding, higher reimbursement, and improved quality metrics. Key areas discussed include documentation for inpatient conditions, procedures, ED levels of care, physician E/M coding, and specialties like radiology, hospitalists, and pain clinics. The document emphasizes that comprehensive documentation is essential for accurate billing and reflects the complexity of care provided.

1. Is Clinical Documentation Improvement the Answer? MAPAM /MAHIMA Joint Meeting Thursday, November 19, 2009 Thomas D. Sills, M.D. Lori Beaudry, CCS-P Clinical Financial Resource

9. Inpatient CDI

28. Principal dx: Colon Cancer, 153.6 Secondary dx: a. fib, 427.31 Procedure: rt hemicolectomy, 45.73 MS-DRG 331 Major bowel surgery w/o cc/mcc Relative weight 1.8415 Payment $11,417 ROM 1

35. The pt was admitted for surgical resection of his pancreatic cancer. The patient presented with obstructive jaundice and CAT scan showed dilated biliary and pancreatic ducts. Did the pt have: 1. obstruction of the biliary duct? 2. obstruction of the pancreatic duct? 3. other_____________?

48. E.D. Diagnostic Coding

52. EMERGENCY DEPARTMENT E/M E/M CODE HISTORY EXAM DECISION MAKING 99281 LEVEL 1 c.c. 1-3 HPI AFFECTED AREA STRAIGHTFORWARD 99282 LEVEL 2 c.c. 1-3 HPI 1 ROS AFFECTED AREA+ 1 OTHER LOW COMPLEXITY 99283 LEVEL 3 c.c. 1-3 HPI 1 ROS 1-3 AREAS OR SYSTEMS MODERATE COMPLEXITY 99284 LEVEL 4 c.c. 4+ HPI 2-9 ROS 1 PFS Hx 5-7 SYSTEMS MODERATE COMPLEXITY 99285 LEVEL 5 c.c. 4+ HPI 10+ ROS 2-3 PFS Hx 8+ SYSTEMS HIGH COMPLEXITY

53. HPI ROS Past Medical, Fam. Soc. Hx Body Areas Organ Systems 1. location 2. quality 3. severity 4. duration 5. context 6. timing 7. modifying factors 8. signs/symp. 1.constitutional 2.eyes 3.ENT 4.cardiovascular 5.respiratory 6. GI 7. GU 8.musculoskeletal 9.derm 10.neuro 11.psych 12.heme/lymph/ immuno 1. past med hx 2. family hx 3. social hx 1. head&face 2. neck 3. chest 4. abdomen 5.genitals 6.back&spine 7. each extremity 1.constitutional 2.eyes 3.ENT 4.cardiovasc. 5.respiratory 6.GI 7.GU 8.musculo- skeletal 9.skin 10.neuro 11.psych 12.heme/lymph/ immuno

54. 2 OUT OF 3 TYPE OF DECISION MAKING NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS COMPLEXITY OF DATA OF TO BE REVIEWED RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY STRAIGHTFORWARD MINIMAL (1) MINIMAL (1) OR NONE MINIMAL (1 Minor problem) e.g. insect bite, cold LOW COMPLEXITY LIMITED (2) Limited (2) Low (Acute uncomplicated illness or injury) MODERATE COMPLEXITY MULTIPLE (3) (new problem or 3+ stable problems) MODERATE (3) MODERATE (prescriptions, acute illness w/syst symp, mild exac. chronic illnesses, undiagnosed new problem) HIGH COMPLEXITY EXTENSIVE (4) EXTENSIVE (4) HIGH ( severe exac. of chronic illness: threat to life or function: parenteral controlled substances

55. E/M TABLE OF RISK Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal one self-limited or minor problem, e.g., cold, insect bite, tinea corporis laboratory tests requiring: venipuncture chest x-rays EKG/EEG urinalysis ultrasound echocardiography KOH prep rest gargles elastic bandages superficial dressings Low two or more self-limited or minor problems one stable chronic illness, e.g., well controlled hypertension, non-insulin-dependent diabetes, cataract, BPH acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain physiologic tests not under stress, e.g., pulmonary function tests non-cardiovascular imaging studies with contrast, e.g., barium enema superficial needle biopsies clinical laboratory tests requiring arterial puncture skin biopsies over-the-counter drugs minor surgery with no identified risk factors physical therapy occupational therapy IV fluids without additives Moderate one or more chronic illnesses with mild exacerbation, progression, or side effects of treatment two or more stable chronic illnesses undiagnosed new problem with uncertain prognosis, e.g., lump in breast acute illness with systematic symptoms, e.g., pyelonephritis, pneumonitis, colitis acute complicated injury, e.g., head injury with brief loss of consciousness physiologic test under stress, e.g., cardiac stress test, fetal contraction stress test diagnostic endoscopies with no identified risk factors deep needle or incisional biopsy cardiovascular imaging studies with contrast and no identified risk factors e.g., arteriogram, cardiac catheterization obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdocentesis minor surgery with identified risk factors elective major surgery (open, percutaneous, endoscopic) with no identified risk factors prescription drug management therapeutic nuclear medicine IV fluids with additives closed treatment of fracture or dislocation without manipulation