How CDI and Coding Can Travel Together in the Outpatient Realm Deanne Wilk, BSN, RN, CCDS, CCS Manager, Clinical Documentation Improvement Milton S. Hershey Medical Center Hershey, PA Melissa Maguire, BSN, RN Educator, Clinical Documentation Improvement Milton S. Hershey Medical Center Hershey, PA 1 Learning Objectives At the completion of this educational activity, the learner will be able to: Understand why and how CDI and coding can work together in the outpatient realm Learn a directional path on both CDI and coding initiatives for outpatient engagement Obtain a specific review format for CDI and coding 2
3 Name a Benefit of CDI and Coding Traveling Together 1. Providers will be taught how to code 2. Quality documentation will support patient care and, in effect, accurate reimbursement 3. Staffing will be doubled 4
Benefits of CDI and Coding Traveling Together Consistency Education Quality and accuracy 5 Benefits of CDI and Coding Traveling Together Consistency in practice for both coding and CDI is crucial for accuracy, specificity, quality, and compliance of both documentation and coding When both areas work together, they can perform congruent education to the provider that over time will reap numerous benefits: Time saved for provider clear guidelines to follow Profiling of the provider specific conditions treated Compliance coding accuracy Quality and reimbursement quality documentation that will support reimbursement 6
Benefits of CDI and Coding Traveling Together Goal of collaboration: Education of providers for documentation quality improvement and appropriate reimbursement 7 CDI and Coding Process Identify Reassess Audit Review Educate 8
Identify the Records to Review: CDI & Coding Population Quality Impact 9 Identify the Records to Review CDI and Coding: Population & Quality Population Medical vs. surgical cases General practice vs. specialty practice Payer defined Quality initiatives Quality Payment Program (QPP) Health screening 10
Identify the Records to Review CDI and Coding: Impact Hierarchical Condition Categories Deficiencies on the Risk Assessment Score Medicare and Medicare Advantage plans Payer denials Necessity Diagnosis Clinical support E/M level/cpt code Provider RVU scores High E/M level cases or those with greatest opportunity historically High comorbid condition patients Inpatient impact Readmissions Continuity of care Population health/social determinants 11 Medical Coding Role 12
Audit Coding To audit the record for key findings in order to educate the provider Key areas of audit: Correct E/M or CPT code assigned Nature of presenting problem Medical decision making (MDM) History Physical exam Time Counseling Coordination of care 13 Audit Coding To audit the record for key findings in order to educate the provider Key areas of audit: Diagnoses supported and specified to highest degree per ICD 10 CM based on documentation Capture of all conditions (up to 4 diagnoses per CPT code) 12 per claim Documentation elements support the diagnoses and CPT code Decreasing unspecified conditions Documentation signed and dated CMS, ICD 10 CM, and CPT regulation changes 14
Case Scenario 15 Nature of Presenting Problem Chief complaint: B/P and surgical incision left breast. Findings by coder: Assessment and plan not correlated to chief complaint: No mention of reason for surgical incision left breast other than breast lump found in PMH. Essential HTN documented in PMH. Previous records indicate a fibrotic cyst. Impression diagnosed by provider: Hyperlipidemia Anxiety and depression Osteoporosis No documentation of HTN or postoperative follow up of fibrotic cyst in provider impression. 16
Was the Correct E/M or CPT Code Assigned? HPI: No history of present illness documented. PMH: 16 conditions including essential HTN and breast lump. Physical exam: B/P 130/80. HR 82. No other physical exam. MDM: Moderate due to number of problems addressed Three conditions. Medications found in patient medication list. Low management decisions required. Low complexity of establishing a diagnosis. Coded as 99214. 17 Review Findings: Coding Provider E/M code 99214 Diagnoses: Mixed hyperlipidemia Age related osteoporosis Other specified anxiety disorders Coder E/M code 99214 Diagnoses: Hyperlipidemia, unspec Age related osteoporosis Anxiety, unspec Review of systems (ROS) not consistent with nature of presenting problem Chief complaint states left breast incision but integumentary system not examined Mixed hyperlipidemia not supported by documentation Other specified anxiety disorder not supported by documentation 18
Why Should CDI and Coding Travel Together? Coding Provides skills and knowledge of specific outpatient guidelines There is time and talent in determining the correct E/M or CPT code that can only be based on what is documented by the provider at the time of the visit. CDI Skills and knowledge of clinical indicators to validate patient conditions 19 CDI Role 20
Review: CDI To review the record for key findings in order to educate the provider Key areas of audit/review: Problem list deficiencies Past medical history (PMH) Chronic conditions Hierarchical Condition Categories (HCCs) Medication diagnosis Chief complaint UHDDS guidelines followed for diagnosis Clinical relevance with no diagnosis documented 21 CDI Review Prospectively Concurrent Retrospective 22
CDI Prospective Review Identify opportunities prior to patient visit Address quality impact HCC/comorbid conditions not previously captured Pay for performance Problem list Physician profiling Social determinants Communicate findings prior to the visit Paper Electronic Face to face Collaborate with coder Specificity 23 Prospective Review Documentation Documentation Physician communication Problems list Asthma type Weight disorder diagnosis Medication correlation Oxycodone Diazepam HCC: Not addressed to Opioid dependence Rheumatoid arthritis date Quality measures Blood pressure Urinary incontinence Management: CKD Stage 3 Quality measures: Health screening Mammogram: 3 years ago Colonoscopy: Never 24
Concurrent Review Elbow to elbow Real time discussion Provider and patient buy in Collaborate with coder in real time Provider Patient CDI Coder 25 CDI Retrospective Review Identify opportunities not captured at time of visit What was missed/what was captured Quality Specificity HCC Communicate findings post visit: Case findings, trends Paper Electronic Face to face Collaborate with coder Educate each other Trends 26
CDI Provider Note Review Example 27 Review Findings: CDI Chart CC: Presents for general follow up. She was diagnosed with Carbon Monoxide. Using asthma medications PMH: Anxiety, asthma, breast lump, CKD 3, essential HTN, GERD, headache, herpes, lupus, meningitis, migraines, mycobacterium infection, prediabetes, Raynaud s syndrome, shingles outbreak, vasculitis, weight disorder HPI: N/A Meds: Acyclovir, albuterol, amlodipine, diazepam, doxycycline hyclate, epipen, fiorinal, guaifenesin, hydrocortisone, inhaler, metroprolol, oxycodone, pantoprazole, qvar, tussionex pennkinetic, volatren, vytorin Assessment: Asthma, GERD, lupus, mycobacterium infection, continue current treatment plan. Reordered acyclovir and oxycodone. Review Findings Chief complaint: B/P and surgical incision left breast (no documented HTN or surgical diagnosis) HPI: Lump, left breast (no documentation of Dx, but previous note states fibrotic cyst) Medications: Diazepam: Anxiety/depression or urinary incontinence or both? Volatren: Costochondritis and fibromyalgia? Vytorin: Hyperlipidemia unspecified? Oxycodone: Dependence? 28
Review Findings: CDI Chart PMH: Anxiety, asthma, breast lump, CKD 3, essential HTN, GERD, headache, herpes, lupus, meningitis, migraines, mycobacterium infection, prediabetes, Raynaud s syndrome, shingles outbreak, vasculitis, weight disorder Assessment: Asthma, essential HTN, GERD, lupus, mycobacterium infection, continue current treatment plan. Reordered acyclovir and oxycodone. Review Findings Acuity, specificity, current condition? Meniere s disease Migraines Shingles Lupus Etiology of CKD Prediabetes or diabetes no care plan documented Allergy lists irritation to throat no medication documented 29 Recommendations to Provider Impression should include: HTN Fibrotic cyst Relevant current conditions: Opioid dependence Meniere s Migraines Shingles 30
Recommendations to Provider Specificity Asthma Hyperlipidemia Etiology Etiology of CKD 3 and vasculitis Is there diabetes? Is it d/t rheumatoid arthritis? What is diagnosis for oxycodone? What type of asthma? Lupus specificity? Medications indications Diazepam: Anxiety/depression or urinary incontinence or both? Volatren: Costochondritis and fibromyalgia? Vytorin: Hyperlipidemia unspecified? Oxycodone: Dependence? 31 Review Findings Review audit findings with key providers and personnel Present education to providers and healthcare team 32
Education Coding Specificity CDI Missed opportunities How Lunch and learn Targeted emails Report card Division meetings Case examples Who Providers Healthcare team 33 Reassess CDI and Coding 3, 6, and 12 month intervals Has education improved outcomes? What does the data tell you? Focused education initiatives Results: Did you receive the outcomes you expected? 34
Future Impact CDI and Coding New providers Engaged Team building Quality measures Denials Provider requests Report cards KPIs 35 Retrospective Chart Review Template 36
Thank you. Questions? Deanne Wilk dwilk@pennstatehealth.psu.edu Melissa Maguire mmaguire@pennstatehealth.psu.edu 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. 37