JUMP START DOCUMENTATION & PHYSICIAN EDUCATION WITH A CDI AUDIT

Transcription

1 JUMP START DOCUMENTATION & PHYSICIAN EDUCATION WITH A CDI AUDIT AHIMA San Diego 2014

2 Introduction: Overview & Goals 2 Documentation is the cornerstone to disease and treatment information As with ICD-9, ICD-10 code assignment relies solely upon physician documentation of diagnoses and procedures Documentation is mentioned over 70 times in the ICD-10-CM guidelines document. Querying is referred to over 20 times in the guidelines document ICD-10 is a clinical classification system that is sophisticated enough, and specific enough, to keep up with the changes in medicine and with regulations

3 Value of Clinical Documentation Audit Each assigned code should be compared, contrasted, and analyzed to: Confirm presence of clinical documentation as expected Assess quality and content of clinical documentation to support assigned codes Evaluate assigned codes vs. the application of final ICD-10 codes based on a coding professional s manual review of the clinical documentation

4 Value of Clinical Documentation Audit-continued Clinical documentation review allows your organization to understand the possibilities related to: Current coding and documentation practices Strengths and opportunities to ensure that the impact of the transition to ICD-10 is positive in terms of accuracy and appropriate reimbursement.

5 CDI Audit Worksheet Sample ORIGINAL (ICD-9) HRS (ICD-9) HRS (ICD-10) Reviewer Scenario Number Admit Date: Disch Date: FinClass MS-DRG DRG Description MS-DRG DRG Description MS-DRG DRG Description Service MAJOR JOINT REPLACEMENT OR MAJOR JOINT REPLACEMENT OR MAJOR JOINT REPLACEMENT OR HRS HRS024 6/24/13 6/26/13 HMO 470 REATTACHMENT OF LOWER EXTREMITY 470 REATTACHMENT OF LOWER EXTREMITY W/O 470 REATTACHMENT OF LOWER EXTREMITY W/O MCC MCC W/O MCC DIAGNOSES Type SEQ# CLIENT ICD-9 CODE CLIENT ICD-9 DESCRIPTION HRS ICD-9 CODE HRS ICD-9 DESCRIPTION HRS ICD-9 COMMENTS HRS ICD-10 CODE HRS ICD-10 CODE DESCRIPTION Documentation Impact Documentation Impact Description Reviewer Comments Dx Admitting / First- Listed Dx Osteoarthrosis, localized, not specified whether primary or secondary, lower leg Osteoarthrosis, localized, not specified whether primary or secondary, lower leg M179 Osteoarthritis of knee, unspecified 000 No Impact; Documentation Supports Dx Principal Dx Osteoarthrosis, localized, not specified whether primary or secondary, lower leg Osteoarthrosis, localized, not specified whether primary or secondary, lower leg M179 Osteoarthritis of knee, unspecified 002 Insufficient Documentation (Disease: Type) To support a more specific ICD-10 codeassignment, the type of OA should be documented. i.e. Primary, post traumatic, secondary Dx Unspecified acquired hypothyroidism 2449 Unspecified acquired hypothyroidism E039 Hypothyroidism, unspecified 002 Insufficient Documentation (Disease: Type) To support a more specific ICD-10 codeassignment, the type of hypothyroidism should be documented. i.e., postinfectious, due to iodine deficiency Dx Unspecified essential hypertension 4019 Unspecified essential hypertension I10 Essential (primary) hypertension 000 No Impact; Documentation Supports Dx Esophageal reflux Esophageal reflux K219 Gastro-esophageal reflux disease without esophagitis 000 No Impact; Documentation Supports Dx Other and unspecified hyperlipidemia 2724 Other and unspecified hyperlipidemia E785 Hyperlipidemia, unspecified 002 Dx 6 V1582 Personal history of tobacco use V1582 Personal history of tobacco use Z87891 Personal history of nicotine dependence 000 Insufficient Documentation (Disease: Type) No Impact; Documentation Supports To support a more specific ICD-10 code assignment, the type of hyperlipidemia should be documented. i.e., Mixed, Type A- D Dx 7 #N/A #N/A #N/A #N/A Dx 8 #N/A #N/A #N/A #N/A Dx 9 #N/A #N/A #N/A #N/A Dx 10 #N/A #N/A #N/A #N/A Dx 11 #N/A #N/A #N/A #N/A Dx 12 #N/A #N/A #N/A #N/A Dx 13 #N/A #N/A #N/A #N/A Dx 14 #N/A #N/A #N/A #N/A Dx 15 #N/A #N/A #N/A #N/A Dx 16 #N/A #N/A #N/A #N/A Dx 17 #N/A #N/A #N/A #N/A Dx 18 #N/A #N/A #N/A #N/A Dx 19 #N/A #N/A #N/A #N/A Dx 20 #N/A #N/A #N/A #N/A PROCEDURES Type SEQ# CLIENT ICD-9 CLIENT ICD-9 DESCRIPTION HRS ICD-9 HRS ICD-9 DESCRIPTION HRS ICD-9 COMMENTS HRS ICD-10 CODE HRS ICD-10 CODE DESCRIPTION Documentation Impact Documentation Impact Description Reviewer Comments Px Principal / First- Listed Px 8154 Total knee replacement 8154 Total knee replacement 0SRT0J9 Replace R Knee Jt, Femoral w Synth Sub, Cement, Open 000 No Impact; Documentation Supports Px 2 #N/A #N/A #N/A #N/A Px 3 #N/A #N/A #N/A #N/A Px 4 #N/A #N/A #N/A #N/A Px 5 #N/A #N/A #N/A #N/A Px 6 #N/A #N/A #N/A #N/A Px 7 #N/A #N/A #N/A #N/A Px 8 #N/A #N/A #N/A #N/A Px 9 #N/A #N/A #N/A #N/A Px 10 #N/A #N/A #N/A #N/A Px 11 #N/A #N/A #N/A #N/A Px 12 #N/A #N/A #N/A #N/A

6 Clinical Documentation Audit Impact ICD-10 Documentation Objectives 001 Insufficient Documentation (Disease: Acuity) Explanation ICD-10-CM code that will replace the ICD-9-CM code used for the same reimbursement will need more specific disease identification Key Findings Legend (Snapshot) Example The acuity of respiratory failure should be documented. i.e., acute, chronic or acute on chronic. The acuity of bronchitis should be documented. i.e., acute or chronic 002 Insufficient Documentation (Disease: Type) ICD-10-CM has more than one disease category under a broad disease category. (i.e.. Diabetes-Type 1, Type 2, secondary, drug or chemical induced). The type of iron deficiency anemia should be documented. i.e., due to chronic blood loss, due to inadequate iron intake. The type of hypothyroidism should be documented. i.e., due to medication, due to infectious process, post-surgical. 003 Insufficient Documentation (Disease: Stage) ICD-10-CM has stages or levels of disease, such as mild intermittent, late onset early onset, intractable or not intractable, stages of disease kidney or pressure ulcer, post and pre. Chronic kidney disease should be documented. i.e., Stage I-V, end stage. The phase of the dysphagia should be documented. i.e., oral, oropharyngeal, pharyngeal, pharyngoesophageal, cervical. 004 Insufficient Documentation (Laterality) s that are assigned in ICD-10 based on laterality The laterality of the acute osteomyelitis of the hand should be documented. i.e. right, left, bilateral. 005 Insufficient Documentation (Site Specificity) s that are assigned in ICD-10-CM based on documented site The site of the furuncle should be documented. i.e., abdominal wall, back, chest wall, groin. The site of Crohn's disease should be documented. i.e., colon, duodenum, ileum, jejunum. The site of the abdominal pain. i.e., LLQ, pelvic or perineal, periumbilical, RLQ, epigastric, LUQ, RUQ. 006 Insufficient Documentation (Combination codes) Combination codes are single codes in ICD-10-CM that are used to classify: two diagnoses, a diagnosis with an associated secondary process (manifestation), a diagnoses with an associated complication The documentation should include any manifestations of the acute respiratory failure. i.e., with hypercapnia or with hypoxemia. The documentation should include any manifestations of Crohn's disease. i.e., abscess, fistula, intestinal obstruction, rectal bleeding.

7 How Can You Prepare? Begin physician education and add the following to queries: Asthma Severity/Acuity Myocardial Infarction Specific site Major Depression Severity/Acuity

8

9

10 How Can You Prepare? continued..add the following to queries: Differentiation between general and focal seizures General seizures require type specificity Identify intractable (treatment-resistant) seizures Trimester of pregnancy Default to the trimester when the complication occurred, not the discharge trimester when an admission crosses trimesters Identification of the substance related to adverse effect, poisoning, or toxic effect 10

11 11 How Can You Prepare? continued add the following to queries: Glasgow (Coma Scale) Need a score from each of the three assessment areas, NOT a total score Eye opening Verbal response Motor response Gustilo Open Fracture Classification I, II, III, IIIA, IIIB, or IIIC

12 How Can You Prepare?- continued add the following to queries: Approach Laterality Root operation 12

13 How Can You Prepare?- continued What policies and procedures need revision? ICD-10-CM/PCS have new Coding Clinic advice What documentation templates need revision? Operative reports History and physicals Query forms 13

14 Conclusion /Next Steps There is much still to do Start Small Pick your Battles Encourage Teamwork Inventory your Query Library 14

15 Kim Carr RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer Director, Clinical Documentation 1777 Reisterstown Road, Suite #330 Baltimore, Maryland Phone (410)