1、Page 1,MS DRGs and the Medicare Quality Initiatives,Ian L. Diener, MD, MBA, FAAFP April , 2008,HP3 A part of Navigant Consulting,Page 2,Documentation Basics,Section 1,Page 3,The Importance of Good Documentation,Improves communication between physiciansEnhances the reputation of physicians by accurat
2、e data analysisHelps the medical staff to analyze their patient populationDefends the physician from medical liability allegationsIMPROVES THE OVERALL QUALITY OF CARE,Page 4,The Information Supply Chain & Quality,During Admission ConcurrentReview,After Discharge RetrospectiveReview,Physician documen
3、tation,Physician Response,Physician Response,Final coded data that represents each patients: Severity of IllnessServices Received Contribution to CMI Quality of Care Indicators for Medicare,Page 5,Documentation Requirements,Documentation by a licensed treating physicians ( and depending on the facil
4、ity and the state other treating clinicians such as NPs) is the only documentation that the coders can use for assigning codes.Diagnoses made by non-treating physicians must be re-documented by treating physicians Cardiology readings (EKGs, Ultrasounds) Radiology findings Pathology reports,Page 6,Av
5、oid Unacceptable Medical Shorthand,Avoid abbreviations, especially confusing abbreviations which may be unknown (“d/t”) or have multiple meanings (“ROM”) Avoid medical slang (“bleeder”) - especially important for your residentsMedical shorthand/abbreviations/symbols Coders are not allowed to transla
6、te medical shorthand into diagnosis codes: Instead of “Na,” document “hypernatremia” Instead of “replete potassium,” document “hypokalemia” Instead of “H&H,” document “anemia” and the acuity and suspected cause “+” should be written as “positive”,Page 7,“Probable” or “Possible” Conditions : Hospital
7、 vs. Pro-fee (E&M) Rules,Hospital (DRG) coding DRG based on the diagnoses under investigation Ex: “Rule-out,” “probable,” “suspected” (Not if “ruled-out” or “unlikely”) Payment is for resources used to diagnose/treat the underlying diagnosis Diagnoses or procedures are required to be documented at l
8、east once, in the current record, by a licensed, treating physicianProfessional fee (E R/O partial SBO.”,Page 8,Document the diagnosis or cause for a symptom if known,INSTEAD OF IDENTIFY CAUSE/POSSIBLE CAUSEChest pain - Type of anginaType of suspected GI disturbance causing chest painSyncope - Speci
9、fic arrhythmia causing syncopeType of CVA and whether there is an infarctType of seizure and whether it is intractableTIA, Stroke - Type of CVA (Be specific hemorrhagic, ischemic,traumatic, non-traumatic; Specify if with infarction)SOB - Type of COPD and whether it is an acute exacerbationSuspected
10、type of pneumoniaAbdominal pain - Suspected etiology, ex: possible cholecystitis, possibleacute pancreatitis,Page 9,Documentation Basics,Principal Diagnosis (PDx) is “The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
11、.” UHDDSThe DRG (Diagnosis Related Group) is a a designation for the relative weight or value of an admission determined by the principal diagnosisCMI (Case Mix Index) is the term for the average relative weight of DRGs,Page 10,Documentation Basics,Secondary diagnoses are conditions and diagnoses ta
12、ken into consideration during a hospitalizationComplications/Comorbidities(“CC”s) (a Medicare misnomer) The name Medicare assigned to the list of secondary conditions and diagnoses which it uses to increase the relative value of an admission. In other words a pre-existing condition or a condition th
13、at arises during a hospital stay that causes an increase in the utilization of hospital resources or an increase in the length of stay,Page 11,Physician Documentation in the Medical Record is Key,History and PMH - pre-operatively all medical conditions should be documented. Family History should be
14、complete.Medications - Include medications and the reason for taking the medications.Progress notes should contain an operative note and record all post operative care and diagnosesOperative reports should document all procedures doneDischarge summary - important for coding; should be dictated on ti
15、me and the final progress note in the chart should contain discharge diagnoses and medications,Page 12,Illegibility: Can you identify whose writing this is?,Page 13,Reasons for Inaccurate Ratings,Unclear or incomplete documentation Coder not able to read the physician notes Missing or incomplete dis
16、charge summary Missing or incomplete operative and pathology reports Incomplete list of secondary diagnoses Incomplete documentation of non OR procedures and supporting diagnoses Incomplete information about malnutrition and tube feeding and TPN Cases may not have been coded correctly or incompletel
17、y by the hospital The determination of risk does not take into consideration conditions and circumstances that are not reflected in the data The risk of certain comorbidities changes with time and new treatment modalities that are not reflected in the methodology Multiple facilities may report data
18、under one provider number,Page 14,Your Effect on Ratings,Paint an accurate picture of how ill the patient is! Write legibly Sign the notes or cosign notes where appropriate Use Standard ICD 9 Terminology not medical slang Avoid arrows and greater than and plus signs Avoid confusing abbreviations Wri
19、te a post op note in the chart Dictate discharge summaries within 24 hours of discharge or write an discharge progress note that is comprehensive If you are informed of pathology diagnoses before discharge document them in the chart In the discharge note mentions any conditions likely to influence t
20、he mortality and morbidity of the patient,Page 15,MS-DRGs,Page 16,Medicare has a new DRG system for FY 2008 (October 2007)The new systems DRGs are called MS-DRGs.The numbering is different and the titles have been revised to avoid ambiguityA three level system similar but not the same to AP DRGs ( N
21、YS All Patient DRGS) is created for most MS-DRGs. There are also MS-DRGs with only two levels with a CC or MCC and without a CC or MCC. There will be MS-DRGs that only are influenced by an MCC and not by a CC. No comorbidity/complication (CC) or Major comorbidity/complication (MCC) With a CC With a
22、MCC,MS-DRG: Medicare Severity DRG,Page 17,Acuity (Acute v. chronic) and type of anemia Type and location of arrhythmia Type of cardiomyopathy, especially if non ischemic Exacerbation of chronic obstructive pulmonary disease Exacerbation of asthma Type of congestive heart failure, and if acute or chr
23、onic and location: Systolic, diastolic or mixed, left, or right Stage of decubitus ulcer and specific location Dehydration specify osmolarity and electrolyte abnormalities Type and control of diabetes and whether associated with ketoacidosis, coma or hyperosmolarity Specific designation of infection
24、s Organism Extent,Common Comorbidities/Secondary Condition capture is directly influenced by physician documentation,Page 18,With GI hemorrhage Specify the location of the ulcer or other lesion, whether acute or chronic and document acute blood loss anemia if present Type and severity of malnutritio
25、n, cachexia present? Type and location of myocardial infarction, and complications Renal failure, acute and degree of chronic kidney disease Specify whether the patient has acute or chronic respiratory insufficiency or failure and length of life support ventilation Type of pneumonia Type of seizures
26、 and whether continuous or intractible Septicemia, Sepsis, or Septic shock Degree of obesity and BMI,Common Comorbidities/Secondary Condition capture is directly influenced by physician documentation,Page 19,In the new system important descriptions and adjectives are key to proper capture of seconda
27、ry diagnoses Acuity: Acute and chronic or acute on chronic Location and/or type of condition Etiology of condition Causative organism Degree of severity Accompanying conditions such as hemorrhage, obstruction, perforation, coma, ketoacidosis, hypersomolarity, (congestive) heart failure (acuity and t
28、ype),Common Comorbidities/Secondary Condition capture is directly influenced by physician documentation,Page 20,Common Comorbidities and Complications (CCs) Impacting MS-DRG Assignment (not a complete listing),Acidosis/ Alkalosis Ascites, specify type Acute bronchiectasis Acute esophagitis Acute exa
29、cerbation of asthma Acute but ill-defined cerebrovascular disease Acute coronary occlusion without myocardial infarction Acute pericarditis Acute exacerbation of COPD Acute post-hemorrhagic anemia Alcohol or drug withdrawal Anorexia nervosa Atelectasis Atrial flutter,Bacteremia Bilateral bundle bran
30、ch block Cachexia Cardiomyopathy, specify type Cellulitis, specify site Chronic diastolic heart failure Chronic kidney disease - stage IV or V Chronic pancreatitis Chronic respiratory failure Chronic systolic and or diastolic heart failure Decubitus ulcer specific type Drug dependence, continuous Ep
31、ilepsy, intractable seizures “itis“ gastrointestinal diagnoses Intermediate coronary syndrome,Page 21,Common Comorbidities and Complications Impacting MS-DRG Assignment (not a complete listing),Hepatitis, specify type Hypernatremia Hyperosmolarity Hypertensive Heart disease with renal failure CKD st
32、age V Hyponatremia Hypoosmolarity Ileus Infection post operative, specify Infectious diarrhea Left heart failure Malignant hypertensive heart disease w/ CHF Melena Obesity, BMI greater than 40,Paroxsymal supraventricular tachycardia Paroxsymal ventricular tachycardia Pathological fracture Phlebitis
33、and thrombophlebitis, femoral vein (deep) (superficial) Pleural effusion, specify type Protein calorie malnutrition Pulmonary edema Pyelonephritis Rheumatic heart failure Schizophrenia Senile Dementia with depression Status asthmaticus Trifascicular block Unspecified shock UTI Ventricular tachycardi
34、a,Page 22,Common Major Comorbidities and Complications Impacting MS-DRG Assignment (not a complete listing),Acute renal failure Acute respiratory failure Aspiration pneumonia Bleeding esophageal varices Cardiac arrest Cardiogenic shock Coma Decubitus ulcer - back, hip, buttock, ankle, heel Diabetes
35、w/ coma Diabetes w/ hyperosmolarity Diabetes w/ ketoacidosis,Acute CVA with infarction Acute diastolic heart failure Acute myocardial infarction Acute systolic and or diastolic heart failure Acute systolic and diastolic heart failure Acute on chronic diastolic heart failure Acute on chronic systolic
36、 heart failure Acute pancreatitis Acute peritonitis,Page 23,Common Major Comorbidities and Complications Impacting MS-DRG Assignment (not a complete listing),Tension pneumothorax, spontaneous Pulmonary embolism/infarction Quadriplegia Ruptured aortic aneurysm Septic shock Septicemia Severe protein-c
37、alorie malnutrition Sepsis/SIRS Ventricular fibrillation Ventricular flutter,Encephalitis End Stage Renal Disease Grand Mal Status Hepatitis with coma “itis” diagnoses with hemorrhage GI obstruction or perforation Meningitis, specify type Nutritional Marasmus Petit mal status Pleural Effusion, speci
38、fic types Pneumonia, specify type,Page 24,CMS Quality Initiatives,Page 25,The Medicare Quality Indicators,The Final Rule increases the number of measures to be submitted to 27. This will increase in the future according to the proposed rule Measure sets include: Acute Myocardial Infarction Heart Fai
39、lure Pneumonia Surgical Care Improvement Infection Prevention* Prevention of DVT* Mortality Statistics* Patient Perception Survey* Choice of prophylactic antibiotic DVT prophylaxis ordered DVT prophylaxis performed AMI Mortality HF Mortality HCAHPS patient perception,Page 26,Present on Admission,Pag
40、e 27,Diagnoses/ Conditions Chosen for FY2009 Implementation,Catheter-associated urinary tract infection Object left in after surgery Air embolism ABO blood incompatibility after blood transfusion Vascular catheter-associated infections (central lines) Mediastinitis after CABG Pressure ulcer Injury w
41、hile in hospital (fracture, dislocation, burn, cranial injury, etc) This will increase in the future If the case has another CC or MCC that is not on the above list, the case will still be paid for the CC or MCCBeginning October 1, 2008, cases coded with one of the above diagnoses and the code has a
42、 POA indicator of “N”, meaning it was NOT present on admission, will NOT be paid for the CC or MCC. (May also include U designation meaning not sufficient documentation.),Page 28,Revenue Auditing Contractors,Page 29,Proactive Steps Preparing for RAC,Incorrect Coding Target - Excisional Debridement M
43、edical Necessity of Inpatient Rehabilitation Carefully document the medical necessity of inpatient rehabilitation Educate the physician about the criteria for inpatient rehabilitation of Medicare patients. Wrong Principal Diagnosis Target respiratory system diagnoses extensive OR procedure unrelated
44、 to principal diagnosis Wrong Diagnosis Code Target - Septicemia, Sepsis Medically Unnecessary Services Target Neulasta Colonoscopy Speech therapy and similar services,Page 30,Proactive Steps Preparing for RAC,Physician documentation should be specific: Explicitly document all diagnoses requiring in
45、patient care. Document other diagnoses which may be co-morbidities affecting the patients treatment and/or length of stay. Apply appropriate adjectives: acute or chronic, severity, and type of condition where appropriate Use appropriate qualifiers, such as a “secondary diagnosis” “due to” or “second
46、ary to”. Use only approved abbreviations and try to use words instead of symbols. (For example, coders may not understand that Na+ is hyponatremia.) Make sure that the documentation is legible. Remember: according to coding guidelines - if it isnt documented it didnt happen and if it cant be read, i
47、t cant be coded!,Page 31,What to Do,Page 32,Clinical Documentation Improvement will be Key,CMS Initiatives MS-DRGs POA Public Quality Data RACSuccess in all of these areas is dependent on high quality documentation and coding Hospital administration, staff, coders, and physicians must understand MS-
48、DRGs, RAC, POA/Quality and the interplay of these programs for financial success.Hospitals must be prepared to actively review and appeal RAC decisions. Those that dont are “easy profit” for the RACs.,Page 33,MS-DRGs & POA Actions to Consider,Implement a Clinical Documentation Initiative Plan for th
49、e MS-DRG transition Improved core measure/quality indicator capture Improved POA capture Plan for the RAC expansionMonitor your hospitals severity of illness profileProvide education to physicians: Focus on hospitalists, cardio-vascular surgery, and general surgery firstSupport education with ongoing communications and touch points. “Market” the changes based on a written communications planEducate coders and conduct severity audits,Page 34,Questions?,Thank You!Ian L. Diener, MD, MBA, FAAFP ,
