3/24/2014 What is your CDI IQ?

Transcription

3/24/2014
What is your CDI IQ?
Clinical Documentation Improvement
Strategies for LTC
Leah Killian-Smith, BA, NHA, RHIA
©Pathway Health 2013
Objectives
• Be able to educate your staff on concepts
for documenting accurately
• Understand the differences in charting for
ICD-10-CM
• Recognize documentation requirements
that will reduce risk of audits
• Gain skills to maintain regulatory
compliance with charting in ICD-10-CM
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Documentation is important
Critical for patient care
Legal document
Audit purposes
Validates care provided
Decreases chance of claim denial
Compliance with CMS, state, and local
rules & regulations
• Impacts coding, billing, &
reimbursement
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What Has Changed?
• ↑ Clinical Needs of patients
• ↑ Scrutiny from regulators / survey
outcomes
• Implementation of documentation
based payment systems
• ↑ Litigation & Legal Challenges
• ↑ Audits (ZIPC, UPIC, RAC)
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CMS Rule
• F514 (2 CFR 483.75(l),Clinical Records
– Determine whether the clinical records:
– Accurately and completely document
the resident's status, the care and
– services provided in accordance with
current professional standards and
practices; and
– Provide a basis for determining and
managing the resident's progress
– including response to treatment, change
in condition, and changes in treatment
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Similarities
• Symbols, Code First, Use additional
code
• Includes & Excludes
• Code to highest level of specificity
• Adherence to HIPAA & Official
Guidelines
• Non-specific codes still available
• Inconsistent, missing, or conflicting
documentation must be resolved by
provider
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Similarities
• Use of Coding Books or E-Encoder
• Tabular List similar to ICD-9 with some
exceptions
• Main Terms – Indented Sub-terms
• Alphabetical Index of external causes
• Table of Neoplasms
• Table of Drugs & Chemicals
• Conventions, Abbreviations,
Punctuation
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Structure of Codes
□□□•□□□ □
Category
Etiology,
Anatomical
Site, Severity
Extension
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Examples of Structure
• S52 –
Fx of Forearm
• S52.5 –
Fx lower end of radius
• S52.52 –
Torus Fx of lower end of
radius
• S52.521 –
Torus Fx of lower end of R
radius
• S52.521D – Torus Fx of lower end of R
radius, subsequent care
Differences
• More Codes! 17,000 versus 68,000
• More codes in the different categories
• Diabetes – 59 to 200+
• Pressure Ulcers – 9 to 125
• Pathologic Fractures – 8 to 150
Codes are longer now (3-7 versus 3-5)
All codes begin with a letter (except “u”)
Code extensions are available for injuries & external
causes
Combo codes are available for diagnoses &
symptoms
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Differences
• Increased precision with diagnoses
• Full diagnostic titles for each code
• More flexibility in incorporating
advances in medicine & technology
• Uses more current & up to date med
terms
• Laterality Added (left and right, both)
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Specificity in Documentation
Condition
ICD‐9
ICD‐10
• Essential HTN
• 401.9 – Essential HTN, unspecified • I10 – Essential primary HTN
• Asthma with acute exacerbation
• 493.92 – Asthma unspecified with acute exacerbation
• J45.21 – mild intermittent asthma with acute exacerbation < 2 weeks or J45.31: >2 weeks or J45.41: Daily ©Pathway Health 2013
Final Rule
• Modifications to HIPAA Electronic Health
Transaction Standards
– http://edocket.access.gpo.gov/2009/pdf/E9740.pdf
• Modifications to Medical Data Code Set
– http://edocket/access.gpo.gov/2009/pdf/E9.743.pdf
• Final Compliance Date
– www.gpo.gov/fdsys/pkg/FR-2012-0905/pdf/2012-21238.pdf
Official Guidance
• Official Coding Guidelines
– http://www.cdc.gov/nchs/data/icd/icd10cm
_guidelines_2014.pdf
• Conventions in the Coding Manual
– Take precedence if conflict in instructions
• Chapter Specific Guidelines
– Some chapters have specific rules
– Example: Diabetes
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Complete Record
• Accurate & functional representation of
the actual experience of the individual
in the facility
• Enough information to show the facility
knows the status of the patient
• Plan of care identified to meet the
resident’s identified conditions
• Effects of the care provided
• Picture of the resident and response to
treatment
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Complete Record cont……
• Main purpose is continuity of care
• Other important reasons
– Clinical
– Administrative
– Financial
– Regulatory
– Legal
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Duplication / Redundant Info
• Duplication of information in the record
– Inefficient
– Creates conflicting / contraindications that
can lead to errors
– Diminishes the credibility of the record
• Answer
– Create a list of documentation elements
that you currently collect on each for and
by each discipline
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Admission Record / Face Sheet
• Some states have certain regulations
for field specificity
• Demographics
• Contact information
• Financial & insurance information
• Professionals involved in patient’s care
• Diagnoses
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Assessments
• Data collection
• Evaluation
• Conclusion – come to a decision as to
the clinical conclusions based on the
data collected
• Conclusion – interpreting and
documenting conclusion based on data
collected
• Plan / recommendations / intervention
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RAI / MDS
• The documentation supports the coding
of the MDS in the assessment reference
period
• The CAAs should be used as a
foundation to create the plan of care
• Section I of the MDS
– Coding diagnoses
– Triggers 3 CAAs (visual function,
psychosocial well being, dehydration /
fluid maintenance)
– Can affect our payment
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MDS Section I Diagnoses
Pneumonia
Septicemia
Diabetes
Multiple Sclerosis
Parkinson’s
Aphasia
Cerebral Palsy
Hemiplegia
Asthma
COPD
Hemiparesis
Quadriplegia
Respiratory Failure
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Payment Categories Affected
Special Care High Special Care Low Clinically Complex ©Pathway Health 2013
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Charting Content
Picture of the resident
Resident’s perception of progress
Observations & assessment of staff
Communication with resident, families,
providers
• Response to interventions / treatment
• Change toward achieving goals
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•
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Determining Principle Dx
• Section II of Official Coding Guidelines
– The condition established after study to
be chiefly responsible for occasioning
the admission of the patient to the
hospital for care
– The application of the UHDDS definitions
has been expanded to include all nonoutpatient settings including LTC
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Determining Secondary Dx
• Section III of the Official Coding
Guidelines
– Additional conditions that affect patient
care in terms of:
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Clinical evaluation
Therapeutic treatment
Diagnostic procedures
Extended length of hospital stay
Increased nursing care
Increased nursing monitoring
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Determining Secondary Dx
• Section I of the MDS – Intent
– To code diseases that have a
relationship to the resident’s current
functional status, cognitive status, mood
and behavior status, medical
treatments, nursing monitoring and risk
of death. To generate an updated,
accurate picture of the resident’s health
status
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Data in CDI
1. Data the organization produces
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–
–
–
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Review LTC data by
Specialty diagnosis
Medicare RUG
Low case mix
High risk
2. Data others produce about the
organization
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Criteria to screen data
• Normative data (comparing ourselves
to others) Quality Measures
• Regulatory guidance (F Tags and State
Licensure Rules and Regulations)
• Organizational Benchmarks (Our QA or
QAPI initiatives)
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Transfer data
• How is our information when we send a
patient to the hospital or when we call
a physician with a new or exacerbated
problem?
• What tools do we use?
– Standardized forms
– Interact tools
– Transfer forms
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Top Diagnoses in LTC
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CVA / Stroke / CVD
Mental disorders
Respiratory diseases
Neoplasms
Chronic kidney disease / Diabetes
Orthopedic aftercare
CAD / CHF / HTN
Arthritis
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Medicare Charting
• Worksheets are helpful
• Reduce risk of denials and audits
• Prove the resident needed & received
skilled services on a daily basis
– Nursing or therapy
• Nursing should have documentation in
addition to therapy to address how
skills learned in therapy area applied on
the nursing unit.
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Physical & Occupational Therapy
• For ADLs (Bed Mobility, Eating,
Transferring, Toilet Use)
• How does the resident perform
activities of daily living?
• Even though therapy is covering for a
specific diagnosis, nursing still needs to
document on skilled needs
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Speech Therapy
• How does the resident communicate
and make needs known?
• Skilled nursing interventions used to
compensate for speech deficits
• Ability to swallow foods and skilled
nursing interventions used to
compensate for impaired swallowing
abilities
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Diabetes
• Document insulin injections daily
• Order changes and physician visits
• Skilled nursing interventions used to
teach resident self administration
• Outcome of resident teaching
• Signs and symptoms associated with
fluctuating blood sugars
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Respiratory Diseases
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Skilled tracheostomy care
Sreath sounds over all lung aspects
Respiration rate, rhythm, and quality
Effectiveness of respiratory treatments
Resident comfort level as it relates to
respiratory status
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Respiratory Diseases
• Changes in level of care, anxiety, or
mental status changes
• Each incident of suctioning or any other
invasive technique
• Overall condition as it relates to his/her
respiratory status and any skilled
nursing used to aid in comfort and
improve overall status
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IM or IV Medications
• Nature of medication used (indication
for use)
• Nursing skills and observations used in
administration of the medication
• Effectiveness of medication and any
observed side effects
• How resident tolerated therapy
(infiltration, fluid volume overload,
pain, phlebitis, etc)
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Gastrostomy
• Amount of fluids delivered
• Ability to communicate and make needs
known to staff
• How resident tolerates tube feeding,
any adverse effects to tube feeding
– Diarrhea
– Abdominal distension
– Cardiac symptoms
– Abnormal lung sounds
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Gastrostomy
• Type of ostomy care provided around
the tube site
• Condition of tube site
• Clinical necessity for G-Tube, J-Tube,
NG-Tube
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Surgical Wounds
• Location and nature of wound
• Pain associated with wound and
interventions for pain management
• Nursing interventions and observations
of healing process
• Drainage, areas of erythema, warmth
• Response to any treatments
• Weekly at least!
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GU Complications
• Nature of resident condition that
warrants use of straight catheterization
technique
• Use of sterile technique during catheter
administration
• Resident teaching due to catheter use
• Clinical conditions present that require
skilled nursing observation such as
frequency, dysuria, indicators of UTI,
etc
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Respiratory Therapy
Skilled tracheostomy care provided
Breath sounds & overall lung aspects
Respiratory rate, rhythm, quality
Effectiveness of respiratory treatments
Resident comfort level as it relates to
respiratory status
• Changes in level of consciousness,
anxiety, or other mental status changes
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•
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Respiratory Status
• Each incident of suctioning and any
other invasive techniques
• Overall condition as it relates to
respiratory status and any skilled
nursing interventions used to aid in
comfort and improve overall status
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Pressure Ulcers
• Condition of wound(s)
• Response to current treatment
• Nursing interventions to prevent further
ulcer development
• Consumption amounts of meals and
fluids, BMI
• Skin condition including poor skin
turgor, bruises, rashes, cyanosis,
redness, edema, other abnormality
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Pressure Ulcers
• Interventions implemented due to
abnormal lab values (low H&H, low
serum, albumin, low Fe+ levels, etc)
• Dietary interventions implemented such
as increased vitamin C and protein
foods offered
• Weekly documentation
• Look to change treatment if no
improvement in 14 days - NPUAP
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Nursing Rehabilitation
• Outcome of insulin injection instruction
• Outcome of colostomy/ileostomy
training
• Outcome of catheter care training
• Outcome of self wound care training
• Outcome of medication self
administration training
• Outcome of stump care training
• Outcome of bowel & bladder training
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Medical Complexity
• Cerebral Palsy, Multiple Sclerosis,
Quadriplegia
• Fever and (vomiting, weight loss, tube
feeding, pneumonia, dehydration)
• Comatose
• Septicemia
• Burns
• End Stage Disease
• Dehydration
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Medical Complexity
• Hemiplegia / Paresis AND ADL
dependence
• Internal Bleeding
• Chemotherapy
• Dialysis
• Transfusions
• Oxygen therapy
• Radiation therapy
• Neurologic
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Medical Complexity
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GI
CV
General
Infection on Foot
Unstable neurological status
Unstable GI status
Unstable cardiovascular status
Unstable condition requiring skilled
medication administration
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Cognition & Behaviors
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Cognitive Loss
Signs of Depression
Behavior Symptoms Present
Hallucinations or Delusions Present
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Documentation Audits
• Concurrent
– Most helpful to ensure accurate clinical
information and proper reimbursement
• Retrospective
– Most helpful for quality assurance
activities
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The IDT
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Medical Director
Business Office
HIM
Compliance / Medicare / MDS
Therapy
Nursing Leadership
Ancillary Departments
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IDT Documentation Functions
• Report quality issues to QA Committee
• Promote CDI for quality &
reimbursement
• Provide ongoing education
• Review case mix ongoing
• Participates in claim check review
• Creates & updates documentation tools
• Audits for complete & accurate
documentation
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Training on Documentation
• Formal education
– Assess the staff members current level
of formal training such as:
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Degree or certification
Medical Terminology
Anatomy & Physiology
Pathophysiology
Pharmacology
Psychology / Abnormal Psychology
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• Determine what training your staff
members have had to date:
– Class room trainig by staff development
– Online learning – (Readilearning,
webinars, Silver Chair, etc)
– Orientation (class room and hands on
with another employee that does the
same job or similar)
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• Determine what training is needed for
your staff members
– By diagnosis
– By specialty program (CCU)
– By identifying any deficient practice or
quality issues
– By identifying reimbursement issues
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References
• AHIMA – American Health Information
Management Association
• NPUAP – National Pressure Ulcer
Advisory Panel
• CMS – Centers for Medicare & Medicaid
Services
• CDC – Centers for Disease Control
• CDI – Clinical Documentation
Improvement Manual - AHIMA
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Thank you for your time!
Leah Killian‐Smith, BA, NHA, RHIA AHIMA Approved ICD‐10‐CM/PCS Trainer
www.pathwayhealth.com
651‐407‐8699
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3/24/2014 What is your CDI IQ?

Transcription

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