challenges in clinical documentation: stories from the front line jon elion md, facc associate...
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Challenges in Clinical Challenges in Clinical Documentation:Documentation:
Stories from the Front LineStories from the Front LineJon Elion MD, FACC
Associate Professor of Medicine, Brown UniversityPresident and CEO, ChartWise Medical Systems
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Jon Elion MD, FACCJon Elion MD, FACC1. Medical Computing: Since 1969
2. Clinical: Duke-trained cardiologist
3. Academic: Assoc Prof at Brown
4. Administration: Hospital Boards,Foundation and Finance Committees
5. Commercial: Medical software since1994. Now President and CEOof ChartWise Medical Systems(Computer-Assisted ClinicalDocumentation Improvement).
Five Things to Know about Jon…
Jon Elion, M.D., FACC
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Clinical DocumentationClinical DocumentationClinical Documentation should be a
thorough record of the diagnos(es) made, symptoms observed, treatment procedure planned and executed, the care provided,
the outcome of treatment and clinical assessment of the entire treatment
process.**From “Guidelines for Improvement in Clinical Documentation”
by Tom Bilmore; http://EzineArticles/5034354
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Clinical Documentation Clinical Documentation ImprovementImprovement
…improve the accuracy, specificity and completeness of clinical documentation through education, assessment, review,
communication, clarification, querying and analysis of clinical documentation patterns…
*
*From Catholic HealthCare West Clinical Documentation Improvement Program
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Clinical Documentation SpecialistClinical Documentation Specialist…Assess the accuracy, specificity and
completeness of physician clinical documentation and to identify if clinical findings suggest the presence of other
conditions that are not explicitly documented…*
*From Catholic HealthCare West Clinical Documentation Improvement Program
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Patient admitted for bowel surgery
““Heart Heart Failure”Failure”““Heart Heart
Failure”Failure”
““Systolic Systolic Heart Heart
Failure”Failure”
““Systolic Systolic Heart Heart
Failure”Failure”
““Acute Acute Systolic Systolic Heart Heart
Failure”Failure”
““Acute Acute Systolic Systolic Heart Heart
Failure”Failure”
Diuresed, patient
does well
Diuresed, patient
does wellPost-op, Congestive Heart Failure is detected,cardiologistis consulted
Background: One ExampleBackground: One ExampleBackground: One ExampleBackground: One ExampleIf note says:
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It’s All About Quality…It’s All About Quality…
If you pursue reimbursement, you will miss the High Quality Medical Record
… but ...
If you pursue the High Quality Medical Record, the proper reimbursement will follow.
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……Not Just About ReimbursementNot Just About ReimbursementComplete and accurate coded data is essential for:
Improved quality of patient careDecision-making on healthcare policiesOptimizing resource utilizationIdentifying and reducing medical errorsClinical research, epidemiological studies
Physician documentation is thecornerstone of accurate coding
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Don’t fall into this trap!Don’t fall into this trap!
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What Would You Code?What Would You Code? A 92 year-old woman is admitted to the Coronary Care Unit
following a fall at home. She complains of chest and hip pain
She has an elevated troponin, and her ECG shows new inferior ST elevation.
The orthopedic resident sees the patient, reviews the x-rays of the pelvis and hip. His note says “The ice cream fell off the cone”
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What Would You Code?What Would You Code?
Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis
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Fracture of neck of femur 820: 820 Fracture of neck of femur 820.0 Transcervical fracture closed 820.00 … intracapsular section neck of femur, unspec. 820.01 … epiphysis (separation) upper neck of femur 820.02 … of midcervical section of neck of femur 820.03 … of base of neck of femur 820.09 … other transcervical of neck of femur
What Would You Code?What Would You Code?
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S72.02 Fracture of epiphysis (separation) (upper) of femur S72.021 Displaced fracture, right femur S72.022 Displaced fracture, left femur S72.022A Initial encounter closed fracture S72.022B Initial encounter open fracture I or II S72.022C Initial encounter open fracture IIIA, IIIB, or IIIC S72.022D Subsequent encounter closed fracture healing S72.022E Subsequent encounter open fracture I or II
with routine healing …
What Would You Code?What Would You Code?
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Documentation:Documentation:Why Should We Care?Why Should We Care?
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Documentation:Documentation:Why Should We Care?Why Should We Care?
THEY AREWATCHING YOU!
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Documentation:Documentation:Why Should We Care?Why Should We Care?
• A patient with cholecystitis undergoes a cholecystectomy
• Post-op, the patient spikes a temperature with high WBC
• Abdomen tender, diffuse rebound, pulse 110, respirations 22
• KUB and abdominal CT unremarkable
• IV Cipro started, Infectious Disease consulted
• Patient improves, is discharged on post-op day 6 on oral Cipro
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Documentation:Documentation:Why Should We Care?Why Should We Care?
Acute Cholecystitis + Laparoscopic Cholecystectomy$8,168, expected LOS 2.4 days
Adding Probable Acute Peritonitis and Sepsis$17,477, expected LOS 6.2 days
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Documentation:Documentation:Why Should We Care?Why Should We Care?
October 21, 2013
United Healthcare dropping R.I. doctors fromMedicare Advantage network
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What Would You Code?What Would You Code? One of the great mentalists of 1800s
A frenetic performance, culminatingin a “catalectic fit”
A note in his pocket stated hiscatatonic state was not death
After a fit at a performance in 1889he was promptly autopsied
His death certificate officially read “hysterocatalepsy”
Washington Irving Bishop 1855 – 1889
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Psychogenic non-epileptic seizures are events superficially resembling an epileptic seizure, but without the characteristic electrical discharges associated with epilepsy
ICD9: 780.39 Other Convulsions
ICD9: 300.11 Conversion Disorder
ICD10: F44.5 Dissociative Convulsions
Death by Autopsy ???
Did they use ICD1 in 1889 ???
FYI: HFYI: Hysterocatalepsyysterocatalepsy
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1853: The 1st International Statistical Congress: Resolution requesting the preparation of a uniform classification of causes of death
1891: The International Statistical Institute (successor to the International Statistical Congress), charged a committee with the preparation of a classification of causes of death
1893: The report of this committee was adopted by the International Statistical Institute
For all practical purposes, this was “ICD1” (but never called that)
Think ICD-10 is Taking a Long Time?Think ICD-10 is Taking a Long Time?
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Near-Death by Autopsy?Near-Death by Autopsy? Best remembered for “Paget’s
Disease” of the bone
Considered as the founder ofscientific medical pathology
Developed septicemia after aself-inflicted injury during autopsy
Thereafter he claimed that he wasthe first person ever to survive the attention of 10 doctors
Sir James Paget 1814 – 1899
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What’s Wrong with This Picture?What’s Wrong with This Picture?Hi Dr. Elion,Can I please get your permission to make this modification:
Patient D.M. (DOB: 10/7/1948) admitted 3/12/14. You billed 401.1 Benign Hypertension; however, documented in note is “Hypertensive Urgency.” There is a more specific diagnosis we could use instead of 401.1. Do you want to bill 402.10 Hypertensive Heart Disease Benign without Congestive Heart Failure in place of 401.1?
Thank you, WLClinical Coding Specialist, CPC-A, CEMC
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My ReplyMy ReplyThere is no corresponding ICD9 code for “Hypertensive Urgency”. If signs of current or impending end-organ damage, then it is one of the variations of “malignant” hypertension. Without that, it is Essential Hypertension, 401.1.
In order the have 402.10 Hypertensive Heart Disease, there would need to be evidence that the heart was involved in the hypertension process. The echo done January 22, 2014 says:
“The left ventricle chamber size, wall thickness, and systolic function are within normal limits”
So the patient would not qualify for 402.10
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What’s Wrong with This Picture?What’s Wrong with This Picture?
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Due ToDue To
This patient is known to have severe Aortic Stenosis.
Her downhill slide is probably due to dietary
indiscretion (she does not follow her diet). She is
symptomatically much improved after initial diuresis.
Her clinical picture is consistent with acute-on-
chronic systolic CHF due to Aortic Stenosis.
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Query for ClarificationQuery for Clarification Query physicians for clarification and additional
documentation when there is conflicting, incomplete, or ambiguous information in the record
Do not query: when there is no supporting clinical information
for gram-negative pneumonia on every pneumonia case, regardless of clinical indicators
for sepsis when the clinical indicators are only suggestive of UTI + fever + increased WBCs
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When to QueryWhen to Query Legibility: Illegible handwritten notes, and cannot
determine the provider’s assessment
Completeness: For example, an abnormal test results without notation of the clinical significance
Clarity: For example, diagnosis noted without statement of a cause or suspected cause
Consistency: Disagreement between two or more providers about diagnosis
Precision: Clinical reports and clinical condition suggest a more specific diagnosis than is documented
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Not Only HandwrittenNot Only HandwrittenNotes are Illegible!Notes are Illegible!
Transfer: x 3 reps min assist progressing to CG with RW
Ambulation: 50 feet with RW with supervision, increased plantarflexion and hip flexion resembling TDWB, …Daughter ed re stair pattern, RW ordered.
Assessment Plan … not able to attempt stairs 2 to c/o and increased HR. RW ordered and received … D/c will likely be postponed today. Continue POC as tolerated.
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Doctors on StrikeDoctors on Strike
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Assessment Plan1.high k- resolved- I am very worried about gi bleed- needs stolls- ? gi consult2.esrd- hd for wed3.avr- on hep> coumadine4.bradycardia- resolved 5.dm
pt follows diet and goes to dial- he has high k , dropped hb, abd pain>>?? gi bleed????
What Would You Query?What Would You Query?
Query on abnormal lab interpretation
Query for clarification of “avr”Query for clarification: what is it due to?
Query for completeness
Query for abnormal lab and for cause
Query for completeness, specificityThis doc needs to
learn about !!!
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The Kwashiorkor StoryThe Kwashiorkor StoryResults from inadequate protein intake.
Early symptoms:•Fatigue•Irritability•Lethargy
Late symptoms:•Growth failure•Loss of muscle mass•Generalized edema•Decreased immunity•Large, protuberant belly
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One Hospital’s Kwashiorkor One Hospital’s Kwashiorkor Around 250 beds in a small town, median home price
$250,000, average income $60,000
1,030 cases reported in Medicare patients (18.6%). $11,463 per patient
Next highest incidence in the state 172 patients (3.8%)
One patient (shown here) has nonotation in the chart about edemaor swelling, no nutrition consult
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Adult Malnutrition:Adult Malnutrition:Two or More FindingsTwo or More Findings
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
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Adult Malnutrition: DocumentationAdult Malnutrition: Documentation History and Clinical Diagnosis: Conditions that might be
associated with inflammation and nutritional disturbances Clinical Signs and Physical Examination: SIRS, fluid
accumulation, signs of weight gain or weight loss. Anthropometric Data: Height, weight and weight history,
skin folds, circumference, other body composition metrics. Laboratory Indicators: Low proteins related to morbidity
and mortality. Inflammation, negative nitrogen balance Dietary Data: A diet history or 24-hour dietary recall Functional Outcomes: Assessment of strength and physical
performance, along with other associated findings.
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Adult Malnutrition: Jon’s TipsAdult Malnutrition: Jon’s Tips Be sure that there is a clinical sense of a potential
nutritional disturbance before proceeding any further! Verify that at least 2of the 6characteristics from the ASPEN
guidelines are present to further confirm the diagnosis Avoid temptation to query about malnutrition (or to code
for it) when the only basis is an abnormal lab result Use the 6-point template suggested by the ASPEN
guidelines to provide complete documentation Look for other conditions and diagnoses that may produce
or be associated with malnutrition Don’t confuse the need for nutrition for the presence of
malnutrition
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EncephalopathyEncephalopathy Rapid involuntary eye movement Inability to swallow or speak Muscle twitching, atrophy, weakness and tremor Memory loss, loss of cognitive ability Personality changes Inability to concentrate Loss of consciousness Dementia, seizures, lethargy
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… … and at One Hospitaland at One Hospital
36% incidence in elderly Medicare patients at one hospitals
Other hospitals in the state reported encephalopathy in 3.6% of that population
A hospital could earn $7,000 per case for treating the condition as a complication
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Not all Altered Mental Status is encephalopathy
Some consultants emphasize pursuing this diagnosis as an apparently easy way to increase revenues
Develop clear criteria for the diagnosis at your hospital
Anticipate close scrutiny from auditors
Beware!Beware!
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First Document the Cause of AMSFirst Document the Cause of AMS Neurodegenerative diseases:
– Alzheimer’s disease (delusional, depressed, or psychotic)– Lewy body dementia (associated with Parkinson’s disease)
Psychiatric illnesses:– Mood disorders (unipolar depression or bipolar disorder 1 & 2)– Schizophrenia (specified as to the type)– Chemical dependencies, including drug withdrawal syndrome
AMS caused by a focal structural problem with the brain; seizure, concussion, stroke, transient ischemic attack, or tumor.
AMS caused by global dysfunction of the brain (encephalopathy!); toxic, septic, metabolic, hypertensive, or hepatic.
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CDI: It’s Front Page NewsCDI: It’s Front Page News
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If you have a high incidence of Kwashiorkor
If your CDI consultant promised in writing to increase revenues
If the first hour of your first day of training is all about encephalopathy
If you have an high incidence of malignant hypertension
If you are told:– Find an MCC then move on– Query for reimbursement or SOI
You May Be Headed forYou May Be Headed forthe Front Page…the Front Page…
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A Few Helpful ReferencesA Few Helpful References Consensus Statement of the Academy of Nutrition and
Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)J Acad Nutr Diet. 2012;112:730-738.www.wvda.org/meeting2012/Malnutrition.pdf
Cut Through the Confusion of Altered Mental Status by Brian Murphy. Association of Clinical Documentation Specialists, June 2009.www.hcpro.com/content/235239.pdf
Clinical Documentation Intelligence: www.chartwisemed.com
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