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

2. What are the Issues? Inpatient MS-DRGs AP-DRGs SOI ROM Quality rankings Health Grades US News &WR CMS data Blue Cross

3. Outpatient Emergency Department Levels, procedure capture, medical necessity Ancillary services: lab, radiology, etc. Medical necessity Anesthesia/Pain Clinic Accurate coding

4. Professional Services Emergency Department Hospitalists Clinics Anesthesia/Pain

5. Audits RAC MIC BC Other payors

6. A physician who heals for nothing is worth nothing. - The Talmud

7. All Billing Depends on Documentation Documentation Coding Billing

8. Quality Measurement Documentation Coding Quality metrics Billing

9. Inpatient CDI

10. Hospitals with Clinical Documentation Improvement Program Report Increased Reimbursement... Mon Aug 11, 2008 8:30am EDT -(Business Wire)--J.A. Thomas and Associates, the leader in healthcare clinical documentation improvement, published today a set of benchmarking reports that show 188 hospitals using its Compliant Documentation

11. Management Program (CDMP(R)) have realized an overall 5 % improvement in CMI than projected by the Centers for Medicare and Medicaid Services/MEDPAR for hospitals adjusting to the new MS-DRG coding system. To download the full report, visit www.jathomas.com.

12. Inpatient Example 1 77 y/o pt admitted from N.H. with documented urosepsis, azotemia, and chronic sacral decubitus. Treated with IV antibiotics; seen by plastic surgeon, who leaves illegible note. Discharged after 8 days.

13. Principal dx: UTI, 599.0 Secondary dx: azotemia, 790.6; sacral decubitus 707.03 MS-DRG 690 Kidney and Urinary Infections without MCC Relative weight 0.7708 Payment $ 4600 ROM 2

14. Principal dx: UTI, 599.0 Secondary dx: azotemia, 790.6; sacral decubitus 707.03; stage III decub MS-DRG 689 Kidney and Urinary Infections with MCC Relative weight 1.2122 Payment $ 7300 ROM 3

15. Principal dx: Septicemia, 038.9, Secondary dx: sepsis, 995.91; azotemia, 790.6; sacral decubitus 707.03; stage III decub MS-DRG 871 Septicemia w/o MV 96h+ w/ MCC Relative weight 1.8437 Payment $11,000 ROM 3

16. Principal dx: Septicemia, 038.9, Secondary dx: sepsis, 995.91; AKI, 584.9 sacral decubitus 707.03; stage III decub Px: Excisional Debridement, 86.22 MS-DRG 853 Septicemia with MCC with procedure

17. Relative weight 5.4946 Payment $33,000 ROM 4

18. Hospitalist - Example 2 77 y/o pt admitted to the ICU with urosepsis. On hospital day 2, progress note documents, “Looks better. VS stable but rales 1/3 up. Will decrease IVF and give IV lasix. +BC for E Coli. Cr down to 1.8. Continue Rocephin. Check CXR.”

19. Documentation as is supports assignment of Level 1 subsequent care, 99231 RVU = 1.03 Payment = $37 Good documentation would support assignment of Critical Care, 99291 RVU = 5.88 Payment = $212

20. Radiology - Example 3 65 y/o sees his primary care physician with a persistent headache, one day after falling and striking his head. The only findings were tenderness of scalp. Because pt was on Plavix, a head CT was obtained.

21. Contusion of head, 920, was documented on record and requisition. Blue Cross denied payment due to lack of Medical Necessity. Head injury, 959.01, was documented on record and requisition. Blue Cross paid the claim.

22. In the midst of your illness you promise a goat, but when you have recovered, a chicken will seem sufficient. - African Proverb

23. Causes of poor inpatient documentation Lack of education Lack motivation Lack of structure for documentation Lack of uniformity of medical semantics Mismatch between language of clinical medicine and coding

24. Approaches to CDI Multiple targets Multiple methodologies No one silver bullet Detail driven Look at each category

25. Inpatient CDI Improve documentation to fully capture complexity by coding. Severity of Illness (SOI) Affects Case Mix Risk of Mortality (ROM) Quality measures

26. Organizational Issues Potential conflict between: Quality and Coding CDS and Coding Increased Staffing: CDI Coding staff

27. Inpatient - Example 3 65 y/o admitted for elective hemicolectomy. On post op day #1 post op patient has episode of atrial fibrillation which resolves with treatment. Pt had prior episode of a fib. 4 years before.

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

29. Principal dx: Colon Cancer, 153.6 Secondary dx: a. fib, 427.31; cardiac comp 997.1 Procedure: rt hemicolectomy, 45.73 MS-DRG 330 Major bowel surgery w/o cc/mcc Relative weight 2.8935 Payment $17,940 ROM 1

30. Inpatient - Example 4 69 y/o pt with widely metastatic breast CA is for management of pain due to new bony mets. CT of head showed 4 cm brain lesion in temporal lobe with vasogenic edema and effacement of sulci and compression of lateral ventricle. Neuro is consulted because of question of focal seizures. The pt is seen in consult and is started on anti seizure medication. During her stay the pt also received a Greenfield filter for recurrent DVT and contraindication to anti coagulation.

31. Principal dx: bone mets 198.5 Secondary dx: seizure, 345.50; brain met, 198.3; DVT, 453.40 Procedure: Vena Cava filter, 38.7 MS-DRGs 516 Other Musc/Skel proc with cc Relative weight 1.8083 Payment $11,400 ROM 3

32. Principal dx: bone mets 198.5 Secondary dx: seizure, 345.50; brain met, 198.3; DVT, 453.40; brain edema 348.5; compression brain, 348.4 Procedure: Vena Cava filter , 38.7 MS-DRG 515 Musc/Skel proc/ mcc Relative weight 3.0669 Payment $18 ,800 ROM 3

33. Inpatient - Example 5 65 y/o male was admitted for surgical resection of his pancreatic cancer. The patient had obstructive jaundice and CAT scan showed dilated biliary and pancreatic ducts. The patient had surgical resection with mild post op ileus and was discharged home after 7 days.

34. Principal dx: Pancreatic Cancer, 157.1 Secondary dx: post op ileus, 997.4; hypertension, 401.9; gout 274.9 Px: Radical Pancreatectomy, 57.2 MS-DRG 406 Pancreas procedures w cc Relative Wt. 2.6729 Payment $16,000 ROM 2

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_____________?

36. Principal dx: Pancreatic Cancer, 157.1 Secondary dx: post op ileus, 997.4; hypertension, 401.9; gout 274.9; obstruction of bile duct, 576.2 Px: Radical Pancreatectomy, 57.2 MS-DRG 405 Pancreas procedures w MCC Relative Wt. 5.5911 Payment $33,500 ROM 3

37. A physician is an angel when employed but a devil when one must pay him. - Latin Proverb

38. How to approach Inpt CDI Conventional approach: Hire RNs; train them in coding issues; educate physicians; concurrent chart review on floor; prompt physicians for documentation; communicate with coders Advantages: Dedicated staff to CDI Increase CMI

39. Disadvantages: High cost Staffing Lack of coding expertise New level of bureaucracy Reporting relationship with HIM Compliance Issues

40. Inpatient CDI Thorough Coding: Back end validation with robust physician query system Front end review and back end queries Adding focused reviews of documentation with ongoing feed back to medical staff

41. Inpatient CDI Separate but equally important issue of documentation for medical necessity

42. Impact of Documentation on E.D. Facility Coding and Billing Assignment of levels Procedure coding Diagnostic coding (Medical Necessity)

43. Assignment of E.D. levels "While awaiting the development of a national set of facility-specific codes and guidelines, we have advised hospitals …” 1. Levels should reasonably relate to intensity of services. 2. Levels should be consistently applied.

44. Assignment of E.D. levels Point systems Includes electronic records; documentation and coding can be problematic ACEP guidelines (2004/2007) Documentation is not an issue

45. E.D. Procedure Coding Documentation can be problematic Infusions and Injections Drug, dose, route of administration, time started, time stopped Splinting Explicit documentation of application

46. E.D. Facility Documentation Improvement Direct organizational issue Pressure VP Nursing Nurse Manager of E.D. E.D. Staff Nurses Ongoing monitoring

47. E.D. Diagnostic Coding Problematic diagnoses: ‘ Normal exam’ ‘ Medical Clearance’ Odd diagnoses

48. E.D. Diagnostic Coding

49. Professional Coding and Billing Evaluation and Management (E/M) E.D. Physicians Hospitalists Clinic Physicians

50. Physician documentation example 64 y/o male c/o chest pain for 2 days . Hx of CAD with prior CABG 2004 and repeat CABG in 2007. Pt had done well until two months ago pt underwent cardiac catheterization after episode of chest pain— Drug eluting stent was placed in circumflex artery. Pt last saw own doctor last week. Two elements of HPI: location and duration

51. Physician documentation example 64 y/o male c/o mild, dull, constant chest pain for 2 days , better after eating and associated with dyspnea . NTG helped slightly . Seven elements of HPI: location, quality, timing, duration, context, associated signs/symptoms, modifying factors.

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

56. Hospitalist Documentation Example Called to see 75 y/o woman admitted by PMD earlier today to ICU for pneumonia and COPD exacerbation. Patient has hx of severe COPD and was quite dyspneic on admission. Improved initially with Solumedrol, nebs but increasing dyspnea and confusion over last 20’. Pulse ox now 88. Meds-- Physical exam: fully documented

57. Labs, ABGs, repeat CXR done Pt placed on BiPAP, given pressors, diuretics, watched closely for 90 minutes. Consult or initial hospital visit 99252 to 99255, 99221-99223 Critical Care 99291, 99292

58. Documentation of Procedures Sutures Incision and Drainage Splinting Smoking cessation Central lines

59. Documentation for Pain Clinic Facet joint injections of spine Trigger point injections Procedures under Fluoroscopic guidance

60. Approach to CDI Identify all areas where improved documentation will have significant impact - inpatient coding - inpatient medical necessity - E.D. coding - Professional coding - Other services

61. Obtain Administrative Support Educate Physicians Effective Feedback Never stop monitoring

62. The doctor demands his fees whether he has killed the illness or the patient. - Polish Proverb