Post on 14-Jul-2018
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CDI for Inpatient CodingKimberly Cunningham CPC, CIC, CCS
No part of this presentation may be reproduced or transmitted in
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without the expressed written permission of AAPC.
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• Clinical Documentation Improvement in an Inpatient setting
• Common inpatient conditions that often create documentation and coding problems
• Accurate physician documentation and tips on how to improve your physician’s
documentation
• Effective query writing and when it is appropriate to query the physician
• Clinical indicators and how they can help improve physician documentation
CDI for Inpatient Coding
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What does CDI look like in the for Inpatient Coders?
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CDI Professionals
• CDI Specialist
• Inpatient Coder
• Auditor
• Nurse Reviewer
• Physician Reviewer
• Quality Department
CDI for Inpatient Coding
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Importance of Clinical Documentation
• The goal of Clinical Documentation Improvement initiatives in the inpatient setting are to
maximize the opportunity to obtain the most accurate account of the patients inpatient
hospital stay. CDI specialists work to review the documentation while the patient is still in
the hospital. This allows for real time interaction between CDI professionals and
Practitioners to capture the most accurate diagnoses.
• CDI professionals have important knowledge regarding documentation requirements for
various diseases and conditions that are often problematic for physicians. By reviewing the
documentation and data while the patient is still in house, the problematic documentation
can be reviewed and clarified by the physician before the patient is discharged from the
hospital.
CDI for Inpatient Coding
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Importance of Clinical Documentation
• With the implementation of ICD 10 CM and PCS in October, 2015, and the specificity to
which to codes account for, physician documentation requires great detail with clear and
concise documentation. Many payers will not allow diagnoses to be submitted to an
unspecified category, so physicians are required to clearly define the patients condition.
• CDI professionals and CDI initiatives promote the best practice for the entire revenue
cycle. From the time the patient is admitted to the facility, CDI professionals analyze the
documentation and data, and work with the physician to ensure that the patient’s condition
is captured completely, prior to discharge. This helps to decrease the number of
retrospective queries to physicians post discharge.
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Emergency Department Admission
Labs and other
Diagnostic tests
performed
Inpatient Admission
Consult Specialist
Labs and other
Diagnostic test results reviewed
Physician MDM and
DD
Attending physician determines
diagnosis and treatment plan
Patient Discharged
Code and Submit
Claim or Bill for IP
Encounter
Each Triangle representsan
opportunity for CDI review and documentation improvement.
CDI for Inpatient Coding
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Impact of CDI on Inpatient Reimbursement
• Clinical Documentation Improvement initiatives can directly impact reimbursement as well as facility quality
measures and data reporting.
• Beyond the ongoing CDI reviews that take place during the inpatient encounter, prebill audits or reviews can be
done to ensure accuracy of the documentation and coding before the bill is dropped.
• Ongoing Quality reviews of CDI specialist and Inpatient Coders to ensure accuracy help to maximize
reimbursement and insure that documentation reviews and coding are accurate.
• Audits of physician documentation, along with physician education can improve physician documentation and
ensure the accuracy of the codes assigned, and maximize reimbursement.
Common Inpatient Conditions in CDI
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Sepsis
• Septicemia is the most expensive condition treated in US hospitals
• Accounts for 5% of all hospitalizations in the United States
• 85% of patients with sepsis are admitted with the infection, the remainder acquire the condition as an inpatient
• Overall Inpatient death rate of 17.2% of those admitted with Sepsis
• Death rate climbs in those with hospital acquired sepsis
• 38.6% for medical admissions
• 29.2% for surgical cases
• Sepsis is more costly to treat in academic facilities
Common Inpatient Conditions in CDI
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Sepsis
• Common Documentation Errors with Sepsis
• Coding/CDI language of sepsis and physician language do not always match. Physicians will
often write statements like “urosepsis” or “sepsis like” among others to describe a patient that
may be septic.
• As coders and CDI specialist, there are very specific terms that indicate sepsis, or another
diagnosis such as bacteremia, SIRS, or another localized infection. It is often necessary to
query a physician to determine if sepsis was POA and treated during the inpatient hospital stay.
• CDI professionals should look for clinical indicators that coincide with a diagnosis of sepsis,
along with clear and concise documentation of sepsis in order to ensure proper code
assignment.
Common Inpatient Conditions in CDI
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Acute Respiratory Failure• There are Two Types of Respiratory Failure:
• Hypoxic: There is not enough oxygen in the blood.
• Respiratory Failure occurs when fluid builds up in the air sacs in the lungs and then oxygen cannot be released into the
blood.
• Hypercapnic: There is to much carbon dioxide in the blood.
• Respiratory failure occurs when the capillaries in the air sacs in the lungs cannot properly exchange carbon dioxide for
oxygen.
• There are many causes of Respiratory failure including, but not limited to:
• Injury
• Obstruction
• ARDS – Acute Respiratory Distress Syndrome – generally occurs with an additional underlying problem
• Drug and/or Alcohol abuse
• Chemical inhalation
• Stroke
• Patients most at risk for having respiratory failure generally smoke, or have a history of smoking, consume excessive amounts of
alcohol, have a family history or respiratory conditions or diseases, sustain an injury, or have a chronic lung disease such as cancer or
COPD.
Common Inpatient Conditions in CDI
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Respiratory Failure
• Common Documentation Errors with Respiratory Failure
• Physicians will often document respiratory failure or acute respiratory failure in instances when
the patient may be having respiratory symptoms due to another underlying condition or cause,
such as heart failure, COPD, lung injury, post surgical period etc.
• Depending on the origin of the respiratory failure, coding guidelines may provide sequencing
instruction that will require specific physician documentation of the cause of the patient
respiratory condition.
• CDI professionals should look for clinical indicators that coincide with a diagnosis of respiratory
failure, along with clear and concise documentation of the condition in order to ensure proper
code assignment.
Common Inpatient Conditions in CDI
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Pneumonia
• Pneumonia is a lung infection caused by a bacteria, virus or fungi.
• There were 1.1 million inpatient discharges for pneumonia in 2015.
• The average length of an inpatient hospital stay for a patient diagnosed with pneumonia is
5.2 days.
• Most healthy people recover from pneumonia, however the condition can be life
threatening.
• Around 1/3 of all pneumonia cases are caused by a virus, with the flu virus being the most
common viral cause.
• A chest x-ray is usually needed to diagnose pneumonia.
• Generally inpatient pneumonia treatment involves fluids, antibiotics and sometimes
respiratory therapies such as inhalers, nebulizers or oxygen.
Common Inpatient Conditions in CDI
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Pneumonia
• Common Documentation Errors with Pneumonia
• Physicians will often document a diagnosis of pneumonia, and they will also document any
bacterial findings that may be present on any diagnostic labs. Unless the physician documents
a relationship between the pneumonia and the organism, the pneumonia cannot be coded to
that type of bacterial pneumonia.
• Pneumonia is a common condition that can develop while a patient is receiving care in a hospital
or facility. Often physicians will document CAP or HAP which indicates, community or hospital
acquired pneumonia. It is important to determine if the pneumonia was present on admission,
or if it developed subsequently following admission to the hospital.
• CDI professionals should look for clinical indicators, including imaging that coincide with a
diagnosis of pneumonia, along with clear and concise documentation of the condition in order to
ensure proper code assignment.
Common Inpatient Conditions in CDI
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Heart Failure
• Congestive heart failure is the leading cause for admissions of adults 65 years of age and
older.
• There are greater than 1 million admissions annually with CHF as the principal diagnosis.
• There are nearly 6 million Americans living with Heart Failure.
• There are over 900,000 new diagnoses each year.
• In 2012, CHF accounted for $17 billion in Medicare expenditures.
• Most common comorbid conditions are coronary artery disease, high blood pressure and a
prior heart attack.
• Common tests done to diagnose Heart Failure include blood tests, chest x-rays, EKG,
ECHO, Stress tests, scans and cardiac catherization.
Common Inpatient Conditions in CDI
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Heart Failure
• Common Documentation Errors with Heart Failure
• Physicians will often document a diagnosis of heart failure, but they will neglect to document the type of heart
failure, either diastolic or systolic, and the acuity of the condition. This documentation is key to accurately
capturing a heart failure diagnosis.
• Another common documentation error that occurs with heart failure is the documentation of comorbid
complications associated with heart failure such as pleural effusions, edema and respiratory conditions. All of
these conditions are inherent, and are symptoms of a heart failure diagnosis. So they would not coded
separately unless there is specific treatment directed to that condition. For example a heart failure patient with
a pleural effusion that is treated with a chest tube placement. The pleural effusion can be coded as an
additional diagnosis.
• Heart failure patients often have many coexisting diagnoses, some of which, when documented by the
physician can be reported with relation to the patient’s heart failure, such as hypertension. It is important that
the physician clearly establishes a relationship between the both conditions for accurate code assignment.
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Common Inpatient Conditions in CDI
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Encephalopathy
• Encephalopathy is a disease that affects the function or structure of the brain.
• There are many different types of encephalopathy. Below are a few types, certainly not all:
• Chronic Traumatic
• Hepatic
• Hypertensive
• Hypoxic
• Lyme
• Static
• Toxic Metabolic
• Patients with encephalopathy may present with altered mental status including severe confusion and
disorientation, and memory loss.
• Other symptoms include weakness, difficulty speaking, seizures, lethargy and even coma.
Common Inpatient Conditions in CDI
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Encephalopathy
• Common Documentation Errors with Encephalopathy
• Physicians will often document a diagnosis of encephalopathy, however within the medical
record the documentation does not clearly support the diagnosis of encephalopathy.
• Often encephalopathy will be reported, and the diagnosis is supported, however it is integral to
another reported condition, and therefore, not separately reported.
• Patients with encephalopathy often have many complicated additional diagnoses and conditions
that can make it difficult to determine if the condition was present and treated during the
inpatient hospital encounter, or if another diagnosis is responsible for the patients condition.
Common Inpatient Conditions in CDI
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Acute Kidney Failure (AKI)
• Acute Kidney Failure occurs when the suddenly lose the ability to eliminate salt, fluid and waste from the blood.
This can cause electrolytes and waste materials to accumulate in the body which can be a life threatening
condition.
• Also documented as acute kidney injury and acute renal failure.
• AKI is a common condition that often develops to patients that are in the hospital for other reasons, and can
develop very quickly, however those that are critically ill are most at risk. AKI often occurs in patients that also
have dehydration, urinary tract obstruction, injury, hemorrhage, burns, low blood pressure, serious injury or
illness, are post surgical or have sepsis.
• AKI requires inpatient treatment and monitoring to effectively treat the condition.
• Labs tests of the blood and urine, along with imaging are used to diagnose and monitor AKI.
Common Inpatient Conditions in CDI
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Acute Kidney Injury (AKI)
• Common Documentation Errors with Acute Kidney Injury
• Physicians will often document kidney dysfunction with terminology of prerenal, intrarenal and
post renal. These terms alone are not enough to document acute renal failure or AKI. The
physician needs to clearly document that the patient has AKI for it to be reported.
• Often AKI will occur in patients that have Chronic Kidney Disease. It is important to carefully
review the documentation and confirm that patients baseline status, as it may differ from a
patient that does not have CKD and is suffering from AKI. If both conditions occur, both are
reportable diagnoses.
• Physicians will often diagnose a patient with renal insufficiency. This is different from AKI.
Renal insufficiency is the early stages of renal impairment that has not progressed to failure. If
this condition is documented it may be necessary to query to physician to determine the proper
diagnosis.
Common Inpatient Conditions in CDI
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Anemia
• Anemia is the most commonly found blood disorder and occurs in more than 3 million Americans.
• Patients with Anemia lack oxygen in their body. Symptoms of Anemia include weakness, shortness of breath, dizziness, fast or irregular heartbeat, headache, whooshing sound or pounding in the ears, cold hands or feet, pale or yellow skin and chest pain.
• There are many risk factors for anemia that make it a common condition among the inpatient population such as poor diet, intestinal disorders, chronic illness, infections and being postsurgical.
• Iron-deficiency anemia is the most common type of anemia and occurs when the body does not have enough iron in the body. This usually occurs due to blood loss, but can also be due to poor absorption of iron.
• Anemia also occurs in chronic diseases such as chronic kidney disease and neoplasms. Patients receiving chemotherapy for treatment of their neoplasm can develop Aplastic Anemia which is a rare type of anemia that occurs when the body stops making red blood cells.
Common Inpatient Conditions in CDI
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Anemia
• Common Documentation Errors with Anemia
• Patients that are having a surgical procedure are at risk for blood loss and anemia. These
patients often incur a post surgical drop in hemoglobin that is an expected occurrence following
some surgical procedures or childbirth. It is important to carefully review physician
documentation to determine the proper diagnosis of documented anemia in those instances.
• There are sequencing guidelines with reference to coding anemia with a neoplasm. It is
important to carefully review the documentation to determine the type of anemia present, and
the focus of care for the inpatient encounter.
Common Inpatient Conditions in CDI
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Complications of Care
• Complications of care range from Hospital Acquired Conditions (HAC) or Hospital Acquired Infections (HAI) to
post surgical and post traumatic complications, pressure ulcers and injuries while an inpatient, as well as adverse
effects and other complications of medical care.
• CMS publishes the list of HACs in the Final Rule each year.
• Many facilities track data as it relates to complications of care and have protocols in place to help prevent
complications from occurring.
Common Inpatient Conditions in CDI
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Complications of Care
• Common Documentation Errors with Complications of Care
• Physician documentation regarding the relationship between medical care and complications
needs to be clearly documented. If there is not a relationship established by they physician it
cannot be documented as such.
• There are sequencing guidelines with reference to coding complications and other conditions
that need to be accounted for when sequencing coding for cases of complications of care.
• Some outcomes are anticipated follow surgical procedures and medical care, and are not
reported as complications of care. Clear and concise physician documentation must be present,
or the physician must be queried when the documentation is unclear.
Common Inpatient Conditions in CDI
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Procedure Coding
• With the implementation of ICD 10 PCS, clear and accurate accounts of procedures is necessary for proper code
assignment.
• ICD 10 PCS requires a strong knowledge of Anatomy and Physiology, as well as surgical terminology in order to
effectively assign the proper procedure codes.
• CDI specialist and coders may not always use the same terminology with regard to procedure descriptions. It is
important to note that it is not the job of the physician to use the terminology that is used by ICD 10 PCS, but
rather it is the job of the coder to review the procedure and determine the proper code assignments based on the
physician account of the procedure.
• DRG assignment for Inpatient encounters is divided by surgical and non surgical DRG assignment. It is important
to accurately ensure the documentation matches the procedure code assignment to insure proper
reimbursement.
Common Inpatient Documentation Issues in CDI
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Importance of Accurate and Detailed Physician Documentation
The detail and accuracy of physician documentation is key to proper reimbursement and data
reporting.
• Common Inpatient Documentation Issues:
• Conflicting Documentation
• Diagnosis not confirmed on Discharge Summary
• Two or more Conditions exist on Admission
• Clinical indicators do not support a diagnosis or vice versa
Common Inpatient Documentation Issues in CDI
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Conflicting Documentation
Conflicting Documentation:
• Principal or secondary diagnosis is confirmed on the discharge summary but not clearly and concisely document
in the body of the medical record, or the documentation in the record is vague or incomplete.
• Two physicians call the same condition two different things. A consulting physician may note one diagnosis, while
an a different or attending physician refers to the same condition with a different diagnosis.
• Early workup, such as ED documents or History and Physical report document one conditions, however over the
course of evaluation, the condition may be an entirely different diagnosis.
Common Inpatient Documentation Issues in CDI
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Diagnosis not confirmed on the Discharge Summary
• Principle of secondary diagnosis that are reported as having existed or established throughout the medical
record, but not confirmed at the time of discharge.
• Diagnosis described as probably, possible, suspected etc. must me documented as such at the time of discharge
in order to be reported. Initial workup may indicate a probably condition, but the continuing evaluation may
determine an entirely different diagnosis.
Common Inpatient Documentation Issues in CDI
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Two or more conditions exist on admission
• When two or more conditions exist on admission but one condition requires treatment with surgical management.
• When two or more conditions exist on admission, but one condition requires more intensive treatment such as IV
medications, and monitoring that is only available as an inpatient.
Common Inpatient Documentation Issues in CDI
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Clinical indicators do not support Physician documentation or vice versa
• Clinical indicators may support a diagnosis, however the physician may not document the diagnosis.
• A physician my report a diagnosis, however, clinically the documentation does not support that diagnosis.
• Clinical Indicators have become a large part of CDI and Inpatient coding. With the implementation of RAC audits,
and the continued scrutiny of physician documentation and coded data, it is important for CDI specialists and
Inpatient coders to have a strong working knowledge of clinical indicators and disease process. This helps
facilitate a collaborative documentation and reporting relationship between the physician and the HIM staff. It
allows for the most accurate account of the patient encounter to be captured, and optimizes reimbursement
potential.
• Many facilities adopt clinical indicator standards for reporting of commonly treated conditions.
Common Inpatient Documentation Issues in CDI
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How to Improve Physician Documentation
• Physician Education
• Clinical Indicator Standards
• Documentation Standards
• Documentation and Coding Audits and Review
Common Inpatient Documentation Issues in CDI
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Physician Queries
• A physician query is a method of communication used by coders and clinical documentation professionals to
request clarification of patient diagnoses or procedures from the physician. The physician query is used to clarify
documentation by clarifying conflicting, ambiguous, or incomplete information about significant conditions or
procedures in the medical record of the patient. In addition to obtaining clarification, the query may serve as an
educational tool to improve physician documentation and the coders’ understanding of clinical scenarios.
• Queries are often necessary for clarification. Queries can be done while the patient is still an inpatient in the
hospital to allow the physician an opportunity to clarify a diagnosis or procedure prior to the patient's discharge.
These are called concurrent reviews and queries. A query that is conducted after the patient has been
discharged is called a retrospective query. The facilities’ processes should include some manner of recording
the queries, such as an electronic database, or inclusion of the query in the medical record.
Common Inpatient Documentation Issues in CDI
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Physician Queries
• Physician Queries should include:
• Patient name
• Admission date and/or date of service
• Health record number
• Account number
• Date query initiated
• Name and contact information of the individual initiating the query
• Statement of the issue in the form of a question along with clinical indicators specified from the chart
Common Inpatient Documentation Issues in CDI
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Physician Queries
• The query should not be constructed in a manner that can be interpreted as leading the physician. Queries can
be open ended, and provide documentation from the medical record, along with clinical documentation to obtain
and a more concise diagnosis from the physician. Multiple choice or yes/no queries can also be utilized, however
it is important when providing choices for physicians to include the option of other, or if the diagnosis was
uncertain, or could not be determined.
• When responding to a query, the physician may document the response to the query in the body of the patient
medical record, such as on the progress notes, or in an addendum to other documentation. The physician query
can also be made part of the medical record.
Questions?
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• American Heart Association – Akshay S. Desai, MD, MPH; Lynne W. Stevenson, MD 2012
• http://circ.ahajournals.org/content/126/4/501.full
• National Kidney Foundation
• https://www.kidney.org/kidneydisease/aboutckd
• Centers for Disease Control and Prevention
• http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm
• Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4751740/
• World J Urol. 2014 Jun;32(3):813-9. doi: 10.1007/s00345-013-1167-3. Epub 2013 Sep 27.
• Pneumonia Fastats
• http://www.cdc.gov/nchs/fastats/pneumonia.htm
• Hospital-Acquired Condition Reduction Program (HACRP)
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html
• Diabetes Fastsats
• http://www.cdc.gov/nchs/fastats/diabetes.htm
• Management of diabetes mellitus in hospitalized patients
• http://www.uptodate.com/contents/management-of-diabetes-mellitus-in-hospitalized-patients
• Acute Respiratory Failure Written by Brindles Lee Macon and Winnie Yu Medically Reviewed by Deborah Weatherspoon, Ph.D, RN, CRNA, COI on October 13, 2015
• http://www.healthline.com/health/acute-respiratory-failure#Causes3
• Encephalopathy Written by Rose Kivi | Published on August 20, 2012 Medically Reviewed by Peter Rudd, MD
• http://www.healthline.com/health/hepatic-encephalopathy#Overview1
• Acute Kidney Failure Written by Bree Normandin and Winnie Yu Medically Reviewed by Steven Kim, MD on November 4, 2015
• http://www.healthline.com/health/acute-kidney-failure#Overview1
• American Society of Hematology
• http://www.hematology.org/Patients/Anemia/
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References: