1、DOCUMENTATION AND DRGS,Documentation Challenges for the Hospital Inpatient CoderJ. K. Sturgeon, C.C.S.,Developed by Patient Financial Services for the University of Texas Medical Branch at Galveston,DOCUMENTATION AND DRGs A general guide,How DRGs work How they affect the provider How the provider af
2、fects them What should be documented in order to assure the most appropriate DRG for each patient: a) generally b) specifically,Updated October 2001,DRG OVERVIEW,Basic information on DRGs What they are and how they work General documentation needs toassure the appropriate DRG for each patient,DRGs:
3、How do they work? How do we use them?,DRGs GROUP PATIENTS WITH SIMILAR RESOURCE CONSUMPTION AND LENGTH-OF-STAY PATTERNS. THERE ARE 523 DRGs AVAILABLE. EACH DRG HAS A “RELATIVE WEIGHT.” The higher the relative weight, the greater the average resource consumption. This is used to calculate reimburseme
4、nt to the hospital for DRG-based payors like Medicare (and in some states, Medicaid, Blue Cross, and others). DRGs ESTABLISH OUR CASE MIX INDEX. This is an average of the relative weights of all of the hospital admissions being evaluated. This in turn is an indicator of the severity / complexity of
5、patient population. DRGs ARE USED FOR: determining hospital reimbursement, budgeting, managed care contracts, economic profiling, physician profiling, case management, residency program justification, and more.,DRG: DIAGNOSIS-RELATED GROUP What affects the DRG assigned for the patient?,PRINCIPAL DIA
6、GNOSIS COMPLICATIONS CO-MORBIDITIES PRINCIPAL PROCEDURE AGE OF PATIENT DISCHARGE DISPOSITION,DEFINITIONS,Principal Diagnosis: The condition, established after study, to be chiefly responsible for causing the admission of the patient to the hospital. Complication: Any condition that arises during the
7、 hospital stay. Co-morbidity: Any pre-existing or chronic condition that the patient already has upon admission to the hospital. Principal Procedure: A procedure performed for definitive treatment rather than for exploratory or diagnostic purposes, or that was necessary to treat a complication. The
8、principal procedure is usually related to the principal diagnosis.,PRINCIPAL DIAGNOSIS: What documentation is needed?,THIS SHOULD BE AS SPECIFIC AS POSSIBLE! ADMITTED FOR MORE THAN ONE REASON? (CHF and COPD; metastatic workup and chemotherapy) ACUTE vs. CHRONIC? (respiratory failure in an asthma pat
9、ient; fluid overload in an ESRD patient; ARF in a patient with chronic renal insufficiency) UNDERLYING CAUSE? (chest pain due to C.A.D., or osteomyelitis due to Diabetic foot ulcer) UNCONFIRMED DIAGNOSIS AT DISCHARGE? A condition that is “probable”, “possible”, or treated as if it exists should be d
10、ocumented as such. Examples: “fever, probably due to viral respiratory infection” or “clinical sepsis, treated, not ruled out.” Physicians Billing staff needs the known diagnosis or symptoms; inpatient coders need the probable cause of those problems.,SECONDARY DIAGNOSES: What documentation is neede
11、d?,Documentation of all diagnoses that, on this admission, require: clinical evaluation, therapeutic treatment, diagnostic procedures, an extended hospital stay, or increased nursing care or monitoring (and in newborns, that have indications for future healthcare needs.) Chronic conditions: all curr
12、ent problems receiving care should be listed. (DM, CHF, AFib, COPD, HTN, ESRD, and so forth) Pt. receiving Meds? There should be a diagnosis associated with each medication. (e.g. “Lasix, xx/qd for control of CHF) Are lab tests ordered? When there is a known or suspected diagnosis associated with th
13、e problem, it should be documented in the patient record. The lab order slip requires the known symptom or problem, but the inpatient record can also use the suspected cause for more specific coding. (“probable UTI” or “R/O sepsis) Are X-rays ordered? Same rule as labs: the order slip must have the
14、known problem that justifies the test, but the inpatient record can also use the suspected cause. (e.g. “suspected pneumonia”, “rule out aspiration pneumonia”, “probable CHF”, “symptoms of atelectasis”, etc.) Positive lab results? What do they mean? (e.g. low H & H is this anemia or dehydration or n
15、either? Elevated creatinine renal insufficiency? urinary obstruction? Positive urine rbcs UTI? Kidney stone? Hematuria?),: COMPLICATIONS AND COMORBIDITIES Documentation of the following diagnoses can increase factors that determine the severity of illness & risk of mortality, and justify resources u
16、tilized for the hospital inpatient. and justify resources utilized for the hospital inpatient.,Diabetes: if documented as uncontrolled or insulin dependent COPD, emphysema Decubitus ulcer Angina Anemia due to blood loss Respiratory Failure Urinary Tract Infection Congestive Heart Failure Chronic or
17、Acute Renal Failure Malnutrition Hyperkalemia, Hypernatremia Dehydration Pleural effusion,Pneumonia Hyponatremia, Hypovolemia Volume Overload Post-op complications: infection, graft failure, dehiscence, atelectasis, wound seroma or hematoma, ileus, urine retention Thrombocytopenia, coagulopathy Hema
18、turia Atrial fib, flutter, heart blocks Drug/Alcohol-induced mental disorders Cirrhosis Seizure Disorder,SURGERIES AND PROCEDURES: DOCUMENTATION MUST BE SPECIFIC, COMPLETE, AND LEGIBLE!,Documentation should include who, what, when and how, and how much. What was the tissue; how was it obtained? (e.g
19、.: lung bx. or only bronchus bx.) Was there a scope, open, or closed procedure? Did they incise, excise, cauterize, or laser ablate? Skin excision only, or also muscle / fascia / soft tissue? How large is the wound repaired or the lesion taken? “I & D” - is this “incision and drainage”, or “incision
20、 and debridement”? Or is it really “excisional debridement”? Or all of the above? Description should be as specific as possible:this determines intensity of service as well as reimbursement for both physicians and hospital billing, inpatient and DSU. Name of attending M.D. and resident need to be le
21、gible to assure that they receive credit for performing the procedure.,“SEVERITY-ADJUSTED” DRGS,determined by secondary diagnoses indicate how sick the patients really are justify greater resource consumption improve M.D.s “physician profile”,APR-DRGs: determine severity of illness / risk of mortali
22、ty Each APR-DRG is split into 2 groups, with 4 grades of severity in each group,Specific documentation needs,Common diseases and disease processes; specific documentation needs for each.Symptoms that may be assigned to more appropriate DRGs with more specific documentation.Procedures that may have t
23、echnical documentation requirements to assure the appropriate DRG and justify resource consumption.,COPD: asthma, emphysema, bronchitis,Acute Exacerbation. what is it? Respiratory failure, status asthmaticus, bleb, pneumonia, acute bronchitis? If pneumonia. is it bacterial? Which bug? Viral? Is it a
24、spiration pneumonia, interstitial pneumonia? Are there other contributing pathologies? (e.g. pleural effusion, congestive heart failure, volume overload, congenital problems, or chronic diseases like fibrosis or T.B.) Acute, chronic, or both should be specified when they apply to the patient.,PNEUMO
25、NIA,The suspected cause should ALWAYS be documented. (e.g. “pneumonia due to HIV infection”, “interstitial pneumonia”, “probable Pseudomonas pneumonia”, “pneumonia likely due to Staph.”) Sputum cultures may well be negative if the patient was on outpatient antibiotics, or if the specimen or its proc
26、essing were not optimal. Coders are prohibited from assuming that the bacteria in the sputum caused the pneumonia: the doctor must document the cause. Different organisms and different etiologies can result in different DRGs, severity of illness, risk of mortality, and hospital resources consumed. U
27、nlike outpatient billing, inpatient accounts can be reimbursed for “suspected, probable, possible” diagnoses based on resources used to treat the suspected problem. If a problem is treated presumptively, it is coded unless it has been ruled out, and is reimbursed accordingly. (e.g. “pneumonia suspec
28、ted due to gram negative organism” in a patient who has failed outpatient abx., or “suspected aspiration pneumonia” in a nursing home patient with dysphagia & aspiration problems from an old CVA),RESPIRATORY FAILURE,What caused the respiratory failure? This can determine the final DRG. (e.g. “respir
29、atory failure due to acute exacerbation of COPD”, “respiratory failure due to CHF”, or “respiratory failure due to CHF and pneumonia”) The patient need not be on a ventilator; the diagnosis can be based on medical criteria including respiratory rate and arterial blood gases. “Arrest” is not synonymo
30、us with “Failure” for coding and DRG assignment. Is the “cardiorespiratory arrest” actually “respiratory failure” and “cardiac arrest”? There is no way to code, or to assign a DRG, for “Multi-Organ System Failure”. each organ system must be listed separately.,U.T.I. and “UROSEPSIS”,The diagnosis of
31、“urosepsis” is coded and reimbursed the same as is a “U.T.I.”. it is considered to be an unspecified infection of ONLY the urinary system. “Septicemia and (or due to) a U.T.I.” should be documented as separate diagnoses. This greatly affects severity of illness, risk of mortality, and can affect the
32、 DRG and hospital reimbursement as well. “Clinical Sepsis” in the patient should always be documented, even in the absence of positive blood cultures. The symptoms from which this diagnosis is made should also be clearly documented. Related complications that may arise should be noted as well: urine
33、 retention, ARF, pyelonephritis, and the like.,HYPERTENSION,Is the hypertension benign or malignant ? “Uncontrolled” does not designate malignant hypertension. Which of the patients symptoms / systems does the hypertension affect? (Hypertensive Renal Disease, Hypertensive Heart Disease, Hypertensive
34、 Encephalopathy) What caused the hypertension? (e.g. renal artery stenosis, PCKD, chronic pyelonephritis, hyperthyroidism),RENAL FAILURE,What caused the renal failure? (e.g. diabetes, hypertension, SLE, PCKD, radio-opaque dye, other?) Is this Acute, Chronic, or Acute and Chronic failure? What does “
35、near-ESRD” mean? It will be coded as “renal insufficiency” unless it is further specified. If a transplant patient is admitted, is it due to a complication of the transplant? What is that complication.ATN, CMV, ARF, rejection, infection, other? Related diagnoses should be documented if they are trea
36、ted, evaluated or monitored, or if they extend the hospital stay. Included should be volume overload, electrolyte imbalances, urine retention, and the like.,DIABETES,Is this AODM (type II, usually adult-onset) or IDDM (type I, usually juvenile-onset)? Is the diabetes “uncontrolled” or does it have “
37、poor control” on this admission? “Insulin-controlled” and “currently insulin-requiring” do not mean “insulin-dependent” for coding or DRG assignment. Adult-onset diabetes can still be “insulin-dependent” if it is now a permanent requirement for treatment. Is this patients cellulitis/foot ulcer/osteo
38、/ESRD/etc. due to the diabetes? Even more critical: is it due to Diabetic neuropathy? Diabetic PVD? Diabetic nephropathy or cardiomyopathy? The above conditions should ALWAYS be documented when they apply to a particular patient.,CARDIAC CONDITIONS,Secondary diagnoses that have an origin or effect t
39、hat is cardiovascular can have significant impact on severity, mortality risk, and reimbursement. Conditions on the list to the right should be documented if they are treated, or evaluated, or monitored, or if they increase hospital stay or nursing care / monitoring.,Hypertensive heart disease Post-
40、myocardial infarction syndrome Septal thrombus. is this Acute or Chronic? Symptomatic? Old MI? Cardiomyopathieswhat type? Cause? Cardiogenic shock, shock not due to trauma V-tach, PSVT, A-fib, A-flutter, V-fib or V-flutter Congestive Heart Failure, Acute Cor Pulmonale Angina - stable, unstable, prin
41、zmetal? Asystole, cardiac arrest, heart blocks( Mobitz, A.V., trifascicular.be specific!) Acute Renal Failure Pulmonary embolus or infarction Myocarditis, Endocarditis Valve disorders - prolapse, insufficiency, regurgitation Rheumatic heart disease,CVA or TIA,Is this due to (or probably due to) an i
42、nfarct? thrombus? embolism? hemorrhage? Is it (probably?) due to cerebral atherosclerosis, stenosis or insufficiency? Is a specific site of the obstruction known or suspected? (e.g. cerebral artery; pre-cerebral or carotid artery) If the “TIA” symptoms last more than 72 hours, is this really a CVA?
43、Residuals still present at discharge should be clearly documented.,ARTERIAL or VENOUS OCCLUSION,What is the (suspected) cause of the occlusion? Thrombus? Atherosclerosis or plaque? Stricture or stenosis? External compression (e.g. tumor or lymphadenopathy)? Diabetic vascular disease?,HIV PATIENT,Is
44、the reason for admission caused by the HIV infection? (e.g. “fever probably due to HIV” or “recurrent community-acquired pneumonia due to HIV”) All co-existing problems being treated, evaluated, monitored, or extending the hospital stay should be listed at least one time. (e.g. candidiasis, PCP, deh
45、ydration, cryptococcosis, diabetes, etc.) The current T-cell or CD4 count should be documented if known.,CANCER,What is the ACUTE reason for the patients admission? Pain control? Mets. workup? Surgery to primary site? Dehydration? Palliative care ONLY? Neutropenic fever or neutropenia with suspected
46、 sepsis or infection? Chemotherapy ONLY? Intractable nausea due to chemo? Post-obstructive pneumonia? Once on each admission, the primary site and all current metastatic sites being addressed on this admission should be listed. It should be specific. “mets. to bladder, colon and liver (or applicable
47、 sites)”, NOT “abdominal mets.” Is the cause of the symptoms at admission known or suspected? (e.g. “urine retention due to bladder cancer at UVJ” or “urine retention probably due to external compression from peritoneal mets.”) All secondary conditions being treated or monitored should be documented
48、. Examples: CHF, COPD, AODM, anemia (blood loss?), electrolyte imbalances, infections, coagulopathies, and so forth.,G. I. BLEED,Can the bleeding be more specifically described as melena, hematochezia, or hematemesis? If a source of the bleed is known or suspected, inclusion in the discharge progres
49、s note would be most helpful. Endoscopy notes should include the cause of the bleed as well as the physical findings. Does “gastric ulcer, no active bleed” mean that the ulcer is NOT the cause of the bleed? Or that despite no current bleeding, we presume the ulcer to be the cause? If workup reveals
50、gastritis, an erythematous polyp, internal hemorrhoids and a healing gastric ulcer: A) is a specific one of these suspected to be the cause of the bleed? B) might any of them be the cause? C) are none of them severe enough to be causing the bleed, and the patient needs further workup? Failure to have the cause, or suspected cause, documented can affect DRG assignment, reimbursement to the hospital, and severity of illness indicators for the patient.,
