Second‐Level Chart Reviews: Advanced Models for …...•02 Subsequent Documentation: Assign this code if the coder finds documentation in the record, subsequent to the reviewer's

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Second‐Level Chart Reviews: Advanced Models for Finding Chart Review Gems

Karen Elmore, RN, BSN, CCDSDocumentation Quality CoordinatorBJC HealthCareSt. Louis, MO

Julie Weiss, RN, CCDS, CCS, CRC Senior Manager Claro HealthcareChicago, IL

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Describe the benefits of second‐level chart (SLR) reviews – Identify effective SLR processes– Describe how to prioritize charts that might benefit from SLR reviews– Define clinical process workflows for SLR reviews


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Discussion Outline

I. Benefits of advanced CDI chart reviewsII. The BJC model

I. Selecting and training the second‐level review (SLR) teamII. PrioritizationIII. Collaboration with HIM/coding departments

III. Probing into the specificsIV. Clinical examplesV. Successes and hurdles


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Benefits of Advanced CDI Chart Reviews


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Expanding Beyond Reimbursement

• Healthcare is migrating away from fee‐for‐service (FFS) payment and toward a more blended payment for quality of services

• The accuracy of the medical record and looking beyond the capture of CCs and MCCs is of utmost importance, now more than ever

• Some benefits are:– Improved expected mortality – Quality ratings – Length of stay (LOS) and medical necessity backing– Denial avoidance – Accurate and appropriate risk adjustment (Value‐Based Purchasing, ACOs, etc.)


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The BJC Model: Process Considerations


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Selecting and Training the SLR Team

• Documentation quality coordinators (DQCs) and coding quality coordinators (CQCs)– Position requirements/job description – Key concepts of training – Process flow – Expanding the knowledge base of the frontline CDI staff– Ongoing growth, successes and hurdles


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Position Requirements/Job Description

• Documentation quality coordinator (DQC)– Perform post‐discharge reviews prior to final coding and billing of target case populations. Respond

to concurrent review requests from CDSs, provides guidance when CDSs and coders cannot reconcile DRG mismatches, approve the withdrawal of queries by coders, and escalate unanswered queries to physician champions. Analyze data and reports to identify trends and areas of opportunity and provide education to facility‐based CDSs and physicians based on this analysis.

– Responsibilities:• Performs post‐discharge, pre‐bill reviews of target case populations• Performs concurrent chart reviews for complex cases and presents to providers to demonstrate documentation opportunities

• Develops and promotes collaborative processes and strong working relationships• Analyzes regular reports and CDI metrics• Regularly reviews changing compliance standards and guidelines and helps to ensure CDSs are aware of and following new standards

• Performs other responsibilities as assigned


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Position Requirements/Job Description

• Coding quality coordinator (CQC)– Reviews records for accurate/complete code assignment and identifies patterns/trends for

educational opportunities – Responsibilities:

• Reviews physician documentation in discharged patient records relative to support of all code assignments, level of severity, and DRG or HCC

• Performs coding audits utilizing audit software by applying Official Guidelines for Coding and Reporting

• Identifies and reports patterns/trends for educational opportunities• Assists in the development of educational program materials • Participates on special projects in collaboration to support the BJC Strategic Priorities for Mortality and Patient Safety

• Performs other responsibilities as assigned


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DQC and CQC Position Highlights

DQC• Assisting with program development

– CDI leaders – Physician champions

• Mortality reviews• Assist with quality reviews• Assisting frontline CDS with:

– Low‐weighted DRGs– Mismatches with the coders– Lack of or minimal CC/MCC/HCC capture

• Query escalation• Review insurance denials • Manage/support assigned hospitals• Education of frontline CDSs• CQC/DQC huddles weekly• Serve on coding advisory from a clinical

standpoint

CQC• Work in collaboration with DQC:

– Coder/CDS mismatches– Insurance denials– DRG Prebill– Mortality reviews

• CQC/DQC huddles weekly• Coding questions mailbox• Release edits

– PSI– HAC– Billing changes

• Educate coding staff• Coding advisory


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Focus of Education for Frontline Staff

• Standardization of education– Decentralized

• Frontline CDS • CDI leaders

– Centralized • DQC• CDI director• CQC• Coding director

• Constant communication with the frontline CDS

CDI collaborative CDI education team

CDI query team CDI process and tech team

CDI analytics team Claro education

DQC mailbox Secure email to Claro Healthcare

Instant messaging Texting

DQC/CDS huddles Staff meetings


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Education of the Team

• Focused training on key concepts– Reinforce the basic foundational concepts

• UHDDS definitions of principal diagnosis and secondary diagnoses – Discussion of alternate principal diagnosis opportunities – Effective and compliant queries – Identifying opportunities: What and where – Medical necessity reviews– Surgical reviews– Risk adjustment methodology and mortality reviews– Diagnosis‐specific topics– Introduction into data analytics


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Prioritization of Cases for Review

• Consideration for DQC for workload prioritization – Clinical denial reviews have potential to be the highest priority if the time frame is critical for an

appeal – Pre‐bill cases receive highest priority as the bill is being held pending review

• Focus list of DRGs based on current metrics• Pending queries, including coding validation queries• Mortality reviews

– Cases requested by frontline CDI team, or identified by DQC as needing a second‐level review concurrently• Low‐weighted or symptom DRGs, as these are typically shorter LOS • Medical and surgical cases without a CC/MCC, especially if beyond the GMLOS• Unrelated DRGs• Quality focused (e.g., PSI, HAC) • Medical or surgical cases with just one CC/MCC, which can be subject to insurance denials


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Examples of Low Acuity, Mortality Cases, and Alternate PDx Consideration DRGs

193 SIMPLE PNEUMONIA & PLEURISY W/MCC (3+ Days LOS)

871 SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC (0‐2 Days LOS)

392 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC (3+ Days LOS)

189 PULMONARY EDEMA & RESPIRATORY FAILURE (0‐2 Days LOS)

981/982/983; 987/988/989 O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

640 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC (3+ Days LOS)

641 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC (3+ Days LOS)

194 SIMPLE PNEUMONIA & PLEURISY W/CC (3+ Days LOS)

872 SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC (0‐2 Days LOS)

638 DIABETES W CC (3+ Days LOS)

391 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/ MCC (3+ Days LOS)

552 MEDICAL BACK PROBLEMS W/O MCC (3+ Days LOS)

637 DIABETES W MCC (3+ Days LOS)

202 BRONCHITIS & ASTHMA W CC/MCC (3+ Days LOS)

312 SYNCOPE & COLLAPSE (3+ Days LOS)

948 SIGNS & SYMPTOMS W/O MCC (3+ Days LOS)

195 SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC (3+ Days LOS)

551 MEDICAL BACK PROBLEMS W MCC (3+ Days LOS)

69 TRANSIENT ISCHEMIA W/O THROMBOLYTIC (3+ Days LOS)


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Collaboration With HIM and Coding Staff

• Process flow chart example• CDI/coding oversight committee purpose• Coding advisory with DQC involvement


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Process Flow Chart: Patients Discharged

Patient discharged No concurrent review performed

Concurrent review

performed

1) Coder reviews CDS documentation if concurrently reviewed

2) Coder codes record utilizing CDS review activity, if applicable

Case qualifies for SLR, coder sends it to the DQC

Case does not qualify for SLR, final code

SLR requested, DQC reviews and notifies coder and CDS of findings If query placed during a SLR and no response after two business days, DQC begins escalation process

Working/final DRG match

DRG mismatch

Mismatch between coder and CDS DQC and/or CQC follows up with CDS or coder If DQC and CQC cannot reconcile mismatch, case is escalated to coding or CDI manager

Query is maintained until answered or directed by DQC/physician champion

Unanswered pending query from CDS

Enterprise Second‐Level Reviews

Coder references “When to Request Second‐Level Review” to determine if case

qualifies for second‐level reviewRecommended Reconciliation Reason Codes•01 Optimal Selection: Indicates that one of the viable working DRGs and the final DRG match; coder and reviewer agree on appropriately selected DRG•02 Subsequent Documentation: Assign this code if the coder finds documentation in the record, subsequent to the reviewer's last review, that changes the DRG offered to a different final DRG•04 Coding Guidelines: Assign this code if the reviewer assigns a DRG that has a coding rule/directive that does not allow the diagnosis to be used as a principal diagnosis•05 Educational Opportunity: Assign this code if the working DRG assignment is not appropriate or is inconsistent with the clinical picture/treatment leading to an educational opportunity (i.e., reason for admission)•06 Retrospective Query by Coder: Assign this code if the DRG assignment changed based on a retrospective query•07 Second‐Level Review by Reviewer: Assign this code if a second‐level review changed the DRG assignment


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CDI/Coding Oversight Committee Purpose

• Create a CDI/coding oversight forum for shared governance and communication. Create a governance structure and approval process for policies, system standards, and best practices. Improve the ability for the coding and CDI teams to manage changes to integrated processes, as changes are being introduced. Members include coding leadership and CDI leadership.


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Coding Advisory Purpose

• Address the gray areas in coding where BJC determines a “stand” on an issue. Submit to 3M Nosology (non‐authoritative source) and AHA Coding Clinic (authoritative source) to assist with decision‐making. Members include coding leadership, second‐level auditors, coding coordinators (CQC), corporate compliance leaders, and clinical subject matter experts (DQC).


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Probing Into the Specifics


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Targeted Reviews

• Assignment of the PDx: – Attempt to ensure the most accurate PDx is chosen, especially with symptom DRGs and low‐weighted DRGs when appropriate

– Linking symptoms on admission to the underlying etiology will help identify a more appropriate PDx

– Records with a status change may need a query to clarify the condition that warranted the IP admission

• Secondary Diagnoses – These are the conditions that provide the CCs/MCCs and/or may be severity drivers for our records. They also serve to more accurately portray the acuity of our patients. – Some patients have an MCC when they hit the door, such as ESRD. In these cases, if the PDx is accurate, review of this chart may now be a lower priority.


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Targeted Reviews: Secondary Conditions

• When we are looking for secondary conditions, we can focus on the following systems/conditions, and the areas in the chart most likely to provide the necessary clinical indicators:– Respiratory– Cardiac– Neuro– Renal– Nutritional– Infectious

• We often see vague or nonspecific documentation in the record, which can clue the reviewer into the need for additional clinical indicators and a query for further clarification


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Targeted Reviews

• Respiratory– Review flow sheets for O2 administration,

amounts, trends, as well as respiratory rate– Review orders for respiratory medications – Review MAR to determine frequency of

PRN meds such as DuoNeb®, etc.– Review details of any pulmonary consults

• Cardiac– Review orders for cardiac medications – Review MAR for PRN medications– Review details of any cardiac consults– Review diagnostics such as EKG, echo, CXR,

etc.

• Neuro– Review details of any neurology consults– Review orders for restraints, sitters, PRN

anxiolytics, mannitol, etc.– Review MAR for frequency of PRN

medications, such as anxiolytics• Renal

– Review details of any renal consults– Review for baseline creatinine if available

and compare to current values and trends– Review orders for IV bolus – amounts and

frequencies, for changes in medications– Review MAR for frequency of any PRN meds


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Targeted Reviews

• Nutritional– Review admission assessment for height, weight, BMI, any identified areas of concern regarding appetite,

weight loss, etc.– Review ED records, H&P, PN, etc. for documentation such as “thin,” “frail,” “cachectic,” “poor appetite,”

“recent weight loss,” “prolonged N/V,” etc., which may indicate a nutritional concern– Review orders for dietary evaluation, calorie counts, nutritional supplements, NPO status, change in diet

orders, etc.– Review details of any dietary evaluations– Review nursing flow sheet for meal intake– Review progress notes and/or orders to see if diet is advancing as would be expected following admission

and/or a procedure• Infectious

– Review flow sheet for vital signs– Review ED notes, H&P, PN, etc. for any reference to an infectious diagnosis, or symptoms suggesting

infection such as “dysuria,” “area is warm and red,” “fluid is cloudy/murky/malodorous/purulent”– Review orders for cultures, antibiotics, etc.; note any change in orders for antibiotic therapy– Review results of all lab and diagnostic reports, such as C&S of any site, U/A, pathology reports, x‐ray, CT,

MRI, US, etc.2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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What to Look for When Performing a Review

• Clinical indicators that may indicate conditions not yet documented. These indicators may include:– Signs, symptoms– Abnormal labs or diagnostic studies– Additional monitoring or tests being ordered– Orders for treatments without corresponding diagnoses

• Discrepancies between providers• Ambiguous terms, conflicting documentation, or nonspecific terms• Documented conditions

– The presence, or absence, of clinical indicators to support conditions such as sepsis or respiratory failure. These conditions are often documented without clinical support in the record. In these situations, a “validation/confirmation” query may be needed.


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Where to Extract Information From the Medical Record

• A common trap that a CDS may fall into when reviewing a record is to first look at what the physician has already documented in the progress notes.

• The CDS/DQC should use their critical thinking skills to determine what they think is clinically occurring with the patient based on the following documentation:– Point of entry: ED notes, H&P, consults, preop notes, anesthesia notes, orders– All labs/tests/x‐rays and other diagnostics to determine if corresponding diagnoses are

documented by the physician in the medical record– Nurses’ notes, telemetry strips– Ancillary notes including nutrition, wound care, PT/OT, speech therapy, respiratory therapy,

etc.• After review of the above, the CDS/DQC would look at the progress notes to see

if the physician has adequately documented what is clinically presented. This is where potential gaps are identified and query opportunities arise.


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Case Scenario #1


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Mortality Example #1

• PMH: OSA, CVA, HTN, CAD.• 81‐year‐old male admitted s/p cardiac arrest. Found slumped over in his chair

by his spouse. EMS found patient to be in V‐fib, O2 sat 64% with no spontaneous respirations and cyanotic, initiated ACLS protocol. After defibrillation, the patient’s rhythm was restored to SR. The patient was intubated in route and placed on a ventilator in ED. He was then sent to the ICU.

• History and physical: – Cardiac arrest, hypoxia, acute renal failure and lactic acidosis

• Consult:– Acute hypoxic respiratory failure, shock liver, comatose

• Patient expired during the night on the day of admission.


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Mortality Example #1 (cont.)

• CDS and coder arrived at DRG 308 – Cardiac Arrhythmia and Conduction Disorders w/ MCC.– RW: 1.2046– GMLOS: 3.8– Mortality rate: 4.55%– SOI/ROM: 3/3

• The case was sent to the DQC as a result of their pre‐determined mortality criteria.• The recommendation was made by the DQC staff to re‐sequence the principal diagnosis to

acute respiratory failure. This condition was also POA and meets the definition of principal diagnosis.

• The final DRG was 208 – Respiratory System Diagnosis with Ventilator Support <=96 hours.– RW: 2.3101– GMLOS: 4.9– Mortality rate: 25.51%– SOI/ROM: 4/4


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Case Scenario #2


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Mortality Example #2

• PMH: Systolic CHF, malnutrition, stage 2 pressure injury. • 70‐year‐old male admitted with aspiration pneumonia, acute hypoxic respiratory failure

resulting in cardiac arrest, anoxic brain damage, and acute‐on‐chronic systolic CHF. WBC 6.8 on admission increasing to 15 in less than 6 hours with neutrophils increasing from 35% to 87%. Lactic acid 4.2 increasing to > 13. Temp 96.4 axillary, HR 111, RR 26.

• ED provider note:– Possible sepsis

• History and physical:– Aspiration pneumonia – Acute hypoxic respiratory failure– Acute‐on‐chronic systolic CHF– Cardiac arrest– Anoxic brain damage

• Dietary note:– Severe protein‐calorie malnutrition


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Mortality Example #2 (cont.)

• CDS and coder arrived at DRG 207 – Respiratory System Diagnosis with Ventilator >= 96 hours.– RW: 5.4864– GMLOS: 12.2 days– Mortality rate: 28.77%– SOI/ROM: 4/4

• The case was sent to the DQC as a result of their pre‐determined mortality criteria.• The recommendation was made by the DQC staff to query the provider for sepsis, which

would re‐sequence the principal diagnosis to Septicemia or Severe Sepsis with Ventilator >96 hours. DQC also queried for severe protein‐calorie malnutrition. These conditions were also POA and meet the definition of principal diagnosis.

• The final DRG was 870 – Septicemia or Severe Sepsis with Ventilator Support >96 hours.– RW: 6.0907– GMLOS: 12.5 days– Mortality rate: 35.55%– SOI/ROM: 4/4


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Case Scenario #3


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CDS Coder Mismatch Example

• PMH: COPD, CAD, Type 2 DM, past history of smoking• History: 60‐year‐old male admitted for CABG d/t atherosclerotic heart disease of a native

coronary artery with unstable angina. BMI 32. Dyspnea on exertion. PFTs WNL preop. EF 45%–50%.

• Postop course:– POD 1 extubated to 4L/nc. CXR small bilateral pleural effusions. Sat and RR WNL.– POD 2 O2 increased to 10L/nc then BiPAP x2 days. O2 saturations 85%–94%. RR 20–30. CXR lower lung

volumes and bibasilar atelectasis.– POD 4 O2 6L/nc. Attempted to wean and sats decreased to the upper 80s at rest then mid 80s with

exertion.– POD 5 remains in the hospital on 2L/nc. – POD 8 dc’d to home with supplemental O2.

• CDS queried for acute pulmonary insufficiency and provider answered acute pulmonary insufficiency d/t pre‐existing COPD.

• The coder did not want to capture the code for acute pulmonary insufficiency J95.1 acute pulmonary insufficiency following a thoracic surgery because it was a complication code.


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CDS Coder Mismatch Example (cont.)

• CDS arrived at DRG 233 – Coronary Bypass with Cardiac Catheterization with MCC.– RW: 7.3437– GMLOS: 11.5 days– Mortality rate: 4.47%– SOI/ROM: 3/3

• Coder arrived at DRG 234 – Coronary Bypass with Cardiac Catheterization without MCC.– RW: 5.8397– GMLOS: 7.7 days– Mortality rate: 0.50%– SOI/ROM: 2/2

• The case was sent to the DQC as a result of the mismatch.• The recommendation was made by the DQC to capture the J95.1 acute pulmonary insufficiency following surgery

as it is not a complication. Following thoracic surgery means occurring after surgery but not due to the surgical procedure, therefore not a complication.

• DQC arrived at DRG 233 – Coronary Bypass with Cardiac Catheterization with MCC.– RW: 7.3437– GMLOS: 11.5 days– Mortality rate: 4.47%– SOI/ROM: 3/3


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Case Scenario #4


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Pre‐Bill DRG 312

• PMH: Type 2 DM, hyperlipidemia, OSA with CPAP at night. Osteoarthritis, CAD, chronic systolic CHF.• 70‐year‐old male admitted with severe dizziness ongoing for 3 days. Admission bun/creat 54/2.2, GFR

37, blood glucose 158, UA clarity turbid with 6–10 hyaline casts & 11–20 RBC, BP on admission 115/72, BP range during stay 89/43–135/57.

• ED provider note:– Syncope– Acute cystitis with hematuria

• History & physical:– Orthostatic hypotension; will hold BP med (Hyzaar®)– Dizziness– Acute renal failure secondary to ATN superimposed on stage 2 CKD– Cystitis with hematuria – Chronic systolic CHF

• Day two BUN/creat 48/1.74.• Day three BUN/creat 37/1.21.


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Pre‐Bill DRG 312 (cont.)

• Documentation by provider on consecutive days and in DC summary.– Dizziness d/t orthostatic hypotension– Acute on chronic renal failure, underlying stage 2 CKD

• Actual LOS 3 days.• CDS and coder arrived at DRG 312 – Syncope and Collapse.

– RW: 0.8015– GMLOS: 2.4– Mortality rate: 0.31%– SOI/ROM: 3/3

• Due to the DRG this record went to a pre‐bill DRG work queue to be reviewed by the DQC.

• After review by the DQC it was recognized acute‐on‐chronic renal failure fit the definition of principal diagnosis. We were treating the diagnosis with IVF and serial labs.


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Pre‐Bill DRG 312 (cont.)

• DQC DRG 683 – Renal Failure with a CC.• Record sent to the CQC for a review. CQC and DQC agreed on DRG reassignment.

• DRG 683 – Renal Failure with a CC.– RW: 0.9293– GMLOS: 3.3 days– Mortality rate: 0.96%– SOI/ROM: 2/2


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Successes and Hurdles


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Successes and Hurdles

Successes• Standardizing processes throughout the

system• Increased physician education through

physician champion buy‐in• Focus on quality

– O/E ratio improvement

• Supportive director• Collaboration with Claro Healthcare in

education and reports• Work remote

Hurdles• Silos• Buy‐in

– CDS– CDI leaders– Physicians/providers– Physician champion– HIM

• Physician/provider accountability• Work remote

– Separation of home and work life


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Thank you. Questions?

[email protected]@clarohealthcare.com

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Second‐Level Chart Reviews: Advanced Models for …...•02 Subsequent Documentation: Assign this code if the coder finds documentation in the record, subsequent to the reviewer's