Clinical Documentation Improvement

Clinical Documentation Improvement (CDI) 2008 The Importance of Documentation Old adage: “If it isn’t documented, you didn’t do it” Philosophy: Write “something” in the medical record Motivation: avoiding malpractice/legal issues The Importance of Documentation Today’s reality: Documentation requires specificity Greater focus on quality of documentation Represents the quality of healthcare Reimbursement implications individual provider hospital CMS and JCAHO’s View Physicians are expected to provide legible, complete, clear, consistent, precise and reliable documentation of . . . Health history POA Present illness Pdx, MCC/CC, SOI Course of treatment Suspected dx, abnormal tests, etc This View Includes: Observations Manifestations/symptoms Underlying pathologies/etiology Physiological consequences of abnormalities Affects on other body systems This View Includes: Evidence of medical-decision-making in determining a diagnosis Documentation of “probable”, “suspected”, “likely”, “questionable”, “possible” & “ruled out” diagnoses Not applicable to outpatient services! Treatment plan Rationale Outcomes/clinical significance Legible Documentation Decipherable by clinical experts If 3 experts can’t decipher then not legible Only use approved/standardized abbreviations Be conscience of local slang variability Complete Documentation Rational for all tests, medications and/or procedures Indicated the suspected dx Interpretation of tests Clinical significance of abnormal tests Verification of suspected dx Elimination of suspected dx Clear Documentation Requires more than a diagnosis/term Describe its manifestation/presentation Describe underlying pathology/etiology Describe its consequences/results on the body WAS IT PRESENT ON ADMISSION? Consistent Documentation Review & explicitly state you concur with the findings and/or dx of other clinicians OR state your own conclusions from their findings Specialist/Consults Nurse Practitioners Nutritionist assessment Radiologist’s impression Wound nurse’s assessment (POA) Precise Documentation Be as specific as possible when assigning a dx Avoid NOS/NEC and/or generic dx  CHF, chest pain, chronic kidney disease Anatomical description  Location and staging of decubitus ulcers  Diastolic vs. systolic vs. right sided heart failure Acute vs. chronic vs. acute on chronic Use current terminology  accelerated HTN (new) vs. hypertensive urgency (old) Who Reads Your Documentation? For the purpose of national quality measures and reimbursement, documentation is not read . . . Inpatient medical services are translated into codes based exclusively on the strength of the attending physician’s documentation Coding Guidelines Established by the Department of Health and Human Services (DHHS) Centers for Medicare/Medicaid Services (CMS) National Center for Health Statistics (NCHS) provide guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Coding Guidelines These guidelines have been approved by: CMS NCHS American Hospital Association (AHA) American Health Information Management Association (AHIMA), Coding Guidelines Coders translate physician documentation into the principal dx: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” Differentiating the Pdx from “other” a.k.a. secondary diagnoses UHDDS Definition of Other Diagnoses “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” Other Diagnoses Affect patient care in terms of requiring: clinical evaluation therapeutic treatment Continuation of home medications diagnostic procedures extended length of hospital stay increased nursing care and/or monitoring. Inpatient Coding Limitations Relies on quality documentation Can’t assume physician’s intent K+ = hyperkalemia Can’t use information not explicitly documented by attending physician Radiologist’s findings Bridging the Gap MUSC is one of a growing number of hospitals to implement a Clinical Documentation Improvement Program (CDI). What is CDI? RNs who work collaboratively with physicians and coders to bridge the gap between the data contained in the medical record i.e., test results, nurses notes, consultant notes, etc., and what is available for coding. Clinical Documentation Improvement Automatically review DRG payers i.e., Medicare, Medicaid, Tricare, and BC/BS following 2nd day of inpatient admission Concurrent review Review records referred by coders Retroactive review Clinical Documentation Improvement Selectively read inpatient medical records for completeness, clarity, consistency and precision regarding applicable diagnoses severity of illness (SOI) conditions present on admission (POA) Clinical Documentation Improvement Ask for clarification from the physician through use of a query process . . . a routine communication and educational method to advocate proper medical record documentation. Queries As with direct patient care, the CDI RN presents relevant data to the physician for review We do not evaluate the “quality of care” Our focus is ensuring the documentation reflects the data in the medical record There are no deficiencies associated with a query Concurrent Queries Resolved in person/text page when possible A standardized 5x7 form specifying the nature of the query may be placed in the progress notes section of the chart A text page and/or e-mail may also be used to notify the physician of its presence Retroactive Queries (discharged patients) Simple issues may be addressed by phone, text page or e-mail Complex issues are typically handled via e-mail with a text page to notify of the pending query Response to a Queries Our goal is a response time of < 24 hours A response should be made to all queries Revise documentation to reflect queried issue Addendum Late entry Do not document on the query form It is not part of the medical record Response to a Queries What if a query is unsubstantiated? Check “not applicable” on the standard query form Reply to the e-mail query with “not applicable” No response will NOT be interpreted as “not applicable” Response to a Queries Feel free to contact me with any questions or concerns: Cheryl Ericson, Manager CDI ericsonc@musc.edu 792-3543