All Entries Tagged With: "DRG"
Few IPPS changes final rule could cause CDIs trouble
There are a few changes in the IPPS final rule that may prove problematic for clinical documentation improvement specialists, according to Robert S. Gold, MD, CEO of DCBA, Inc., Atlanta.
Hypoxic ischemic encephalopathy (HIE), for example, has its roots in the pediatric population. So it will be important to recognize that the code for an adult with HIE is 348.1— anoxic brain damage. “And we need to be specific about the causes of encephalopathy in the neonate,” says Gold, “they’re not all HIE.”
The 285.3 code for anemia due to anti neoplastic treatment is different from anemia due to neoplastic disease and different from aplastic anemia from chemotherapy. The CDI specialists has to know what cell lines are missing and determine the true cause of the anemia in order to frame the question to the physician properly.
Gold also suggested that CDIs require better specificity of location of blood clots currently under treatment with Coumadin in order to assign the right code for deep vein thrombosis. He also suggested that physicians need to document whether the condition is new during the patient’s current hospital stay or whether it had been under treatment from a previous hospitalization.
Finally, Gold urged healthcare professionals to “work to preserve” the terms acute renal failure and acute kidney injury and to totally downplay the new definition of acute kidney failure. “This is a misunderstanding currently under discussion. You don’t want to promote the use of a term that might not last long. You don’t want to have to re-teach,” he says.
Fall intro to ICD-9-CM offered in Boston
Gee, it seems like I’m all about the local trivia recently—from hazelnuts to evergreens, state flags to historic settlements. Well, since I’m apparently on a roll. Let’s talk about my hometown Boston.
- The first American lighthouse was built in the Boston Harbor in 1716.
- The first public school system was founded in Boston in 1635.
Boston Common is the center piece of the Olmstead designed Emerald Necklace of parks.
- When you take a stroll on the Boston Common, you are visiting the nation’s first public park, established in 1634.
- Boston Common is part of the larger Emerald Necklace parkway designed by landscape architect Frederick Law Olmstead who also designed Central Park in New York City and a little place call Moraine Farm in Beverly, MA, where yours truly married the love of her life five years ago. (By the way, according to the US Census Bureau, Massachusetts has the lowest divorce rate in the country with 2.2 divorces per 1000 people.)
- The Hyatt Harborside Hotel in Boston is the site of the next stellar program “ICD-9-CM Coding Essentials: What Every CDI Specialist Needs to Know,” on September 21.
Now I’m not saying Shannon McCall’s class is as exciting as my wedding nor as relaxing as a stroll along Boston Common, it’s definitely a day full of invaluable information. I participated in this program during the 2009 ACDIS conference in Las Vegas and was nearly overwhelmed with the depth and breadth of tools she was able to cover. And for once I’m not just playing my own tune. Many CDI specialists who attended also found it beneficial.
“I would recommend this seminar to colleagues,” said Pamela Lindsey, RN, BSN, MCRMC, Fraser, MI. “It provides a good base of information for a CDS (RN) program. It was helpful to gain information on navigating through the ICD-9 manuals along with the other materials.”
They’ve extended the early bird registration rate through August 24, which saves you $100, and if you are currently an ACDIS member be sure to ask for member discounts too. To register, visit www.hcmarketplace.com.
CMS abandons IPPS payment reduction for now
Though many hospitals feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31. CMS had originally proposed a documentation and coding adjustment to account for the effect of increases in aggregate payments due to changes in hospital coding practices that it says do not reflect increases in patients’ severity of illness.
The proposed adjustment would have resulted in historically low payments for hospitals and especially penalize hospitals that have yet to develop a clinical documentation improvement (CDI) program, says DeAnne Bloomquist, RHIT, CCS, president and chief consultant for Mid-Continent Coding, Inc. in Overland Park, KS. “I think that means that hospitals can breathe a sigh of relief.”
In the proposed IPPS rule, CMS intended to reduce future payment rates “based on the observed increase in spending due to documentation and coding that occurred in fiscal 2008,” according to CMS’ press release. However, because it does not have a full year of data that would show the extent of documentation and coding effects on 2009, CMS decided not to implement the adjustment until it has a full year of FY 2009 data.
In the next year, hospitals with CDI programs should continue their initiatives, while those who have not implemented one yet should work toward that goal, says Gloryanne Bryant, RHIA, CCS, CCDS, Regional Managing HIM Director at Kaiser Foundation Health Plan Inc & Hospitals.
Chapter 3: The MS-DRG Training Handbook
We’re constantly talking about to get the word out about the importance of clinical documentation improvement. How can we teach physicians that the specific language they use in the medical record affects their patient’s treatment, their quality scoring, hospital reimbursement, and their own reimbursement too?
First to answer the triva questions wins a set!
Some of you may be familiar with The MS-DRG Training Handbook written by ACDIS Advisory Board member Gloryanne Bryant, BS, RHIA, RHIT, CCS, but for those who haven’t seen it yet there’s a collection of examples for explaining the MS-DRG system to physicians in Chapter 3, I thought I’d share with you:
“1. Call upon physicians to better document the character, underlying causes, complications, and severity using ICD-9-CM language. For example, in order to get decompensated CHF to count as an MCC, physicians must clearly state that it is acute and must document whether it is systolic or diastolic heart failure. Stating one without the other will result only in a CC.
“2. Ask physicians to clearly document the underlying mechanisms of certain manifestations. For example, if a patient has hyperkalemia as the result of the drug spironolactone, the physician needs to document the state of hypoaldosteronism. Similarly, if a patient has delirium due to narcotics, the CDI specialist needs to query the physician regarding the extent or possibility of toxic encephalopathy. “
The Handbook includes a good amount of basic, easy-to-understand information regarding the development and importance of the MS-DRG system, which I’m sure I’ll excerpt from again. Not to be pushing product but it comes in packs of 10, which. . . when we’re talking about educating physicians. . . can be a quick item for CDI specialists to hand out.
Educating physicians and others about how the implementation of MS-DRGs increased the need for CDI is particularly important during a new CDI program’s inception. That’s when the only thing physicians want to know is: Who are you? Why are you doing this? What’s in it for me? Understanding MS-DRG basics can help them see the bigger picture behind the healthcare reimbursement system.
So here’s some trivia. First person to answer BOTH questions correctly will get a pack of the Handbooks.
- When did the MS-DRG system take affect?
- What three basic categories of the system?
ACDIS Precon: What you need to know before you go
More than 100 people signed up for the preconference “ICD-9 Coding Essentials: What every CDI specialist needs to know.” I’m personally looking forward to learning all about how CDI fits into the coding realm from Shannon McCall, RHIA, CCS, CPC-I.
I’ve participated in her Boot Camps before and know firsthand that she is a tremendous teacher. Students from her previous courses rave about her capabilities in their evaluations so I’m sure we’ll all learn a lot and have a good time, too. Last I spoke with Shannon she was working on gathering some Las Vegas themed music to help wake us up on Wednesday.
Speaking of which, if you are among the 100+ pre-conference attendees, head down to registration around 8 a.m. Grab a muffin or bagel and some coffee and take a minute to look over the bookstore. We’ll have an hour to get 100 people registered so be patient with us. Class starts at 9 a.m.
Knock, knock: Picking a principal diagnosis is no joke
There was some controversy on CDI Talk this week concerning the correct way to code a case where the patient had shortness of breath, Pneumothorax, DVT, and hypoxia. The debate centered around which diagnosis was the principal: Emboli or DVT. There were many opinions, mine included, and as the talk ensued, it made me chuckle. There did not seem to be a clear-cut answer.
We all seemed to reach separate conclusions while all doing the same jobs. We all agreed with which sequence pays the most-DVT with Pneumothorax as the MCC. And we all know which diagnosis is the most resource intensive-Pneumothorax with DVT as CC. But nevertheless, we couldn’t agree about how to properly code this. It reminded me of an old knock, knock joke I heard as a kid.
It went something like this:
Anyone got this answer?
Knock.
Knock.
Who’s there?
Who’s where?
The Coding Guidelines state:
“When there are two or more interrelated conditions potentially meeting the definition of principal diagnoses, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.”
When sequencing fractures in the trauma setting, the most significant should be sequenced as the principal. Does this rule only apply to bones? An emboli is certainly more life threatening than a DVT.
Knock.
Knock.
Who’s there?
Who’s where?
Who’s right?
Code sequencing is no knock knock joke. It’s a real compliance trick. CDI specialists, coders, help us out on this one. . .
CMS cheat sheet on IPPS basics available
Page three and four of CMS’ revised Acute Inpatient Prospective Payment System Fact Sheet (January 2009) contains a number of pastel looking charts outlining what seems to be mathematical equations. These graphical details show how IPPS payments are derived through a series of adjustments applied to separate operating and capital base payment rates.
Although I don’t recommend it for bedtime reading, the Medicare Learning Network Payment System Fact Sheet should be on your CDI required reading list.
Maybe you’ve read it before, maybe you’re already well-versed in the IPPS process and know all about how DRGs became MS-DRGs and how the wage-index fits into the final cost analysis, but maybe all this sounds like you need an accounting degree or a master’s in business healthcare administration. Either way, it’s always good to keep an eye on what CMS says about its own systems.
Maybe make it your lunch-time reading instead.
How to handle multiple reasons for admission
When the physician directs medical treatment toward one condition, or when one condition is the only reason for the inpatient admission to the hospital, select that condition as the principal diagnosis (PDX). The PDX is the condition that the physician determines to be the primary reason for admitting the patient to the hospital.
Okay, let’s say Mrs. Happy Hinklebottom (yes, I just made that up) comes to the hospital complaining of a urinary tract infection (UTI) and exacerbation of congestive heart failure (CHF). The physician orders all sorts of tests and treats both conditions. The coder/clinical documentation specialist still needs to determine which condition justifies the inpatient admission. It could be the UTI. It could be the CHF. It could be both.
If the answer is truly both, then select the optimal DRG, writes Colleen Garry, RN, BS, clinical documentation improvement specialist at the New York University Medical Center in NYC, in The Clinical Documentation Improvement Specialist’s Handbook. However, if you are unsure as to which condition is the PDX you’ll need to query the physician. In Mrs. Happy Hinklebottom’s case, the CDI specialist should query about the type of CHF to determine if it is acute, chronic, systolic, diastolic, or both systolic and diastolic.
Editor’s note:This excerpt was adapted from the book The Clinical Documentation Improvement Specialist’s Handbook.
In defense of Lumbergh’s TPS report
In one scene from the movie Office Space, the boss (Lumbergh) has to remind his staff members to put a cover sheet on the TPS reports. Company management even writes a memo about it.
To some, documentation queries may seem like that Office Space scene. Who cares about the cover sheet? Unlike that fictitious account of office hijinks however, the nuances of capturing every bit of clinical evidence in patient care documentation is much more important than a cover sheet.
Lack of complete, specific documentation means the potential loss of reimbursement dollars for a facility. It also misrepresents patient needs, facility expenditures, population data, and more-all of which will soon become paramount as payers aggregate data and focus their attention on quality of care.
Physicians will use this data, too. They’ll drill into documentation to spot trends, identify diseases, and develop new treatments for our top health concerns.
That’s why CDI programs can’t be compartmentalized strictly into a DRG capture service or a severity of illness analysis tool, nor a revenue generating program, says ACDIS board member Shelia Bullock, RN, BSN, MBA, CCM, manager of Clinical Documentation Services, at the University of Mississippi Medical Center, in Jackson.
“CDI is very important not just for physician documentation but for the total hospital process. Everyone needs to understand how this little piece affects the global picture of how things work,” Bullock says.
The most appropriate adjective to describe a patient’s condition may seem insignificant. A physician might think everyone knows the differenct between an acute and systolic CHF.
Did I push the Office Space movie metaphor too far? Ah, well. It’s a good movie at any rate. Take it as my suggestion for your next Netflix pick.
Welcome to CDI Blog
I’m honored to be asked to write the first post for our soon-to-be-famous CDI Blog! There are so many wonderful people involved with the ACDIS, many whom I’ve met over the phone and many over the internet. The internet is really a great tool: it allows us to communicate instantly and directly with one or many, share our ideas and it’s a wonderful venue for building our community: that of Clinical Documentation Specialists.
What we do is hard to explain to outsiders. It involves the ability to read a patient’s chart, understand their diagnosis and treatment plan and to identify whether the documentation in the record, once translated into ICD-9 codes, will paint an accurate picture of their inpatient stay. Our efforts impact a facility’s public quality ratings, affect physician profiles, and determine the revenue a hospital receives. [more]