clinical documentation –why we care shelley l. oglesby, m.ed, rhit, ccs-p manager, coding &...
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Clinical Documentation –Why We Care
Shelley L. Oglesby, M.Ed, RHIT, CCS-P
Manager, Coding & Reimbursement
Nancy Ignatowicz RN, BS, MBA, CCDS Manager Clinical Documentation
July 24, 2013 Surgical Residents Orientation
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Significance of Documentation
Acuity / severity of illness
Risk of mortality, O:E Pt walks out alive, the hospital’s profile improves when comparing hospitals & outcomes.
QUALITY measures
Patient safety indicators
Physician profiles, research data & funding
Intensity of services provided => hospital receives the appropriate reimbursement.
Academically sound note writing.
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Why Care?
Proper documentation ensures appropriate severity of illness (SOI) and risk of mortality (ROM):
Substantiates Medical Necessity for Appropriateness of admission/continued stay Versus observation status or even outpatient
Truly reflects how complex your patient is, how ill they are, and how likely they are to die
It’s the right thing to do
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CDI
Clinical Documentation Improvement Team
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The role of the Clinical Documentation Specialist (CDS)
RN’s review the medical record concurrently to ensure treated diagnoses are documented with specific terminology so the coder can code the most appropriate codes for Severity of Illness (SOI) & Risk of Mortality (ROM)
Clarifications are asked when an additional or more specific diagnosis may be present but not documented in verbiage that can be coded
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The role of the Coder
Coder reviews the medical record post-discharge to assign the most appropriate ICD diagnosis(es) and procedure(s) codes to ensure accurate Severity of Illness (SOI) & Risk of Mortality (ROM) and appropriate MS-DRG assignment
Clarifications are asked when an additional or more specific diagnosis may be present but not documented in verbiage that can be coded
Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive 8
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Common opportunities for clarification
Records indicate
-..Post surgical anemia…
-..Hypotensive, requires vasopressors, tachycardia, multiple fluid boluses…
-..Intubated for airway protection…
-In PACU patient unresponsive, desat to 88% requiring reintubation…
Consider Documenting
Acute Surgical Blood Loss
Anemia
Shock and Type
Acute Respiratory Failure/
Acute Respiratory Distress
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How to Avoid a Clarification/Query
With EVERY DIAGNOSIS consider:
Etiology
Severity
Type
Present or evolving on admission (POA)
Clinical manifestations
Treatment
Pathology findings
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Valued Tips
1. Specify the diagnosis that best supports the principal reason for the inpatient admission to the hospital (condition established after study)
2. Use the following acceptable terms to describe uncertain diagnoses: Probable, suspected, likely, possible Avoid terms such as “concern for” or “VS”
Diagnoses should be based on a physicians clinical judgment.
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Valued Tips
3. Identify conditions/diagnoses that are present on admission (POA status)- present at the time the inpatient admission occurs, includes conditions that develop during an outpatient encounter (emergency room, observation, outpatient surgery) that result in an inpatient admission
Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive
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Valued Tips
4. List comorbid/complication diagnosis which are defined as: conditions that coexist at time of admission conditions that develop subsequently conditions that affect the treatment/care conditions that impact the length of stay Include chronic conditions such as hypertension, COPD etc
Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive
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Gaps in Documentation
UNABLE TO CODENa 130 -> fluid restriction
Dirty UA -> antibiotics
Post surgical anemia, will monitor/Blood loss-> PRBC
Elevated creatinine-> IVFs
LUL opacity -> Zosyn
Flash pulmonary edema
ACCEPTABLE TO CODEHyponatremia
UTI
Acute Blood loss anemia due to trauma/ruptured aneurysm
AKI or ARF
LUL bacterial pneumonia
Acute pulmonary edema
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Avoid the TERM POST-OP
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Gaps in Documentation
UNABLE TO CODE
Abdominal fluid
Dyspnea, SOB requiring BiPap/high flow O2 NC/intubation
Hypotension, vasopressors,
EBL,temp, tachycardia,
Tachypnea
ACCEPTABLE TO CODE
Abscess/ intraperitoneal abscess/peritonitis
Acute respiratory distress or acute respiratory failure
Consider shock and type
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Examples
Documentation of ALL secondary diagnoses present is how Severity of Illness (SOI) & Risk of Mortality (ROM) is captured
Do you think Loyola patients are sicker than patients in community hospitals??
Patients are only as critical / complex as their documentation indicates
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Inherent DiagnosesSigmoidectomy Sigmoidectomy
PDx: DiverticulitisSigmoidectomy
PDx: DiverticulitisSigmoidectomyPeritonitis present on
admission
RW LOS SOI ROM RW LOS SOI ROM
1.6361 5.0 1 1 5.2599 14.9 2 1
With post op Ileus
2.5731 8.6 2 1
If Acute Kidney Injury added If Acute Kidney Injury added
RW2.5731
LOS 8.6
SOI 2
ROM 2
RW5.2599
LOS 14.9
SOI 3
ROM 2
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Admitted with colon cancer
52 yo with esophageal cancer with left hemicolectomy
RW LOS SOI ROM
1.6361 5.0 2 1
Documented: Stage 3 colon cancer 1.6361 5.0 2 1
With confirmation of path findings for positive lymphadenectomy: lymph nodes positive for metastatic carcinoma
2.5731 8.6 2 2
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Admitted for Lumbar Spinal Fusion
63 yo with chronic back pain s/p lumbar/sacral fusion T10 to S1 EBL 1000cc
RW LOS SOI ROM
3.8783 3.6 1 1
Clinical: history of diastolic heart failure hold lasix
3.8783 3.6 2 2
Documented: overnight Pt hemodynamics unresponsive to fluid resuscitation requiring pressors
3.8783 3.6 2 2
With complete documentation: Overnight Pt hemodynamics unresponsive to fluid resuscitation requiring multiple pressors. Hypovolemic shock
6.5390 9.1 2 2
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Admitted for removal of renal mass/lesion
52 yo with enhancing lesion right kidney, suspicious for solid lesion
RW LOS SOI ROM
1.3335 2.9 2 1
Clinical: history of atrial fibrillation
1.3335 2.9 2 1
Documented: underwent right robotic assisted retroperitoneal partial nephrectomy without complication
1.3335 2.9 2 1
With complete documentation: Right renal cell carcinoma
1.4836 3.2 2 1
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Admitted with esophageal cancer
52 yo with esophageal cancer for surgical resection
RW LOS SOI ROM
5.6118 15.4 3 2
Documented: celiac lymphadenectomy also performed 5.6118 15.4 3 2
With confirmation of path findings for lymphadenectomy: celiac lymph nodes positive for metastatic carcinoma
5.6118 15.4 3 3
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QualityYour notes get better from an academic standpoint
Explains reason for admission/readmissionExplains mortalityLow SOI/ROM score could be explained from review of records showing failure to document comorbidities I.E. malnutrition, pre-op ileus, anxiety, obesity, Chronic systolic CHF, CKD stage 3, Acute blood loss anemia due to liver laceration from trauma, Shock, peritonitis, sepsis from pre-surgical rupture diverticulum, Respiratory failure from pulmonary fibrosis, toxic encephalopathy related to sepsis…
Present on admission (POA)Define if condition was POA, evolving on admission/natural progression of diseaseLINK symptoms to diagnosis determined after further diagnostics and evaluations
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Inpatient Medical Record
History & PhysicalWhy inpatient admission necessary
Reason for inpatient surgical admission
Include diagnoses in assessment plan not just PMH
Progress Notes & ConsultationsLink significance of findings/treatments (medications, diagnostics) to diagnoses
Discharge SummaryShould include all diagnoses addressed during this admission including chronic,resolved problems and any pathological findings(including post discharge)
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ICD-10
Lack of documentation is becoming a problem for acceptance.
Wieste Venema
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ICD-10- Prepare Now
For example, if a patient has a diagnosis of an abscess of bursa of the right shoulder, the appropriate code is M71.011 (abscess of bursa, right shoulder).
In ICD-9-CM, coders would report this condition with code 727.89 (disorder of synovium/tendon/bursa), which lacks site and laterality specificity.
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ICD-10- Prepare Now For 34 years, a closed, midcervical fracture of the femur has been coded as 820.02, using ICD-9,no other information needed
ICD-10-CM requires additional detail—Is it the right femur or the left femur? Is this an initial encounter or a subsequent encounter? Is the fracture healing nicely or delayed? ICD-10 has four codes and your documentation must note which femur, what type of encounter, and whether a complication exists.
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Take Away
Document Who
Document What
Document Why
Document How
Document When
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Contact Information
CDS – Michele E. Huguley RN (9)646-9235 [email protected]
CDS – Gail Klotz RN BSN (9)250-4108 [email protected]
Manager - Nancy Ignatowicz RN, BS, MBA, CCDS (9)646-9057 [email protected]
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Contact Information
Lead Coders – Anjie Marth x64559 [email protected]
Lead Coders –Pattie Hise x68542 [email protected]
Manager – Shelley L. Oglesby, M.Ed, RHIT,CCS-P x62132 [email protected]
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