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1 Pediatric CDI: Lessons Learned From a Tertiary, Freestanding Children's Hospital Jodi P. Carter, MD, CDI Physician Champion Nancy C. Rush, RN, BSN, CCM, CDI Manager Mary Ellen Fee, RN, CCDS, CDI Specialist Phoenix Children s Hospital Phoenix, Arizona 2 Learning Objectives At the completion of this educational activity, the learner will be able to: Identify opportunities commonly found in pediatric tertiary medical centers Describe documentation opportunities found in the inpatient pediatric surgical population List two documentation opportunities found in pediatric ICU settings 3

2 Participating With Poll Everywhere How to Vote Via the Web or Text Messaging From any browser Pollev.com/pchmeded From a text message PCHMEDED <your response> 4 Participating With Poll Everywhere How to Vote Via the Web Example instruction slide without custom or simple keywords pchmeded 5 Participating With Poll Everywhere How to Vote Via Texting Example instruction slide without custom or simple keywords pchmeded 6

3 Practice Poll 7 Phoenix Children s Hospital 8 Phoenix Children s Hospital 385 licensed beds More than 70 subspecialty fields of pediatric medicine Over 18,000 inpatient admissions per year Over 16,000 surgical cases per year 9

4 Phoenix Children s Hospital Provides approximately 60% of Arizona s pediatric tertiary medical and surgical care for cardiac, orthopedic, neurologic, and oncologic populations Transplant services: Heart, renal, bone marrow, liver ECMO capability Level one trauma center 10 Phoenix Children s Hospital Payer mix = approximately 60% Medicaid U.S. News & World Report Best Children s Hospitals Cancer Cardiology/heart surgery Neurosurgery/neurology Orthopedics Leapfrog Group Top Children s Hospital 11 Phoenix Children s Hospital CDI Program Established 2011 Hospital CMI = local community hospital pediatric care Only one major DRG payer, but other contracts in active negotiation to convert to DRG 3 CDI specialists 1 physician champion Housed in finance with direct report to CFO 12

5 Get Your Cell Phones Ready! 13 Phoenix Children s Hospital CDI Program Our perception of critical success factors: All team members share equal responsibility for project success Engage providers in a personal and professional manner Develop a user friendly program Create specific queries for individual diagnoses Choosing to retain all queries as a permanent part of the medical record Includes concurrent and retrospective queries Includes queries generated by either CDI or coding 14 Pediatric CDI Program Success Hospitalwide CMI equivalent to local community hospitals pediatric care Nonspecific documentation leading to lower reimbursement Growing importance of public quality metric reporting Only one major payer reimbursing by DRG, but actively renegotiating active commercial contracts CMI now in top quartile of freestanding children s hospitals Consistent financial contribution through improved documentation Improved public quality metrics (Leapfrog Group Top Children s Hospital; U.S. News and World Report) 90% of payers reimbursing by DRG, including Arizona Medicaid (APR DRG) 15

6 DRG Systems MS DRG Used by Medicare Identify the sicker patient with: CC = Complications and comorbidities Example: Salmonella gastroenteritis MCC = Major complications and comorbidities Example: Salmonella septicemia CCs AND MCCs ARE IDENTIFIED BY PROVIDER DOCUMENTATION APR DRG Used by Arizona Medicaid Identify the sicker patient with: SOI = Severity of illness (1 4) ROM = Risk of mortality (1 4) SOI AND ROM INCREASE WHEN PROVIDERS DOCUMENT THE INTERACTION BETWEEN MULTIPLE DISEASE PROCESSES AND COMORBIDITIES 16 Pediatric CDI Program Success CDI metric 2014 Physician response rate Physician concurrence rate DRG reassignment rate 99% average/year 75% average/year 34% average/year 17 Pediatric Hospitals Adult Hospitals 18

7 Get Your Cell Phones Ready! 19 Top Performing Pediatric Opportunities 20 Pediatric Hospital Medicine Children with complex chronic illness Multiple comorbidities Potential for long LOS Example: Cystic fibrosis Healthy children with acute illness Few comorbidities High intensity/short stay High volume of respiratory disease Top 2 admissions by volume each year: Asthma Bronchiolitis 21

8 Maximizing Common Respiratory Illnesses Common respiratory illnesses Asthma Acute respiratory failure (MCC) Acute on chronic respiratory failure (MCC) All comorbid secondary conditions Bronchiolitis Acute respiratory failure (MCC) Acute on chronic respiratory failure (MCC) All comorbid secondary conditions Capture isolation precautions (increases SOI) Our definitions of respiratory failure Acute respiratory failure Blood gas with pco2 > 50, ph < 7.35, po2 < 60 Initiation of positive pressure ventilation to maintain gas exchange Acute on chronic respiratory failure Patient chronically on positive pressure ventilation Blood gas with pco2 > 50, ph < 7.35 Increase in positive pressure ventilation 22 Cystic Fibrosis: A Challenge in Sequencing For a patient admitted with a CF exacerbation, should the exacerbation of CF always be sequenced first? Not always Ask yourself, Is the reason for admission the cystic fibrosis itself (e.g., poor compliance with home respiratory therapies has led to difficulty breathing) or a cystic fibrosis complication (e.g., an infectious bronchitis has led to difficulty breathing)? If the reason is the cystic fibrosis itself, the principal diagnosis will be cystic fibrosis with pulmonary manifestations (277.02) If the reason is an infectious bronchitis, the principal diagnosis will be infectious bronchitis (466.0) and the CF will be a secondary diagnosis Reminder: Capture isolation precautions (increases SOI) 23 Get Your Cell Phones Ready! 24

9 Pediatric Surgical Opportunities 25 Pediatric Surgical Opportunities Neurosurgery Brain compression Cerebral edema Orthopedic surgery Cerebral palsy General surgery Anemia from acute blood loss around the time of surgery 26 Neurosurgery Brain compression INSTEAD OF DOCUMENTING Mass effect Midline shift PLEASE CONSIDER Brain compression (MCC) Note: Incidental findings on an imaging study with no clinical impact should not be coded. There must be clinical impact. 27

10 Brain Compression Example 15 mo old female with history of brainstem PNET. Despite chemotherapy tumor has grown. Admitted to hospital for surgical debulking. Pre op brain MRI: There has been marked interval increase in size of irregular exophytic brainstem mass with mass effect upon the optic nerves Progress note: s/p suboccipital craniotomy for resection of posterior fossa PNET Mass effect with compression of the brain Other Mass effect on imaging without clinical significance Unable to determine ORIGINAL REVISED Weight SOI/ROM 1/1 3/4 Reimbursement Over $25, Neurosurgery Cerebral edema INSTEAD OF DOCUMENTING Brain swelling PLEASE CONSIDER Cerebral edema (MCC) Brain edema (MCC) 29 Cerebral Edema Example 6 month old male presented to ER with fever, lethargy, and emesis. LP done in ER was concerning for gram negative bacterial meningitis. Patient admitted to PICU. Brain MRI demonstrated intra ventricular debris (that was concerning for pus) as well as some small loculated collections in the subdural space, and patient was started on Decadron. CSF culture ultimately grew H. flu. H. flu meningitis with ventriculomegaly and cerebral edema H. flu meningitis with ventriculomegaly without compression or edema Unable to determine H. flu meningitis with ventriculomegaly and compression of the brain Other ORIGINAL REVISED Weight SOI/ROM 3/2 4/3 Reimbursement Over $40,000 30

11 Orthopedic Surgery INSTEAD OF DOCUMENTING PLEASE CONSIDER CP Specific type of cerebral palsy (plegia = paralyzed; paresis = weakened) Cerebral palsy Topography: Monoplegia/monoparesis Diplegia/diparesis (CC) Hemiplegia/hemiparesis (CC) Paraplegia/paraparesis (CC) Triplegia/triparesis (CC) Tetraplegia/tetraparesis (MCC) Quadriplegia/quadriparesis (MCC) Spasticity: Spastic Non spastic Note: When a CP patient has quadriplegia, you should not look for an additional code of functional quadriplegia. It is inherent to the code of CP quadriplegia. 31 Cerebral Palsy Example 8 yo female, ex 34 weeker with history of cerebral palsy and GERD admitted for Nissen fundoplication Congenital quadriplegic cerebral palsy Congenital paraplegic cerebral palsy Congenital diplegic cerebral palsy Other Unable to determine ORIGINAL REVISED Weight SOI/ROM 2/1 2/2 Reimbursement Over $50, Surgery Acute blood loss anemia INSTEAD OF DOCUMENTING Low hemoglobin Low hematocrit Decreased RBC count PLEASE CONSIDER Anemia due to acute blood loss from a disease (name the disease) (CC) Anemia caused by acute blood loss from surgical complication (name the complication) (CC) Low hematocrit from hemodilution (not a CC) 33

12 Acute Blood Loss Anemia Example 16 yo female with a history of idiopathic scoliosis that is now > 50 degrees Admitted for posterior spinal fusion, T3 > L3 EBL = 1000 cc; 525 cc cell saver given H/H 10.0/ /20.4 Postoperatively patient becomes tachycardic, PRBCs given Note: You must account for the expected dilutional effect on H/H when making the decision to query for this diagnosis postoperatively Acute blood loss anemia Chronic blood loss anemia Acute on chronic blood loss anemia Other Unable to determine ORIGINAL REVISED Weight SOI/ROM 1/1 2/1 Reimbursement Over $16, Pediatric ICU Opportunities 35 Pediatric ICU Opportunities PICU NICU CVICU 36

13 Pediatric ICU Opportunities Respiratory failure INSTEAD OF DOCUMENTING Tracheostomy dependent Ventilator dependent BiPAP dependent CPAP dependent Increased work of breathing PLEASE CONSIDER Chronic respiratory failure (CC) Acute respiratory failure (MCC) Acute on chronic respiratory failure (MCC) Note: Clinical correlation needed to confirm appropriateness of these CCs and MCCs 37 Example: Respiratory Failure 6 mo female with hx of type I SMA (on BiPAP at all times) admitted to PICU with increased thoracic/abdominal asynchrony and increased work of breathing ABG shows pco2 = 60 In PICU BiPAP settings increased above baseline and aggressive airway clearance initiated Provider queried for respiratory failure: Acute respiratory failure Chronic respiratory failure Unable to determine Acute on chronic respiratory failure Other ORIGINAL REVISED Weight SOI/ROM 3/2 3/3 Reimbursement Over $10, Pediatric ICU Opportunities Shock INSTEAD OF DOCUMENTING Hypotension PLEASE CONSIDER Shock (CC) SPECIFIED shock (MCC) 39

14 Example: Shock 13 yo female with hx of a genetic syndrome, global developmental delay, spastic quadriplegic CP, epilepsy, GERD, and neuromuscular scoliosis admitted for posterior spinal fusion. L pleural space entered while dissecting to the spine. Pt became hypotensive. Dopamine drip started. Crystalloid, albumin, PRBCs, FFP, and cell saver given in OR. Transferred to PICU on dopamine drip, intubated, and hypothermic with a SBP in the 50s. Hypotension without shock Postoperative cardiogenic shock during/resulting from surgery Postoperative hypovolemic shock Postoperative shock during/resulting from surgery Other Unable to determine ORIGINAL REVISED Weight SOI/ROM 3/2 3/2 Reimbursement Over $20,000 Note: This example assumes the CDI specialist is aware of the connection between the pneumothorax and the shock state. In this example, there is also a coding opportunity for iatrogenic pneumothorax. 40 Neonatal ICU Opportunities Neonatologists forget how sick their patients are Acute respiratory failure (MCC) Cardiogenic shock (MCC) 41 Cardiovascular ICU Opportunities Hypoplastic left heart syndrome (MCC) Three phase surgical correction Norwood Performed within the first 2 weeks of life Bi directional Glenn shunt Performed between the ages of 4 and 6 months Fontan Performed between 18 months of age and 3 years of age 42

15 Hypoplastic Left Heart Syndrome INSTEAD OF DOCUMENTING s/p Norwood s/p Glenn s/p Fontan PLEASE CONSIDER Hypoplastic left heart syndrome (MCC) 43 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. 44