Physician Education in Clinical Documentation Improvement

1 Physician Education in Clinical Documentation Improvement : Accurately Documenting and Supporting Diagnoses in the Delivery of Medically Necessary and Appropriate HealthcareMarianne Ries, MD, MBA, CPER evenue Cycle and Institute for Population HealthLost in Middle America3 The , And We Have Weather of Problematic Physician source Risk Physician and paste and services stay inpatient admissions3 Documentation Connection Between Diagnoses and Medical Necessity Supports that services are reasonable and medically necessary to the diagnosis made and/or treatment of that medical condition Shows evaluating, diagnosing.

2 Or treating an illness, injury, or disease, is in accordance with accepted standards diagnosis reported supports the medical necessity of services3 Valid Diagnoses: Foundation of Medical Necessity for Hospitalization -The Bread and Pasta of Medically Necessary Services3 Valid Diagnoses3 Unsupported Diagnoses = Invalid diagnosis = Non-Medically Necessary Service3 Providing Non-Medically Necessary to Violation of payer contract Violation of the False Claims Act3 Most Common DRG Diagnoses for Respiratory Kidney Syncope3 General Principles for Physician exam findings for the by key objective the data with recognized Clinical accurate and detailed as evaluation indicates further evaluation and treatment driven by

3 Differential irrelevant, static, and non-urgent medical problems not impacting or impacted by diagnoses3 Heart subjective symptoms reported? Physical exam findings? Targeted lab evaluation? Radiologic exams? Type? Acuity? What cause or condition? it togetherExample: Acute decompensated HF with diastolic dysfunction and preserved ejection fraction (or HFpEF) with BNP 0f 2,000. POA due to non-compliance with recently prescribed diuretics and Respiratory Failure: Details, details, : hypoxia without hypercarbia2: hypercarbia3: acute post operative4: shock3 Community Acquired PneumoniaMust have: Chest Xray indicating new infiltrate(s), consolidation, cavitation, or diffuse abnormality not explained by HFANDS upporting Signs, symptoms, vital signs, physical exam findings.

4 SOB, cough, pleuritic chest pain, new onset functional and cognitive decline Temp > 100 Tachypnea Crackles, rhonchi, isolated decreased breath sounds3 Community Acquired PneumoniaSupporting: Leukocytosis with left shift/bandemia Arterial blood gas abnormalities Specific urine antigen titersNot Helpful: Procalcitonin Routine sputum and blood cultures3 Acute Respiratory , probable, likely: to more concise diagnosis to evolve as result of evaluation and treatment guided by differential diagnosis supports medical necessityExample: Acute respiratory failure likely due to pneumonia, might later be documented as: 80 year old female with Acute hypoxemic respiratory failure from left lower lobe CAP pneumonia due Streptococcus pneumoniae.

5 CURB-65 score of 3 and PSI of 90: medically necessary hospitalization for identify new infection and likely source(s) least 2 SIRS > > 20 or PaCO2 < > 90 >12k or <4k or Bandemia > 10%3 SepsisTie it together:Severe Sepsis SIRS due to from urinary tract source. Tachycardia, temp of , leukocytosis with left shift, lactic acidosis with lactate of Hypotension of 80 mm Hg systolic responsive to IV NS 2 and Paste Physician doubt that the true Clinical picture and/or progress is suggest that testing and therapy is ordered and delivered but is not utilized to determine diagnosis or guide not reflect complex decision by commercial payers and the in quick, easy, and expensive not your friend3 Problem.

6 Voice-to-Text Dictation , may not reflect true Clinical , may not make sense and , can lead to unintended interpretation and even worse3 What Are We Doing to Support Improvement in Physician Documentation ?Touch points: group talks/lectures/discussions with Physician Physician outlier interventions/referral to CMO and Physician from DRG validation denials from podcast series with CME credit available3 CDI Video Podcast SeriesPurpose Statement:The Clinical Documentation Improvement video podcast series is designed to review key Clinical indicators and other information for healthcare providers, necessary for accurate and concise Documentation that reflects and supports valid diagnoses consistent with recognized Video Podcast Series Topics.

7 The most frequently diagnosed medical illnesses of patients who present to an acute care hospital for evaluation and treatment , interspersed with a few key regulatory compliance topicsDRG Diagnoses CDI Podcast Failure10. Atrial GI Acquired Pneumonia13. Acute Kidney Respiratory Failure15. Failure to Syncope/Syncope16. Pain17. Renal Replacement Embolism18. Post-op Respiratory Failure3 CDI Video Podcast Series What does it look like? Go to A few learning objectives 13-16 minute video podcast listen or listen and watch CME Credit: Following each 13 to 16 minute video podcast is a unique CME link.

8 Click on the link, answer a few questions, and complete an evaluation to obtain CME credit. hour free AMA PRA Category 1 Credit for each topic. Key Physician Education DRG diagnosis is the foundation of further evaluation, treatment , appropriate disposition, and accurate must be reflective of, and consistent with, established Clinical of symptoms is not a substitute for a valid DRG is for Clinical Documentation to accurately reflect Clinical status and support valid Physician behavior requires multi-modal Education , specific and targeted intervention when appropriate, aligned incentives, a lot of time, and it can get