Documentation Improvement at the LTAC Level of Care

Transcription

1 Documentation Improvement at the LTAC Level of Care Timothy Brundage, MD, CCDS Medical Director Brundage Group This is the Full Title of a Session St. Petersburg, Florida 1

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Documentation education for the LTAC provider Learn to document to optimize metrics at the LTAC level Learn to document to reduce denial issues at the LTAC level Learn the criteria and words to document when diagnosing 10 hospital based diagnoses 2

3 Coding Basics 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 3

4 Coding Basics Diagnose using coding based language Make sure your doctors put the diagnoses in the chart at least once Secondary diagnoses into one of 3 buckets No SOI CC MCC Not Sick Sick Very Sick Renal Insufficiency AKI ATN 4

5 LTAC Documentation Supporting Medical Necessity Action words Acute Worsening Decompensated Exacerbated Physical examination Support acuity and severity of the diagnosis Inability to tolerate PO Documented vomiting STABLE means its time for DISCHARGE!!! 5

6 LTAC Documentation Supporting Medical Necessity What bought the bed Failed lower level of care Learn to document to support admission medical necessity Barriers to safe discharge Why can the patient not go to a lower level? Why should Medicare pay for this admission? 6

7 LTAC Documentation Supporting Medical Necessity 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/active diagnoses History of C. Diff does not code to C. Diff colitis Possible MRSA pneumonia Rather than history of MRSA 7

8 Uncertain Diagnoses 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. Flow through to the date of discharge 8

9 Conflicting Documentation Audit candy Work with hospitalists to clarify and specify subspecialist documentation without conflicting it Troponin leak, type 2 event, NSTEMI 9

10 Cloning STAC records shared through transfer Copy and paste carelessness Re use all or parts of the health record Saves physicians time Multiple documentation errors Repeated errors Difficulty tracking progression/resolution of illness Red flags for auditors Lazy documentation POD #3 for an entire week Recommendations: review note each day Action words: improving, resolving, worsening, resolved 10

11 Copy and Paste Used Correctly Copy and paste can be used effectively Radiology reports Copy and paste into the progress note and agree or clarify if the diagnosis is accurate and pertinent Pneumonia for example Anatomic pathology Copy and paste into the progress note and agree or clarify if the diagnosis is accurate and pertinent Bronchial carcinoma for example 11

12 LTAC Specific Issues Chief complaint do not use "continuation of care" or admit for rehab Consider instead using the diagnosis with that phrase Pneumonia, will continue care Document the etiology and probable causative organism Sepsis, improving, high risk for failure (etc.) POA document all respiratory issues Patient admitted for another issue then goes to the unit with respiratory failure 12

13 LTAC Specific Issues Status post means the disease is over and requires no treatment History of means disease is in the past and not clinically relevant Put h/o in past medical history only What would happen if you stopped ABX in that patient? 13

14 LTAC Specific Issues Are you still treating issues related to that AMI < 4 weeks old? For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the myocardial infarction meets the definition for other diagnoses, codes from category I21 may continue to be reported. Reference: ICD 10 CM Coding Guidelines.pdf 14

15 LTAC Surgical Complications Link the complication to the surgery in the LTAC setting when appropriate Ileus Fistula Dehiscence Infection Non healing wound Post Op pneumonia Post Op respiratory failure 15

16 Clinical Criteria Supporting LTAC Diagnoses 16

17 Clinical Intuition Symptom Diagnosis Altered Mental Status Coma Altered Mental Status Encephalopathy Altered Mental Status Sepsis Altered Mental Status Shock 17

18 Sepsis: If Some Are Due to Infection 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 UPDATED above the normal value Hypotension (SBP < 90 mmhg or SBP decrease > 40 mmhg) Hypoxemia (PaO2/FiO2 < 300) FEB 22, 2016 Acute oliguria (urine output < 0.5mL/kg/hr for 2 hours) Creatinine increase >0.5mg/dL INR >1.5 Ileus Thromobocytopenia (PLT < 100,000) Hyperbilirubinemia (> 4 mg/dl) Hyperlactatemia (> 1 mmol/l Decreased capillary refill or mottling 18

19 Sepsis 3 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. 19

20 Sepsis 3 SOFA JAMA. 206;315(8): doi: /jama

21 Sepsis 2 to Sepsis 3 Crosswalk Sepsis 2 AMS Hypotension SBP < 90 Sepsis 2 and Sepsis 3 Sepsis 3 SOFA Glasgow Coma Scale 14 MAP < 70 or Vasopressors Hypoxemia PaO2/FiO2 <300 PaO2/FiO2 < 400 Acute Oliguria Urine Output < 500 Creatinine increase > 0.5 mg/dl Creatinine > 1.2 Thrombocytopenia < 100k Platelets < 150k Hyperbilirubinemia > 4 mg/dl Bilirubin 1.2 Sepsis 2 ONLY SIRS criteria Significant Edema or Positive Fluid Balance Hyperglycemia in the absence of DM CRP more than 2 SD above normal Procalcitonin more than 2 SD above normal INR > 1.5 Ileus Hyperlactatemia > 1 mmol/l Decreased Capillary Refill or Mottling Sepsis 2 and Sepsis 3 share multiple criteria The criteria below are present only in Sepsis 2 criteria. The criteria below are NOT criteria for sepsis using Sepsis 3 X 21

22 Sepsis No code for urosepsis Never document this as it has no meaning Bacteremia is the presence of viable bacteria in the blood. Bacteremia codes to a lab finding. R78.81 Finding of other specified substances, not normally found in blood; Bacteremia Septicemia is the presence of viable bacteria in the blood causing infection. Septicemia codes to sepsis A41.9 Sepsis, unspecified organism; Septicemia No Severity CC (Low Severity) MCC (High Severity) + blood cultures Bacteremia Septicemia 22

23 Sepsis for ICD 10 ICD 10 code Description CC or MCC A41.9 Sepsis, unspecified organism (Includes Septicemia, NOS) MCC A40.3 Sepsis due to Streptococcus Pneumoniae MCC A40.9 Streptococcal sepsis, unspecified MCC A41.01 Sepsis due to MSSA MCC A41.02 Sepsis due to MRSA MCC A41.50 Gram negative sepsis, unspecified MCC R65.10 SIRS of non infectious origin w/o acute organ dysfunction R65.11 SIRS of non infectious origin with acute organ dysfunction CC MCC R65.20 Severe Sepsis without septic shock MCC R65.21 Severe Sepsis with septic shock MCC 23

24 Respiratory Failure 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 24

25 Link the Respiratory Failure Link the respiratory failure to the cause when appropriate Acute respiratory failure due to resolving sepsis List the criteria used to make the diagnosis (22) Acute respiratory failure due to gram negative pneumonia Treating with cefepime 25

26 LTAC: Intubation for Airway Protection This is not a diagnosis and will not be coded When does airway protection move to acute respiratory failure? Clinical decision Pulmonary consensus > 48 hours is reasonable Shorter if any underlying lung pathology e.g., COPD history 26

27 Chronic Respiratory Failure Criteria: continuous oxygen use (not just overnight oxygen) po2 < 60 mmhg No significant deviation from baseline ABGs Without significant increase in work of breathing Continuous oxygen use or continuous ventilatory support Not Sick No Severity CC (Sick) Moderate Severity MCC (Very Sick) Maximal Severity On home O 2 Chronic respiratory failure Acute on chronic respiratory failure 27

28 Respiratory Failure for ICD 10 ICD 10 code Description CC or MCC J96.00 Acute respiratory failure, unspecified MCC J96.01 Acute respiratory failure with hypoxia MCC J96.02 Acute respiratory failure with hypercapnia MCC J96.10 Chronic respiratory failure, unspecified CC J96.11 Chronic respiratory failure with hypoxia CC J96.12 Chronic respiratory failure with hypercapnia CC J96.20 Acute and chronic respiratory failure MCC J96.21 Acute and chronic respiratory failure w hypoxia MCC J96.22 Acute chronic respiratory failure w hypercapnia MCC 28

29 COPD COPD with acute exacerbation Rarely the reason for LTAC admission COPD is a chronic condition Document acute exacerbation Steroids & nebs Evaluate for: Acute respiratory failure Increased oxygen requirement and respiratory distress Chronic respiratory failure Continuous home oxygen 29

30 COPD for ICD 10 ICD 10 code Description CC or MCC J44.0 COPD with acute lower respiratory infection CC J44.1 COPD with acute exacerbation CC J44.9 COPD unspecified F Nicotine dependence unspecified, uncomplicated F Nicotine dependence unspecified with withdrawal CC Z Personal history of nicotine dependence Z72.0 Tobacco use 30

31 Heart Failure Acute or Chronic Acute on chronic Exacerbation Decompensated Systolic (EF < 40%) HFrEF codes to systolic Diastolic (normal EF) HFpEF codes to diastolic Both (valvular heart failure) Simply writing EF= % is not sufficient Heart failure not dysfunction 31

32 Heart Failure Audit Protection 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: 32

33 Heart Failure for ICD 10 ICD 10 code Description CC or MCC I50.1 Left Ventricular Failure CC I50.20 Systolic HF CC I50.21 Acute Systolic HF MCC I50.22 Chronic Systolic HF CC I50.23 Acute on Chronic Systolic HF MCC I50.30 Diastolic HF CC I50.31 Acute Diastolic HF MCC I50.32 Chronic Diastolic HF CC I50.40 Combined Systolic & Diastolic HF I50.41 Acute Combined Systolic & Diastolic HF I50.9 CHF CC MCC 33

34 Encephalopathy Encephalopathy Definition: Global cerebral dysfunction in the absence of structural brain disease. Underlying etiology: Toxic/Metabolic UTI or sepsis Hepatic Anoxic Hypertensive Document these symptoms in the history or exam Altered mental status Mental status changes Confusion Chen R, Young GB. Metabolic Encephalopathies. In: Baillere's Clinical Neurology, Bolton CF, Young GB (Eds), Balliere Tindall, London p

35 Encephalopathy AMS caused by a medical diagnosis is encephalopathy AMS caused by a psychological manifestation is delirium American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) F05 Delirium due to known psychological condition Acute brain syndrome Acute confusional state Delirium superimposed on dementia Sundowning m 35

36 Glasgow Coma Scale Behavior Response Score Eye Opening Spontaneously 4 To Speech 3 To Pain 2 MCC No Response 1 MCC Best Verbal Response Oriented x 3 5 Confused 4 Inappropriate Words 3 Incomprehensible Words 2 MCC No Response 1 MCC Best Motor Response Obeys Commands 6 Moves to pain 5 Withdraws from pain 4 Abnormal flexion (decorticate) 3 MCC Abnormal extension (decerebrate) 2 MCC No Response 1 MCC 36

37 Encephalopathy for ICD 10 ICD 10 code Description CC or MCC R41.82 Altered Mental Status, unspecified (includes Change in mental status) R41.0 Disorientation, unspecified (includes Delirium & Confusion) G93.40 Encephalopathy, unspecified MCC G93.41 Metabolic Encephalopathy (includes Septic Encephalopathy) MCC G92 Toxic Metabolic Encephalopathy MCC I67.4 Hypertensive Encephalopathy CC G93.1 Anoxic brain damage (includes anoxic encephalopathy) CC 37

38 Malnutrition ASPEN 2 criteria Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may sometimes mask weight loss Diminished functional status as measured by hand grip strength Notice that ALBUMIN and PREALBUMIN are NOT criteria for diagnosis 38

39 Malnutrition for ICD 10 ICD 10 code Description CC or MCC E44.1 Mild protein calorie malnutrition CC E44.0 Moderate protein calorie malnutrition CC E43 Severe protein calorie malnutrition, unspecified MCC 39

40 Pneumonia Probable gram negative pneumonia, Rx Zosyn Probable MRSA pneumonia, Rx Vancomycin Suspected aspiration pneumonia Clindamycin or Flagyl Rx All below map to the DRG for simple pneumonia Community acquired pneumonia Healthcare associated pneumonia (HCAP) Nosocomial pneumonia 40

41 Pneumonia for ICD 10 ICD 10 code Description CC or MCC J15.9 Unspecified bacterial pneumonia MCC J18.9 Pneumonia, unspecified organism (includes CAP & HCAP & Nosocomial) MCC J69.0 Aspiration Pneumonia MCC J15.6 Pneumonia due to gram negative bacteria MCC J Pneumonia due to MRSA MCC J15.8 Pneumonia due to specified bacteria (anaerobic) MCC Simple pneumonia maps to DRG 195 Pneumonia Specified codes map to DRG 177 Resp Diseases 41

42 Third Universal Definition of Acute Myocardial Infarction 2012 Detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin) with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following: Symptoms of ischemia New or presumed new significant ST segment Twave (ST T) changes or new left bundle branch block (LBBB) Development of pathological Q waves on ECG Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Identification of an intracoronary thrombus by angiography or autopsy 42

43 Troponin Leak Is NOT a Diagnosis Only 3 Options for Abnormal Troponin Not clinically relevant CKD stage Demand ischemia Does not code to an AMI I24.8 Other forms of acute ischemic heart disease CC STEMI, NSTEMI or Type 2 MI 43

44 MI Type 2 v. Demand Ischemia Very similar pathophysiologically Demand ischemia Due to supply demand mismatch MI type 2 has a new code as of October 2017 MI due to demand ischemia MI due to ischemic imbalance Associated with a higher severity of illness Quality metrics tracked for AMI 44

45 Acute Myocardial Infarction for LTAC AMI 4 weeks that require continued care code to acute MI I21 Subsequent MI Acute myocardial infarction within 4 weeks of a previous AMI regardless of site Old myocardial infarction I25.2 Old healed myocardial infarctions not requiring further care 45

46 Acute Myocardial Infarction for ICD 10 ICD 10 code Description CC or MCC R79.89 Other specified abnormal findings of blood chemistry (troponin elevation) I21.4 NSTEMI MCC I21.3 STEMI of unspecified site MCC I21.01 STEMI of the L main MCC I21.02 STEMI of the LAD MCC I21.09 STEMI of the anterior wall MCC I21.11 STEMI of the RCA MCC I21.19 STEMI of the inferior wall MCC I21.21 STEMI of the L Circumflex MCC I21.A1 MI type 2 (due to demand ischemia) MCC I24.8 Demand ischemia CC I22.2 Subsequent NSTEMI MCC I22.9 Subsequent STEMI unspecified site MCC 46

47 Morbid Obesity Morbid Obesity BMI > 40 BMI matters! Physician must make the diagnosis of morbid obesity when the BMI is > 40 to support illness Cannot be taken from a calculated BMI BMI > 40 Morbid obesity BMI < 19 Underweight malnourished 47

48 Morbid Obesity for ICD 10 ICD 10 code Description CC or MCC E66.9 Obesity, unspecified E66.01 Morbid Obesity due to excess calories E66.1 Morbid Obesity with alveolar hypoventilation CC 48

49 Pressure Ulcers Decubitus ulcers Document the Present on admission status for decubitus ulcers Provider should document the wound etiology and location Wound care nurse can document the stage LTAC: UN link diabetes to wounds when clinically appropriate Trauma causing a wound unrelated to DM 49

50 LTAC Wound Documentation Document if the wound is a complication Diabetic Gangrene Dry gangrene is ischemic Wet gangrene is infectious Use clinical intuition to link organisms Your antibiotic selection will guide your documentation Injury Surgery Device Document the causal link if possible 50

51 Pressure Ulcer for ICD 10 Laterality, Site, Etiology, Type ICD 10 code Description CC or MCC L Pressure Ulcer Sacral Region, unstageable L Pressure Ulcer Sacral Region, stage 1 L Pressure Ulcer Sacral Region, stage 2 L Pressure Ulcer Sacral Region, stage 3 MCC L Pressure Ulcer Sacral Region, stage 4 MCC L Pressure Ulcer Sacral Region, unspecified L Pressure Ulcer of Right Buttock, unstageable L Pressure Ulcer of Left Buttock, unstageable 51

52 Excisional Debridement Physicians/Providers must document excisional debridement of bone, fascia or muscle, Terms such as sharp debridement or statement of use of scalpel alone are not considered sufficient for code assignment of excisional debridement The following information must also be documented by the provider: Description of the area debrided The instrument used (scalpel, scissors, forceps, etc.) The depth of the debridement (up to and including skin, muscle, tendon, bone, etc.) Documentation of removal or cutting away of devitalized tissue, necrosis, or slough Coders may not assume that debridement of bone, fascia, or muscle is excisional. May not they assume that sharp debridement is excisional. The exact wording of excisional debridement with the supporting documentation must be present. Failure to document appropriately may result in problems with physician reimbursement and/or denials. 52

53 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 53