What's in a Review? Key Factors to Include and Exclude

Transcription

1 What's in a Review? Key Factors to Include and Exclude Deanne Wilk, BSN, RN, CCDS, CCS, CMS Manager, Clinical Documentation Improvement Penn State Health Hershey This is the Full Title of a Session Hershey, PA 1

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Define the CDI review Demonstrate construction of CDI review elements Contrast the balance of the review and production goals Differentiate various quality focus reviews Distinguish advanced CDI review factors 2

3 CDI Review Purpose and Definition 3

4 CDI Review Purpose and Definition The CDI review is that information captured to communicate CDI principles and other pertinent factors relevant to the individual institution. 4

5 Review Purpose Quality Compliance Revenue Documentation quality Documentation compliance Coding specificity Quality initiatives Present on admission (POA) Coding accuracy Patient care and outcomes Coding appropriateness Value based purchasing Public reporting Medical necessity Denials 5

6 Goals of the Review Documentation Clear, concise, complete Organizational and regulatory bylaw compliance UHDDS and Official Coding Guidelines followed Clinical support Clinical indicators Medical necessity Diagnostics and medications Patient care Patient severity Complications POA Quality 6

7 Review Prioritization Sample 7

8 Initial Subsequent Medicare Top DRGs with opportunity Unit/complex cases Surgical cases post surgery or transfers in Poor documentation providers Blues Queries outstanding Medicare No MCC/CC x 2 Low APR Surgical cases post surgery or transfers in Blues Top DRGs with opportunity Complex cases and mortalities to achieve MCC/CCs (x 2+) and 4/4 SOI/ROM Surgical cases for complications/psis Poor provider documentation Commercial Medicaid Commercial *Prioritization should always be facility specific Medicaid Self Pay Self Pay 8

9 What s In a Review? 9

10 When Performing a Review, Ask Yourself Why is the patient here? What do I need to prove or disprove about this patient? Diagnoses Normal and abnormal What is important to capture in my review so that I remember on the subsequent review? What is important for me to capture if someone else reviews this patient after me? CDI or coding What do I need to follow up? Self talk What coding needs further specification? 10

11 Chart Review Workflow ED Progress notes Nursing notes H & P Diagnostics Query Consults OR Follow up and focus 11

12 Emergency Department Vitals initial: May need for SIRS, sepsis, infections, respiratory failure, POA status support, medical necessity. Compare to subsequent vitals. Chief complaint (CC): Must relate to principal diagnosis. What did the patient or family say? Confusion? Behavioral disturbance? Not eating or drinking? Fall? (Where, how, doing what?) Relevant physical findings: Diagnosis support (pressure injuries, respiratory failure, malnutrition). Relevant PMH: Chronic conditions. Diagnoses to capture. What medications were they on coming in, and is there a diagnosis to match? Are there antibiotics, and what are they still treating? Recent surgery or surgery that removed an organ or limb? (HCC captures) DNR or palliative care status? (mortality risk factors) POA (devices, ostomy site): Complications, recent surgery, conditions still being treated (PNA, cancer, UTI). Patient Safety Indicators (PSIs)? Confusion/AMS/skin ulcers: Present? Diagnosis to match? Query or follow up needed? Dx/impression: Medical necessity. Diagnoses to capture. Does it relate to admission diagnosis? 12

13 History and Physical CC: Does it compare or contrast to ED diagnosis? Must relate to principal diagnosis. Diagnoses to capture. Vitals or significant changes from ED record: What is new or different? What is further supported or not mentioned or no longer supported clinically? Query required? Follow up in first progress notes? Relevant PMH: Chronic conditions not documented in ED. Alzheimer's or Parkinson's or encephalopathy? What did nursing or ED say about their behavior? HCC risk factors. Relevant physical findings: Complete physical exam reviewed for normal and abnormal. Ostomy site presence and appearance. Skin dry? Skin moist but patient dehydrated. Pressure injury but no mention on skin assessment. Sepsis diagnosed but patient in No Acute Distress (NAD) and no findings of chills, rigors, or clamminess. Respiratory failure but no SOB, work of breathing, elevated respiratory rate, accessory muscle use. Wheelchair/bed bound, disability, lack of mobility, DNR status = mortality risk factors. Significant findings: Diagnoses to capture. Normal and abnormal. Diagnostics to prove or disprove a diagnosis. Clinical support for your diagnoses? Dx/impression: Diagnoses to capture. What has changed from the ED diagnoses and are they clinically supported? Query required? Follow up required? What is the plan? What diagnostics do you need to follow up on? 13

14 Progress Notes, Consults, and Nursing Notes Diagnoses: Diagnosis capture. New diagnoses clinically supported? Diagnostic findings with a relevant diagnosis? Does it prove or disprove a diagnosis? Significant skin assessment: Nursing compared to provider. Pressure injuries and staging. Status changes: What is different today? What is new or different from what the consult vs attending is documenting? Query needed for discrepancy of documentation? Significant findings: What is normal or abnormal? Why? Is it clinically supported? Is it diagnosed? Is there a query needed? Impression/plan: Diagnosis capture. Clinical support query necessary? What is supporting the diagnosis (diagnostics)? Relevant nutrition notes with abnormal BMI: Do they clinically support nutrition diagnosis? Educate them to write patient meets indicators for. 14

15 Operative Note or Bedside Procedures OP report: Coding specificity required to get the right DRG. Don t review surgery cases until after the operation. Compare the brief op note with the dictated report for discrepancies. Postop dx: How is it different than the preop dx? Significant findings: Complications, blood loss, extra procedures. Complications: Is it documented as a complication? Does it need to be referred to patient safety or reviewed as a PSI? 15

16 Diagnostics and Medications Pertinent diagnostics: Review your diagnostics together to save time as it provides a timeline comparison. Normal and abnormal. Lab, radiology, EKG, echo. Does it prove or disprove a diagnosis? Query required on abnormal findings with no diagnosis? Relevant abnormal trends such as: WBC = Infection or immunosuppression, cancer Na, K, Mg = hyper/hypo conditions INR, PT, PTT = bleeding, coagulopathy (mortality risk factors) H/H = anemia, cancers Amylase/lipase = pancreatitis Protein/albumin/pre albumin = malnutrition (labs sometimes used by auditors) LFTs = liver disease Significant/incidental findings: Findings diagnosed and documented in the record. Is the report copied/pasted or corroborated by the provider in documentation? Radiology reports (renal calculus, gallbladder sludge, liver mass, lung mass) severity factors. Labs with abnormals not diagnosed. EKG with arrhythmias and blocks. Echo with regurgitation, insufficiency and ejection fraction %. Abnormal BMI: Always capture BMI. BMI code only relevant with a nutritional diagnosis to match. Query needed? Significant medication diagnoses: Diagnosis to match medication? Is there a new medication introduced? Why? Changed in antibiotics? Why? (Complex vs simple PNA?) Sepsis? Surgical infection? (PSI?) Do the medications clinically support the diagnoses documented? 16

17 Summary Follow up CDI comments: Summation of what needs further review: Diagnoses, diagnostics, reports, consults. Queries. Note last progress note reviewed. Pertinent notes to self and others: Self talk. What you want to tell yourself or others for current or subsequent reviews. What are your thoughts? What conditions are still uncertain or need follow up, clinically supported or possibly queried? Possible queries: May query but not enough clinical indicators to support a query. Strive for 2 or more clinical indicators to query. Focus review/follow up: Focus reviews performed and noted (risk factors, PSIs, etc. and if record forwarded to physician advisor): Specific reviews for your institution such as: Quality: mortality, readmissions, PSIs, HACs, infections, devices and lines, never events, pressure injuries HCC risk factors APR DRG conditions: SOI/ROM High denial DRGs: principal dx unrelated, malnutrition, one MCC/CC, sepsis, pneumonia PEPPER report outliers Length of stay: LOS excessive for severity Queries: Queries performed to clarify documentation and/or coding: Document your queries to remind yourself and others what needs to be followed up on. 17

18 How Do YOU Document Your Review? Use common abbreviations and symbols in your review. Condense wording vs fluffy and full sentences CT head 5/1 cerebral edema Query K 3.1 Although CDI reviews are a personal expression and preference, you will save time and frustration if you are consistent in how and what you write in your reviews. Decide together as a team what is important to capture, how to write, and what you will write! 18

19 Talk to Yourself! Don t forget to talk to yourself in the review. Saves time when summarizing, querying, and following up Also helps subsequent reviewers know what you were thinking Differentiate provider documentation from your self talk and your summary of findings. Provider in quotes: CT shows cerebral edema CDI summary in regular text: Patient CT 5/1 with cerebral edema CDI self talk in parentheses: (query on TBI from 5/1 CT findings of cerebral edema) Common self talk: Query Follow up (malnutrition, EKG, echo, surgery, electrolytes, H/H) 19

20 Quality Over Quantity: How to Balance Review Quality and Production Rates 20

21 Quality Over Quantity It is important to set up new staff correctly with a focus on QUALITY review over QUANTITY Quantity will increase with time, but quality must be ingrained from the start Utilize a review template Teaches new staff what to capture Keeps reviews consistent for the team Quality standards can be measured Easy to memorize and will decrease review time 21

22 Review Template ED: Vitals initial: Chief complaint (CC): Relevant physical findings: Relevant PMH: POA (devices, ostomy site): Confusion/AMS/skin ulcers: Dx/impression: H&P: CC: Vitals or significant changes from ED record: Relevant PMH: Relevant physical findings: Significant findings (diagnoses, diagnostics, labs): Dx/impression: PN, consults, nursing notes: Diagnoses: Significant skin assessment: Status changes: Significant findings: Impression/plan: Relevant nutrition notes with abnormal BMI: OP report: Postop DX: Significant findings: Complications: Diagnostics and medications: Pertinent diagnostics (labs, radiology, cardiology): Relevant abnormal trends: Significant/incidental findings: Abnormal BMI: Significant medication diagnoses: Incidental/significant findings: Follow up/cdi comments: Summation of what needs further review: Pertinent notes to self and others: Possible queries: Focus review/follow up: Focus reviews performed and noted (risk factors, PSIs, etc. and if record forwarded to physician advisor): Queries: Queries performed to clarify documentation and/or coding: 22

23 Production and the Review Initial review Avg mins depending on service, severity and LOS. Prioritize (payer, service, etc.). Don t review cases without an ED/H&P or first progress note. Don t review surgical cases until after surgery. Key in on your template requirements vs reading every word and getting bogged down with the case itself. Mondays and Tuesdays are usually Initial reviews only with no subsequent reviews. Hold for later in week or perform Wednesday Friday while adding in initial reviews. Remember, the goal is to have impact vs going through the motions to push your production numbers higher. Subsequent review Avg mins depending on service and severity. Read your review notes and pick up from last progress note. Key in on new diagnostics, diagnoses, and findings. FOLLOW UP the query to get the case resolved: Call, text, page, , face to face, escalate in order to get it answered quickly and off your list. Again, the goal is to have impact. Determine if there is an impact potential. If not, stop reviewing it and go review another initial case! Don t let production quotas destroy your review process, impact, and provider education. High production does not always equal high impact and revenue; it may lower quality by burning out CDI staff. 23

24 Advancing the CDI Review 24

25 Advancing Your Reviews With Value Based CDI CMI MCC/CC (re evaluate case < one MCC/CC) DRG High financial impact DRGs Top DRGs with opportunity for improvement (OFI) SOI/ROM Evaluate score (4/4) Query impacts Service lines with high impact requiring queries Quality PSI HAC Mortality risk factors Readmissions LOS Bundles Focus reviews Coding and documentation Accuracy, specificity, severity, consistency, clinical support Denials prevention Track denials Financial impacts, volume, type Clinical indicators UHDDS guidelines, coding guidelines, facilitydefined clinical indicators Education/liaison Poor provider documentation Opportunities for improvement Interdisciplinary coordination and collaboration Risk adjustment HCCs/chronic conditions ICD 10 CM Guidelines.pdf 25

26 Reviews for Education Use your review information to educate providers. Put education examples in your review to pull later for rounding and education purposes. Pertinent patient history: Type 2 DM, poorly controlled Wheelchair bound at baseline ED summary: Left buttocks ulcer WOCN: Left buttocks pressure ulcer, stage 3 Sacral pressure ulcer, stage 3 connecting right buttocks ulcer to left buttocks pressure ulcer Progress note: Sacral ulcer Right buttocks ulcer Query response: Pressure ulcers on right buttocks (stage 3), left buttocks (stage 2), and sacrum (stage 2) 26

27 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. 27

28 ED: CC/injury: Cause/action of injury: Significant findings: PMH: Physical findings (Foley, confusion/ams, ulcers): Diagnoses: Impression: Vital signs: Meds (Dx for med?): Lab/radiology: Readmission: POA: H&P: CC: PMH: Physical findings (Foley, confusion/ams, ulcers): Significant findings: Diagnoses: Plan: Vital signs/bmi: Meds/labs: PN: Diagnoses: Status changes: Significant findings: Impression: Plan: Radiology/lab/EKG: Findings: Impression:

29 NN/therapy notes (behavior, stroke residuals, dysphagia): CN (palliative care order/consult, clinical nutrition, WOCN): Impression: Plan: OP report: Postop Dx: Significant Dx: Relevant findings: Complications: Focus review/follow up: Risk factors: PSI: Quality: Pertinent notes to self and others: What needs further review: Queries: Subsequent review: OR/diagnostic studies: PN: CN: Postop complications: Queries: Follow up: