ICD-10 Based Physician Queries and Notes

Donna BarnardURMC

The Magic Bullet

I Don’t Have One!!

Important Background Info• EMR fully functional

• HIM and UM reporting to same person

• CDI and LOC done concurrently by UM

• HIM doing some concurrent coding (both for high query accts and high $ accts)

Important Background Info (cont)

• HIM doing retrospective coding• HIM asking UM further questions

(database) and UM working before dropping bill

• UM/HIM analytic staff member (UM/DRG/ coding knowledge)

Do you have a CDI Analyst?ACDIS Poll

• –45% Yes• –7% Yes, but shared with HIM and

coding• –3% No, but considering hiring in 2014• –3% Don’t know• –42% No

How we started….• Know your data/find your analytic• Work with Finance/Data Vendor

/Providers• What are your key clinical services• Review current data to know top DRGs

(MS and APR) • What diagnoses are part of your data• What diagnoses affect your DRGs

What is your hook?

• What is your grab for your providers’ involvement

• Find your champions

• Communicate/Communicate/Communicate

Some of our hooks….

• Our population is sicker. Is it? Prove it!!• Chiefs’ reports (internal finance reports)• Readmission issues• HACs/PSIs/Core Measures• UHC comparative data

Ok…..BREATHE for a minute…..

Tools of documentation

• Smart notes• Smart lists• Concurrent query• Retrospective query• Documentation guidelines• UM/HIM database (communication tool)

Heart Failure Smart NotePLEASE COMPLETE THE FOLLOWING UM QUERY. REVIEW EACH SECTION AND ENTER THE APPROPRIATE DIAGNOSIS Admission Date: 5/22/2014

It was present on admission: {Diagnosis Present on Admission: Yes/No Ejection/Fraction (EF) Date of result: 04/03/2014 1:00 PM Impression: LVEF = 30% Chest X-ray Results Date of result: 5/22/2014 8:55 AM Impression: CHF with pleural effusions Medications Medication Dose Route Frequency

• spironolactone (ALDACTONE) tablet 25 mg

25 mg Oral Daily

• furosemide (LASIX) injection 60 mg

60 mg Intravenous BID

BNP Lab results: 05/22/14

1147 NT-pro BNP 4915*

Heart Failure Smart List

HF Concurrent QueryUtilization Management Cardiovascular Query Form

This form is a permanent part of the patient's medical record. _____________________________________________________________________ A. Utilization Management Query & Provider Response: UM Nurse: Jane Doe Nurse Pager #: 5555 Query Date: 5/22/2014 UM QUERY: The following clinical information is documented in the patient's medical record. Please review the clinical indicators and clarify the patient's diagnosis. 04/03/2014 EF 30%, 5/22/2014 Chest X-ray results: CHF with pleural effusions, Lasix 60 mg IV administered twice a day, 5/22 BNP 4915 Provider Response to Query: In your professional judgment, does this information indicate to you that the patient has a diagnosis of acute systolic heart failure? [{X:20130}] Yes, I agree that this is the patient's diagnosis _____________________________________________________________________ B. Alternative Diagnosis Response: [{X:20130}] No, the information indicates that the patient has the diagnosis specified below. Shock {UM - CV - SHOCK:19678}

Heart Failure {UM - CV - HEART FAILURE:19683}

Arrythmias {UM - CV - ARRHYTHMIAS:19757}

Acute MI {UM - CV - ACUTE MI:19758}

Angina {UM - CV - ANGINA:19759}

Hypertension {UM - CV - HYPERTENSION:19760}

Deep Vein Thrombosis {UM - CV - DVT:19761}

Pulmonary Embolism {UM - CV - PULMONARY EMBOLISM:19762}

Cardiomyopathy {UM - CV - CARDIOMYOPATHY:19763}

C. No Change Response: [{X:20130}] No clarification or change needed in the documentation.

HF Retrospective QueryUtilization Management

DATE: 5/22/2014

Re: Retrospective Query

Dear Dr. Clarification ,

To establish a diagnosis which most accurately reflects your patient’s Severity of Illness, Risk of Mortality and possible Complications, please clarify the following clinical documentation queries. An eRecord addendum may need to be added to the progress note section of the patient hospit al visit in order to provide documented clarification. The fact that a query is asked does not imply that any particular answer is desired or expected.

MR Number

Pt Name Admit Date Diagnosis/ Possible Complication Query

555555 John Doe 5/22/2014 • 04/03/2014 EF 30%• 5/22/2014 Chest X-ray results: CHF with pleural effusions• 5/22/2014 Lasix 60 mg IV administered twice a day• 5/22/2014 BNP 4915

Based on the above and in your professional judgment, did the patient have acute systolic heart failure, acute on chronic systolic heart failure, or another diagnosis ?

Please feel free to page me for any questions or assistance needed.

Thank you,

Jane SmithPager 5555

HF Documentation GuidelinesDOCUMENTATION CLARIFICATION

HEART FAILURE SERVICE DOCUMENTATION GUIDELINES

Cardiogenic ShockLiver ShockAcute Systolic Heart FailureAcute Diastolic Heart FailureAcute Systolic and Diastolic Heart FailureAcute on Chronic Systolic Heart FailureAcute on Chronic Diastolic Heart FailureAcute on Chronic Systolic and Diastolic Heart FailureAcute Pulmonary EdemaPrimary Cardiomyopathy Acute Cor PulmonalePrimary Pulmonary HypertensionChronic Pulmonary Heart Disease Pleural EffusionAcute Tubular NecrosisSepsisSevere SepsisAwaiting Organ Transplant Status

Database Tool(handout)

UM - HIM DATABASE INCLUSIONS ** All white boxes require RR (Ruth Yeomans) Final Review if criteria not met

Target DRG's -SOI Review 1-3

001 Liver Transplant

003 Bone Marrow Transplant *UM RN can close Auto at SOI 3 or 4004 Tracheostomy w/ long term mechanical ventilation w/ extensive procedure005 Tracheostomy w/ long term mechanical ventilation w/o extensive procedure006 Pancreas Transplant021 Craniotomy Exc for Trauma090 Major Larynx & Trachea Procedures091 Other Major Head & Neck Procedures160 Major Cardiothoracic Repair of Heart Anomaly161 Cardiac defibrillator & heart assist implant162 Cardiac valve procedures w/cardiac catheterization163 Cardiac valve procedures w/o cardiac catheterization 165 Coronary bypass w/cardiac cath or percutaneous cardiac procedure 166 Coronary bypass w/o cardiac cath or percutaneous cardiac procedure173 Other vascular procedures 191 Cardiac catheterization w circ disord exc ischemic heart disease SOI 1 & 2--only 734194 Heart failure SOI 1 & 2--only 734310 Intervertebral disc excision & decompression SOI 1-3: Pediatric cases by Dr. Saunders440 Kidney Transplant690 Acute Leukemia842 Full thickness burn w/ skin graft SOI 1 and 2

Analyze the work you do!

Analysis of Database for one month

Discharged Unit Total Cases

Cases w DRG RW Increased

% Cases w DRG RW Increased Diagnoses Recommended to Review Unit & Inclusion Criteria

100 1 1 100 Cellulitis No

200 4 2 50Pleural effusion, hypocalcemia, hypophosphatemia No

300 14 6 43 Acute respiratory insufficiency following surgery No

400 10 4 40 Alcohol withdrawal, extensive lysis of adhesions, hypokalemia, hypocalcemia, laceration No

500 6 2 33 Acute respiratory insufficiency following surgery No

600 6 2 33 Sepsis No

700 34 9 29Blood in stool, sepsis, protein calorie malnutrition, acute respiratory insufficiency following surgery, hypocalcemia, morbid obesity, hypomagnesemia No

800 4 1 25 Aphasia No

900 33 6 18Acute respiratory failure in newborn, congenital pneumonia, respiratory acidosis, transitory ileus of the newborn Yes

910 6 1 17 Moderate Malnutrition, hypokalemia, hypomagnesia, and hypophosphatemia Yes

920 8 1 13 Pleural effusions, hypocalcemia, hypomagnesemia Yes

930 1 0 0 Yes

940 6 0 0 Yes960 1 0 0 Yes

960 6 0 0 Yes

970 4 0 0 Yes

980 1 0 0 Yes

990 2 0 0 Yes

110 2 0 0 Yes

120 4 0 0 Yes

130 6 0 0 Yes

160 35 22

Colorectal APR-DRG Analysis

Pediatric CMI

0.90

0.710.76

0.90

0.83

0.90

0.99

1.14

0.00

0.20

0.40

0.60

0.80

1.00

1.20

2013 July 2013 August 2013 September

2013 October 2013 November

2013 December

2014 January 2014 February

CMI

416

Keep working on data• Grouper changes

• Classification changes (I-9 to I-10)??

• Hospital service changes

• New technology

APR Grouper 29 to 30 ChangesTRENDS OF INCREASE SOI TRENDS OF DECREASE SOI

Heart Transplant Heart Transplant• Sepsis • Thrombocytopenia• ATNKidney Transplant Kidney Transplant• AKI • Acidosis• Sepsis • ThrombocytopeniaNICU NICU• BPD (Broncho pulmonary dysplasia) • Sepsis• Neonatal neutropenia • Hydronephrosis• Acute pulmonary edemaHematology/Oncology Hematology/Oncology• ATN • AKI• Cerebral edema • Idiopathic Peripheral Neuropathy NOS• Other Secondary Thrombocytopenia • HypopotassemiaCardiac Surgery Cardiac Surgery• Pleural effusion • Congenital Insufficiency of Aortic Valve• AKI • Osteum Secundum Type Atrial• Acute respiratory insufficiency following surgery • Type II Controlled• Thrombocytopenia • AKI• Acute (specificity) Heart FailureCardiology Cardiology• Hypophosphatemia • Paroxysmal Ventricular Tachycardia

• Chronic Pulmonary Heart Disease• Thrombocytopenia• Hypopotassemia• CHF• ESRD• AKI• Chronic Diastolic Heart Failure

Key I-9 to I-10 Codes for us!

ICD 9 Diagnosis/Terminology ICD 9 Code ICD 10 Diagnosis/Terminology ICD 10 CodeEncephalopathy

***ICD 10 no code for hepatic encephalopathy--ICD 10 code hepatic failure with coma ***ICD 10 no code for alcoholic encephalopathy--ICD 10 code alcohol dependence with alcohol induced persisting dementia

Encephalopathy acute 348.3

G9340 Encephalopahty, unspecified G9340

Encephalopathy,metabolic 348.31 G9341 Metabolic encephalopathy G9341Other encephalopathy 348.39 G9349 Other encephalopathy G9349Encephalopathy, toxic 349.82 G92 Toxic encephalopathy G92

Heart Failure ***no noted change

Acute systolic heart failure 428.21

I5021 Acute systolic (congestive) heart failure I5021

Chronic systolic heart failure 428.22 I5022 Chronic systolic (congestive) heart failure I5022 Acute on chronic systolic heart failure 428.23 I5023 Acute on chronic systolic (congestive) heart failure I5023 Acute diastolic heart failure 428.31 I5031 Acute diastolic (congestive) heart failure I5031 Chronic diastolic heart failure 428.32 I5032 Chronic diastolic (congestive) heart failure I5032 Acute combined systolic and diastolic heart failure 428.41 I5041 Acute combines sytolic (congestive) and diastolic (congestive) heart failure I5041 Chronic combined systolic and diastolic heart failure 428.42 I5042 Chronic combines systolic (congestive) and diastolic (congestive) heart failure I5042 Acute on chronic combined systolic and diastolic heart failure 428.43 I5043 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I5043 CHF 428.0 I509 Heart failure, unspecified I509

Pneumonia ***no noted changeAspiration pneumonia 507.0 J690 Pneumonitis due to inhalation of food and vomit J690Bacterial pneumonia 482.9 J159 Unspecified bacterial pneumonia J159Pneumonia 486 J189 Pneumonia, unspecified organism J189Pneumonia, Viral 480.9 J129 Viral pneumonia, unspecified J129

Pneumonia with Flu 487.0J1100 Influenza due to unidentified influenza virus with unspecified type of pneumonia, J189 Pneumonia, unspecified organism J1100 J189

Sepsis ***no noted changeSepsis 038.9 A419 Sepsis, unspecified organism A41.9Sepsis Secondary to UTI 038.9, 599.0 A419 Sepsis, unspecified organism N390 Urinary tract infection, site not specified A419 N390Septicemia 038.9 A419 Sepsis, unspecified organism A41.9Septicemia due to anaerobes .038.3 A414 Sepsis due to anaerobes A414Septicemia due to enterococcus .038.8 A4181 Sepsis due to enterococcus A4181Septicemia due to methicillin resistant staphylococcus aureus .038.12 A4102 Sepsis due to Methicillin reistant Staphylococcus aureus A4102Septicemia due to staphylococcus .038.1 A412 Sepsis due to unspecified staphylococcus A412Septicemia due to staphylococcus aureus .038.11 A4101 Sepsis due to Methicillin susceptible Staphylococcus aureus A4101Septicemia due to streptococcus pneumonia .038.2 A403 Sepsis due to Streptococcus pneumonia A403

CDI Circle of Life

ICD-10 isn’t a coding problem...

It’s a documentation problem.