8/17/2016 www.BrundageMedicalGroup.com Documenting to Reduce Denials Timothy N. Brundage, MD, CCDS Certified Clinical Documentation Specialist [email protected] Principal Diagnosis ◦ The condition after study to be chiefly responsible for occasioning the admission to the hospital Secondary Diagnosis ◦ Conditions that consume one of the following Clinical Evaluation Therapeutic Treatment Diagnostic procedures/testing Extended length of stay (LOS) Increased nursing care and/or monitoring High quality coding based language ◦ Supported by descriptive language What “bought the bed” ◦ Learn to speak to your physicians ◦ Barriers to safe discharge – why can the patient not go home? Action words ◦ Acute ◦ Worsening ◦ Decompensated ◦ Exacerbated Physical examination ◦ Support acuity and severity of the diagnosis Inability to tolerate PO ◦ Documented vomiting 1 8/17/2016 Do NOT document versus… versus… versus… Differential diagnosis as a vertical of Uncertain Diagnoses ◦ Possible diagnosis ◦ Probable diagnosis ◦ Likely diagnosis ◦ Suspected diagnosis “history of” ◦ Belongs in the PMHx ◦ A/P: Prefer documentation of Chronic diagnosis If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. ◦ Auditor denial example “probable sepsis” documented multiple times hospitalist changed UTI was documented on the DC summary “Audit Candy” Work with hospitalists to clarify and specify subspecialist documentation without conflicting it ◦ troponin leak, type 2 event, NSTEMI 2 8/17/2016 Used by auditors to deny medical necessity ◦ Same note day after day without update or Can be used correctly if proof read and updated Can be used to bring radiography and pathology reports into the clinical record Necessitates that all outpatient diagnoses and treatments are pertinent to the inpatient admission for 72 hours prior to admission The 3 day rule - inpatient diagnosis supported by ◦ EMS ◦ ER evaluation ◦ PCP note ◦ Lower level of care documentation Respiratory failure diagnosed by the hospitalist ◦ ER and EMS data ◦ Protected a $10,000 MCC On July 1, 2015, CMS released the updates to the “Two Midnight” rule. CMS emphasis on physician’s medical judgment Physician or other practitioner must decide whether to admit as inpatient or treat as outpatient CMS observed a higher frequency of extended observation services Inpatient admissions will generally be payable under Part A if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supports that reasonable expectation All treatment decisions for beneficiaries were based on the medical judgment of physicians CMS sought to respect the judgment of physicians 3 8/17/2016 Patients hospitalized in Observation services have three options at the 48 hour mark (after 2 midnights) 1. Discharge 2. Patient remains OBS only if there is a delay in care, facility delay in testing, physician delay in consult, etc. 3. If the attending physician continues to opine that his/her patient requires continued hospitalization then the patient is changed to inpatient status by the attending physician and he/she will document in the chart his/her medical judgment as to why his/her patient requires continued hospitalization Symptom Diagnosis Altered Mental Status Coma Altered Mental Status Encephalopathy Altered Mental Status Sepsis Altered Mental Status Shock ??? 12 4 8/17/2016 SIRS criteria Altered Mental Status Significant edema or positive fluid balance Hyperglycemia in the absence of diabetes CRP more than two SD above the normal value Procalcitonin more than 2 SD above the normal value UPDATED Hypotension (SBP < 90 mmHg or SBP decrease > 40 mmHg) Hypoxemia (PaO2/FiO2 < 300) Acute oliguria (urine output < 0.5mL/kg/hr for 2 hours) Creatinine increase >0.5mg/dL INR >1.5 Ileus FEB 22, 2016 Thromobocytopenia (PLT < 100,000) Hyperbilirubinemia (> 4 mg/dL) Hyperlactatemia (> 1 mmol/L Decreased capillary refill or mottling 13 Severe Sepsis ◦ sepsis w/ evidence of end-organ damage ◦ Lactic Acid > 2.0 Septic shock ◦ sepsis refractoryUPDATED to fluid resuscitation (requiring pressors.) ◦ Lactic Acid > 4.0 FEB 22, 2016 14 New Terms and Definitions Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection. ◦ A SOFA score ≥2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection. http://jama.jamanetwork.com/article.aspx?articleid=2492875 15 5 8/17/2016 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287 Sepsis syndrome does not code to sepsis per coding clinic Sepsis resolving, does not code to sepsis per coding clinic Sepsis-2 is supported by the ACCP Sepsis-3 is supported by the SCCM Need consistent documentation by the providers that does not conflict ◦ Rule in or rule out sepsis by the date of discharge Auditor – “We know that is not sepsis” 18 6 8/17/2016 KDIGO: increase in the patient’s serum creatinine of 0.3 mg/dl or more over their normal baseline level Link Dehydration Azotemia Do Not document Acute Renal Insufficiency Acute Renal Failure is a Comorbidity/Complication (CC) ATN is a Major Comorbidity/Complication (MCC) KDIGO published in 2012 ◦ Cr change of 0.3 mg/dl without mention of rehydration AKI changed from an MCC to a CC in 2010 AKIN criteria published in 2007 ◦ Cr change of 0.3 mg/dl after hydration RIFLE criteria published in 2004 ◦ Cr up 2 times for injury ◦ Cr up 3 times for failure Question: Please reconsider the advice previously published in Coding Clinic, First Quarter 2014, page 25, stating that the coder cannot assume either diastolic or systolic failure or a combination of both, based on documentation of heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Would it be appropriate to code diastolic or systolic heart failure when the provider documents HFpEF or HFrEF? Answer: Based on additional information received from the American College of Cardiology (ACC), the Editorial Advisory Board for Coding Clinic for ICD- 10-CM/PCS has reconsidered previously published advice about coding heart failure with preserved ejection fraction (HFpEF), and heart failure with reduced ejection fraction (HFrEF). HFpEF may also be referred to as heart failure with preserved systolic function, and this condition may also be referred to as diastolic heart failure. HFrEF may also be called heart failure with low ejection fraction, or heart failure with reduced systolic function, or other similar terms meaning systolic heart failure. These terms HFpEF and HFrEF are more contemporary terms that are being more frequently used, and can be further described as acute or chronic. Therefore, when the provider has documented HFpEF, HFrEF, or other similar terms noted above, the coder may interpret these as "diastolic heart failure" or "systolic heart failure," respectively, or a combination of both if indicated, and assign the appropriate ICD-10-CM codes. 7 8/17/2016 Acute or Chronic Heart failure ◦ Acute on Chronic ◦ not dysfunction ◦ Exacerbation ◦ Decompensated Systolic (EF < 40%) ◦ HFrEF Diastolic (normal EF) ◦ HFpEF Both ◦ Simply writing “EF=____%” is not sufficient Failed outpatient therapy Severity of history ◦ Worsening, decompensated ◦ Hypoxia noted ◦ Dyspnea, fragmented sentences Quality of physical examination ◦ Retractions, respiratory distress Abnormal findings ◦ BNP ◦ chest X-ray Documentation of aggressive intervention ◦ Frequency of IV diuretics Framingham Criteria for CHF exacerbation diagnosis Major Minor Acute Pulmonary Edema Ankle Edema Cardiomegaly on CXR Dyspnea on exertion (DOE) Hepatojugular reflex Hepatomegaly JVD Nocturnal cough PND or orthopnea Pleural effusion Rales Tachycardia Third Heart Sound (S3) *Heart failure exacerbation is diagnosed when two major criteria or one major and two minor criteria are met Reference: http://www.aafp.org/ 8 8/17/2016 Acuity ◦ Acute, Chronic or Acute on Chronic Type ◦ Hypoxic or hypercapneic Criteria for Acute respiratory failure includes 2 out of 3: pO2 < 60mmHg pCO2 > 50mmHg with pH <7.35 Respiratory Distress – document this in the Physical Exam Chronic Respiratory Failure ◦ Continuous home Oxygen or normal pH w/ high CO2 25 History ◦ Failed outpatient treatment ◦ High frequency of Nebs outpatient ◦ Worsening dyspnea Physical Exam findings – should demonstrate resp distress ◦ Retractions, tripoding ◦ Accessory muscle use ◦ Fragmented sentences, dyspnea ◦ BIPAP is always supportive of resp distress Room Air ABG ◦ Extremely important to support hypoxia and/or hypercapnia 3 Day rule ◦ Key to supporting admission to the hospital in a patient who improved via therapy in the ER 26 COPD with acute exacerbation ◦ COPD is a chronic condition ◦ Consider acute exacerbation Steroids & nebs Evaluate for: ◦ Acute Respiratory Failure Increased oxygen requirement and respiratory distress ◦ Chronic Respiratory Failure