This is the Full Title of a Session

Inpatient Psychiatric Hospitals: Let's Talk About Quality Care and Reimbursement Potential Linda Jackson, RHIT Director, Health Information Management Arkansas State Hospital This is the Full Title of a Session Little Rock, Arkansas 1

Learning Objectives At the completion of this educational activity, the learner will be able to: Identify the potential pros and cons of implementing a CDI program in a behavior health setting Discuss quality care and optimum reimbursement in a behavior health setting Identify behavior health CDI specialist tools and educational objectives Recognize organizational culture and mores 2

Arkansas State Hospital (ASH) 3

Arkansas State Hospital Staff 18 Physicians 14 Psychologists 29 Social Workers 152 Nurses Total # staff = 602 4

Patient Days (2017) 10,000 8,000 6,000 4,000 2,000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Gen Adult Adolescent Forensics 5

Average LOS (2017) 500 450 400 350 300 250 200 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ASH Gen Adult Adolescent Forensics 6

Where Shall I Begin RESEARCH 7

CDI in Behavior Health Where Do I Begin? Assess documentation practices Random audits Revealed comorbidities were being missed on treatment plans, progress notes and final diagnoses Hire consultants Consultants identified issues with data incompleteness in 2009 and a need for change on documentation practices You already know there is a problem A look at our codes revealed 70% 80% of our diagnoses were coded to an unspecified ICD 9 diagnosis code Denials after submitting supportive documentation, reimbursement was consistently reduced or denied Identify a physician advisor for your program (This is key and he/she becomes your strongest clinical ally) 8

How Is Coding Being Performed? Comprehensive review of coding process: Admission diagnosis Concurrent Retroprospective Encoder Coding manuals Superbill 9

Borrowing From My Neighbors Don t always try to reinvent, but do not fear creating your own tools Visit facilities with established CDI programs and discuss implementation Identify gatekeepers and ask questions Create your own CDI goals and plans; outline what it should look like and functionality that best suits your facility 10

The secret to my influence has always been it remained secret Salvadore Dali 11

Administration Buy In or Not Arrange a presentation with hospital staff comprised of various disciplines (physicians, administrators, psychologists, finance, nursing, social work etc.) Do your research and know exactly what it will take for an initial start up of a CDI program You have to show the benefit and highlight the detriment, based on your facility s current documentation practices, to support change Multiple entities scrutinize most behavior health facilities Disability rights, health department, child protective services, adult protective services, The Joint Commission, 3rd party payers, RAC, legal community, etc. 12

Looking for your CDI Specialist Hire within your facility: Licensed nurse (RN or LPN) Health information management professional Recruit external candidates Create a multi discipline interview panel including a physician was pivotal to this process ASH panel consisted of QA/QI, billing, HIM and physician leaders/managers 13

CDI Training ICD 10 CM classes Certified procedure coding (CPC) classes (optional?) Invested in ACDIS CDI training off site Gave birth to various tools needed for implementation Query forms Newsletter Etc. Annual membership in ACDIS for CDI Specialists 14

CDI Training cont... One on one meeting(s) with key staff members Billing Admissions UR Coding staff (CDI and coders should have an ongoing relationship) QA/QI Physicians and psychologists monthly newsletter Visit other facilities that have successfully implemented CDI programs (Children s Hospital and University of Arkansas for Medical Sciences medical school and ancillary professional health facility) 15

CDI Training cont. Hospital ADT, MPI, and billing system Encoder Transcription database Medimar system electronic medication record Electronic treatment plan repository 16

Serving on Hospital Committees Utilization review (UR) Individual unit UR Medical record Executive medical P&T Nursing QA/QI 17

Staff Education Tools CDI focused monthly newsletter One on one training Hospital newsletter Hospital monthly meetings (various disciplines) Anytime CDI staff interacts with clinical staff, is a possible teaching moment 18

Clinical Indicators Infectious disease department Behavior health medical clinic (consults) Traditional CDI resources such as lab, x rays, scans, etc. Transfers to acute care hospitals Patient is transferred back to behavior health hospital 19

DSM 5 vs ICD 10 CM DSM 5 Dementia is described as major or mild neurocognitive disorder in DSM 5 ICD 10 CM Major or minor neurocognitive disorder does not exist in the ICD 10 CM classification system Schizophrenia is only described as schizophrenia in DSM 5 Schizophrenia has multiple qualifiers in ICD 10 CM and could be coded with more specificity 20

DSM 5 (Alcohol Use Disorder, Moderate, in Early or Sustained Remission) Prior to October 1, 2017 F1020 After October 1, 2017 F1021 Alcohol use disorder, moderate Alcohol use disorder, severe Alcohol use disorder, moderate, in early remission Alcohol use disorder, moderate, in sustained remission Alcohol use disorder, severe, in early remission Alcohol use disorder, in sustained remission 21

Clinical Picture Bipolar Disorder Diagnosis code F319 Bipolar Disorder, Unspecified Diagnosis code F312 Current episode Manic episode Severe w/ psychotic features 22

Let s Discuss Handouts Queries Policy CDI newsletter 23

Working Relationship With Clinical, UR and QA/QI Departments and Others What is your case mix index? What are your billing cycles for 3rd party payers? What documentation is monitored by your QA/QI staff? Do you serve on your Billing,UR and QA/QI committees? Do you attend nursing huddle meetings, as well as unit UR meetings? Do you attend Executive Medical Meetings? 24

Top 3 Codes (2017) #Uses F20.9 Schizophrenia 169 F25.0 Schizophrenia disorder, bipolar 86 Z76.5 Malingerer 41 25

Is Our Presence Known CDI requested to attend P&T meetings by director of pharmacy (CDI staff requested review 3rd party denials and record requests) CDI requested to review records by CFO as part of annual account closing CDI requested to review records before impending 3rd party payer audits Director of pharmacy requested that CDI staff be a mainstay on pharmacy & therapeutic committee CDI staff are very helpful with monitoring compliance with clinical indication on physician orders and their overall knowledge contributes to this committee. 26

When Push Back Occurs Don t take it personally Identify person(s) most likely to have concerns regarding the program and look for common ground Show the benefit of having complete documentation as it pertains to discharge planning and smooth transitions of his/her patients to other facilities/programs Consistency Say what you mean and mean what you say. Praise and healthy competition No one wants to be the one to be the reason compliance rating are low 27

Simple Stats Calendar Year: 2013 2014 2015 2016 2017 #Patients 715 723 591 551 560 total # Diagnoses 2553 2534 2394 2443 2808 #Patients with 1 Diagnoses %Patients with 1 Diagnoses Avg #Diagnoses/ Patient 105 88 67 59 22 14.69% 12.17% 11.34% 10.71% 3.93% 3.57 3.5 4.05 4.43 5.01 28

CDI Reviews Total CDI reviews since CDI implementation 8/29/2016: 596 Total query with response within 48 hours: 274 Total queries completed: 315 Query response compliance rate: 87% Note: As of 2/8/2018 29

Five Things I Have Learned CDI Specialist 1. To obtain physician buy in, you have to remain persistent, vigilant, and confident in your acquired knowledge and ability. 2. Learn your clinical staff s personality and love language. 3. There will be push back. 4. Learn your comorbidities, but understand in behavior health setting the focus will be quality first and the financial impact will follow. 5. DSM V does not completely align with ICD 10 CM. Be prepared for this disjoint and its impact on documentation and reimbursement. 30

Physician Feedback THEN Helpful to know what I was missing in my documentation. I was not educated on the reimbursement needs. Fear of someone looking over my shoulder and evidence collected that would be used punitively against me. Indifferent Seemed like another auditing tool/entity of an oversaturated area. Did not fully understand what was being asked of me. Communication was not the greatest. Here we go with another thing for me to do. NOW Nothing but helpful to me. I like seeing the CDI staff on the unit interacting with me and other staff. As a result of CDI queries and education, I document differently. I am more acutely aware of DSM V vs ICD 10 diagnoses and use of specifiers. I don t mind it. Persons selected for the role of CDI appear to be more helpful then punitive. I do see some conflicts with diagnoses such as obesity being added to the treatment plan when there in no treatment being provided. It is conflicting to me. Totally see the benefit and I am using the learned skills at my part time job at another hospital. CDI staff is intelligent and confident and it makes me trust our interactions. 31

Finance and Billing Then Potentially be very positive for the hospital. Concerns about how we would integrate CDI processes into our billing processes. Realizing CDI staff had little billing experience, I wondered how receptive they would be to learning billing processes. Now Overall CDI project has been a success. Impressed and encouraged by how much CDI staff reaches out to billing department with updates that positively impact revenue. Equally impressed with their willingness to ask questions and take recommendations. Would like to see more of their involvement in appeals and medical necessity. 32

Some Things Have Occurred Since CDI Program Implementation CDI staff was recently used during Joint Commission survey to escort surveyors on each patient unit and respond to surveyor documentation questions. Assisted locating documentation needed by Joint Commission surveyor and participated in Joint Commission Update and Exit meetings. Discussed documentation compliance with the surveyor when clarification was needed. CDI staff is used to perform adhoc QA/QI review on physician staff when new documentation requirements are rolled out. 33

Always hire someone better than yourself. CDI Staff Tunisha Spencer, BSN, RN Kandy Farmer, RN 34

Allow room for them to be great. ASH Coders Monica Sloan Audrea Phipps 35

Special Thanks!! Shalah Joiner (IT Department) Tina Grissom (IT Department) Terrance Moore (Billing and Finance Department) Ebony Gaines, RN (Utilization Review) 36

Thank you. Questions? Linda.jackson2@dhs.arkansas.gov 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

DEPARTMENT OF HUMAN SERVICES DIVISION OF DIVISION OF BEHAVIORAL HEALTH SERVICES CDI Clarification Bipolar I PATIENT S ID LABEL NOTE: This form is part of the patient s permanent record. Date: Time: Dear Dr. In response to this query, please exercise your independent professional judgment. Please be advised that coding regulations for an in-patient admission allows the physician to document presumptive/possible diagnoses. The fact that a question asked does not imply that any particular answer is desired or expected. Thank you for your clarification on this document. Please refer to the following clinical indicators for clarification regarding Bipolar I Disorder:. Current episode: Mild Partial remission Most recent episode: Moderate Full Remission Severe Manic with psychotic features Hypomanic without psychotic features Depressed Other, please specify:. Unable to clinically determine Physician s Signature Date Time Verbal Request Electronic Query Thank you! Requested by: Tunisha Boston, RN, 501-396-6240, Tunisha.boston@dhs.arkansas.gov Kandy Farmer, RN, 501-396-6239, Kandy.farmer@dhs.arkansas.gov ASH 11.04.03 F 04 FORM (Effective 08/17/2016) 1 of 1 CDI Clarification Bipolar I (Reviewed 12/01/2016) File in Master Treatment Plan Tab

Volume 3 Issue 1 (February 2018) #Allspecifersmatter SRA Reminder: Please remember to address History of Substance Use located at very TOP of form by marking Yes or No PHYSICIAN QI OPEN AUDIT ITEMS: Psychiatric Evaluation Suicide Risk Assessment CONDUCT DISORDERS Obesity: The Growing Epidemic Almost 70% of Americans are considered Overweight or Obese according to the CDC Obesity=BMI >30 Concerns or Questions: Kandy Farmer, RN, CDIS 501-396-6239 kandy.farmer@dhs.arkansas.gov & Tunisha Spencer, BSN, RN, CDIS 501-396-6240 tunisha.boston@dhs.arkansas.gov Morbid Obesity=BMI >40 AIMS H&P Laboratory Services Physician Orders Treatment Plan Progress Notes Did you Know:

Volume 3 Issue 3 (April 2018) #Allspecifersmatter Nursing: Please remember to document when a TB skin test is both CONDUCT DISORDERS GIVEN and READ on the designated form Substance Use Coding Update (Oct. 2017): There have been codes added to further specify if Substance Use disorders are mild, moderate, or severe in early or sustained remission (including Tobacco Use) Please include Severity of the Substance Use Disorder when documenting it as in early or sustained remission on the MTP and Discharge Summary Physician QI Reminders: 1:1 & LOS orders should be renewed Q 24 hours Progress notes should be completed Q 7 Days for 1 st 8wks Basis for Estimation should be provided for Psychiatric Evaluation findings All sections of MTP should be completed All sections of H&P should be completed Documentation should be Legible Concerns or Questions: Kandy Farmer, RN, CDIS Tunisha Spencer, BSN, RN, CDIS 501-396-6239 501-396-6240 kandy.farmer@dhs.arkansas.gov tunisha.boston@dhs.arkansas.gov