All Entries Tagged With: "documentation"

Listen to expert interpretation of Condition Code 44 regulations

Condition code 44 is one of those topics that never goes away.

• Can we use condition code 44 if the physician has already written the discharge order?
• Can we use condition code 44 if the attending physician doesn’t concur with the utilization review committee?
• Can we use condition code 44 to change inpatient time to observation services?

For whatever reason questions like these continue to come up. Perhaps it’s the vaguely-worded regulation or the conflicting advice found on the internet. Whatever it is, people are confused.

We at HCPro were thinking that because condition code 44 is such a contentious and confusing topic perhaps a written article is not the best way to explain it. That’s why we decided to call in the experts (Kimberly Anderwood Hoy, JD, CPC, the director of Medicare and compliance for HCPro, Inc and Sandra McCune BSN, RN utilization management specialist) for a 90-minute audioconference that will hopefully put all your condition code 44 concerns to bed.

How and McCune will share their interpretation of the rule using the official guidance provided by CMS. The program includes a 30-minute question and answer portion that will give you the chance to get your burning condition code 44 question addressed by our experts.

Take a listen to the following audio clip I recorded with Kimberly Hoy. In it, she explains why it is important for folks to listen to the program and highlights some of the important information the audience will take away.

If you like what you hear head over to the HCMarketplace and sign up for the program, Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance.

CMW news: Incomplete discharge summaries to blame for preventable errors

A study released by the Indiana University School of Medicine finds that hospital discharge summaries lack information important to patients’ continuity of care.

Indiana University School of Medicine researchers published their findings in the September issue of Journal of General Internal Medicine under the title Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers.

The researchers reviewed 668 discharge summaries from two academic medical centers. They found that the hospitals discharged nearly 41% of the patients with test results pending—9% of those tests required changes with respect to patient care. However, the hospitals documented only 16% of those tests in patient discharge summaries. Only 13% of summaries included all pending tests.

Researchers say without that information, primary care physicians can’t provide the appropriate care patients need after discharge.

"Errors in communication reportedly contribute to over half of all preventable adverse events and are associated with twice as many deaths when compared with errors due to clinical inadequacy,” researchers conclude in their report.

Source: American Academy of Professional Coders and American Medical Association

One year later: How are you handling HAC and POA

Last October, CMS began paying hospitals less for certain hospital-acquired conditions (HAC) that occur in specific situations and are not present on admission (POA). CMS designed the program to save money by ceasing to pay hospitals for conditions that could have been avoided. However, a new study published in the September 9 issue of Health Affairs, estimates that the program has saved $1.1 million to $2.7 million annually.

Before the HACs took effect, many experts warned that the HACs could affect the hospital’s bottom line, but this study suggests that may not be the case. Have they affected your hospital’s bottom line?

The following HAC conditions took effect October 1, 2008:

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma

• Fractures
• Dislocations
• Intracranial Injuries
• Crushing Injuries
• Burns
• Electric Shock

6. Manifestations of Poor Glycemic Control

• Diabetic Ketoacidosis
• Nonketotic Hyperosmolar Coma
• Hypoglycemic Coma
• Secondary Diabetes with Ketoacidosis
• Secondary Diabetes with Hyperosmolarity

7. Catheter-Associated Urinary Tract Infection          (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection Following:

• Coronary Artery Bypass Graft (CABG) – Mediastinitis
• Bariatric Surgery
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow

10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Total Knee Replacement
• Hip Replacement

If you are finding HAC and POA is an issue at your facility, check out these tips. Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services at 3M Health Information Services in Atlanta, offered the following tips for keeping staff up to speed on HACs and POA in the September 2008 issue of Case Management Monthly:

• Educate case managers on what POA status is and partner with your health information management department to determine where POA codes apply.
• Be aware of new HACs when they’re announced by CMS. “This is just the beginning. It’s likely these conditions will continually evolve,” Garrison says.
• Look at your facility’s current documentation selection tools to see whether they lend themselves to capturing these data on admission. If they don’t, improve them.
• Do a self-audit. Randomly pull 30 charts to see whether they accurately note POA conditions. If you think there are gaps, chances are an auditor will as well.

“If you fail your own audit, you’re going to fail others, such as the recovery audit contractors’,” says Garrison, who describes case managers as “quality of care managers” and points to POA guidelines as “quality indicators.”

For more information on HACs, visit www.cms.hhs.gov

To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com.

To read the complete article ” Don’t let HACs cut into your bottom line“, visit the ACDIS Web site’s Helpful Resources section.

Documentation requirements for critcal care services

Editor’s Note: This blog was originally posted by Melissa Varnavas, CPC, the associate director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional billing, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

• Critical care delivery by time increments for the first encounter
• Additional critical care when the patient crashes again
• A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery. [more]

Tip: Query for Noncompliance with medical treatment (V15.81)

Editor’s note: This blog was written by Brian Murphy, CPC, the director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.

CDI specialists should be on the lookout for indications of patient noncompliance with medical treatment when reviewing patients’ charts, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services with 3M Health Information Systems (HIS) and a member of the ACDIS advisory board.

According to Garrison, payers are increasingly denying hospital readmissions and the problem is likely to worsen with the nationwide rollout of the Recovery Audit Contractor (RAC) program and CMS’ increasing scrutiny of the cost of readmissions. “Readmissions can be the result of, or influenced by, patients who leave the hospital and refuse or elect not to follow recommended treatment plans (by choice, by misunderstanding of discharge instructions, or due to costs), which may cause their condition to worsen, resulting in a readmission,” Garrison says.

However, CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report V15.81, hospitals can use this documentation and coded data to help prevent or appeal denials, Garrison says. “If the V code is reported in the top nine diagnosis codes when it is transmitted on the UB-04, (it allows) the payer to have the knowledge that patient noncompliance may have contributed to the readmission,” she says.

“I have always recommend the use of the V15.81 code for noncompliance to both coders and physicians when supported by the clinical documentation,” adds Gloryanne Bryant, RHIA, CCS, CCDS, regional managing HIM director, NCAL Revenue Cycle of Kaiser Foundation Health Plan Inc. and Hospitals in Oakland, CA, and a member of the ACDIS advisory board. “I agree this is helpful, but mostly for understanding which patients really are not following medical instructions. Is it the diabetic patient or the dialysis patient, etc?

“It further explains and provides insight into healthcare resource use, length of stay, costs, and readmission rates,” Bryant adds. ”I would recommend that facilities run a data report on their inpatients with this V code assigned and conduct some audits and reviews to gather insight. I would also track/trend this V code over time and share the information with providers.”

The physician advisor: An invaluable resource

If your facility does not have a physician advisor, my recommendation is to get one. The physician advisor at our facility is great. Dr. Jim Chambers is very knowledgeable, not only in the field of cardiology, but he is quite knowledgeable in the area of coding. Dr. Chambers has spend countless hours educating and assisting our hospital billing department in establishing correct billing codes.

Documentation is key in obtaining the appropriate billing code. Physicians work hard taking great care of their patients, but what they lack is being able to document everything they have done for the patient and the outcomes. Outcomes are essential in the world of coding. For example, when a patient comes in with an abnormal prealbumin level, the physician treats this, but yet sometimes only documents that the patient has malnutrition. In this case, the hospital is reimbursed at the lowest level for malnutrition.

The stages of malnutrition are based on the prealbumin level, so the physician needs to document what level of malnutrition the patient is experiencing as there is dollar difference in the different levels of malnutrition. Our physician advisor has been working with our physicians to correct this. [more]

Medical necessity beyond screening criteria

An underlying foundation for case management is the practical and consistent use of commercially available screening criteria as guidance for initial admission patient status designation as well as continued stay determinations. I call your attention to the term “guidance” from the perspective of Medicare and the Recovery Audit Contractors (RAC).

In a RAC Special Open Door Forum held by Medicare on April 9th, several comments by Medicare representatives and RAC representatives, including the medical director for Health Data Insights, make it very clear that the screening criteria will not be used in and of itself to determine medical necessity or lack thereof for inpatient hospitalization. Consider the HDI medical director comment regarding his organization’s application of screening criteria in the medical necessity determination process:

“We follow CMS guidelines which are that these different products are guidelines. They’re not conclusive for a decision to or for a finding or not a finding.  We have contracts with both Milliman and Interqual and intend to use those along with clinical review judgment and of course, first and foremost the CMS guidelines.”

The implications for the case manager

Unequivocally, screening criteria should be applied and followed as part of the patient status
designation determination process. Just the same, the physician’s clinical judgment, medical-
decision making and clinical impression can and must be incorporated in this decision-making
guidance process.

The real challenge faced by case managers is the physician’s medical record documentation of the same. Commonly, the documentation available to the case manager upon initial and continued stay chart review fails to accurately and completely capture and represent the patient’s true clinical acuity, risk of morbidity and mortality, and other physician clinical concerns that ultimately led the physician decision to admit the patient to the hospital. This lack of focus in clinical documentation further challenges the case manger in providing objective guidance in the complex, arbitrary patient designation status process. [more]

In the wake of the RAC, don’t forget about Present on Admission (POA)

I’m sure everyone is aware of the Hospital-Acquired Conditions (HAC) the Centers for Medicare & Medicaid Services (CMS) announced would not be paid for beginning October 1, 2008. The 10 categories of HACs are:

(1) Foreign objects retained after surgery
(2) Air embolism
(3) Blood incompatibility
(4) Stage III & IV pressure ulcers
(5) Falls & trauma
(6) Manifestations of poor glycemic control
(7) Catheter-associated urinary tract infections
(8) Vascular catheter-associated infection
(9) Surgical site infection following: Coronary Artery Bypass Graft (CABG)—Mediastinitis, Bariatric surgery, and some orthopedic surgeries
(10) Deep vein thrombosis (DVT)/Pulmonary embolism (PE) following some ortho procedures.

When looking through this list of conditions, as healthcare professionals we realize there are steps that can take place to reduce and/or eliminate the possibility of these conditions, and then there are conditions that no matter what we do may unfortunately happen.

[more]

Challenges for case managers in discharge planning

Discharge planning is a constant state of mind for our case management team. We continually strive to create a plan that is safe and comprehensive.
Discharge planning is also a major focus of accrediting agencies including both The Joint Commission (formerly JCAHO) and the Centers for Medicare & Medicaid Services (CMS). Our case management team has found that creating a safe discharge plan and initiating a thorough multidisciplinary assessment (including functional, psychological, and cognitive) within the first twenty-four hours has been a challenge. The challenge in safe discharge planning is usually the coordination of critical communication of all team members.
[more]

CMW Sneak Peek: Harnessing technology to advance case management

You know the drill: rally for improved documentation practices at your facility, train everyone on proper documentation procedures, and become foiled by inexplicably incomplete records, illegible handwriting, and records that are lost in transition. But you’re not alone. This is exactly what case managers at Cleveland Clinic dealt with.

“We used to handwrite all of our documents and referrals,” says Joyce Lewis, RN, case manager at Cleveland Clinic’s postop cardio thoracic unit. “Sometimes things worked out well, but other times, it was extremely cumbersome” due to incomplete patient care records and significant delays in placing patients who required some sort of postacute care. [more]