CDI program data includes:
1. All cases that were reviewed
2. Number of cases with queries
3. Nature of the query
4. Physician response to the query
Queries should only be asked:
1. If there is clinical evidence that the documentation is imcomplete or does not meet one of the seven criteria for high-quality clinical documentation.
2. By an individual with solid clinical knowledge.
3. In an open-ended manner (no yes or no questions)
4. In a nonleading manner.
5. To the individual whose documentaion is in question or who is responible for interpreting test results or other data in the patient’s record.
Query process and procedure should address:
1. When queries will be asked.
2. Who will ask queries and to whom queries will be asked.
3. The hospital’s responsibility in supporting the quering process.
4. The physician’s responsibility in responding to queries.
5. Acceptable ways to responding to queries.
Examples of when a query is required may include:
1. Documentation of reportable conditions or procedures is conflicting, ambigious, or is otherwise incomplete.
2. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already documented condition.
3. The patient is receiving treatment for a condition that has not been documented.
4. Abnormal operative or procedureal findings are not documented.
5. It is unclear as to whether a condition was ruled out.
6. The pricipal diagnosis is not clearly identified.
A systemic disease with the presence and persistence of pathogenic micro-organisms or toxins in the blood. No longer considered synonymous with sepsis.
Sepsis is SIRS due to an infection . Infection can originate anywhere in the body and be triggered by a bacterial, viral, parasitic, or fungal infection.
Severe Sepsis
SIRS due to infection with organ dysfunction.
Sepsis associated with acute dysfunction in one or more organs.
Organ dysfunction bay be cardiovascular, renal, respiratory, hepatic, hematological, central nervous system, or metabolic acidosis.
SIRS is the systemic response to infection or trauma.
The systemic response is manifested by a variety of clinical signs and symptoms such as:
Fever (>100.4 degrees F), Hypothermia (= to 12000 cellsmm3 (leukocytosis), WBC 90 bpm, respirations >20 breaths/minute or PcCO2
Septic Shock
Sepsis with hypotension or a failure of the cardiovascular system.
Endotoxic shock and gram negative shock are synomymous with septic shock, septic shock = severe sepsis
Bacteria in the blood without an associated inflammatory response.
Denotes laboratory findings of viable bateria in the blood with no systemic manifestations.
Progresses to septicemia only when there is a more severe infections process or an impaired immune system.
Infection confined to the urinary system.
Refers to pyuria or bacteria in the urine (not in the blood).
Query the physician to determine if the bacteria in the urine has progressed to septicemia or sepsis.
7 criteria for high-quality documentation
Legible Complete Timely
Reliable Consistent
Precise Clear
Evidence Based Medicine-practicing medicine using only the best scientific data available.
Four kinds of standards in EBM
Design Performance
Terminology Procedural
Theory of high-quality of clinical documentation
If the 7 criteria of high-quality clinical documentation are applied ot clinical documentation, then clinical documentation quality will be high and the accuracy of care, quality indicators, reimbursement, healthcare planning, and research will be improved.
What year was TEFRA (Tax Equity and Fiscal Responsibility Act) implemented?
Developed by Yale in the 70’s to describe all types of patient care in an acute care hospital. Implemented for Medicare IPP in 1983.
Implemented in 1987 by 3m. For NY non-Medicare discharges reimbursement program.
Developed by 3m in 1990; addressed severity of illness and risk of mortality over all patient populations.
When did CMS adopt MS-DRGs to better recognize severity of illness (SOI) in Medicare IPPS?
A pre-existing condition which because of it’s presence with the principal diagnosis will increase the LOS by at least 1 day in approximately 75% of cases.
A condition arising in a hospital that prolongs the LOS by at lease one day in approximately 75% of cases.
What is the 3 tiered structure of MS-DRGs?
1. MCC-Major complication/cormorbidity
2. CC-Complication/comorbidity
3. Non-CC
How to calculate CMI
Sum of all of the DRG’s relative weights/# of cases per time period
Medicare Code Editor-Addresses 3 basic types of edits that support MS-DRG assignment which are code edits, coverage edits, and clinical edits.
MCC/CC conditions consist of:
Significant acute diseases, acute exacerbations of chronic significant diseases, advanced end-stage diseases, chronic diseases with extensive debility, consistnely greater impact on hospital resources.
Levels of DRGS in each system: MS-DRGs
Stand alone DRGs (TIA), without a CC, with a CC, with a MCC.
Levels of DRGS in each system: AP-DRGs
Stand alone DRGs (TIA), without a CC, with a CC, with a MCC.
Levels of DRGS in each system: APR DRGs
No stand alone DRGs, severity 1 (minor), severity 2 (moderate), severity 3 (major), severity 4 (extreme).
What is the ultimate of the POA program?
To craft a reimbursement system that considers not only severity and resouce utilization, but also quality indicators.
POA Indicators and Definitions
Y = Present at the time of inpatient admission
N = Not present at the time of inpatient admission
U = documentation is insufficient to determine if conditions is present on admission
W = provider is unable to clinically determine whether condition was present on admission or not
MCC/CC conditions consist of:
Significant acute diseases
Acute exacerbations of chronic significant diseases
Advanced end stage diseases
Chronic diseases with extensive debility
Consistenly greater impact of hospital resources
Key Facts to CMI
Two Major Factors with IPPS DRGs and CMI:
-Medical record documentation
-Coding Changes
Changes in documentation and/or coding practices will affect the DRG assignment and thus the CMI
Changes in the coding process for translating the diagnostic information into standard codes likewise affects DRG assignment.
The DRG System
1970’s: Yale University developed DRGs to describe all types of patient care in an acute care hospital.
1983: DRGs implemented for the Medicare IPPS.
1987: 3M developed AP-DRGs to address severity of illness and risk of mortality over all patient populations
2007: CMS adopted MS-DRGs to better recognize severity of illness in Medicare payment rates for acute care hospitals.
PPS Examples
Acute inpatient PPS (IPPS): DRGs
Hospital Outpatient PPS (OPPS): APCs
Home Health PPS (HH PPS): OASIS
Skilled Nursing Facility PPS (SNF PPS): MDS
Inpatient Rehabilitation Facility (IRF PPS): PAI
Who makes quality measure available to the public?
AHRQ via their annual report, CMS via Hospital Compare, and Leapfrog via the Individual Hospital website.
Who is recognized as the leading source of HIM knowledge?
Who serves as the WHO collaborating center for North America?
National Center for Health Statistics (NCHS)
What did CMS introduce in 2007?
What resulted from the Medicare Prescription Drug Improvement and Modernization Act of 2003?
IPPS Quality Measures
Created in 2006 by the Tax Relief and Health CAre Act this reporting measure has over 100 current measures.
Physician Quality Reporting Initiative (PQRI)
Which agency strives to advance the health of individuals and communities?
What association is a part of HCPRO?
The Association of Clinical Documentation Specialists (ACDIS)
Which external auditor began the audit revolution and returned over $240 million dollars to the Medicare Trust Fund in the first six months of 2011?
What is the acronym for CMS’s OPPS Quality Measurement program?
Hospital Outpatient Quality Reporting Program (HOP QDRP)
Which agency oversees the National Patient Safety Goals?
The Joint Commission (TJC)
Which agency is the publisher for Coding Clinic for ICD-9-CM?
American Hospital Association (AHA)
Which agency, established in 1967 outlines it’s focus areas in a “Scope of Work?”
Office of Inspector General (OIG)
Which diagnosis is a part of the CMS IPPS Quality Measures program?
Acute Myocardial Infarction, heart failure, and pneumonia
Top 10 diseases in the US
Heart disease, obesity (HTN, DM), cancer, infectious disease, tuberculosis, HIV/AIDS, lower respiratory tract infections, COPD, influenza, and depression
Heart Disease Tests
Electrocardiogram (ECG), Echocardiogram, stress tests, chest x-ray, nuclear imaging, CAT scan (SPECT), cardiac cauterization, angiography, doppler studies, blood tests, arterial blood gas
Lifestyle Modifications Heart Disease Tx
Dietary modification, exercise, smoking cessation
Drug Therapy Heart Disease Tx
Vasodilators, Beta-blockers, Calcium channe blockers, Digoxin, Antihypertensive drugs, Adrenergic-blocking drugs, Angio-tensin-converting enzyme inhibitors, Diuretics, Anticoagulants, Cholesterol or lipid-lowering drugs
Types of Heart Disease
Coronary artery disease (CAD)
-Angina Pectoris
-Myocardial Infarction (MI)
Cardiac Dysrhythmias
-Bradycardia/Tachycardia/Sick Sinus Syndrome (SSS)
-Premature atrial contractions (PACs)
-Atrial flutter/fibrillation
-Heart block (1st degree, 2nd degree)
-Bundle branch block
-Ventricular tachycardia/fibrillation
-Premature ventricular contractions (PVCs)
Types of Heart Disease
Congestive Heart Failure
Heart Failure
-Systolic: weak heart contraction, decreased cardiac output
-Diastolic: heart cannot fully relax
3 major classification of Hypertension
Sepsis Tests
Organ function studies – Kidney, liver, etc.
Chest x-ray
Liver profiles
Culture – blood, urine, CSF
CBC with differential
Blood gases
Sepsis Tx
Antibiotics, IV fluids, Oxygen, Blood transfusion, Steroids, Total parenteral nutrition, Mechanical ventilation, Central VAD insertion, Infusions of Dopamine/Vasopressors, Dialysis, Surgery
Changes and updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenence Committee, a federal committee co-chared by representatives from the NCHS and who?
Pateint has HIV and disseminated candidiasis, what is the correct code assignment?
042-Human Immunodeficiency Virus (HIV) Disease
112.5-Candidiases, Disseminated
A 68 year old woman was admittd to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?
038.11-Methiciliin Susceptible Staphylococcus Aureus Septicemia
562.11-Diverticulitis of colon (without mention of hemorrhage)
Which of the following terms equals SIRS?
What is the term for a condition in which the heart’s functions as a pump is inadequate to deliver oxygen rich blood to the body?
Congestive Heart Failure
Which of the following treatments would you expect to see in a patient admitted for COPD?
Bronchodilators, Glucocorticoids, Antibiotics, Flu vaccine, Pneumonia vaccine, Oxygeyn Therapy
Which of the following would be prescribed for a patient with hyponatremia?